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Revisiting joint replacements

The National Institute for Health and Care Excellence (NICE) has set out for consultation a revised code of practice covering all aspects of primary joint replacements. The consultation closes at 5pm on 26 November, with individuals and organisations being able to comment either on the entire proposal or on single aspects.

The code which covers knee, hip and shoulder replacements aims not only to support professionals but also to improve outcomes for patients, their families and carers. As such it covers all aspects of the process from ensuring that patients fully understand the options available to them to the levels of support and rehabilitation provided both before and after the operation. Aspects of the code also offer advice on surgical procedures and ensuring safety during operations.

In drawing up the new recommendations, NICE acknowledges that ‘there are wide variations in the care provided before, during and after joint replacement surgery’. Furthermore they comment that the level of care provided is a vital factor in the success of the surgery. This, taken together with the acknowledged variety of surgical procedures followed and choice of implants can have a long term effect not only on recovery but also on the need for further surgery in the long term.

The NICE recommendations set out the way in which pre-operative support should not simply arise from a discussion of the surgical options available. Other areas to be covered should include the provision of exercises that can be performed before surgery in order to improve recovery times alongside advice on weight management, diet, and smoking cessation.

When it comes to post-operative support the report’s authors underline the importance of outpatient rehabilitation. Commenting that evidence suggests that self-directed rehabilitation and supervised rehabilitation are similarly effective in respect of hip and knee replacements they note that self-directed rehabilitation is most effective when undertaken with ‘advice and ongoing support, if needed, from a physiotherapist or occupational therapist.’

Having said that, the NICE committee acknowledges that there is no evidence available to support recommendations on follow-up and monitoring following joint replacement surgery. A study is underway in respect of hip and knee surgery and no doubt further recommendations will follow once that study is complete.

The report also acknowledges that people with additional needs may benefit from supervised group or individual rehabilitation. Noting the lack of evidence in this area the authors call for further research to investigate how to identify individuals who would benefit from supervised rehabilitation and how best to provide that support. Interestingly the authors also identify a lack of evidence in respect of shoulder replacement rehabilitation and they therefore call for further research in this area.

Despite the need for further evidence in some areas, the report does highlight the importance of physiotherapists and occupational therapists in delivering pre and post-operative care to those undergoing joint replacement operations. With some 250,000 joint replacements carried out each year and with the numbers rising year on year (up 10,000 between 2017 and 2018) the better the outcome, the lower the ongoing burden on health resources.

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