People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on 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.
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.
The committee were unable to make recommendations for practice in this area. They included preoperative rehabilitation for shoulder replacement in their recommendation for research on preoperative rehabilitation.
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 the rationale and impact section on preoperative rehabilitation .
Full details of the evidence and the committee's discussion are in evidence review C: preoperative rehabilitation.
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 these recommendations and how they might affect practice, see the rationale and impact section on anaesthesia and analgesia for hip replacement.
Full details of the evidence and the committee's discussion are in evidence review D: anaesthesia for hip replacement.
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 these recommendations and how they might affect practice, see the rationale and impact section on anaesthesia and analgesia for knee replacement.
Full details of the evidence and the committee's discussion are in evidence review E: anaesthesia for knee replacement
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 these recommendations and how they might affect practice, see the rationale and impact section on anaesthesia and analgesia for shoulder replacement.
Full details of the evidence and the committee's discussion are in evidence review F: anaesthesia for shoulder replacement.
In June 2020, tranexamic acid solution for injection was off label for topical (intra-articular) use. See NICE's information on prescribing medicines.
In these recommendations 'renal impairment' refers to 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.
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 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, give a reduced dose of intravenous tranexamic acid on its own.
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 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 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 these recommendations and how they might affect practice, see the rationale and impact section on tranexamic acid to minimise blood loss.
Full details of the evidence and the committee's discussion are in evidence review G: tranexamic acid to minimise blood loss.
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.
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 these recommendations see and how they might affect practice, see the rationale and impact section on preventing infections.
Full details of the evidence and the committee's discussion are in evidence review H: wound lavage and evidence review I: ultra-clean air.
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.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on avoiding implant selection errors.
Full details of the evidence and the committee's discussion are in evidence review J: wrong implant selection.
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 and how it might affect practice, see the rationale and impact section on partial and total knee replacement.
Full details of the evidence and the committee's discussion are in evidence review K: total knee replacement.
Offer resurfacing of the patella to people having primary elective total knee replacement.
For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on patella resurfacing.
Full details of the evidence and the committee's discussion are in evidence review L: patella resurfacing.
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 surgical approaches in primary elective hip replacement.
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 the rationale and impact section on surgical approaches for primary elective hip replacement.
Full details of the evidence and the committee's discussion are in evidence review M: hip replacement approach
For NICE technology appraisal guidance on implants for primary elective hip replacement see the NICE topic page on joint replacement.
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 and how it might affect practice, see the rationale and impact section on shoulder replacement for osteoarthritis with no rotator cuff tear.
Full details of the evidence and the committee's discussion are in evidence review N: shoulder replacement – intact rotator cuff.
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 did not make a recommendation, see the rationale on shoulder replacement for pain and functional loss for people with a previous proximal humeral fracture.
Full details of the evidence and the committee's discussion are in evidence review O: hemiarthroplasty – proximal humeral fracture.
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 this recommendation and how it might affect practice, see the rationale and impact section on inpatient rehabilitation.
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.
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.
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.
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.
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.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on outpatient rehabilitation.
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.
The committee were unable to make recommendations for practice in this area. They made a recommendation for research on follow-up.
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 did not make a recommendation, see the rationale on follow-up and monitoring in secondary care.
Full details of the evidence and the committee's discussion are in evidence review T: long-term follow-up and monitoring