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Preoperative education for hip or knee replacement

  1. Steve McDonald1,*,
  2. Matthew J Page1,
  3. Katherine Beringer2,
  4. Jason Wasiak3,
  5. Andrew Sprowson4

Editorial Group: Cochrane Musculoskeletal Group

Published Online: 13 MAY 2014

Assessed as up-to-date: 31 MAY 2013

DOI: 10.1002/14651858.CD003526.pub3


How to Cite

McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD003526. DOI: 10.1002/14651858.CD003526.pub3.

Author Information

  1. 1

    Monash University, School of Public Health & Preventive Medicine, Melbourne, Victoria, Australia

  2. 2

    University of Melbourne, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia

  3. 3

    The Epworth Hospital, Richmond, Australia

  4. 4

    University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, UK

*Steve McDonald, School of Public Health & Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. Steve.McDonald@monash.edu.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 13 MAY 2014

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

 
Summary of findings for the main comparison. Preoperative education versus usual care for hip replacement

Preoperative education versus usual care for hip replacement

Patient or population: hip replacement
Settings: inpatient and outpatient
Intervention: preoperative education versus usual care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlPreoperative education versus usual care

Pain
Visual analogue scale. Scale from: 0 to 10 (lower scores indicate less pain).
Follow-up: up to 3 months
The mean pain in the control groups was
3.11
The mean pain in the intervention groups was
0.34 lower
(0.94 lower to 0.26 higher)2
-227
(3 studies)
⊕⊝⊝⊝
low3,4
Absolute risk difference -3% (95% CI -9% to 3%); relative per cent change -11% (95% CI -30% to 8%).

NNTB NA

SMD -0.17 (95% CI -0.47 to 0.13)

Function
WOMAC function (Likert scale version). Scale from: 0 to 68 (lower scores indicate better function).
Follow-up: from 3 to 24 months
The mean function in the control groups was
18.45
The mean function in the intervention groups was
4.84 lower
(10.23 lower to 0.66 higher)6
-177
(4 studies)
⊕⊝⊝⊝
low3,4
Absolute risk difference -7% (95% CI -15% to 1%); relative per cent change -26% (95% CI -56% to 4%).

NNTB NA

SMD -0.44 (95% CI -0.93 to 0.06).

Health-related quality of lifeSee commentSee commentNot estimable-See comment2 trials reported measuring health-related quality of life using the Nottingham Health Profile, but neither reported data suitable for analysis.

Global assessment of treatment successSee commentSee commentNot estimable-See commentNo trial reported measuring global assessment of treatment success.

Postoperative anxiety
Spielberger State-Trait Anxiety Index. Scale from: 20 to 80 (lower scores indicated less anxiety).
Follow-up: mean 6 weeks
The mean postoperative anxiety in the control groups was
32.167
The mean postoperative anxiety in the intervention groups was
2.28 lower
(5.68 lower to 1.12 higher)
-264
(3 studies)
⊕⊕⊝⊝
low4,8
Absolute risk difference -4% (95% CI -10% to 2%); relative per cent change -7% (95% CI -18% to 4%).

Total number of serious adverse events (infection, thrombosis, other serious adverse events)Study populationRR 0.79 (95% CI 0.19 to 3.21)150 (2 studies)⊕⊝⊝⊝
very low3,4,9
Absolute risk difference -10% fewer adverse events with preoperative education (-46% fewer to 27% more); relative per cent change -21% (95% CI -81% to 221%).

227 per 1000179 per 1000
(43 to 728)

Re-operation rateSee commentSee commentNot estimable-See commentNo trial reported measuring re-operation rate.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; NA: not available; NNTB: number needed to treat for an additional beneficial outcome; RR: risk ratio; SMD: standardised mean difference; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Mean visual analogue scale (VAS) (0-10) pain score at 3 months in the usual care group reported in McGregor 2004 was used as the assumed control group risk.
2 To convert SMD to mean difference (MD), the pooled baseline standard deviation (SD) in McGregor 2004 (SD = 2) was multiplied by the SMDs and 95% CIs to convert values to a 0- to 10-point VAS.
3 In all but 1 randomised controlled trial, allocation concealment was unclear, and no trial blinded participants.
4 95% CIs of the MD are wide.
5 Mean WOMAC function score at 3 months in the usual care group reported in McGregor 2004 was used as the assumed control group risk.
6 To convert SMD to MD, the pooled baseline SD in McGregor 2004 (SD = 11) was multiplied by the SMDs and 95% CIs to convert values to the 0- to 68-point WOMAC function (Likert scale version) score.
7 Control group mean calculated as the mean of Butler 1996 and Doering 2000 (which both reported end of treatment values; Giraudet 2003 was excluded from this estimation as only change scores were reported).
8 Only 1 of the 3 included RCTs had unclear allocation concealment (the remaining 2 RCTs had clear allocation concealment), though no RCT blinded participants.
9 Heterogeneity was very high (I2 = 85%).

 Summary of findings 2 Preoperative education versus usual care for knee replacement

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

Hip replacement and knee replacement are commonly performed surgical procedures. Although global data are not readily available, in the US alone, over 230,000 hip and 540,000 knee replacements were carried out in 2006, up from 124,000 and 209,000, respectively, in 1994 (DeFrances 2008). Other developed economies have witnessed similar increases. In England and Wales, for example, over 89,000 hip and over 93,000 knee procedures were carried out in 2012 (NJR 2013). This trend is likely to continue as populations age and surgical techniques become more commonplace.

 

Description of the condition

The main indicators for hip or knee replacement are persistent pain or limitation of function (or both) that cannot be managed by conservative treatment alone (Brady 2000). The leading cause of such pain is osteoarthritis but may also include rheumatoid arthritis, trauma, congenital abnormalities, dysplasia and osteochondritic disease. In the absence of treatments that provide a cure for conditions such as osteoarthritis, management is directed primarily towards relieving pain and reducing functional limitation. Joint replacement is one surgical option when medical treatment provides inadequate symptom relief (Creamer 1998).

 

Description of the intervention

Preoperative education refers to any educational intervention delivered before surgery that aims to improve patients' knowledge, perspectives, health behaviours and health outcomes (Hathaway 1986; Oshodi 2007a; Oshodi 2007b; Shuldham 1999). The content of preoperative education varies across settings, but often comprises discussion of presurgical procedures, the surgical procedure, postoperative care, potential stressful scenarios associated with surgery, potential complications, pain management and movements to avoid post-surgery (Louw 2013). Education is often provided by physiotherapists, nurses or members of multidisciplinary teams, including psychologists (Johansson 2005; Louw 2013). The format of education ranges from one-to-one verbal communication, group sessions, or video or booklet with no verbal communication (Hathaway 1986; Louw 2013; Shuldham 1999).

 

How the intervention might work

Hip or knee replacement is a major surgical procedure that requires inpatient physiotherapy and outpatient rehabilitation following a stay in hospital (Palmer 1999). These surgical procedures can be stressful, affecting the person both physically and psychologically (Gammon 1996b). Perception of pain and anxiety is often heightened when people feel a lack of control over their situation, and is very common around surgery (Bastian 2002). If a person is unduly anxious, physical recovery and well-being may be affected, prolonging hospital stay and increasing the cost of care. By ensuring full understanding of the operation and postoperative routines, and promoting physical recovery and psychological well-being through preparatory information, it is hypothesised that people will be less anxious, have a shorter hospital stay and be better able to cope with postoperative pain (biopsychosocial approach) (Louw 2013; Shuldham 1999). In addition, educating people about postoperative care routines may reduce the incidence of postoperative complications, the most serious of which is pulmonary embolism resulting from deep vein thrombosis (Brady 2000). A key component of preoperative education is to provide the person with a greater understanding of potential complications, such as dislocation in hip replacement, and recognition of complications, such as deep vein thrombosis. It is also important to emphasise the most common post-surgical side effects (e.g. swelling after knee replacement around the knee and in the ankle).

 

Why it is important to do this review

Following the publication of the original version of this review (McDonald 2004), plus another systematic review published shortly afterwards (Johansson 2005), the evidence base for preoperative education has grown. The most recent systematic review of preoperative education for hip or knee replacement by Louw 2013 included trials published up to February 2011. The review authors chose not to synthesise the results in a meta-analysis, though reported that of the 13 included trials, only one had a positive effect on postoperative pain while the remaining trials identified no significant difference between groups on this outcome. Postoperative pain was the only outcome of interest in the Louw 2013 systematic review. Therefore, an up-to-date systematic review of the efficacy and safety of preoperative education on other outcomes (e.g. function, health-related quality of life, adverse events) is necessary.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

To determine whether preoperative education in people undergoing total hip replacement or total knee replacement improves postoperative outcomes with respect to pain, function, health-related quality of life, anxiety, length of hospital stay and the incidence of adverse events (e.g. deep vein thrombosis).

