Musculoskeletal conditions 1 Summary There is no specific population recording of the extent of the effects of conditions that affect the musculoskeletal system. However, modelled estimates suggest that over 208,700 people in Hampshire have musculoskeletal conditions. This represents the people who have been identified by their GP and is based on 2001 data from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) 1 which provides the best estimate of the total burden of disease as presented for health care. An increasingly ageing population in Hampshire is likely to create further need for services as more people live longer with musculoskeletal conditions as one of several chronic conditions they live with. Pain is the most prominent symptom in most people with musculoskeletal problems. It leads to limitation in function and can result in long- term work disability with economic consequences. It can also lead to significant health and social care expense: prescriptions for pain, biological therapies, surgical procedures, referrals to physiotherapists, occupational therapists, podiatrists, chiropractors; GP appointments, consultations with rheumatologists, orthopaedic surgeons, pain specialists and rehabilitation specialists. Falls are the most common cause of accidental injury to children and A&E attendances are highest among the under 5s. Falls from a height tend to be associated with the most serious childhood injuries and older children are more likely to sustain fractures than younger ones. Falls also disproportionately affect older people. Residents from Rushmoor (1,933/100,000), Hart (1,847/100,000) and Gosport (1,844/100,000) had the highest hospital admission rates from falls and fall injuries between 2009/10-2011/12. Winchester residents (1,432/100,000) had the lowest hospital admission rate. Trend data suggest an ongoing increase particularly for women. Sports injuries are an important cause of fractures and dislocations in children and adolescents but there is very little known about their epidemiology. Hip fracture admission rates were the highest among residents from Gosport (513/100,000) and East Hampshire (501/100,000) and lowest from Rushmoor (409/100,000) but appear to be stabilising. Preponderance among women is clear. Havant (112/100,000), Rushmoor (112/100,000), and the New Forest (102/100,000) had some of the highest primary hip replacement rates across Hampshire. Winchester had the lowest numbers of hip replacements, with a rate of 85/100,000 population. Revision rates were highest at 21/100,000 in both in Rushmoor and Basingstoke and Deane, and lowest in Fareham (10/100,000). Eastleigh residents (44/100,000) had the highest rate of hip resurfacing procedures, followed by residents from Test Valley (41/100,000), Winchester (40/100,000) and Rushmoor (39/100,000). The lowest resurfacing rates were amongst East Hampshire residents (20/100,000). 1 Unpublished 2001 incidence and prevalence of diseases data provided by the RCGP Research & Surveillance Centre (formerly the Birmingham Research Unit) during the period Oct 2005 – June 2009 cited by Sarah Parsons et al., The University of Manchester, 2011 http://www.medicine.manchester.ac.uk/musculoskeletal/aboutus/publications/heavyburden.pdf
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Musculoskeletal conditions
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Summary
There is no specific population recording of the extent of the effects of conditions that affect the musculoskeletal system. However, modelled estimates suggest that over 208,700 people in Hampshire have musculoskeletal conditions. This represents the people who have been identified by their GP and is based on 2001 data from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC)1 which provides the best estimate of the total burden of disease as presented for health care. An increasingly ageing population in Hampshire is likely to create further need for services as more people live longer with musculoskeletal conditions as one of several chronic conditions they live with.
Pain is the most prominent symptom in most people with musculoskeletal problems. It leads to limitation in function and can result in long- term work disability with economic consequences. It can also lead to significant health and social care expense: prescriptions for pain, biological therapies, surgical procedures, referrals to physiotherapists, occupational therapists, podiatrists, chiropractors; GP appointments, consultations with rheumatologists, orthopaedic surgeons, pain specialists and rehabilitation specialists.
Falls are the most common cause of accidental injury to children and A&E attendances are highest among the under 5s. Falls from a height tend to be associated with the most serious childhood injuries and older children are more likely to sustain fractures than younger ones. Falls also disproportionately affect older people. Residents from Rushmoor (1,933/100,000), Hart (1,847/100,000) and Gosport (1,844/100,000) had the highest hospital admission rates from falls and fall injuries between 2009/10-2011/12. Winchester residents (1,432/100,000) had the lowest hospital admission rate. Trend data suggest an ongoing increase particularly for women.
Sports injuries are an important cause of fractures and dislocations in children and adolescents but there is very little known about their epidemiology.
