A-Z
Topics
Latest

Joint replacement

About

What is covered

This NICE Pathway covers care before, during and after hip, knee or shoulder replacement. It includes recommendations to ensure that people are given full information about their options for surgery, including anaesthesia. It offers advice for healthcare professionals on surgical procedures and ensuring safety during operations. It also offers guidance on providing support and rehabilitation before and after surgery.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on joint replacement in an interactive flowchart

What is covered

This NICE Pathway covers care before, during and after hip, knee or shoulder replacement. It includes recommendations to ensure that people are given full information about their options for surgery, including anaesthesia. It offers advice for healthcare professionals on surgical procedures and ensuring safety during operations. It also offers guidance on providing support and rehabilitation before and after surgery.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Midcarpal hemiarthroplasty for wrist arthritis (2019) NICE interventional procedures guidance 663
Total prosthetic replacement of the temporomandibular joint (2014) NICE interventional procedures guidance 500
Minimally invasive total hip replacement (2010) NICE interventional procedures guidance 363
Shoulder resurfacing arthroplasty (2010) NICE interventional procedures guidance 354
Mini-incision surgery for total knee replacement (2010) NICE interventional procedures guidance 345
Total wrist replacement (2008) NICE interventional procedures guidance 271
Metatarsophalangeal joint replacement of the hallux (2005) NICE interventional procedures guidance 140
Artificial trapeziometacarpal joint replacement for end-stage osteoarthritis (2005) NICE interventional procedures guidance 111
HemaClear for bloodless surgical field during limb surgery (2019) NICE medtech innovation briefing 187

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Give people having hip or knee replacement advice on preoperative rehabilitation. Include advice on:
For primary elective hip or knee replacement:
  • Give intravenous tranexamic acid.
  • If there is no renal impairment, also apply 1 g to 2 g of topical (intra-articular) tranexamic acidAt the time of publication (June 2020), tranexamic acid solution for injection did not have a UK marketing authorisation for topical (intra-articular) use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing unlicensed medicines for further information. diluted in saline, given after the final wash-out and before wound closure. Ensure that the total combined dose of tranexamic acid does not exceed 3 g.
  • If there is renal impairmentMild to moderate renal impairment. See the summary of product characteristics for dosage reductions according to serum creatinine level. Tranexamic acid is contraindicated for people with severe renal impairment. give a reduced dose of intravenous tranexamic acid on its own.
Follow the recommendations on antibiotic prophylaxis, wound irrigation and intracavity lavage, and antiseptics and antibiotics before wound closure in the NICE Pathway on preventing and treating surgical site infections for people having primary elective hip, knee or shoulder replacement.
Use ultra-clean air ventilation in operating theatres for primary hip, knee or shoulder elective joint replacement.
Use 2 intraoperative 'stop moments', 1 before implantation and 1 before wound closure, to check all implant details and ensure compatibility of each component.
Consider intraoperative real-time data entry before implantation using a system that provides an alert of mismatched implant components, such as the National Joint Registry database.
A physiotherapist or occupational therapist should offer rehabilitation, on the day of surgery if possible and no more than 24 hours after surgery, to people who have had a primary elective hip, knee or shoulder replacement. Rehabilitation should include:
  • advice on managing activities of daily living and
  • home exercise programmes and
  • mobilisation for people who have had knee or hip replacement or
  • ambulation for people who have had shoulder replacement.
For people who have had primary elective hip or knee replacement:
  • a member of the physiotherapy or occupational therapy team should give advice on self-directed rehabilitation
  • the advice should be given before the person leaves hospital
  • the advice should be adjusted in line with the recommendations below if needed.
Offer supervised group or individual outpatient rehabilitation to people who:
  • have difficulties managing activities of daily living or
  • have ongoing functional impairment leading to specific rehabilitation needs or
  • find that self-directed rehabilitation is not meeting their rehabilitation goals.
Consider supervised group or individual outpatient rehabilitation for people with cognitive impairment.
Ensure that people who are undertaking self-directed rehabilitation have:
  • a clear understanding of their rehabilitation goals and the importance of doing the exercises prescribed to achieve these goals
  • a point of contact for advice and support.

Glossary

local infiltration anaesthesia

Paths in this pathway

Pathway created: June 2020 Last updated: August 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

Recently viewed