Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about 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.

1.1 Shared decision making and information for people offered hip, knee or shoulder replacement

1.1.1 Follow communication, information and shared decision making in the NICE guideline on patient experience in adult NHS services when discussing treatment with people offered primary elective hip, knee or shoulder replacement.

1.1.2 Support shared decision making by discussing treatment options with people offered primary elective hip, knee or shoulder replacement and their families or carers (as appropriate). Include in the discussions:

  • the alternatives to joint replacement

  • the potential benefits and risks of the available procedures and types of implant for joint replacement, including the possible need for more surgery in the future

  • the options for anaesthesia and analgesia, and the potential benefits and risks of each option (see the section on anaesthesia and analgesia).

1.1.3 Give people offered primary elective hip, knee or shoulder replacement and their family members or carers (as appropriate) information that is:

  • specific to the procedure they are being offered

  • in a format they can easily understand

  • provided starting at the first appointment, then whenever needed throughout their care.

1.1.4 Give information on primary elective hip, knee or shoulder replacement that includes:

  • what to expect before, during and after surgery, including length of hospital stay, recovery and rehabilitation

  • who to contact if they have questions or concerns before or after surgery

  • preparing for surgery, including steps they can take to optimise their recovery (see the section on preoperative rehabilitation)

  • pain after surgery and how it can be managed

  • wound care

  • returning to work

  • returning to usual activities, for example playing sports, driving and sexual activity.

For a short explanation of why the committee made the recommendations on shared decision making and information for people offered hip, knee or shoulder replacement, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review A: information needs.

Decision aids for elective joint replacement

The committee did not make recommendations for specific decision aids for elective joint replacement but recognised that they could have value in shared decision making. They made a recommendation for research on the components of a decision aid.

For a short explanation of why the committee were unable to make recommendations on decision aids for elective joint replacement, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review B: decision aids.

1.2 Preoperative rehabilitation

Preoperative rehabilitation for hip or knee replacement

1.2.1 Give people having hip or knee replacement advice on preoperative rehabilitation. Include advice on:

  • exercises to do before and after surgery that will aid recovery

  • lifestyle, including weight management, diet and smoking cessation (see NICE's guidance on lifestyle and wellbeing)

  • maximising functional independence and quality of life before and after surgery.

Preoperative rehabilitation for shoulder replacement

The committee were unable to make recommendations for practice in this area. They included preoperative rehabilitation for shoulder replacement in their recommendation for research.

For a short explanation of why the committee made the recommendation on preoperative rehabilitation for hip or knee replacement and how it might affect practice, and why they were unable to make recommendations on preoperative rehabilitation for shoulder replacement, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review C: preoperative rehabilitation.

1.3 Anaesthesia and analgesia

Anaesthesia and analgesia for hip replacement

1.3.1 Offer people having primary elective hip replacement a choice of:

  • regional anaesthesia in combination with local infiltration analgesia (LIA) or

  • general anaesthesia in combination with LIA.

    Consider a nerve block that does not impair motor function as an alternative to LIA in either of the options above, provided it does not delay surgery significantly.

For a short explanation of why the committee made the recommendation on anaesthesia and analgesia for hip replacement and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review D: anaesthesia for hip replacement.

Anaesthesia and analgesia for knee replacement

1.3.2 Offer people having primary elective knee replacement a choice of:

  • regional anaesthesia in combination with LIA or

  • general anaesthesia in combination with LIA.

    Consider adding a nerve block that does not impair motor function to either of the options above, provided it does not delay surgery significantly.

For a short explanation of why the committee made the recommendation on anaesthesia and analgesia for knee replacement and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review E: anaesthesia for knee replacement.

Anaesthesia and analgesia for shoulder replacement

1.3.3 Discuss the options for anaesthesia and analgesia with people having primary elective shoulder replacement, including general anaesthesia, regional anaesthesia, local infiltration analgesia and nerve blocks.

The committee were unable to recommend specific options for anaesthesia and analgesia for shoulder replacement. They made recommendations for research on supplementary anaesthesia, and on regional compared with general anaesthesia or a combination in elective shoulder replacement.

For a short explanation of why the committee made the recommendation on anaesthesia and analgesia for shoulder replacement and why they were unable to make recommendations on specific options see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review F: anaesthesia for shoulder replacement.

1.4 Tranexamic acid to minimise blood loss

1.4.1 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 acid[1] diluted in saline 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 impairment[2], give a reduced dose of intravenous tranexamic acid on its own.

1.4.2 For primary elective shoulder replacement:

  • Consider intravenous tranexamic acid.

  • If there is no renal impairment, consider 1 g to 2 g of topical (intra-articular) tranexamic acid[1] diluted in saline applied 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 impairment[2] and tranexamic acid is used, give a reduced dose of intravenous tranexamic acid on its own.

For a short explanation of why the committee made the recommendations on tranexamic acid to minimise blood loss and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review G: tranexamic acid to minimise blood loss.