Hip fracture admission rates were the highest among residents from Gosport (513/100,000) and East Hampshire (501/100,000) and lowest from Rushmoor (409/100,000) but appear to be stabilising. Preponderance among women is clear.
Havant (112/100,000), Rushmoor (112/100,000), and the New Forest (102/100,000) had some of the highest primary hip replacement rates across Hampshire. Winchester had the lowest numbers of hip replacements, with a rate of 85/100,000 population. Revision rates were highest at 21/100,000 in both in Rushmoor and Basingstoke and Deane, and lowest in Fareham (10/100,000).
Eastleigh residents (44/100,000) had the highest rate of hip resurfacing procedures, followed by residents from Test Valley (41/100,000), Winchester (40/100,000) and Rushmoor (39/100,000). The lowest resurfacing rates were amongst East Hampshire residents (20/100,000).
1 Unpublished 2001 incidence and prevalence of diseases data provided by the RCGP Research &
Surveillance Centre (formerly the Birmingham Research Unit) during the period Oct 2005 – June 2009 cited by Sarah Parsons et al., The University of Manchester, 2011 http://www.medicine.manchester.ac.uk/musculoskeletal/aboutus/publications/heavyburden.pdf
Knee arthroscopic activity shows variation with the age standardised rate ranging from the lowest of 172/100,000 in Gosport to 252/100,000 in Test Valley. Overall activity suggests a declining trend.
Admission rates for knee replacements are highest in both Hart and Rushmoor at 110/100,000 and lowest in Winchester (77/100,000). These admission rates are more likely to reflect demand and supply, rather than need. The highest revision rates occurred among residents from Basingstoke and Deane (18/100,000) and Test Valley (17/100,000), and lowest at 11/100,000 in Havant, the New Forest and Winchester.
There is substantial variation in facet joint injection activity across Hampshire, ranging from an age standardised rate of 69/100,000 in Eastleigh to 581/100,000 in Rushmoor, 421/100,000 in Hart and 283/100,000 in Basingstoke and Deane, suggesting that this is provider driven as the evidence base is weak.
Recommendations
Prioritise and take a life course approach to optimising bone health.
Tailor services to meet musculoskeletal needs.
Ensure services rely on evidence-based practice to optimise outcomes and value.
Audit the delivery of care for musculoskeletal conditions in line with the musculoskeletal services framework (MSF) which is still relevant today:
Prioritise interventions and actions designed to reduce the numbers of people of all ages who are injured through falls and sports injuries.
Ensure people with hip fracture have prompt admission to orthopaedic care; surgery within 48 hours, with effective medical care and rehabilitation.
Determine the proportion of cementless knee arthroplasty procedures relative to all arthroplasty undertaken. Decide the appropriate proportion of cementless knee arthroplasty procedures according to local population need.
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1. Introduction The Global Burden of Disease Study 2010 (The Lancet2) reported that musculoskeletal disorders (muscles, bones and joints) are the single biggest cause of disability in the UK, at 31.3% of the population. Of the entire burden of disability, low back pain is the single biggest cause of disability, followed closely by osteoarthritis. Musculoskeletal related disability is going to increase because of the ageing population, increased levels of obesity and lack of physical activity. Health and safety statistics (Labour Force Survey for 2011/12) suggest that musculoskeletal disorders accounted for a total of 439,000 cases (41%) out of a total 1,073,000 all work-related illnesses in the UK. The estimated prevalence of work-related back disorders was 176,000 cases in 2011/12.3 Department of Health figures for 2011/12 identified musculoskeletal conditions as the third largest NHS programme budget spend, at £118 per weighted head of population in Hampshire (excluding ‘other’).4 Although this spend has reduced from 2010/11 (when it was £130 per weighted head of population), it remains above average when compared to similar Office for National Statistics (ONS) cluster groups5 and is not associated with better, or improvements, in hip and knee outcomes.6 This chapter uses high level routine data for the Hampshire population. Not all the data can be standardised for age, sex, unhealthy risky behaviours and level of deprivation, differences in clinical coding or take account of case mix. This means that interpretation of variation is not straightforward. However, it provides an overarching picture, local authority benchmarking and allows distillation of areas that require further investigation and action. 2. Level of need in the population
Musculoskeletal disorders (MSD) are a group of conditions affecting joints, bones, muscles and soft tissue. They affect all age groups, but the prevalence generally rises with age. Sports injuries are an important cause of fractures and dislocations in children and adolescents but there is very little known about their epidemiology. The numbers of people with reported musculoskeletal conditions has risen in recent years associated with the increase in the number of elderly people, compounded by increased obesity throughout the population and lack of physical activity. There are no disease registers or systems to capture the prevalence of musculoskeletal conditions among Hampshire residents, although the
