Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Total hip and knee replacement indications
Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Elective replacement pauses when an active threat is present
Active joint or remote infection, uncontrolled medical instability, acute fracture, severe skin compromise or an undiagnosed rapidly destructive joint changes the timing and sometimes the operation.
Action: Identify and treat sepsis, fracture, vascular or medical instability first; investigate unexplained rapid destruction and optimise active infection, skin, diabetes, anaemia and medicines through a named pathway while maintaining proportionate access to arthroplasty assessment.
Synopsis
Make referral and operative decisions from quality-of-life impact, failed or unsuitable non-operative care, anatomy, goals and individual risk; explain implant choices and optimisation without inequitable numerical or demographic barriers.
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.
Key red flags
A hot joint, draining sinus, persistent wound or unexplained raised inflammatory markers requires infection investigation before primary implantation.
Rapid femoral-head or tibiofemoral collapse, night pain, mass or constitutional symptoms requires malignancy, infection and osteonecrosis assessment rather than routine listing.
Critical cardiac, respiratory or metabolic instability requires coordinated optimisation, but should produce a documented plan rather than indefinite removal from care.
Poor pulses, active ulceration or major skin disease near the operative limb requires vascular or dermatological treatment to protect wound healing and infection risk.
Investigation priorities
01
Clinical indication assessmentFirst step
Measure symptom impact, goals and response or unsuitability of non-operative care.
Management branches
ReferBase referral on impact
Symptoms substantially affect quality of life and evidence-based non-operative care is ineffective or unsuitable.
Confirm the likely pain-generating joint and document function, goals and previous treatment.
Discuss replacement and continued non-operative options and refer without a numerical-score or demographic barrier.
Obtain planning radiographs through the surgical pathway and identify urgent alternative diagnoses.
Continue active symptom and fitness management while assessment proceeds.
Key medicines
Perioperative antimicrobial prophylaxisGive 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 prophylaxisPrescribe 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.
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.