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials (RCT) or quasi-randomised trials comparing educational interventions given preoperatively to people undergoing total hip or total knee replacement surgery.

 

Types of participants

People undergoing planned total hip or total knee replacement. We originally planned to include only trials of people undergoing surgery for osteoarthritis or rheumatoid arthritis (or where such people accounted for at least 90% of the entire trial population) to avoid clinical heterogeneity. However, few trials reported these data so we included all trials of people undergoing planned hip or knee replacement surgery.

 

Types of interventions

Any preoperative education regarding the surgery and its postoperative course delivered by a health professional within six weeks of surgery. Education could be given verbally or in any written or audiovisual form, and could include preoperative instruction of postoperative exercise routines.

All comparators were considered, although we excluded trials comparing various methods of delivery of preoperative education in the absence of a control group receiving standard or routine care. We also excluded trials that incorporated some form of postoperative intervention (e.g. use of reminder systems to perform exercises).

 

Types of outcome measures

 

Major outcomes

The major outcomes were:

  • pain measured by visual analogue scales (VAS), numerical or categorical rating scales; and
  • function. Where trialists reported outcome data for more than one function scale, we extracted data on the scale that was highest on the following list: 1. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function; 2. Harris Hip Score; 3. Oxford Hip/Knee Score; 4. 36-item Short Form (SF-36) Physical Component Score; 5. Health Assessment Questionnaire; 6. any other function scale;
  • health-related quality of life measured using the SF-36 or Nottingham Health Profile;
  • global assessment of treatment success as defined by the trialists (e.g. proportion of participants with significant overall improvement);
  • postoperative anxiety measured using the State-Trait Anxiety Inventory or Hospital Anxiety and Depression Scale;
  • number of participants experiencing any serious adverse events (e.g. infection, deep vein thrombosis, other serious adverse events);
  • re-operation rate.

 

Minor outcomes

Other outcomes were:

  • preoperative anxiety measured using the State-Trait Anxiety Inventory or Hospital Anxiety and Depression Scale;
  • length of hospital stay;
  • mobility (number of days to stand or walk);
  • range of motion.

 

Time points

For this update of the review, we did not pre-specify a primary time point. We extracted data from all time points and performed separate analyses (forest plots not shown) to include all available studies per outcome per time point. There did not appear to be an effect of time on any outcome, so we chose to include only the latest time point available per outcome.

 

Search methods for identification of studies

 

Electronic searches

We searched the following electronic databases, unrestricted by date or language, up to 31 May 2013:

  • Cochrane Central Register of Controlled Trials (Issue 5, 2013);
  • MEDLINE (Ovid);
  • EMBASE (Ovid);
  • CINAHL (EBSCO);
  • PsycINFO (Ovid).

We also searched the Physiotherapy Evidence Database (PEDro) in July 2010.

We used specific subject headings and additional text words describing the intervention and participants to identify relevant trials. The complete search strategy for the MEDLINE database is provided in Appendix 1. This strategy was adapted for the other electronic databases as appropriate (Appendix 2; Appendix 3; Appendix 4; Appendix 5).

We searched for ongoing randomised trials and protocols of published trials in the clinical trials register maintained by the US National Institute of Health (www.clinicaltrials.gov) and the Clinical Trial Register at the International Clinical Trials Registry Platform of the World Health Organization (www.who.int/ictrp/en/).

 

Searching other resources

We handsearched the Australian Journal of Physiotherapy (1954 to 2009) and screened the reference lists of retrieved review articles and reports of trials to identify potentially relevant trials.

 

Data collection and analysis

The description below relates to the methods for data collection and analysis applied during the update of this review in 2013. The previous version of this review (published in 2003) followed methods recommended at that time.

 

Selection of studies

Two review authors (SM, KB) independently selected the trials to be included in the review. We retrieved all articles selected by at least one of the review authors for closer examination. We resolved disagreements through discussion or by consulting a third review author (JW).

 

Data extraction and management

Two review authors (SM, KB) independently extracted the following data from the included trials and entered the data in Review Manager 5 (RevMan 2012). The third and fourth review authors (JW, MP) checked the data.

  1. Design, size and location of the trial.
  2. Characteristics of the trial population including age, gender, reason for undergoing surgery and any reported exclusion criteria.
  3. Description of the intervention including the content and format of the preoperative education, the timing and duration of its delivery, and the type of personnel involved.
  4. Methodological characteristics as outlined below in the Assessment of risk of bias in included studies section.
  5. Outcome measures - number of events for dichotomous outcomes, and means and standard deviations for continuous outcomes.

Multiplicity of outcome data is common in RCTs (Page 2013). We used the following a priori decision rules to select which data to extract:

  • where trialists reported both final values and change from baseline values for the same outcome, we extracted final values;
  • where trialists reported both unadjusted and adjusted values for the same outcome, we extracted unadjusted values; and
  • where trialists reported data analysed based on the intention-to-treat (ITT) sample and another sample (e.g. per-protocol, as-treated), we extracted ITT-analysed data.

 

Assessment of risk of bias in included studies

The same two review authors (SM, KB) independently assessed the risk of bias of each included trial and resolved any disagreement through discussion or consultation with the third and fourth review authors (JW, MP). We assessed the following methodological domains, as recommended by The Cochrane Collaboration (Higgins 2011):

  • sequence generation;
  • allocation concealment;
  • blinding of participants, personnel and outcome assessors;
  • incomplete outcome data;
  • selective outcome reporting;
  • other potential threats to validity.

Each of these criteria were explicitly judged as: low risk of bias, high risk of bias or unclear risk of bias (either lack of information or uncertainty over the potential for bias). As part of the updating process, we completed the risk of bias assessment for the nine original included trials.

 

Measures of treatment effect

As far as possible, the analyses were based on ITT data (outcome data provided for every randomised participant) from the individual trials. For each trial, we present continuous outcome data as point estimates with 95% confidence intervals (CI). We presented the results for continuous outcomes as mean differences (MD) if outcomes included in a meta-analysis were measured using the same scale. If outcomes were measured using different scales, we pooled data using standardised mean differences (SMD). We presented the results of dichotomous outcomes as risk ratios (RR).

 

Unit of analysis issues

The unit of analysis was the participant. None of the trials were cluster trials and we did not identify any trials in which participants underwent double knee or double hip replacements.

 

Dealing with missing data

We requested additional trial details and data from trial authors when the data reported were incomplete.

 

Assessment of heterogeneity

We assessed clinical heterogeneity by determining whether participants, interventions, comparators, outcome measures and timing of outcome assessment were similar across the included trials. We quantified statistical heterogeneity across trials using the I2 statistic. We interpreted the I2 statistic using the following as an approximate guide: 0% to 40% might not be important heterogeneity; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent substantial heterogeneity; 75% to 100% may represent considerable heterogeneity (Deeks 2011).

 

Assessment of reporting biases

To assess publication bias, we would have generated funnel plots if at least 10 trials examining the same treatment comparison were included in a meta-analysis (Sterne 2011); however, we identified too few trials to undertake this analysis. To assess outcome reporting bias, we planned to compare the outcomes specified in trial protocols with the outcomes reported in the corresponding trial publications. If trial protocols were unavailable, we compared the outcomes reported in the methods and results sections of the trial publications (Dwan 2011). We generated an Outcome Reporting Bias In Trials (ORBIT) Matrix (ctrc.liv.ac.uk/orbit/) using the ORBIT classification system (Kirkham 2010).

 

Data synthesis

We anticipated substantial clinical heterogeneity between trials, so we used a random-effects model for all meta-analyses.

 

'Summary of findings' table

We collated the main results of the review into 'Summary of findings' tables, which provide key information concerning the quality of evidence and the magnitude and precision of the effect of the interventions (Schünemann 2011a). We included the following outcomes in the 'Summary of findings' tables: pain, function, health-related quality of life, global assessment of treatment success, postoperative anxiety, total adverse events (infection, thrombosis, other serious adverse events) and re-operation rate. For all outcomes, data for the latest time point available were included. Outcomes pooled using SMDs were re-expressed as MDs by multiplying the SMD by a representative control group baseline standard deviation from a trial, using a familiar instrument. The 'Summary of findings' table includes an overall grading of the evidence related to each of the main outcomes, using the GRADE approach (considers study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of a body of evidence for each outcome (Schünemann 2011b).