5ONS cluster groups have been devised by the ONS to allow areas with similar characteristics to be
compared. Hampshire PCT was attributed to the ‘Prospering Smaller Towns’ group 6 Outcomes for the 2011/12 spend were PROMs* EQ-5D Hips Health Gain 0.40
musculoskeletal Quality and Outcomes Framework (QOF7) targets for osteoporosis and rheumatoid arthritis in 2013/14 will allow estimation of local prevalence of these conditions by GP practice. In recognition of this, primary care level estimates of Hampshire residents with specific MSDs have been calculated using the Arthritis Research UK Epidemiology Unit report8 prevalence data, with the exception of systemic lupus erythematosus (SLE), scleroderma and ankylosing spondylitis (AS) (table 1). The information therefore reflects healthcare demand and utilisation rather than healthcare need. The main conditions for which there is likely to be a discrepancy between need and demand are back and other regional pain syndromes, osteoarthritis and osteoporosis. As the individual disease categories are not mutually exclusive these rates cannot simply be added together to produce estimates of the overall burden of musculoskeletal conditions in Hampshire. Apart from the number of people affected, musculoskeletal disease ‘burden or need’ is also defined by its healthcare impact. 2.1 Back pain Back pain is a major health care burden and is the single largest reported cause of absence from work. It is a symptom triggered by a variety of factors, making it difficult to assess numbers of people affected by individual cause. The RCGP survey data in table 1 suggest a figure of 57,508 back pain sufferers in Hampshire but this does not include possible unmet need of those not accessing services. Information on work-related back pain is not available at a county or local authority level. Table 1: Estimated prevalence per 100,000 of specific MSDs
Musculoskeletal condition National prevalence rate (per 100,000)
All musculoskeletal conditions 16,344 21,843 86,127 122,622 Source: Prevalence rates from the Arthritis Research UK Epidemiology Unit ‘A Heavy Burden Report’, 2011
7 The Quality and Outcomes Framework (QOF) rewards GP practices financial incentives for good
practice in diagnosis and treatment. 8 http://www.medicine.manchester.ac.uk/musculoskeletal/aboutus/publications/heavyburden.pdf
2.2 Osteoarthritis/Joint failure Osteoarthritis is a disorder in which the joint surfaces are damaged, resulting in joint failure over time. It tends to be the end point in the natural history of many musculoskeletal conditions. Like back pain, the number of 27,173 individuals with joint failure in Hampshire is an underestimate of the extent of the problem as a proportion of those affected do not consult their GPs. 2.3 Osteoporosis Osteoporosis is a condition where there is thinning of the bones, causing them to become fragile and more likely to break (fracture). The prevalence increases with age. Optimising bone health in childhood through physical activity, eating a well-balanced diet rich in calcium and adequate vitamin D intake, helps build bones and presents a window of opportunity to prevent osteoporosis in later life. In Hampshire there are an estimated 73,586 residents with the condition. Osteoporosis tends to be asymptomatic and so reported figures underestimate the true picture of the condition in the community. 2.4 Falls and fall-related injuries Falls are a significant public health problem and much health and social care activity results from people who have fallen and fall-related injuries. They are the most common cause of accidental injury to children. The rate of A&E attendances for falls are highest among the under 5s. Falls from a height tend to be associated with the most serious childhood injuries and there is evidence that older children are more likely to sustain fractures than younger ones.9 Falls also disproportionately affect older people. This is likely to continue to increase with an ageing population, unless falls prevention strategies are uniformly and effectively implemented. Falls information for the people of Hampshire is informed by emergency hospital admissions, with 14,897 falls between 2009/10 and 2011/12, giving a rate of 1,623 per 100,000 population. Residents from Rushmoor recorded the highest rate of hospital admissions as a result of falls and fall injuries during this period at 1,933 per 100,000, followed by Hart (1,847/100,000) and Gosport (1,844/100,000) residents. Winchester residents had the lowest hospital admission rate due to falls and fall injuries (1,432/100,000) (table 2 and figure 1). Table 2: Admissions - Falls and fall injuries - Emergency - Aged 65+, 2009/10-2011/12
HAMPSHIRE 14,897 1,623 1,596 1,649 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
Figure 1: Rate of falls and fall injuries in people aged 65+ in Hampshire, 2009/10 to 2011/12
Over the past four years there has been a gradual rise in hospital admission rates due to falls and fall injuries (figure 2), and admissions are higher among women. Figure 2: Trend in hospital admissions for falls and fall injuries in people aged 65+, 2009/10 to 2011/12