1.5 Preventing infections

Antibiotic or antiseptic agents in wound wash-out solutions

1.5.1 Follow the recommendations on antibiotic prophylaxis, wound irrigation and intracavity lavage, and antiseptics and antibiotics before wound closure in the NICE guideline on surgical site infections, for people having primary elective hip, knee or shoulder replacement.

Ultra-clean air ventilation in operating theatres

1.5.2 Use ultra-clean air ventilation in operating theatres for primary hip, knee or shoulder elective joint replacement.

For a short explanation of why the committee made the recommendations on preventing infections, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review H: wound lavage and evidence review I: ultra-clean air.

1.6 Avoiding implant selection errors

1.6.1 Use 2 intraoperative 'stop moments', 1 before implantation and 1 before wound closure, to check all implant details and ensure compatibility of each component.

1.6.2 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.

For a short explanation of why the committee made the recommendations on avoiding implant selection errors and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review J: wrong implant selection.

1.7 Procedures for primary elective knee replacement

Partial and total knee replacement

1.7.1 Offer a choice of partial or total knee replacement to people with isolated medial compartmental osteoarthritis. Discuss the potential benefits and risks of each option with the person.

For a short explanation of why the committee made the recommendation on partial and total knee replacement and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review K: total knee replacement.

Patella resurfacing

1.7.2 Offer resurfacing of the patella to people having primary elective total knee replacement.

For a short explanation of why the committee made the recommendation on patella resurfacing and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review L: patella resurfacing.

1.8 Surgical approaches and implants for primary elective hip replacement

Surgical approaches for primary elective hip replacement

1.8.1 Consider a posterior or anterolateral approach for primary elective hip replacement.

The committee were unable to make recommendations on the direct anterior, direct superior and supercapsular percutaneously assisted (SuperPATH) surgical approaches. They made a recommendation for research on these approaches.

For a short explanation of why the committee made the recommendation on surgical approaches for primary elective hip replacement and how it might affect practice, and why they were unable to make recommendations on the direct anterior, direct superior and SuperPATH approaches, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review M: hip replacement approach.

Implants for primary elective hip replacement

For NICE technology appraisal guidance on implants for primary elective hip replacement see surgical procedures for hip replacement in the NICE Pathway on joint replacement.

1.9 Procedures for primary elective shoulder replacement

Shoulder replacement for osteoarthritis with no rotator cuff tear

1.9.1 If glenoid bone is adequate, offer conventional total shoulder replacement to people having primary elective shoulder replacement for osteoarthritis with no rotator cuff tear.

For a short explanation of why the committee made the recommendation on shoulder replacement for osteoarthritis with no rotator cuff tear and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review N: shoulder replacement – intact rotator cuff.

Shoulder replacement for pain and functional loss for people with a previous proximal humeral fracture

The committee were unable to make recommendations for practice in this area. They made a recommendation for research on procedures for shoulder replacement for people with a previous proximal humeral fracture.

For a short explanation of why the committee were unable to make recommendations on shoulder replacement for pain and functional loss for people with a previous proximal humeral fracture, see rationale.

Full details of the evidence and the committee's discussion are in evidence review O: hemiarthroplasty – proximal humeral fracture.

1.10 Postoperative rehabilitation

Inpatient rehabilitation

1.10.1 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 a short explanation of why the committee made the recommendation on inpatient rehabilitation and how it might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review P: inpatient hip and knee postoperative rehabilitation and evidence review Q: inpatient shoulder postoperative rehabilitation.

Outpatient rehabilitation

1.10.2 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 recommendations 1.10.5 and 1.10.6 if needed.

1.10.3 For people who have had primary elective shoulder replacement:

  • a member of the physiotherapy or occupational therapy team should give advice on:

    • self-directed rehabilitation or

    • supervised group rehabilitation or

    • individual rehabilitation

  • the advice should be given before the person leaves hospital

  • the advice should be adjusted in line with recommendations 1.10.5 and 1.10.6 if needed.

1.10.4 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.

1.10.5 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.

1.10.6 Consider supervised group or individual outpatient rehabilitation for people with cognitive impairment.

For a short explanation of why the committee made the recommendations on outpatient rehabilitation and how they might affect practice, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review R: outpatient hip and knee postoperative rehabilitation and evidence review S: outpatient rehabilitation after shoulder replacement.

1.11 Long-term care

Follow-up and monitoring

The committee were unable to make recommendations for practice in this area. They made a recommendation for research on follow-up.

Referral from primary care

1.11.1 Primary care practitioners should refer people who develop new or worsening pain, limp or loss of function related to their joint replacement to an orthopaedic surgical service.

For a short explanation of why the committee were unable to make recommendations on follow‑up and monitoring in secondary care and why they made the recommendation on referral from primary care, see rationale and impact.

Full details of the evidence and the committee's discussion are in evidence review T: long-term follow-up and monitoring.



[1] At 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.

[2] Mild 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.

  • National Institute for Health and Care Excellence (NICE)