In addition to the absolute and relative magnitude of effect provided in the 'Summary of findings' table, we have reported the absolute per cent difference, the relative per cent change from baseline, and the number needed-to-treat (NNT) for an additional beneficial outcome (NNTB) or for an additional harmful outcome (NNTH) (the NNT was only provided for outcomes that shows a statistically significant difference).

For dichotomous outcomes, we calculated the absolute risk difference using the risk difference statistic in Review Manager 5 (RevMan 2012) and the result expressed as a percentage; the relative percentage change was calculated as the RR - 1 and was expressed as a percentage; and the NNT from the control group event rate and the RR were determined using the Visual Rx NNT calculator (Cates 2008).

For continuous outcomes, we calculated the absolute risk difference as the MD between intervention and control groups in the original measurement units (divided by the scale), expressed as a percentage; the relative difference was calculated as the absolute change (or MD) divided by the baseline mean of the control group from a representative trial. We used the Wells calculator to obtain the NNTB for continuous measures (available at the Cochrane Musculoskeletal Group (CMSG) Editorial office; musculoskeletal.cochrane.org/). The minimal clinically important difference (MCID) for each outcome was determined for input into the calculator. We assumed an MCID of 1.5 points on a 10-point pain scale (15 points on 100-point scale), and 10 points on a 100-point scale for function or disability (Gummesson 2003) for input into the calculator.

 

Subgroup analysis and investigation of heterogeneity

We did not plan or undertake any subgroup analyses.

 

Sensitivity analysis

We performed a sensitivity analysis to investigate the robustness of the treatment effect for postoperative pain and postoperative function to allocation concealment by removing the trials that reported inadequate or unclear allocation concealment from the meta-analysis to see if this changed the overall treatment effect.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies.

 

Results of the search

The database searches were revised and re-run in both June 2012 and May 2013 to cover the period from 2003 to 2013. Following the process of automatic deduplication, the updated search identified 1309 records. From screening the titles and abstracts of the 1309 records, we excluded 1287 records that were clearly not relevant. Of the 22 potentially eligible full-text reports assessed, we identified nine trials that met our inclusion criteria (see flow chart in Figure 1). Nine excluded trials are listed in the Characteristics of excluded studies table. Three trials are awaiting assessment (Eschalier 2012; Huang 2012; Wilson 2012), and one trial is ongoing (Riddle 2012). The nine new included trials (Beaupre 2004; Giraudet 2003; Gocen 2004; Johansson 2007; McDonald 2004; McGregor 2004; Siggeirsdottir 2005; Sjöling 2003; Vukomanović 2008) were added to the existing nine trials from the previous version (Butler 1996; Clode-Baker 1997; Cooil 1997; Crowe 2003; Daltroy 1998; Doering 2000; Lilja 1998; Santavirta 1994; Wijgman 1994). The earliest trials were published in 1994 and the most recent in 2008. All trials were published in English with the exception of Wijgman 1994, which was published in Dutch.

 FigureFigure 1. Trial flow diagram for the review update (literature searches from 2003 to 2013).

 

Included studies

See Characteristics of included studies table.

 

Design

Seventeen of the included trials were randomised and one was quasi-randomised (Sjöling 2003). Sixteen were two-arm trials, one was a three-arm trial (McDonald 2004), and one was a four-arm trial (Daltroy 1998). One trial used stratification to produce balanced groups according to age (Daltroy 1998), and another used gender, age and socioeconomic status (Cooil 1997).

 

Setting

Trials were set in hospitals and were conducted in North America or Europe; five each in Scandinavia and continental Europe, three each in Canada and the UK, and two in the USA. With the exception of Siggeirsdottir 2005, trials were conducted at a single site.

 

Participants

Thirteen trials involved people undergoing hip replacement (Butler 1996; Clode-Baker 1997; Cooil 1997; Doering 2000; Giraudet 2003; Gocen 2004; Johansson 2007; Lilja 1998; McGregor 2004; Santavirta 1994; Siggeirsdottir 2005; Vukomanović 2008; Wijgman 1994); three involved people undergoing knee replacement (Beaupre 2004; McDonald 2004; Sjöling 2003); and two included people with both hip and knee replacements (Crowe 2003; Daltroy 1998). Overall, the 18 included trials involved 1463 participants (range 26 to 222). The number of people undergoing hip replacement was 1074 (73% of the total). Most participants were women (59%) and the mean age of participants was within the range of 58 to 73 years, with the exception of Gocen 2004.

The inclusion and exclusion criteria varied considerably between the trials. Half of the trials reported age as an inclusion criterion, with none of these explicitly excluding older people. The most commonly stated exclusion criteria were previous hip or knee replacement surgery and difficulties in communicating (reading, writing and language). The patient profile differed most markedly in Crowe 2003 since the inclusion criteria deliberately targeted people with poor functioning, limited social support and existing co-morbidities.

 

Interventions

The nature, content and timing of the preoperative education varied considerably between trials. In four trials, participants received written information in addition to one or more education sessions before admission to hospital (Giraudet 2003; Johansson 2007; McGregor 2004; Siggeirsdottir 2005). Written information alone was provided before admission in one trial (Butler 1996). Santavirta 1994 combined the provision of pre-admission written information with a teaching session on admission that was planned according to the needs of each participant. Sjöling 2003 also provided a teaching session on admission, though in this trial the written information was distributed at the time of the education session rather than before.

Five trials included an audiovisual component. Clode-Baker 1997 sent written information, a video and plastic model bones to participants before admission; Crowe 2003 combined a video presentation with an individually tailored programme of education before admission; McDonald 2004 showed either one of two films to participants in two of the intervention groups after the standard preoperative class; Daltroy 1998 and Doering 2000 showed participants a video after admission in the presence of the investigator. In six trials, information was provided in teaching sessions delivered by physiotherapists or nurses; three of these took place before admission (Beaupre 2004; Gocen 2004; Vukomanović 2008), and three after admission (Cooil 1997; Lilja 1998; Wijgman 1994).

All trials provided some form of standardised information for participants, consisting mainly of printed materials, thus ensuring all participants (including people in the control group) received some information before surgery. Detailed descriptions of the content and methods used to deliver the education interventions are given in  Table 1.

The nature of the intervention and the patient profile differed most markedly in Crowe 2003. In this trial, various interventions tailored to individual needs were offered to participants in addition to educational material. In contrast to all other trials, the inclusion criteria deliberately targeted people with poor functioning, limited social support and existing co-morbidities. Only one other trial incorporated tailoring the intervention (a teaching session) to each participant's specific situation (Santavirta 1994).

 

Outcomes

The outcomes measured varied considerably (see  Table 2), though many trials only partially reported results (e.g. reported the difference between groups as being non-significant, though did not report the summary statistics required for meta-analysis). Of the primary outcomes, 11 trials reported measuring pain, but only five trials reported data in a format suitable for analysis (Beaupre 2004; Doering 2000; Giraudet 2003; McDonald 2004; McGregor 2004), whereas five trials measured and fully reported data for function (Beaupre 2004; Gocen 2004; McGregor 2004; Siggeirsdottir 2005; Vukomanović 2008), and five trials measured adverse events, of which three fully reported outcome data (Beaupre 2004; Giraudet 2003; Siggeirsdottir 2005). The most common fully reported outcomes were length of hospital stay (eight trials: Beaupre 2004; Butler 1996; Crowe 2003; Doering 2000; Giraudet 2003; Siggeirsdottir 2005; Vukomanović 2008; Wijgman 1994), and mobility (days to stand or walk) (six trials: Crowe 2003; Doering 2000; Giraudet 2003; Gocen 2004; Vukomanović 2008; Wijgman 1994).

 

Excluded studies

We excluded trials for the following reasons: information was not specific to hip or knee surgery (Bondy 1999; Mikulaninec 1987); trial was not randomised (Hough 1991; Roach 1995); participants received a combined pre- and postoperative intervention (Gammon 1996a; Pour 2007; Ródenas-Martínez 2008; Wong 1985); trial investigated the effect of preoperative depression on postoperative recovery and was not a randomised trial of preoperative education (Brull 2002); and the trial did not investigate postoperative outcomes (Haslam 2001) (see Characteristics of excluded studies table).

