This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Many people do not need a routine follow-up appointment after hip or knee replacement surgery. Research found that most people who had first replacement surgery using UK-recommended replacement joints can safely stop routine follow-up in the 1- to 10-year period after surgery.
People rarely develop problems after hip replacements or knee replacements. Services struggle to follow-up everyone after surgery, and many hospitals have either reduced or stopped follow-ups altogether. But there is little research into how safe this practice is.
The team gathered information from previous research, national datasets, and from people with lived experience of joint replacements. They worked with a panel of surgeons, GPs and people with joint replacements to interpret the data.
Together, they concluded that people with replacements recommended by the National Institute for Health and Care Excellence (NICE) were unlikely to need follow-up within 10 years of surgery, as long as they were able to self-refer to rapid-access specialist orthopaedic care (bypassing their GP) if they develop symptoms.
The issue: Is routine follow-up necessary?
Joint replacements may be offered to people with such severe hip or knee pain that everyday tasks are difficult or impossible. This surgery usually improves people’s quality of life and mobility. Rarely, people can develop problems afterwards, such as pain or difficulty doing everyday activities. This might signal a problem with the replacement; it could have shifted or caused a fracture in the surrounding bone.
Follow-up appointments are intended to find problems early. But offering these appointments to everyone after surgery is expensive. Many hospitals have reduced or stopped routine follow-ups and the consequences to patients are not known.
Researchers explored whether it is safe to stop follow-up appointments after surgery. They looked at when people are most likely to develop problems, and what impact early follow-up has on when people have revision surgery.
Analysis of national datasets including more than 350,000 people showed that few knee replacements (5%) or hip replacements (3-6%) needed revision. Another analysis (of primary care data on 10,000 people with replacement joints) indicated that those who attended routine follow-up appointments were more likely to have revision surgery (than those who had no follow-up).
The team discussed their results with a panel of surgeons, GPs, and people with a joint replacement.
They considered people who:
- had straightforward surgery (first surgery, for example)
- received a NICE-recommended joint
- have rapid access to an orthopaedic review if they develop symptoms.
Together, they recommended that, for this group:
- routine follow-up is not needed in the 1- to 10-year period after surgery
- 10 years after surgery, people should have X-rays to assess the joint, and a clinical assessment including questionnaires on pain and mobility
- the results of the 10-year assessment should influence later follow-ups.
People with complications or who have received a different type of replacement may need earlier follow-up.
Why is this important?
This study suggests that most people who have a joint replacement do not need follow-up in the 1- to 10-year period after their surgery.
The group interpreting the findings included people with lived experience to make sure that the recommendations were relevant to them. The researchers hope clinicians and patients alike will find the results reassuring. They provide evidence to support the changes they may have seen in practice.
Up to half (30-50%) of the replacement joints used in surgery are not recommended by UK guidance, which may be due to surgeon’s preference. The researchers’ recommendations only apply to replacements recommended in NICE guidance.
The researchers say that people need to know what to look out for after their surgery. They should make an appointment with their orthopaedic service if they have worsening pain, or any other red flags (such as difficulty with walking).
People who attended routine follow-up appointments were more likely to have revision surgery than those who had no follow-up, in this study. The researchers suggest that people who have no pain or discomfort may be less likely to attend follow-up appointments.
The recommendations depend on rapid access to an orthopaedic service without having to be referred by the GP. Further research could explore how best to deliver such a service, and whether virtual clinics could be more convenient and less costly than face-to-face follow-ups.
Previous studies have shown that people from more deprived backgrounds are less likely to have revision surgery for knee replacements. One concern is that reduced follow-up appointments could widen health inequalities. Further research could identify groups of people who are more likely to need revision surgery, so that they could receive targeted follow-up.
There are few data beyond 10 years. More research 20 to 30 years after a joint replacement could be relevant to people having surgeries at younger ages.
You may be interested to read
This Alert is based on: Kingsbury SR, and others. Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: the UK SAFE evidence synthesis and recommendations. Health and Social Care Delivery Research 2022;10.
Data on hip replacements from the same study: Smith LK, and others. UK post arthroplasty follow-up recommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after hip replacement? Retrospective cohort study. BMJ Open 2022;12:e050877.
Data on knee replacements from the same study: Smith LK, and others. UK post arthroplasty follow-up recommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after knee replacement? BMJ Open 2022;12:e046900.
Another publication by the same team: Pinedo-Villanueva R, and others. Association between outpatient follow-up and incidence of revision after knee and hip replacements: a population-based cohort study. BMC Musculoskeletal Disorders 2023;24:106.
A publication by the same team on the UK SAFE recommendations: Kingsbury SR, and others. Mid-to late-term follow-up of primary hip and knee arthroplasty: the UK SAFE evidence-based recommendations. Bone and Joint Open 2023;4:72-78.
UK guidance on hip replacement surgery: National Institute for Health and Clinical Excellence. Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip.
Funding: This project was funded by the NIHR Health and Social Care Delivery Research programme.
Conflicts of Interest: Some of the authors declared conflicts of interest. Full details can be found on the original research.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.