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2.5 Hip fractures A hip fracture is the most important immediate consequence of falls and pre-existing osteoporosis among older people. It can result in a loss of independence, decreased quality of life, a need for more support in the community or admission to residential care. Women are more likely than men to sustain a hip fracture and the incidence rises with age, associated with the decrease in oestrogen production after the menopause which accelerates bone loss. In Hampshire between 2009/10 and 2011/12, 4,369 people aged 65 and over were admitted to hospital with a broken hip. Data for 2011/12 show a slight decrease in this rate (447/100,000), compared to 2010/11 figures (462/100,000) although longer trend data are more reliable. This admission rate was similar to the national rate (452/100,000). Table 3 and figure 3 show hip fracture admissions from 2009/10 to 2011/12 with the lowest rates among residents in Rushmoor (409/100,000) and the highest in Gosport (513/100,000) and East Hampshire (501/100,000) residents. Trend data suggest that hospital admissions for hip fractures in Hampshire appear to be stabilising (figure 4). Again the gender characteristic with preponderance among women is clear. Table 3: Admissions – Hip fracture - Emergency - Aged 65+, 2009/10-2011/12
Local Authority
DSR/100,000 95% CI
Number RateLL RateUL
Basingstoke and Deane 388 467 420 514
East Hampshire 420 501 452 550
Eastleigh 352 447 399 495
Fareham 414 446 401 490
Gosport 285 513 452 575
Hart 223 433 376 491
Havant 445 449 406 492
New Forest 896 451 420 482
Rushmoor 202 409 350 468
Test Valley 358 446 399 494
Winchester 386 435 389 480
HAMPSHIRE 4,369 455 441 469 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
2.5.1 Mortality There is a significant mortality associated with hip fractures. Individual hospitals see populations with varying case mix in terms of frailty, co-morbidities, deprivation and hence differing risks in terms of reported mortality. National trend data in the National Hip Fracture Database (NHFD) is standardised (i.e. case mix adjusted) and reported a decline in 30-day mortality from 9.4% in 2008 to 8.0% in 2012. Funnel plot data show that none of the hospitals used by Hampshire’s residents were outliers with excess mortality warranting concerns. Among Hampshire’s residents there has also been a decline in the age and sex standardised mortality over a four year period from 9216.73/100,000 in 2007/08 to
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5581.83/100,000 in 2010/11. The comparative national rates were 9361.15 /100,000 in 2007/08 and 7321.38/100,000 in 2010/11. Figure 3: Hospital admissions for hip fractures in people age 65+ in Hampshire, 2009/10 to 2011/12
Figure 4: Trend in hospital admissions for hip fractures, 2009/10 to 2011/12
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3. Projected service use and outcome in 3-5 years and 5-10 years Office for national statistics (ONS) projections suggest that between 2011 and 2021, Hampshire’s population is expected to increase by 7% to almost 1,421,645, which is an additional 99,527 people. The older age groups will experience much larger increases in numbers, for instance the over 65 population will increase by 30% to almost 319,426, which is an additional 73,457 people by 2021. The incidence of musculoskeletal conditions is strongly associated with age. However, increasing obesity, less physical activity, other risky health behaviours and associated co-morbidities, will also increasingly impact on the musculoskeletal health of younger people. There is already a growing demand for a range of orthopaedic musculoskeletal procedures that could stretch health and social care systems. 4. Current services in relation to need Across Hampshire there is variation in NHS commissioned musculoskeletal services. In highlighting these local variations there’s a need to improve NHS musculoskeletal services – to ensure that people living with a musculoskeletal disorder receive access to the same, high-quality, standard of care. Further work needs to be undertaken by CCGs to make an accurate assessment of musculoskeletal needs of their local population to inform the commissioning of effective and value services. 4.1 Primary hip replacements Primary hip replacement surgery involves replacing a damaged hip joint with a prosthetic implant. Rates of primary hip replacement surgery tend to be higher for osteoarthritis compared to inflammatory arthritis and trauma, for example, in 2011, osteoarthritis was recorded as the main indication for surgery in 93% of hip replacement patients in England. The 2011 Atlas of variation information (figure 5) shows that in general, Hampshire has low need for hip replacements compared to the rest of England. (Rates of need were adjusted for the socio-demographic characteristics of an area, which were age, sex, Index of Multiple Deprivation 2004 deprivation quintiles, rurality, and ethnic mix of the area). The overall “rate of need for hip replacement” in those aged ≥50 years in England was 46.8 per 1,000 population. The map shows that Hampshire districts other than Havant, Gosport and New Forest, fall into the quintile with the lowest need. The need for hip replacements in Havant falls in the middle quintile (39.78-46.57 hip replacements needed per 1,000 population), while Gosport and New Forest fall into the second lowest quintile with regards to need (32.41-39.78 hip replacements needed per 1,000 population). Hart featured second in the list of 10 local authorities across England with the lowest need for hip replacements, with a rate of 23.06 hip replacements needed per 1,000 population. These data suggest that we might expect Havant and the New Forest to have higher hospital admission rates for hip replacement than other districts across Hampshire and Hart the lowest, if intervention rates were aligned to meet need.