 

Risk of bias in included studies

See Characteristics of included studies table. The results of the risk of bias assessment are also presented graphically in Figure 2 and Figure 3.

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
 FigureFigure 3.

 

Allocation

We assessed three trials as low risk of selection bias having both adequate random sequence generation and allocation concealment (Clode-Baker 1997; Crowe 2003; Giraudet 2003). We assessed three other trials as low risk of selection bias on the basis of adequate allocation concealment even though the method of random sequence generation was not specified (Beaupre 2004; Butler 1996; Siggeirsdottir 2005). We assessed risk of selection bias as unclear in eight trials reported to be randomised since neither the methods of random sequence generation nor treatment allocation were specified (Cooil 1997; Daltroy 1998; Johansson 2007; Lilja 1998; McGregor 2004; Santavirta 1994; Vukomanović 2008; Wijgman 1994). We assessed a further three trials as unclear risk of selection bias despite reporting an adequate method for the random sequence generation because the method of treatment allocation was either not specified (Doering 2000; McDonald 2004), or unclear (Gocen 2004). We assessed one trial as high risk of selection bias as participants were allocated to groups on an alternate basis (Sjöling 2003).

 

Blinding

Blinding was considered by type of outcome (self reported and objective). For self reported outcomes, two trials attempted to blind participants by not informing them of the aim and design of the trial (Lilja 1998), and by obscuring the purpose of the trial during the explanation to participants (Cooil 1997). We rated the remaining 16 trials at high risk of bias because blinding of participants was either not attempted or not described (but since blinding is difficult to achieve with an educational intervention, it was likely not to have been attempted).

Blinding of outcome assessors for the objective outcomes was attempted in eight trials (Beaupre 2004; Cooil 1997; Crowe 2003; Daltroy 1998; Doering 2000; Gocen 2004; Lilja 1998; McDonald 2004), though measures of success of blinding were not provided. It is feasible that participants may have accidentally unblinded assessors by describing a facet of their preoperative care. The remaining 10 trials did not provide any details about the blinding of objective outcomes so we rated them as having unclear risk of bias on this domain.

 

Incomplete outcome data

Incomplete outcome data were not particularly well accounted for. We assessed eight trials as low risk of bias (Beaupre 2004; Daltroy 1998; Giraudet 2003; Gocen 2004; Johansson 2007; Sjöling 2003; Vukomanović 2008; Wijgman 1994). Of these, Beaupre 2004 explained the distribution of, and reasons for, incomplete data and used statistical strategies to compensate for missing values. The remaining seven trials described drop-outs adequately without correcting statistically for missing values. However, we considered the drop-outs were unlikely to have affected the results because the missing values were small and the outcomes were continuous. We rated eight trials as unclear in their reporting of incomplete data either because the amount or reasons for missing data were not explained (Clode-Baker 1997; Cooil 1997; Crowe 2003; Doering 2000; Lilja 1998; McGregor 2004; Santavirta 1994; Siggeirsdottir 2005). We assessed two trials as high risk of bias: Butler 1996 had unexplained missing values in all data (ranging from 2 to 12 participants missing); and McDonald 2004 removed some data post-hoc due to author interpretation.

 

Selective reporting

We rated eight trials at high risk of selective reporting bias because the data necessary to include the trial in a meta-analysis of at least one outcome (e.g. standard deviations) were not reported (Clode-Baker 1997; Daltroy 1998; Gocen 2004; Johansson 2007; Lilja 1998; McGregor 2004; Siggeirsdottir 2005; Sjöling 2003). We rated all remaining trials as unclear risk of bias because trial protocols were unavailable, making it impossible to determine whether additional outcomes were measured but not reported based on the results.

 

Other potential sources of bias

We rated two trials at high risk of other bias. The control group in Crowe 2003 had worse function at baseline, and this baseline imbalance may have biased the results to favour the intervention group. McDonald 2004 reported changing the protocol in order to minimise confounding, but this was done after the initial data analysis (i.e. result-driven modification).

 

Effects of interventions

See:  Summary of findings for the main comparison Preoperative education versus usual care for hip replacement;  Summary of findings 2 Preoperative education versus usual care for knee replacement

Eleven trials presented data in a format suitable for analysis (i.e. number of participants with events or means and standard deviations) (Beaupre 2004; Butler 1996; Crowe 2003; Doering 2000; Giraudet 2003; Gocen 2004; McDonald 2004; McGregor 2004; Siggeirsdottir 2005; Vukomanović 2008; Wijgman 1994). The data from three other trials were reported as medians and ranges and are reported in an additional table (Clode-Baker 1997; Johansson 2007; Sjöling 2003) ( Table 3). The remaining four trials either did not measure any outcomes of interest to the review or partially reported outcome data (Cooil 1997; Daltroy 1998; Lilja 1998; Santavirta 1994). Despite attempts to contact all authors, we were only able to secure additional data for three trials (Butler 1996; Crowe 2003; Doering 2000). Although the trials differed somewhat in the participant characteristics and intervention components, we judged that there was sufficient clinical homogeneity to pool the results using random-effects meta-analyses.

 

Preoperative education for hip replacement versus usual care

See  Summary of findings for the main comparison.

 

Pain

See  Analysis 1.1. Three trials measured useable outcome data for postoperative pain using a visual analogue scale (VAS) at at least one time point (Doering 2000; Giraudet 2003; McGregor 2004). At up to three months postoperatively, pain was lower in participants receiving preoperative education, though the difference was not statistically significant (3 trials, 227 participants, SMD -0.17; 95% CI -0.47 to 0.13; I2 = 20%; this is equivalent to a MD of -0.34 points (95% CI -0.94 to 0.26) on a 10-point scale). Clode-Baker 1997 measured pain using a 6-point ordinal scale and only reported that there was no statistically significant difference between groups on this outcome at the end of the first postoperative week. Daltroy 1998 only reported that pain measured on a 1 to 5 scale was not statistically significantly different between groups four days postoperatively. Gocen 2004 reported measuring pain but reported no results in the publication. Lilja 1998 only reported mean scores for VAS pain and identified no statistically significant difference between groups on day one, two and three postoperatively. Sjöling 2003 reported median (interquartile range (IQR)) data for VAS pain and identified no statistically significant difference between groups on postoperative day one, two and three (see  Table 3). Vukomanović 2008 reported skewed data for VAS pain and identified no statistically significant difference between groups at hospital discharge (see  Table 3).

 

Function

See  Analysis 1.2. Four trials measured postoperative function using either the WOMAC function, Oxford Hip Score, or Harris Hip Score (Gocen 2004; McGregor 2004; Siggeirsdottir 2005; Vukomanović 2008). Participants receiving preoperative education had better function scores compared with people receiving usual care at 3 to 24 months postoperatively (4 trials, 177 participants, SMD -0.44; 95% CI -0.93 to 0.06; I2 = 61%; this is equivalent to a MD of -4.84 points (95% CI -10.23 to 0.66) on the WOMAC Likert (0 to 68) scale). However, participants were not blind to treatment in any of these trials, so self reported function may have been overestimated by participants receiving preoperative education. No other hip replacement trials reported measuring function.

 

Health-related quality of life

Two trials reported measuring health-related quality of life (Clode-Baker 1997; Siggeirsdottir 2005), but neither presented outcome data in a format suitable for inclusion in a meta-analysis. Clode-Baker 1997 reported median (IQR) data for the Nottingham Health Profile and identified no statistically significant difference between groups on this outcome (see  Table 3). Siggeirsdottir 2005 also used the Nottingham Health Profile and reported that the usual care group had lower scores on this outcome, but did not report the statistical significance of the difference.

 

Global assessment of treatment success

Global assessment of treatment success was not assessed in any of the trials included in the review.

 

Postoperative anxiety

See  Analysis 1.3. Three trials measured postoperative anxiety using the Spielberger State-Trait Anxiety Index at different time periods (Butler 1996; Doering 2000; Giraudet 2003). Anxiety was 2.28 points lower (on the 60-point scale) at up to six weeks postoperatively in participants receiving preoperative education, though this difference was not statistically significant (3 trials, 264 participants, MD -2.28; 95% CI -5.68 to 1.12; I2 = 22%). Clode-Baker 1997 reported median (IQR) data for the Hospital Anxiety and Depression Scale postoperatively and identified no statistically significant difference between groups on this outcome (see  Table 3). Daltroy 1998 only reported that anxiety measured on a 1 to 4 scale was not statistically significantly different between groups four days postoperatively. Lilja 1998 only reported mean scores for the Hospital Anxiety and Depression Scale and identified no statistically significant difference between groups on day one, two and three postoperatively.

