Primary Hip Replacement Surgery

Referralform for GPs / Consultants/Specialists

Patient Details
Name:
NHS Number:
Date of Birth:
Clinician Details
Name of Referring Clinician: / Date:
Practice:
Please indicate if the patient is suitable for treatment in the Intermediate Surgical Treatment Centre 

Referral should be made when other pre-existing medical conditions have been optimised ANDconservative measures have been exhausted and failed.

Note that all reasonable weight management attempts should have been tried if BMI is > 30

Body Mass Index......

Oxford hip score………..

Please refer to the classification of pain levels and functional limitations in the table overleaf.

GP referral criteriafor orthopaedic services / tick boxes as appropriate
The initial non-surgical management of hip pain due to osteoarthritis has been provided, ie a package of care that may include weight reduction, activity modification, adequate doses of non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, introducing walking aids, and other forms of physical therapies.
Patient has moderate to severe persistent pain not adequately relieved by an extended course of non-surgical management.
ANDClinically significant (moderate to severe) functional limitation resulting in diminished quality of life.
ANDRadiographic evidence of joint damage.
Consultants/Specialists thresholds for hip replacement surgery / tick boxes as appropriate
A / The patient has severe joint pain:
ANDhas severe functional limitation irrespective of whether conservative management has been trialled;
orhas minor to moderate functional limitation, despite the use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies.
OR
B / The patient has mild to moderate joint pain:
ANDhas severe functional limitation, despite the use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies.
ANDis assessed to be at low surgical risk.
OR / Oxford score is ≤ 26 on the 0 to 48 system, or ≥ 34 on the 60 to 12 system.
Please enter referral letter text here (optional). Please expand or shrink box as required.
Please state clearly if the referral is outside of policy criteria giving relevant clinical information.

Classification of Pain Levels and Functional Limitations Table

Variable / Definition
Pain Level
Mild / Pain interferes minimally on an intermittent basis with usual daily activities.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol.
Moderate / Pain occurs daily with movement and interferes with usual daily activities.
Vigorous activities cannot be performed.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol.
Severe / Pain is constant and interferes with most activities of daily living.
Pain at rest or interferes with sleep.
Pain not controlled, even by narcotic analgesics.
Previous non-surgical treatments
Correctly Done / NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses during 6 months with no pain relief; weight control treatment if overweight, physical therapies done.
Incorrectly Done / NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses or less than 6 months with no pain relief; or no weight control treatment if overweight or no physical therapies done.
Functional Limitations
Minor / Functional capacity adequate to conduct normal activities and self care.
Walking capacity of more than one hour.
No aids needed.
Moderate / Functional capacity adequate to perform only a few or none of the normal activities and self care.
Walking capacity of about one half hour.
Aids such as a cane are needed.
Severe / Largely or wholly incapacitated.
Walking capacity of less than half hour or unable to walk or bedridden.
Aids such as a cane, a walker or a wheelchair are required.