History

Please include detail such as:

• Pain
  • In the groin, medial thigh or greater trochanter radiating to thigh or knee at rest and/or after activity
  • isolated knee pain
• Impact on occupation, daily activity or sports (e.g. decrease in walking distance, difficulty in negotiating stairs or performing pedicure)
• Duration and onset
• Aggravating and relieving factors
• Perthes
• Details of previous surgery

Red Flags which will bypass the Community Assessment Service (should be referred urgently to secondary care)

• Fracture or trauma
• Suspicion of tumour or evidence of any destructive lesion on radiograph
• Unexplained, increasing or sudden onset severe pain in a previously replaced joint
• Any features suspicious of infection, including:
  • Cellulitis over the joint
  • Large effusion and erythema
  • Inflamed scar/wound over a previously replaced joint
• Inability to walk or weight bear
• Evidence of new inflammatory arthropathy
• Avascular necrosis/osteonecrosis
• The following hip condition:
  • Protrusio acetabula

• A plain A-P X-ray of the pelvis should ideally be requested to confirm the diagnosis after history and examination if OA is suspected.

The clinical indications for this are:

1) to rule OA in or out as a differential for the patient's symptoms

2) to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral)

3) deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up-to-date X-ray is extremely useful for remote/virtual consultations.

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

• No further imaging (e.g., MRI or bone scan) is appropriate before referral.

Mild Symptoms

• see MyHealth Devon Hip Pain (Osteoarthritis)
• Offer verbal and written information about condition
• Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
• Advise on local muscle strengthening and general aerobic exercise as a core treatment
• Use of shared decision making tools
• Suggest OTC oral simple analgesia/anti-inflammatories or topical agents
• Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid.
• Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

• As above, and
• Consider prescription analgesia and NSAIDs - Joint Formulary Chapter 10.1

Unless red flags are present all patients referred for consideration of arthroplasty due to osteoarthritis will be assessed by a community assessment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Surgery

• Primary Hip Replacement
• Hip Resurfacing is commissioned in line with NICE TA 304 (Total Hip Replacement and resurfacing arthroplasty for end-stage arthritis of the hip). Other forms of arthroscopic or open hip surgery are low priority procedures and will only be funded through exceptional cases panel approval

Referral Criteria

Referral to specialist secondary care:

All referrals should include:

• History and duration
• Instability symptoms or history of overuse
• Relevant examination findings
• Relevant investigations

All referrals must include:

1. Details of persistent pain or disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. Please include details (including dates) of conservative treatment (e.g. analgesia, steroid joint injection)
2. A recent course of physiotherapy will be expected unless this is not clinically appropriate (within the twelve months prior to referral). This clinical decision needs to be stated and if it is not then the referral will be returned.
3. A plain A-P X-ray of the pelvis report must accompany all hip referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.
   

The clinical indications for this are:

1. to rule OA in or out as a differential for the patient's symptoms
2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g. avascular necrosis (an indication for expedited referral).
3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up to date X-ray is essential to facilitate remote/virtual consultations

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient's symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

Please ensure that the X-ray report is attached to avoid unnecessary delay.

It is the responsibility of the referrer to attach the report.

Please note primary care is encouraged to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Form

DRSS Referral Form

GP Information

NICE OA Guideline

Patient Information

Patient Information for pain arising from the hip in adults

MyHealth patient information - Hip pain

Hip joint replacements - Patient.co.uk

Hip replacement - NHS.uk

Pathway Group

This guideline has been signed off on behalf of the NHS Devon.

Publication date: July 2020

Updated: December 2023