 

Adverse events

See  Analysis 1.4. Four trials reported measuring adverse events (Giraudet 2003; McGregor 2004; Santavirta 1994; Siggeirsdottir 2005), but only two reported sufficient data to include in a meta-analysis (Giraudet 2003; Siggeirsdottir 2005). The risk of experiencing any serious postoperative complication was reduced by 21% in participants receiving preoperative education, though this effect was not statistically significant (2 trials, 31 participants, RR 0.79; 95% CI 0.19 to 3.21; I2 = 78%). McGregor 2004 reported that some participants reported minor postoperative complications and that these were similar in number between groups, and Santavirta 1994 reported that there was no statistical difference in the number of early complications. No trial referred specifically to incidence of infection or deep vein thrombosis.

 

Re-operation rate

Re-operation rate was not assessed in any of the trials included in the review.

 

Preoperative anxiety

See  Analysis 1.5. Four trials measured preoperative anxiety using the Spielberger State-Trait Anxiety Index (range of scores 20 to 80) (Butler 1996; Crowe 2003; Doering 2000; Giraudet 2003). Preoperative education resulted in preoperative anxiety that was 5.1 points lower (on the 60-point scale) compared with usual care (4 trials, 333 participants, MD -5.10; 95% CI -7.17 to -3.03; I2 = 4%). However, participants were not blind to treatment in any of these trials, so self reported anxiety may have been overestimated by participants receiving preoperative education. Clode-Baker 1997 reported median (IQR) data for the Hospital Anxiety and Depression Scale preoperatively and identified no statistically significant difference between groups on this outcome (see  Table 3). Lilja 1998 only reported mean scores for the Hospital Anxiety and Depression Scale and identified no statistically significant difference between groups preoperatively. Sjöling 2003 only reported that there was no statistically significant difference between groups in state or trait anxiety preoperatively.

 

Length of hospital stay

See  Analysis 1.6. Seven trials measured length of hospital stay (days) (Butler 1996; Crowe 2003; Doering 2000; Giraudet 2003; Siggeirsdottir 2005; Vukomanović 2008; Wijgman 1994). Preoperative education resulted in a non-statistically significant reduction in length of hospital stay by less than one day (7 trials, 487 participants, MD -0.79; 95% CI -1.96 to 0.37; I2 = 82%). Note that the high statistical heterogeneity suggests that this result should be interpreted with caution. Clode-Baker 1997 reported median (IQR) data and Johansson 2007 reported mean values only, and both identified no statistically significant difference between groups on this outcome (see  Table 3). Daltroy 1998; Gocen 2004; and Sjöling 2003 only reported that there were no statistically significant differences between groups in length of hospital stay.

 

Mobility

See  Analysis 1.7. Six trials reported data on mobility (Crowe 2003; Doering 2000; Giraudet 2003; Gocen 2004; Vukomanović 2008; Wijgman 1994). Preoperative education did not result in a statistically significant reduction in days to stand or walk (6 trials, 417 participants, MD -0.12; 95% CI -0.30 to 0.07; I2 = 47%). Clode-Baker 1997 reported median (IQR) data and identified no difference between groups on this outcome (see  Table 3).

 

Range of motion

See  Analysis 1.8. Two trials assessed various measures of hip range of motion (degrees) at up to six weeks postoperatively (Gocen 2004; Vukomanović 2008). None of the differences between groups on any measure of range of motion were clinically or statistically significant (hip abduction: 2 trials, 95 participants, MD -1.09; 95% CI -5.35 to 3.17; I2 = 0%; flexion of the hip with flexed knee: 1 trial, 36 participants, MD 0.75; 95% CI -7.67 to 9.17; flexion of the hip with extended knee: 1 trial, 36 participants, MD -0.25; 95% CI -9.17 to 8.67).

 

Sensitivity analyses

See  Analysis 1.9 and  Analysis 1.10. For the outcome of pain, after removing trials with inadequate or unclear allocation concealment, only one of the trials remained (Giraudet 2003). Similar to the main analysis, there were no statistically significant differences in pain at up to six weeks postoperatively (1 trial, 100 participants, MD -7.00; 95% CI -14.85 to 0.85). For the outcome of function, one of four trials with adequate allocation concealment remained (Siggeirsdottir 2005). This trial found that function was 7 points lower on the Oxford Hip Scale (0-60 scale) in the group receiving preoperative education at six months postoperatively (1 trial, 47 participants, MD -7.00; 95% CI -10.55 to -3.45); however, non-blinded participants receiving preoperative education may have overestimated their self reported function.

 

Preoperative education for knee replacement versus usual care

See  Summary of findings 2.

 

Pain

See  Analysis 2.1. Two trials measured postoperative pain using a VAS at at least one time point (Beaupre 2004; McDonald 2004). Differences between groups on a 100-point scale were small and not statistically significant at two days postoperatively (1 trial, 26 participants, MD -12.20; 95% CI -29.77 to 5.37) or 12 months postoperatively (1 trial, 109 participants, MD 2.00; 95% CI -3.45 to 7.45). We chose not to combine these RCTs in a meta-analysis given the considerable heterogeneity in time points.

 

Function

See  Analysis 2.2. One trial measured postoperative function using the WOMAC function (Beaupre 2004). Participants receiving preoperative education had function scores that were not statistically significantly different from people receiving usual care at 12 months postoperatively on a 100-point scale (1 trial, 109 participants, MD 0; 95% CI -5.63 to 5.63).

 

Health-related quality of life

See  Analysis 2.3. One trial measured health-related quality of life using the SF-36 (Beaupre 2004). At 12 months postoperatively, scores were lower (worse) for the preoperative education group on the Physical Component Score (1 trial, 109 participants, MD -3.00; 95% CI -6.38 to 0.38) and Mental Component Score (1 trial, 109 participants, MD -2.00; 95% CI -5.06 to 1.06), but these differences were not statistically significant.

 

Global assessment of treatment success

Global assessment of treatment success was not assessed in any of the trials included in the review.

 

Postoperative anxiety

Postoperative anxiety was not assessed in any of the trials included in the review.

 

Adverse events

See  Analysis 2.4. One trial measured adverse events (Beaupre 2004). The risk of experiencing any serious postoperative complication was reduced by 31% in participants receiving preoperative education, though this effect was not statistically significant (1 trial, 115 participants, RR 0.69; 95% CI 0.29 to 1.66). Risk ratios for each type of postoperative complication were as follows: deep vein thrombosis (1 trial, 115 participants, RR 0.55; 95% CI 0.14 to 2.08); pulmonary emboli (1 trial, 115 participants, RR 1.09; 95% CI 0.16 to 7.48); and infection (1 trial, 115 participants, RR 0.73; 95% CI 0.13 to 4.19).

 

Re-operation rate

Re-operation rate was not assessed in any of the trials included in the review.

 

Preoperative anxiety

See  Analysis 2.5. One trial measured preoperative anxiety using the Spielberger State-Trait Anxiety Index (range of scores 20 to 80) (Crowe 2003). Preoperative education resulted in preoperative anxiety that was 5.5 points lower in participants undergoing knee replacement, though participants were not blind to treatment, so the preoperative education group may have overestimated their self reported anxiety (1 trial, 68 participants, MD -5.52; 95% CI -8.34 to -2.70).

 

Length of hospital stay

See  Analysis 2.6. Two trials measured length of hospital stay (days) (Beaupre 2004; Crowe 2003). Preoperative education reduced length of stay for participants with knee replacement by 1.86 days (2 trials, 183 participants, MD -1.86; 95% CI -3.40 to -0.32; I2 = 0%). Both trials were at low risk of selection and detection bias.

 

Mobility

See  Analysis 2.7. One trial reported data on mobility (Crowe 2003). Preoperative education resulted in a reduction in days to stand or walk that was not statistically significant (1 trial, 68 participants, MD -1.13; 95% CI -2.82 to 0.56).