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Figure 5: Hip replacement need, 2011 Atlas of variation
Table 4 and figure 6 show the rate of hip replacements per 100,000 population
across Hampshire based on data pooled between 2009/10-2011/12. These data
include all diagnoses and both planned and unplanned interventions and suggest
that intervention rates do match need. Residents from both Havant and Rushmoor
(112/100,000) and the New Forest (102/100,000), had some of the highest hip
replacement rates across Hampshire suggesting greater need. Winchester featured
as having the lowest numbers of hip replacements, with a rate of 85/100,000
population.
Several characteristics including age, gender, smoking status, obesity and co-morbidities are associated with outcomes from hip replacement surgery.
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Table 4: Primary hip replacement procedures, 2009/10-2011/12
Local Authority
DSR/100,000 95% CI
Number RateLL RateUL
Basingstoke and Deane 574 95 87 103
East Hampshire 507 99 91 108
Eastleigh 462 91 83 100
Fareham 532 99 90 108
Gosport 317 95 85 106
Hart 335 93 83 103
Havant 660 112 103 121
New Forest 1,001 102 95 108
Rushmoor 333 112 100 124
Test Valley 447 92 83 101
Winchester 427 85 77 94
HAMPSHIRE 5,595 98 95 101 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
Figure 6: Rate of primary hip replacements in Hampshire, 2009/10 to 2011/12
4.1.1 Trend data for Hampshire Data indicate a steady rise in primary hip replacements across Hampshire, with rates in women exceeding men (figure 7). The trends reported have important ramifications with regards to the number of hip replacements expected to be performed in the future. Current trends suggest a greater number of revision joint replacements.
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Figure 7: Trend in primary hip replacements, 2008/09 to 2011/12
4.2 Revision hip replacement procedures Over time a proportion of people may need replacement to their hip replacement and this is called a revision. The most common reason for this is that the joint implant has worn out. In 2009/10 to 2011/12 there were 5,595 hip replacements and 894 were revision surgeries, representing a revision ratio of 15% of the 5,595 primary hip replacements. Revision rates were the highest in Rushmoor and Basingstoke and Deane (table 5 and figure 8). Table 5: Revision hip replacement procedures, 2009/10-2011/12
Local Authority
DSR/100,000 95% CI
Number RateLL RateUL
Basingstoke and Deane 121 20 17 24
East Hampshire 70 13 10 16
Eastleigh 65 13 10 16
Fareham 55 10 7 13
Gosport 32 11 7 14
Hart 52 14 10 19
Havant 74 11 8 14
New Forest 191 18 15 21
Rushmoor 70 21 16 27
Test Valley 87 17 13 21
Winchester 77 15 11 18
HAMPSHIRE 894 15 14 16 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
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Figure 8: Rate of revision hip replacement in Hampshire, 2009/10 to 2011/12
4.2.1 Trend data for Hampshire After an initial declining trend in revision rates, 2011/12 saw a rise in revision rates (figure 9). It is difficult to make any long term trend assumptions from a change affecting a single year. Figure 9: Trend in revision hip replacement, 2008/09 to 2011/12
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4.3 Hip resurfacing procedures A hip resurfacing procedure may be recommended to some people as an alternative to hip joint replacement, as durability of prosthetic joints in younger people is a concern. The procedure is similar to a hip replacement, except that the femoral head is not replaced, but is reshaped with a metal cap. Recent National Joint Registry (NJR) research10 reported on the inferior performance of hip resurfacing procedures compared to conventional hip replacement. This is now not recommended in older people, women or smaller men because of high failure rates. Despite the decline in usage there is variation in hip resurfacing activity. Pooled data from 2009/10 to 2011/12 suggest that Eastleigh residents (44/100,000) had the highest rate of hip resurfacing procedures, followed by residents from Test Valley (41/100,000), Winchester (40/100,000) and Rushmoor (39/100,000). Lowest resurfacing rates were amongst East Hampshire (20/100,000) residents (table 6 and figure 10). This may relate to access to this intervention rather than need. Overall, activity for hip resurfacing procedures in men was higher compared with women. Table 6: Hip resurfacing procedures, 2009/10-2011/12
