Intended for healthcare professionals

Practice Practice Pointer

Primary care management of postoperative shoulder, hip, and knee arthroplasty

BMJ 2017; 359 doi: (Published 18 October 2017) Cite this as: BMJ 2017;359:j4431
cropped thumbnail of infographic

Infographic available

A visual summary of management and restrictions for people following joint replacement surgery.

Re: Primary care management of postoperative shoulder, hip, and knee arthroplasty

I was amazed to read that enhanced recovery programmes after hip arthroplasty are now “fully implemented” in the NHS (1).
This was certainly not my experience when I had a displaced neck of femur fracture eleven months ago. I saw from my ‘neighbours’ in the ward that my problems were not a personal one-off.
I don’t think, either, that the problems I saw are restricted to the central London hospital I was treated in. Perry et al reviewed data from the UK’s National Hip Fracture Database in 2016. They found that only 32% of adults with a displaced intracapsular fracture of the femoral neck who were eligible under NICE criteria had a total hip replacement (THA). Of those who underwent THA, 42% did not meet the NICE eligibility criteria.(2) As the accompanying editorial commented, “the degree of non-adherence to [the] guidance was remarkable.” (3)
White, writing less than two months before my operation, reported that, even in trials, “current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients.”(4)
Even if the surgery can be got right, this ‘practice pointer’ was aimed at primary care, but did not mention osteoporosis - I had to insist on a DEXA scan for myself before I could get the appropriate medication - or other co-morbidities, when these are surely likely to affect, and be affected by, the short and long-term outcomes of major surgery. I felt there was an especial difficulty with, and for, the large number of patients with some degree of dementia. Their distress was evident when they cried out through most nights, increasing exhaustion and so deconditioning for all of the inpatients.
And it’s really important to get hip fractures right. Just the hospital costs have been estimated at £1131 million a year in the UK. Incidence is expected to rise by 32 % in 2025: with hospital costs expected to increase to £1493 million.(5)

1. Aresti N, Kassam J and Kutty S. Primary care management of postoperative shoulder, hip, and knee arthroplasty. BMJ 2017;359:j4431
2. Perry DC. Inequalities in use of total hip arthroplasty for hip fracture: population based study BMJ 2016;353:i2021
3. Chaudhry H. Total hip arthroplasty after hip fracture BMJ 2016;353:i2217
4. Huxley C. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur. Bone Joint Res. 2016 Oct; 5(10): 444–452.
5. Leal J et al. Impact of hip fracture on hospital care costs: a population-based study
Osteoporos Int. 2016; 27: 549–558.

Competing interests: For my THA, I begged to be given a spinal anaesthetic. After it was made clear to me that this was unusual, the anaesthetist failed to achieve a spinal block, so I had to have a GA. 10 hours with only water in ‘recovery’ because of bed shortages did not help my post op nutrition. Catheterisation was routine and, after the catheter bag was placed above my bladder, I had bypass incontinence and a UTI. The severe shooting pains through the nights for several months after I was discharged, made the exhaustion and inevitable deconditioning worse. I had to wait a month before an OT gave me any advice about washing at home other than telling me not to get in a bath or shower, and not to sit on the stool they had given me. The article doesn’t mention the constipation with opioid analgesia - this can only be ignored by someone who has not suffered from it. I was told that senna would 'soften' my stools, but was not surprised when this did not happen. I was also not surprised that the ward staff had ‘lost’ the iPad for patient feedback on my discharge: I told one of the night nurses when she gave me someone else’s medication, and it didnt go down well at all. Especially when she couldnt find some of my medication, and I presumed she’d given that to another patient. She had clearly thought more deeply when she came back at, I think it was 2 or 3 am, to insist on shaking my hand and telling me that we were ‘friends after all’. I’m still not as fit as I was before my fracture.

21 October 2017
Caroline Mawer
Ex-GP, and NOF Patient