 

Range of motion

See  Analysis 2.8. One trial assessed knee flexion and extension (i.e. total range of sagittal knee motion in degrees) (Beaupre 2004). The difference between groups at 12 months postoperatively favoured the preoperative education group but was not statistically significant (1 trial, 109 participants, MD -4.00; 95% CI -10.02 to 2.02).

 

Sensitivity analyses

See  Analysis 2.9 and  Analysis 2.10. For the outcomes postoperative pain and postoperative function, after removing trials with inadequate or unclear allocation concealment, only one trial remained (Beaupre 2004). WOMAC pain scores (0-100 scale) were 2 points higher in the preoperative education group at 12 months postoperatively (1 trial, 109 participants, MD 2.00; 95% CI -3.45 to 7.45), and WOMAC function scores (0-100 scale) were not different between groups at 12 months postoperatively (1 trial, 109 participants, MD 0; 95% CI -5.63 to 5.63). Neither of these differences were statistically significant.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
 

Summary of main results

The results of the 18 trials (1463 participants) suggest that preoperative education may be no better or worse than usual care for several participant-reported outcome measures, including pain, function, health-related quality of life and postoperative anxiety.

Preoperative education was found to reduce preoperative anxiety in people undergoing hip replacement. This is potentially of clinical importance because anxiety is not only an uncomfortable psychological state, but it also interacts with pain and coping, which are thought to influence functional outcomes. Being very anxious before surgery does not necessarily mean a person will have worse outcomes, or find it harder to recover from the procedure, but it may have an effect on a person's ability to understand and retain important information (Bastian 2002; Wallace 1986). However, the results of the meta-analysis of preoperative anxiety should be treated with caution as the effect was small and participants were not blind to treatment.

Length of hospital stay was statistically significantly reduced by almost two days in participants receiving preoperative education for knee replacement, but the corresponding reduction for people receiving education for hip replacement was smaller and non-significant. Along with preoperative education, enhanced recovery or 'fast track' programmes have also been introduced into clinical practice over a similar period (Savaridas 2013). These programmes aim to enhance each component part of the patient pathway, from preoperative education to postoperative rehabilitation. Enhanced recovery programmes represent a biopsychosocial model that aims to address the physical, psychological and social need of the patient. Reduction in length of stay is widespread with such programmes, and is almost certainly related to multiple pathway changes, rather than simply one component. In many of the larger centres, hip and knee replacements are treated by different groups of surgeons, which has led to the development of joint specific pathways, introduced at different times. Traditionally, greater focus has been upon knee replacements, due to the worse patient-reported outcomes, which may explain the differences in length of stay between hip and knee replacement.

For length of stay, established ward routines may also determine when people are mobilised and discharged, and the pressure on need for hospital beds means that people are returning home at the earliest safe opportunity (Clode-Baker 1997). Therefore, it is not surprising that the length of hospital stay is largely unaffected by preoperative education. A person's level of anxiety and knowledge may determine how much time staff spend with them but may not prevent hospital staff mobilising the person on the prescribed day. Differences between the trials regarding length of hospital stay and days to standing or walking may be more of a reflection of when and where these trials were conducted, and the guidelines and protocols in place at the time.

Adverse events such as infection and deep vein thrombosis were lower in participants receiving preoperative education for hip or knee replacement compared with usual care, though differences were not statistically significant (trials would likely have been underpowered to detect differences between groups in adverse events).

 

Overall completeness and applicability of evidence

The findings of this review need to be interpreted after consideration of several factors. Only a small number of trials contributed data to the pooled analyses. The small sample size of many of the trials means that rare but potentially important postoperative complications were less likely to be detected. Only five trials included people undergoing total knee replacement, and thus the results should be applied cautiously to this group of people. Few trials reported suitable data on our patient-important outcomes of interest (particularly pain, function, health-related quality of life, global assessment of treatment success and re-operation rate, the latter two were not reported as an outcome in any of the trials). The included trials more commonly measured surrogate outcomes such length of hospital stay and days to stand or walk.

 

Quality of the evidence

The overall quality of the evidence was low according to the GRADE approach (see  Summary of findings for the main comparison;  Summary of findings 2). We limited the presentation of pain and function to evidence from trials with adequate allocation concealment. For most outcomes, the main reasons for downgrading of evidence were serious concerns about risk of bias due to lack of blinding (and unclear allocation concealment for some trials reporting outcomes other than pain and function), and the imprecision of the effect estimates (reflected in wide 95% CIs that crossed the null value). The lack of participant blinding in the majority of trials is concerning given that many outcomes were self reported, and empirical evidence indicates that unblinded trials with self reported outcomes show exaggerated treatment effects (Savović 2012). An additional concern is that eight trials were rated at high risk of selective reporting bias because the data necessary to include the trial in a meta-analysis of at least one outcome (e.g. standard deviations) were not reported (Clode-Baker 1997; Daltroy 1998; Gocen 2004; Johansson 2007; Lilja 1998; McGregor 2004; Siggeirsdottir 2005; Sjöling 2003). This is concerning given the results of one study that suggests that selective outcome reporting of 'positive' or statistically significant trial results can bias the results and conclusions of systematic reviews (Kirkham 2010).

 

Potential biases in the review process

While our described methods attempted to minimise bias in the selection of trials, collection of published data and analysis for the review, our searches were limited to electronic databases, and, as a result, we have only included published trials. In future updates of this review, we will attempt to identify grey literature, given that empirical evidence suggests that published trials tend to have exaggerated treatment effects compared with unpublished trials (Song 2010). It was also difficult to obtain relevant unpublished data from the authors of included trials. Further, it was difficult to assess selective outcome reporting as we identified no protocols or trial registry entries for the included trials.

 

Agreements and disagreements with other studies or reviews

The results of the current review agree with several other recently published reviews. Louw 2013 included the trials by Beaupre 2004; Clode-Baker 1997; Daltroy 1998; Doering 2000; Giraudet 2003; Gocen 2004; Lilja 1998; McDonald 2004; McGregor 2004; Sjöling 2003; and Vukomanović 2008, and, in agreement with our review, concluded that preoperative education for hip or knee replacement has no statistically significant effect on postoperative pain (which was the only outcome investigated). One systematic review by Wallis 2011 examined the effect of a range of preoperative interventions for hip or knee replacement (exercise and education, exercise alone, manual therapy, cognitive therapy, braces, orthotics, acupuncture); however, trials of education alone were not eligible. Only three trials in the Wallis 2011 review were included in the current review (Beaupre 2004; Gocen 2004; Vukomanović 2008). In one meta-analysis of 'days to stand or walk', which pooled data from Gocen 2004 and Vukomanović 2008, Wallis 2011 concluded that preoperative exercise and education for hip replacement was superior to usual care. However, we reached a more cautious conclusion regarding this outcome because we combined data from these two trials with data from an additional four "education only" trials (Crowe 2003; Doering 2000; Giraudet 2003; Wijgman 1994). Wallis 2011 also included the trial conducted by Ferrara 2008, which was excluded from the current review as the education component of the "exercise plus education" intervention was delivered postoperatively. Finally, one review of randomised trials and non-randomised studies published from 2004 to 2010 and investigating the effect of preoperative education for a range of surgical procedures (e.g. hip replacement, thoracic surgery, cardiac artery by-pass graft surgery) concluded that knowledge about the surgical procedure was the only beneficial outcome of education (Ronco 2012).

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

 

Implications for practice

Our review was unable to establish if preoperative education reduces anxiety or leads to improved surgical outcomes such as improvements in pain and function, or reduced adverse events over and above usual care. However, educating and informing people preoperatively has become such an essential part of patient care that it would be unethical to exclude this from current practice. Indeed, preoperative education is now so embedded within practice around the world that it can be seen as integral to the consent process. Despite the excellent results experienced by a large proportion of people having hip and knee replacements, many people experience ongoing pain, dysfunction and disability. Improving patient outcomes is thus a high priority that increasingly relies on non-surgical factors. Preoperative education may represent a useful adjunct, with low risk of undesirable effects, particularly in certain people (e.g. people with depression, anxiety or unrealistic expectations) who may respond well to preoperative education that is stratified according to their physical, psychological and social need. The review did provide low-quality evidence that preoperative education may have a small beneficial effect on preoperative anxiety.