Local Authority
DSR/100,000 95% CI
Number RateLL RateUL
Basingstoke and Deane 143 26 21 30
East Hampshire 87 20 16 24
Eastleigh 184 44 37 50
Fareham 103 23 18 27
Gosport 72 26 20 32
Hart 104 33 27 40
Havant 105 23 19 28
New Forest 251 34 30 39
Rushmoor 114 39 32 46
Test Valley 178 41 35 47
Winchester 166 40 33 46
HAMPSHIRE 1507 31 30 33 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
4.3.1 Trend data for Hampshire Following a steady rise in hip resurfacing replacements in the previous three years, trends across Hampshire show a decline in resurfacing hip replacement procedures in 2011/12 (figure 11) although this appears to be static amongst men. The earlier rising trend may have been demand-driven activity as a result of marketing of the procedure to the "young and active" population and local surgical expertise. The subsequent decline has occurred following the NJR evidence on the inferior performance of these replacements.
10
Failure rates of metal-on-metal hip resurfacings: analysis of data from the National Joint Registry for England and Wales The Lancet, Volume 380, Issue 9855, Pages 1759-1766 Alison J Smith, Paul Dieppe, Peter W Howard, Ashley W Blom
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Figure 10: Rate of hip resurfacing in Hampshire, 2009/10 to 2011/12
Figure 11: Trend in hip resurfacing procedures, 2008/09 to 2011/12
4.4 Knee arthroscopies A diagnostic knee arthroscopy involves inserting a small camera (arthroscope) into the knee joint to examine it. Knee arthroscopic activity (wash outs/lavage/therapeutic/diagnostic) shows variation across Hampshire, with the age standardised rate ranging from the lowest in Gosport (172 per 100,000 population) to the highest in Test Valley (252/100,000) (table 7 and figure 12). Men underwent more knee arthroscopies than women.
HAMPSHIRE 8,887 216 211 221 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
Figure 12: Rate of knee arthroscopy procedures in Hampshire, 2009/10 to 2011/12
4.4.1 Trend data for Hampshire Overall activity during the past four years suggests a declining trend for both men and women (figure 13). 4.5 Primary knee replacement procedures As for osteoarthritis of the hip, symptoms of osteoarthritis of the knee can be managed conservatively and knee joint replacement surgery is a therapeutic option if conservative means fail to offer relief. Again, risk factors such as age, gender, smoking status, obesity and co-morbidities correlate with outcomes from knee replacement surgery. Weight loss improves function in people with osteoarthritis of the knee. Joint replacement surgery is a cost effective intervention for accidents or injury of the knee including secondary arthritis. Benefit and improving quality of life has led to a continuing increase in the number of knee replacements performed in
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Hampshire over the past four years. Knee replacements can be cemented, cementless or a hybrid operation (both cemented and cementless) depending on the type of knee prosthesis fixation. Figure 13: Trend in knee arthroscopies, 2008/09 to 2011/12
HAMPSHIRE 5,466 95 93 98 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
There is variation in admission rates for knee replacements (cemented/ cementless/ hybrid) across Hampshire (table 8 and figure 14). Rates are highest in both Hart and Rushmoor at 110 per 100,000 population and lowest in Winchester (77/100,000). These admission rates are more likely to reflect demand and supply, rather than need.
