01Purpose and principlesWhat the treatment does and how it fits into care.
Joint replacement is considered when symptoms and functional loss matter enough to justify operative risk and conservative treatment no longer provides an acceptable life. Document walking, stairs, sleep, work, self-care, caring responsibilities and valued activities, plus what the person expects surgery to restore. Establish duration, progression and whether hip, spine, vascular or neurological disease contributes. A radiograph is necessary for planning but cannot by itself prove that the target joint causes the disability.
NICE osteoarthritis guidance recommends referral when pain, stiffness or reduced function substantially affects quality of life and non-surgical management is ineffective or unsuitable. The decision uses clinical assessment rather than a scoring tool. Therapeutic exercise, weight support and appropriate analgesia should have been available, but repeated low-value treatment is not a prerequisite. Severe toxicity, contraindication or inability to access an option can make non-surgical management unsuitable and should not trap the person outside referral.
Do not exclude referral solely because of age, sex, smoking, comorbidity or overweight or obesity. These factors influence absolute risk and optimisation, and some may alter anaesthetic or implant choices, but blanket thresholds create inequity. Explain individual risks honestly and agree achievable optimisation: smoking cessation support, diabetes control, anaemia treatment, nutrition, weight management, skin and ulcer care, dental infection management and physical conditioning. State who provides support and when readiness is reviewed.
Confirm diagnosis and anatomy with examination and weight-bearing radiographs. For hip replacement assess hip-spine interaction, leg length, abductor function, prior surgery and deformity. For knee replacement assess alignment, range, flexion contracture, ligament stability, patellofemoral symptoms and compartment distribution. Investigate unexplained inflammatory, infective, rapidly destructive or neuropathic patterns before implantation. MRI is not routine for established end-stage osteoarthritis unless a specific alternative question persists.
Shared decision-making covers no operation, continued non-operative care and the available replacement designs. Explain likely improvement rather than promising a normal joint. Discuss pain persistence, stiffness and dissatisfaction as well as infection, bleeding, thrombosis, fracture, nerve or vessel injury, dislocation after hip replacement, instability after knee replacement, wear, loosening and revision. Explore transfusion, rehabilitation, driving, work and home support. Give accessible written information and time to reconsider.
Total hip replacement replaces both femoral head and acetabular surface. Implant fixation, bearing and surgical approach depend on bone, anatomy, age, activity, evidence and surgeon practice; marketing claims should not replace registry and guidance. Total knee replacement resurfaces all compartments selected by the implant while unicompartmental replacement treats suitable isolated compartment disease with intact relevant stabilisers. NICE asks surgeons to offer a choice of partial or total knee replacement when isolated medial disease makes both appropriate.
Preoperative assessment addresses cardiopulmonary fitness, frailty, renal function, anaemia, diabetes, nutrition, venous-thrombosis risk, anticoagulants, infection and home circumstances. Medication plans specify which anticoagulants, antiplatelets and diabetes drugs change and when they restart. Prehabilitation builds strength and prepares aids and discharge. Enhanced recovery combines multimodal analgesia, early oral intake and mobilisation, thromboprophylaxis and early recognition of bleeding, infection, dislocation, neurovascular injury and urinary or cognitive complications.
Referral does not guarantee operation, and deferral should be a shared, revisable decision. If benefit is uncertain because pain source is mixed, use targeted assessment rather than exploratory arthroplasty. If risk currently outweighs benefit, write the exact remediable factors, support and review date. Continue exercise, walking aids and safe analgesia during optimisation or waiting. Deterioration, falls, new rest pain or acute swelling requires reassessment. Outcome review includes pain, function, complications and whether the person's stated goals were achieved.
Key points
- Refer when joint pain, stiffness, deformity or reduced function substantially affects quality of life and non-surgical management is ineffective or unsuitable.
- Use clinical assessment and shared decision-making; do not require a numerical severity score and do not exclude referral solely because of age, sex, smoking, comorbidity, overweight or obesity.
- Confirm that symptoms arise from the target joint and that reasonable education, exercise, weight support and safe medication have been offered or are unsuitable; this is not a rigid checklist that prolongs avoidable disability.
- Discuss expected pain and function benefit, persistent symptoms, recovery demands, implant survival, infection, thrombosis, dislocation or instability, fracture, nerve injury, loosening and revision.
- Use standard radiographs for anatomy and templating; radiographic severity supports planning but does not override the person's symptoms and goals.
- For isolated medial-compartment knee osteoarthritis suitable for either operation, NICE recommends giving people a choice of partial or total knee replacement after discussing both outcomes and risks.
- Optimise anaemia, diabetes, smoking, nutrition, weight, skin, dental and medication risks collaboratively and make the required target, support and review date explicit.
- Prehabilitation, discharge planning and expectation alignment begin before surgery; an informed decision can also be to defer replacement while maintaining active non-operative care.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Substantial restriction of sleep, mobility, self-care, work or valued activity despite ineffective or unsuitable non-operative treatment supports referral.
Symptoms, examination and radiographs should align sufficiently to avoid replacing a joint when spine, vascular or regional disease is dominant.
End-stage painful hip disease with restricted movement and compatible radiographs supports total replacement after risk and goal discussion.
Painful compartment disease, deformity and functional loss are assessed with alignment, stability and weight-bearing views to select total or partial options.
Active infection, unstable medical disease, ulceration or untreated anaemia triggers a named optimisation plan rather than automatic permanent exclusion.
Diffuse pain, minimal joint findings or expectations of complete normality need diagnostic and expectation work before listing.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Clinical indication assessmentFirst step - Why
- Measure symptom impact, goals and response or unsuitability of non-operative care.