 
Implications for research

Preoperative education in its current form may not be sufficient to improve postoperative outcomes. One possible reason for the lack of demonstrable benefit is that the preoperative education evaluated is not targeted at the individual person, and is thus not adapted to the person's psychosocial factors. Future research should investigate how a stratified biopsychosocial approach could be used to assess individual patient requirements (e.g. physical, psychological and social need) and tailor preoperative education accordingly. Further research could also assess which method, or combination of methods, is best for delivering patient-stratified education, and how preoperative education can be reinforced by postoperative care.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

We thank Amrita Williams for assistance in drafting the background section; Cristel Dunshea for help with extracting data from Wijgman 1994; and Gordon Butler, Stephan Doering and Jean Crowe for providing additional trial data.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
Download statistical data

 
Comparison 1. Preoperative education for hip replacement versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Hip (up to 3 months)
3227Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.47, 0.13]

 2 Function4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Hip (3 to 24 months)
4177Std. Mean Difference (IV, Random, 95% CI)-0.44 [-0.93, 0.06]

 3 Postoperative anxiety (Spielberger State-Trait Anxiety Index)3Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 Hip (up to 6 weeks postoperatively)
3264Mean Difference (IV, Random, 95% CI)-2.28 [-5.68, 1.12]

 4 Total number of serious adverse events2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Hip (any serious postoperative complications)
2150Risk Ratio (M-H, Random, 95% CI)0.79 [0.19, 3.21]

 5 Preoperative anxiety (Spielberger State-Trait Anxiety Index)4Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Hip
4333Mean Difference (IV, Random, 95% CI)-5.10 [-7.17, -3.03]

 6 Length of hospital stay (days)7Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Hip
7487Mean Difference (IV, Random, 95% CI)-0.79 [-1.96, 0.37]

 7 Mobility (days to standing or walking)6Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Hip
6417Mean Difference (IV, Random, 95% CI)-0.12 [-0.30, 0.07]

 8 Range of motion (degrees)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    8.1 Hip abduction (up to 6 weeks postoperatively)
295Mean Difference (IV, Fixed, 95% CI)-1.09 [-5.35, 3.17]

    8.2 Flexion of the hip with flexed knee (up to 6 weeks postoperatively)
136Mean Difference (IV, Fixed, 95% CI)0.75 [-7.67, 9.17]

    8.3 Flexion of the hip with extended knee (up to 6 weeks postoperatively)
136Mean Difference (IV, Fixed, 95% CI)-0.25 [-9.17, 8.67]

 9 Sensitivity analysis: pain1Mean Difference (IV, Random, 95% CI)Subtotals only

    9.1 Hip (up to 6 weeks postoperatively)
1100Mean Difference (IV, Random, 95% CI)-7.0 [-14.85, 0.85]

 10 Sensitivity analysis: function1Mean Difference (IV, Random, 95% CI)Subtotals only

    10.1 Hip (6 months postoperatively)
147Mean Difference (IV, Random, 95% CI)-7.0 [-10.55, -3.45]

 
Comparison 2. Preoperative education for knee replacement versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Knee (2 days postoperatively)
126Mean Difference (IV, Random, 95% CI)-12.20 [-29.77, 5.37]

    1.2 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)2.0 [-3.45, 7.45]

 2 Function1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)0.0 [-5.63, 5.63]

 3 Health-related quality of life1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 SF-36 Physical Component Score (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-3.0 [-6.38, 0.38]

    3.2 SF-36 Mental Component Score (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-2.0 [-5.06, 1.06]

 4 Total number of serious adverse events1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Knee (deep vein thrombosis)
1115Risk Ratio (M-H, Random, 95% CI)0.55 [0.14, 2.08]

    4.2 Knee (pulmonary emboli)
1115Risk Ratio (M-H, Random, 95% CI)1.09 [0.16, 7.48]

    4.3 Knee (infection)
1115Risk Ratio (M-H, Random, 95% CI)0.73 [0.13, 4.19]

    4.4 Knee (any serious postoperative complications)
1115Risk Ratio (M-H, Random, 95% CI)0.69 [0.29, 1.66]

 5 Preoperative anxiety (Spielberger State-Trait Anxiety Index)1Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Knee
168Mean Difference (IV, Random, 95% CI)-5.52 [-8.34, -2.70]

 6 Length of hospital stay (days)2Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Knee
2183Mean Difference (IV, Random, 95% CI)-1.86 [-3.40, -0.32]

 7 Mobility (days to standing or walking)1Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Knee
168Mean Difference (IV, Random, 95% CI)-1.13 [-2.82, 0.56]

 8 Range of motion (degrees)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    8.1 Knee flexion and extension (i.e. total range of sagittal knee motion) (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-4.0 [-10.02, 2.02]

 9 Sensitivity analysis: pain1Mean Difference (IV, Random, 95% CI)Subtotals only

    9.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)2.0 [-3.45, 7.45]

 10 Sensitivity analysis: function1Mean Difference (IV, Random, 95% CI)Subtotals only

    10.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)0.0 [-5.63, 5.63]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
 

Appendix 1. MEDLINE search strategy



1. exp Arthroplasty, Replacement/

2. exp Joint Prosthesis/

3. ((hip$ or knee$) adj5 (arthroplast$ or prosthe$ or replac$)).tw.

4. or/1-3

5. exp Preoperative Care/

6. exp Patient Education/

7. exp Postoperative Period/

8. (information or instruct$ or educat$ or advice or support$).mp.

9. (video$ or tape$ or audio$ or leaflet$ or pamphlet$ or booklet$).mp.

10. or/5-9

11. clinical trial.pt.

12. randomized.ab.

13. placebo.ab.

14. dt.fs.

15. clinical trials/

16. randomly.ab.

17. trial.ti.

18. group.ab.

19. or/11-16

20. animals/

21. humans/

22. 20 and 21

23. 20 not 22

24. 19 not 23

25. and/4,10,24



 

Appendix 2. EMBASE search strategy



1. exp Arthroplasty, Replacement/
2. exp Joint Prosthesis/
3. ((hip$ or knee$) adj5 (arthroplast$ or prosthe$ or replac$)).tw.
4. or/1-3
5. exp Preoperative Care/
6. exp Patient Education/
7. exp Postoperative Period/
8. (information or instruct$ or educat$ or advice or support$).mp.
9. (video$ or tape$ or audio$ or leaflet$ or pamphlet$ or booklet$).mp.
10. or/5-9
11. (random$ or placebo$).ti,ab.
12. ((single$ or double$ or triple$ or treble$) and (blind$ or mask$)).ti,ab.
13. controlled clinical trial$.ti,ab.
14. RETRACTED ARTICLE/
15. or/11-14
16. (animal$ not human$).sh,hw.
17. 15 not 16
18. and/4,10,17



 

Appendix 3. CENTRAL search strategy

1. ARTHROPLASTY REPLACEMENT explode all trees (MeSH)
2. JOINT PROSTHESIS explode all trees (MeSH)
3. ((hip* near replac*) or (hip* near prosthe*) or (hip* near arthroplast*))
4. ((knee* near replac*) or (knee* near prosthe*) or (knee* near arthroplast*))
5. PATIENT EDUCATION as Topic explode all trees (MeSH)
6. PREOPERATIVE CARE explode all trees (MeSH)
7. (information or instruct* or educat* or advice* or support*)
8. (preoperativ* or pre-operativ*)
9. (#1 or #2 or #3 or #4)
10. (#5 or #6 or #7 or #8)
11. (#9 and #10)

 

Appendix 4. CINAHL search strategy



S1 (MH "Arthroplasty, Replacement+") 
S2 (MH "Orthopedic Prosthesis+")  
S3 TI hip* N5 replace* or TI hip* N5 arthroplast* or TI hip* N5 prosthe* or TI knee* N5 replace* or TI knee* N5 arthroplast* or TI knee* prosthe* or AB hip* N5 replace* or AB hip* N5 arthroplast* or AB hip* N5 prosthe* or AB knee* N5 replace* or AB knee* N5 arthroplast* or AB knee* N5 prosthe*  
S4 S1 or S2 or S3  
S5 (MH "Patient Education+")  
S6 (MH "Preoperative Education")  
S7 TI ( information or instruct* or educat* or advice or support* ) or AB ( information or instruct* or educat* or advice or support* )  
S8 TI ( video* or tape* or audio* or leaflet* or pamphlet* or booklet* ) or AB ( video* or tape* or audio* or leaflet* or pamphlet* or booklet* )  
S9 S5 or S6 or S7 or S8 
S10 S4 and S9  
S11 (MH "Clinical Trials+")  
S12 TI "clinical trial*" or AB "clinical trial*" 
S13 PT clinical trial  
S14 TI singl* blind* or TI singl* mask* or TI doubl* blind* or TI doubl* mask* or TI trebl* blind* or TI trebl* mask* or TI tripl* blind* or TI tripl* mask*  
S15 AB singl* blind* or AB singl* mask* or AB doubl* blind* or AB doubl* mask* or AB trebl* blind* or AB trebl* mask* or AB tripl* blind* or AB tripl* mask*  
S16 TI Randomi?ed control* trial* or AB Randomi?ed control* trial*  
S17 (MH "Random Assignment") 
S18 TI Random* allocat* or AB Random* allocat*  
S19 TI Placebo* or AB Placebo*  
S20 (MH "Placebos")  
S21 (MH "Quantitative trials")  
S22 TI Allocat* random* or AB Allocat* random*  
S23 S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22  
S24 S10 and S23 



 

Appendix 5. PsycINFO search strategy



1. ((hip$ or knee$) adj5 (replac$ or arthroplast$ or prosthe$)).mp.
2. exp Client Education/
3. (information or instruct$ or educat$ or advice or support$).mp.
4. (video$ or tape$ or audio$ or leaflet$ or pamphlet$ or booklet$).mp.
5. or/2-4
6. 1 and 5



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

Last assessed as up-to-date: 31 May 2013.