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4.5.1 Trend data for Hampshire The volume of knee replacements over the past four years shows an increasing trend, with a slightly higher number among women (figure 15). Figure 14: Rate of primary knee replacements in Hampshire, 2009/10 to 2011/12
Figure 15: Trend in primary knee replacement, 2008/09 to 2011/12
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4.6 Revision knee replacements There is variation in the rates of revision knee replacements across Hampshire (table 9 and figure 16). The highest revision rates occurred among residents from Basingstoke and Deane (18 per 100,000 population) and Test Valley (17/100,000), and lowest at 11/100,000 among residents in Havant, the New Forest and Winchester. Table 9: Revision knee replacement procedures, 2009/10-2011/12
Local Authority
DSR/100,000 95% CI
Number RateLL RateUL
Basingstoke and Deane 107 18 14 21
East Hampshire 69 14 11 18
Eastleigh 61 13 10 16
Fareham 78 15 12 19
Gosport 37 12 8 15
Hart 49 13 9 16
Havant 55 11 8 14
New Forest 104 11 9 13
Rushmoor 46 16 11 20
Test Valley 81 17 13 21
Winchester 50 11 8 14
HAMPSHIRE 737 13 12 14 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
Figure 16: Rates of knee replacement revisions, 2009/10 to 2011/12
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4.6.1 Trend data for Hampshire There appears to be a steady decline in the volume of revision knee procedures undertaken in Hampshire over the past four years (figure 17). Figure 17: Trend in knee replacement revisions, 2009/10 to 2011/12
4.7 Facet joint injections Facet joint11 injections may be suggested to treat low back and neck pain. However, their benefit is unclear. Moreover, most back pain usually improves within a few weeks with conservative treatment. In spite of the lack of evidence12 for the long-term effectiveness of facet joint injections, this has been popular, with a continued rise in activity across Hampshire. There is substantial variation in facet joint injection activity across local authorities in Hampshire, ranging from an age standardised rate of 69 per 100,000 population in Eastleigh residents to 581/100,000 in Rushmoor, 421/100,000 in Hart and 283/100,000 in Basingstoke and Deane residents (table 10 and figure 18). The noticeably high activity in the North East of Hampshire suggests that this is supply driven. Provision of alternative back pain management programmes, both for work and general issues, that are in line with the British Pain Society13 recommendations need to be considered.
11
Facet joints are small stabilising joints linking the vertebrae of the back and allowing its movement. Facet joint pain is difficult to define because of the confusion around the cause and uncertainty around pain pathways 12
The NICE clinical guideline 88 on chronic non-specific low back pain cites the lack of evidence of clinical effectiveness of facet joint injections for any particular condition/patient sub-group. 13
British Pain Society. Recommended guidelines for pain management programmes for adults. London: British Pain Society. 2007
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Table 10: Facet joint injections, 2009/10-2011/12
Local Authority Number
DSR/100,000 95% CI
RateLL RateUL
Basingstoke and Deane 1,566 283 269 297
East Hampshire 751 190 175 204
Eastleigh 285 69 61 77
Fareham 337 77 69 86
Gosport 215 78 67 88
Hart 1,316 421 397 444
Havant 390 90 80 99
New Forest 529 77 70 84
Rushmoor 1,669 581 553 609
Test Valley 436 107 97 118
Winchester 337 84 75 93
HAMPSHIRE 7,831 172 168 175 Sources: CDS received from Provider Trusts via SUS & ONS LSOA mid-year population estimates
4.7.1 Trend data for Hampshire The overall number of facet joint procedures over a three year period from 2008/09 shows a gradually increasing trend across Hampshire (figure 19). Figure 18: Rate of facet joint injections, 2009/10 to 2011/12
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Figure 19: Trend in facet joint injections, 2008/09 to 2011/12
5. User and provider views Information on user and provider views including Pathways to Work schemes or voluntary and community groups would be gathered in a needs assessment. Links with voluntary and community groups would be a way of empowering people with musculoskeletal disorders and help them to remain in or return to work. 6. Evidence of what works
The Department of Health’s Musculoskeletal Services Framework (MSF)14 - A joint responsibility: doing things differently, published in 2006, is still relevant today and musculoskeletal services need to be reshaped in line with its recommendations. For example, it recommended an integrated delivery model which utilised ‘clinical assessment and treatment services (CATS)’, described as the ‘keystone’ of the MSF.