- Interpretation and limitations
- Use narrative function and shared judgement rather than a mandatory numerical threshold.
- 02
Weight-bearing radiographs - Why
- Confirm compartment anatomy, deformity and templating information.
- Interpretation and limitations
- Structural severity informs operation but should not be used alone to accept or reject a person.
- 03
Targeted infection screen - Why
- Exclude active joint or remote infection when suggested.
- Interpretation and limitations
- Use examination, CRP or ESR and aspiration through the appropriate pathway; do not screen every asymptomatic joint indiscriminately.
- 04
Preoperative blood and cardiac assessment - Why
- Identify anaemia, renal dysfunction, diabetes and anaesthetic risk.
- Interpretation and limitations
- Results should lead to proportionate optimisation and shared risk, not unexplained cancellation.
- 05
Perfusion and skin review - Why
- Assess wound-healing capacity and infection route.
- Interpretation and limitations
- Active ulceration, severe arterial disease or skin infection needs treatment and coordinated timing.
- 06
Additional imaging selectively - Why
- Resolve occult pathology, severe deformity or mixed pain source.
- Interpretation and limitations
- CT, MRI or diagnostic injection answers a defined question and is not routine simply because surgery is discussed.
04Treatment approachPreparation, options, escalation and aftercare.
01ReferBase referral on impactFirst stepSymptoms substantially affect quality of life and evidence-based non-operative care is ineffective or unsuitable.+
- 1Confirm the likely pain-generating joint and document function, goals and previous treatment.
- 2Discuss replacement and continued non-operative options and refer without a numerical-score or demographic barrier.
- 3AlternativeObtain planning radiographs through the surgical pathway and identify urgent alternative diagnoses.
- 4Continue active symptom and fitness management while assessment proceeds.
02OptimiseReduce modifiable risk with ownershipThe person may benefit, but anaemia, diabetes, smoking, nutrition, skin, medicines or fitness can be improved.+
- 1Quantify the individual risk and agree a realistic target rather than imposing an unexplained threshold.
- 2Provide the service, named clinician and review date needed to achieve it.
- 3Plan anticoagulant, diabetes and analgesic changes and home and rehabilitation support.
- 4Revisit the benefit-risk decision promptly instead of allowing indefinite optimisation limbo.
03ChooseMatch operation to anatomy and valuesDiagnosis, risk and expected benefit are sufficiently clear for consent and implant selection.+
- 1Discuss total hip or knee replacement benefits, persistent symptoms, complications, implant survival and revision.
- 2For suitable isolated medial knee disease, offer balanced choice between partial and total replacement.
- 3Record the person's priorities, approach and implant reasoning and perioperative prophylaxis plans.
- 4Deliver enhanced recovery, early mobilisation and structured surveillance for early complications.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Perioperative antimicrobial prophylaxis
Give the hospital's current primary hip or knee replacement prophylactic antibiotic at the full weight-, allergy- and renal-adjusted dose within the protocol time before incision, record administration, and repeat intra-operatively only when the specific protocol duration or blood-loss criterion is met.Use the exact local formulary because MRSA status and immediate beta-lactam allergy change selection; therapeutic postoperative antibiotics are not routine prophylaxis and unexplained extension increases adverse effects and resistance.
Venous-thromboembolism prophylaxis
Prescribe the exact mechanical and pharmacological regimen from the current hospital elective-arthroplasty and NICE pathway, starting and continuing at the procedure-specific times after balancing thrombosis, neuraxial and bleeding risk.Agent, dose and duration depend on hip versus knee surgery, renal function, body weight, bleeding, anaesthetic technique and long-term anticoagulation; document interruption and restart rather than duplicating anticoagulants.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Before surgery, revisit pain source, goals, consent and any change in benefit-risk balance.
- Track anaemia, glucose, renal function, nutrition, smoking support, skin and infection issues through optimisation.
- Document perioperative antimicrobial and thromboprophylaxis timing and reconcile anticoagulant restart.
- After surgery, monitor wound, fever, neurovascular status, haemoglobin, pain, mobility and dislocation or instability signs.
- Measure recovery against the person's walking, sleep, work and self-care goals and address persistent pain early.
- Follow implant and revision concerns through the appropriate arthroplasty and registry pathway.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Referral is not a radiographic prize
Quality-of-life impact and failed or unsuitable care drive referral; imaging supports anatomy and planning.
Optimisation needs a clock
A modifiable risk plan without support, ownership and a review date can become indefinite denial of treatment.
No operation is a valid choice
Shared decisions include continued non-operative care when expected benefit does not outweigh recovery and risk.
Partial knee replacement is not lesser
For suitable isolated medial disease, partial and total replacement have different advantages and both require balanced consent.
Persistent pain belongs in consent
A technically successful implant may not abolish pain, especially when pain sources and expectations were poorly aligned.
Prehabilitation starts discharge
Strength, aids, home support and medicine plans prepared before surgery shorten avoidable postoperative barriers.
08Common pitfallsFrequent interpretation and management errors.
- 01
Using a numerical score or X-ray grade as the sole gate to referral.
- 02
Refusing assessment solely because of BMI, age, smoking or comorbidity.
- 03
Listing before confirming that the target joint is the dominant pain source.
- 04
Describing only infection and thrombosis while omitting persistent pain, stiffness, instability and revision from consent.
- 05
Calling risk optimisation without providing support or a time for reassessment.
- 06
Stopping exercise and safe symptom control while the person waits for surgery.