Pre-operative education for hip or knee replacement
Editorial Group: Cochrane Musculoskeletal Group
Published Online: 8 OCT 2008
Assessed as up-to-date: 22 NOV 2003
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
McDonald S, Hetrick SE, Green S. Pre-operative education for hip or knee replacement. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003526. DOI: 10.1002/14651858.CD003526.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 8 OCT 2008
Hip or knee replacement is a major surgical procedure which can be physically and psychologically stressful for patients. It is hypothesised that education before surgery reduces anxiety and enhances postoperative outcomes.
To determine whether preoperative education improves postoperative outcomes (anxiety, pain, mobility, length of stay and the incidence of deep vein thrombosis) in patients undergoing hip or knee replacement surgery.
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1980 to June 2002), CINAHL, PsycINFO and PEDro until May 2003. We handsearched the Australian Journal of Physiotherapy (1954 to 2001) and reviewed the reference lists.
Randomised trials of preoperative education (verbal, written or audiovisual) delivered by a health professional within six weeks of surgery to patients undergoing hip or knee replacement.
Data collection and analysis
Two reviewers independently assessed study quality and extracted data. Continuous outcomes were combined using weighted mean difference (WMD) and 95% confidence intervals (CI).
Nine studies involving 782 participants met the inclusion criteria. Four studies involving 365 participants assessed length of hospital stay (days) but detected no significant difference between preoperative education and usual care (WMD -0.97; 95% CI -2.67 to 0.73). However, one study of 133 participants with more complex needs, indicated that individually tailored programmes of education and support were beneficial in reducing length of stay. The four studies reporting length of stay did not find any significant effect of preoperative education on days to standing and days to climb stairs. Three trials found preoperative education was beneficial in reducing preoperative anxiety (WMD -5.64; -7.45 to -3.82) on a scale of 0 to 100. No significant effect on postoperative anxiety was detected either on the day following surgery , or at discharge. None of the five studies reporting postoperative pain detected any difference between the groups.
There is little evidence to support the use of pre-operative education over and above standard care to improve postoperative outcomes in patients undergoing hip or knee replacement surgery, especially with respect to pain, functioning and length of hospital stay. There is evidence that preoperative education has a modest beneficial effect on preoperative anxiety. There may also be beneficial effects when preoperative education is tailored according to anxiety, or targeted at those most in need of support (e.g. those who are particularly disabled, or have limited social support structures).
Plain language summary
Pre-operative education for hip or knee replacement
How well does information and education given before hip or knee replacement surgery improve recovery?
To answer this question, scientists analysed 9 studies testing over 750 people, 58 to 71 years old. These people had hip or knee replacement surgery because of arthritis, an accident or another reason. Some people received written information, discussed the surgery with a health professional, watched a video or received no information. These studies provide the best evidence we have today.
Why might education before surgery help with recovery?
Often when other treatments do not work to provide relief in diseases such as osteoarthritis, hip or knee replacement surgery may be necessary. But, surgery can be stressful - emotionally and physically. It is thought that people who receive information and are educated about their surgery and recovery before their surgery, will be less anxious, be able to handle pain better and not have to stay in hospital long.
Does it improve recovery?
Studies showed that people with or without education before surgery had about the same amount of pain, were just as satisfied with their surgery, started walking and climbing stairs at about the same time after surgery and stayed in hospital for about the same amount of time. One study did show that in people who could not move well and didn't have support, the ones that had education before surgery did not stay in hospital as long as those who did not have education.
Three studies showed that people with education before surgery were less anxious before surgery, but two other studies found that anxiety was the same. Four studies showed that people with or without education before surgery had about the same amount of anxiety after surgery.
One study showed that people with education before surgery had fewer complications, but another study showed people had about the same amount. Whether it improved the risk of blood clots or Deep Vein Thrombosis (DVT) was not tested.
What is the bottom line?
There is "Silver" level evidence that education before surgery does not seem to decrease pain, improve function or decrease the number of days in hospital after surgery. But education before surgery may decrease anxiety before surgery. Education and information that is individually geared to a person and given before surgery may improve recovery in people who need support or do not move well.
Future research should find out which people need education before surgery, what type of education (pamphlets, videos, etc.) works best and whether education before and after surgery is better.