Early diagnosis plays a crucial part especially for inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis.
Access to early intervention with physiotherapy and analgesia is clinically and cost effective in the management and treatment of musculoskeletal disorders.
Early self-referral to physiotherapy can reduce diagnostic (magnetic resonance imaging [MRI] scans) and prescribing costs and also time off work.
Promoting bone health from antenatally, in childhood with good diet and exercise, to maintaining weight bearing exercise as adults, to early detection of osteoporosis as people age through bone mineral density (BMD) measurement
14
Department of Health, A joint responsibility: doing it differently – the musculoskeletal services framework, 12 July 2006
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scans, assessment of fracture risk, assessment for the likelihood of future falls, prevention of falls, maintenance of mobility, correction of nutritional deficiencies, particularly of calcium, vitamin D and protein, and bone protection drugs have been shown to significantly reduce the risk of hip fractures15.
Local pathways for the management of knee pain, which clearly indicate the contribution of MRI assessment, diagnostic and therapeutic knee arthroscopy and knee washout procedures need to be developed and agreed.
Integrated musculoskeletal care pathways, supported self-management and shared decision-making are cost-effective ways of delivering high-quality, patient-centred care that will not only improve patients’ lives, but deliver better outcomes and high patient satisfaction.
Evidence from the Cochrane Collaboration on how shared decision-making makes a significant positive impact on patient care is compelling, also highlighting the risk of over-treatment.
Compliance with the British Orthopaedic Association (BOA) Blue Book Standards, for example, ensuring prompt surgery within 48 hours, falls assessment and promoting bone health. Mortality is widely recognised as an important indicator of the quality of hip fracture care and access to an orthogeriatrician prior to surgery is one of the ways both length of hospital stay and mortality can be reduced, as the vast majority of hip fracture patients are old and frail.
The National Institute for Health and Clinical Excellence (NICE) has published clinical guidelines and other guidance on a number of musculoskeletal conditions including osteoarthritis, rheumatoid arthritis and back pain. NICE Quality Standards for osteoarthritis, rheumatoid arthritis, and other conditions are in preparation.
Additionally, adherence to guidelines from the British Society for Rheumatology, National Osteoporosis Guideline Group (NOGG), Arthritis Research UK, National Osteoporosis Society Bone Research Society, British Geriatrics Society, British Orthopaedic Association, Primary Care Rheumatology Society, The Chartered Society of Physiotherapists, The British Pain Society, Royal College of Physicians, is key.
In particular, hip replacement surgery is performed to primarily undertaken in England to relieve pain arising from osteoarthritis or inflammatory arthritis and as part of hip fracture treatment. However it is an effective intervention to maintain and improve mobility.
Knee arthroscopies may include therapeutic interventions, including wash outs (lavage). Arthroscopic lavage of the knee joint and removal of loose debris should not be offered as part of treatment for knee osteoarthritis unless there are clear mechanical symptoms and overt evidence of loose bodies in the joint. Arthroscopic lavage and therapeutic reconstructions of knee components (knee ligament reconstruction) are useful for rheumatoid knees and inflammatory arthritis. Diagnostic knee arthroscopy of trauma is important for optimal clinical management. Arthroscopic removal of damaged knee cartilage (meniscectomies) should not be done because of the increased risk of osteoarthritis developing after a number of years.
7. Recommendations These present the opportunity for Hampshire to achieve better musculoskeletal care and outcomes, using a care pathway approach, starting with prevention: encouraging healthy behaviours (prevention); effective referral mechanisms; appropriate treatment; integrated care pathways in orthopaedic, rheumatology and pain management services across primary, community, acute and social care; engaging patient organisations; self-management and shared decision making.
Prioritise and take a life course approach to optimising bone health.
Tailor services to meet musculoskeletal needs.
Ensure services rely on evidence-based practice to optimise outcomes and value.
Audit the delivery of care for musculoskeletal conditions in line with the musculoskeletal services framework (MSF) which is still relevant today:
Prioritise interventions and actions designed to reduce the numbers of people who are injured through falls and sports injuries.
Ensure people with hip fracture have prompt admission to orthopaedic care; surgery within 48 hours, with effective medical care and rehabilitation.
Determine the proportion of cementless knee arthroplasty procedures relative to all arthroplasty undertaken. Decide the appropriate proportion of cementless knee arthroplasty procedures according to local population need.