DateEventDescription

4 February 2014New citation required but conclusions have not changedA substantial amount of new information has been added to the updated review including: the addition of nine new studies; important changes to the methodology (risk of bias and summary of findings tables were added to review); and extensive re-writing (not affecting the conclusions) in the reporting of the methods and results to align with the standards recommended by the Cochrane Collaboration's Methodological Expectations of Cochrane Intervention Reviews (MECIR) project.

31 May 2013New search has been performedA new search was conducted on 31st May 2013. Nine new studies were included (Beaupre 2004; Giraudet 2003; Gocen 2004; Johansson 2007; McDonald 2004; McGregor 2004; Siggeirsdottir 2005; Sjöling 2003; Vukomanović 2008) in the update, in addition to the nine trials included in the previous version.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

Protocol first published: Issue 1, 2002
Review first published: Issue 1, 2004


DateEventDescription

10 May 2008AmendedConverted to new review format.

CMSG ID: A017-R



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

SM ran the searches. SM and KB assessed trials for inclusion. SM, MJP, KB and JW assessed risk of bias and extracted data. SM and MJP drafted the text of the review, and all authors contributed to interpreting the results and writing the discussion. AS commented on the text of the review and helped draft the discussion and implications for practice/research sections. Two authors of the first published version of this review (Sally Green and Sarah Hetrick) were not involved in this update.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms
 

Internal sources

  • Australasian Cochrane Centre, Australia.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

In the previous version of this review (McDonald 2004), types of outcome measures included in the review were as follows:

  1. postoperative pain (short- and long-term);
  2. length of hospital stay;
  3. compliance with postoperative exercise routine;
  4. patient satisfaction;
  5. occurrence of postoperative deep vein thrombosis;
  6. range of motion;
  7. preoperative anxiety;
  8. postoperative anxiety;
  9. postoperative mobility.

The outcomes reported in this review have been modified from the original review to make them as consistent as possible with other Cochrane reviews on hip and knee replacement. Assessment for study risk of bias has been performed using The Cochrane Collaboration's 'Risk of bias' tool in this update of the review. We have included a 'Summary of findings' table and an ORBIT outcome matrix.

 

Notes

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Index terms

For Doering 2000, we are waiting for translation of the report published in Zeitschrift Fuer Psychosomatische Medizin Und Psychotherapie in 2001 that presents three-month follow-up data on mobility.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Notes
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Beaupre 2004 {published data only}
  • Beaupre LA, Lier D, Davies DM, Johnston DBC. The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty. Journal of Rheumatology 2004;31(6):1166-73.
Butler 1996 {published and unpublished data}
Clode-Baker 1997 {published data only}
  • Clode-Baker E, Draper E, Raymond N, Haslam C, Gregg P. Preparing patients for total hip replacement. A randomized controlled trial of a preoperative educational intervention. Journal of Health Psychology 1997;2(1):107-14.
Cooil 1997 {published data only}
  • Cooil J, Bithell C. Pre-operative education for patients undergoing total hip replacement: a comparison of two methods. Physiotherapy Theory & Practice 1997;13(2):163-73.
Crowe 2003 {published and unpublished data}
  • Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Canadian Journal of Occupational Therapy - Revue Canadienne d'Ergotherapie 2003;70(2):88-96.
Daltroy 1998 {published data only}
Doering 2000 {published and unpublished data}
  • Doering S, Behensky H, Rumpold G, Schatz DS, Rossler S, Hofstotter B, et al. Videotape preparation of patients before hip replacement surgery improves mobility after three months. Zeitschrift Fuer Psychosomatische Medizin Und Psychotherapie 2001;47(2):140-52.
  • Doering S, Katzlberger F, Rumpold G, Roessler S, Hofstoetter B, Schatz DS, et al. Videotape preparation of patients before hip replacement surgery reduces stress. Psychosomatic Medicine 2000;62(3):365-73.
Giraudet 2003 {published data only}
  • Giraudet-Le Quintrec J-S, Coste J, Vastel L, Pacault V, Jeanne L, Lamas J-P, et al. Positive effect of patient education for hip surgery. Clinical Orthopaedics and Related Research 2003;414:112-20.
Gocen 2004 {published data only}
  • Gocen Z, Sen A, Unver B, Karatosun V, Gunal I. The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial. Clinical Rehabilitation 2004;18:353-8.
Johansson 2007 {published data only}
  • Johansson K, Salantera S, Katajisto J. Empowering orthopaedic patients through preadmission education: results from a clinical study. Patient Education and Counseling 2007;66:84-91.
Lilja 1998 {published data only}
  • Lilja Y, Ryden S, Fridlund B. Effects of extended preoperative information on perioperative stress: an anaesthetic nurse intervention for patients with breast cancer and total hip replacement. Intensive & Critical Care Nursing 1998;14(6):276-82.
McDonald 2004 {published data only}
McGregor 2004 {published data only}
  • McGregor AH, Rylands, H, Owen A, Dore CJ, Hughes SPF. Does preoperative hip rehabilitation advice improve recovery and patient satisfaction?. Journal of Arthroplasty 2004;19(4):464-8.
Santavirta 1994 {published data only}
  • Santavirta N, Lillqvist G, Sarvimaki A, Honkanen V, Konttinen YT, Santavirta S. Teaching of patients undergoing total hip replacement surgery. International Journal of Nursing Studies 1994;31(2):135-42.
Siggeirsdottir 2005 {published data only}
  • Siggeirsdottir K, Olafsson O, Jonsson H, Iwarsson S, Gudnason V, Jonsson B. Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement. Acta Orthopaedica 2005;76(4):555-62.
  • Sigurdsson E, Siggeirsdottir K, Jonsson H Jr, Gudnason V, Matthiasson T, Jonsson BY. Early discharge and home intervention reduces unit costs after total hip replacement: results of a cost analysis in a randomized study. International Journal of Health Care Finance and Economics 2008;8(3):181-92.
Sjöling 2003 {published data only}
  • Sjöling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Education and Counseling 2003;51:169-76.
Vukomanović 2008 {published data only}
  • Vukomanović A, Popović Z, Durović A, Krstić L. The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty [Efekti kratkotrajne preoperativne fizikalne terapije i edukacije na rani funkcijski oporavak bolesnike mladih od 70 godina sa totalnom artroplastikom kuka]. Vojnosanitetski Pregled 2008;65(4):291-7.
Wijgman 1994 {published data only}
  • Wijgman AJ, Dekkers GH, Waltje E, Krekels T, Arens HJ. No positive effect of preoperative exercise therapy and teaching in patients to be subjected to hip arthroplasty. Nederlands Tijdschrift Voor Geneeskunde 1994;138(19):949-52.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Notes
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Berge 2004 {published data only}
  • Berge DJ, Dolin SJ, Williams AC, Harman R. Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial. Pain 2004;110(1-2):33-9.
Bondy 1999 {published data only}
  • Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The effect of anesthetic patient education on preoperative patient anxiety. Regional Anesthesia & Pain Medicine 1999;24(2):158-64.
Brull 2002 {published data only}
  • Brull R, McCartney CJL, Chan VWS. Do preoperative anxiety and depression affect the quality of recovery and the length of stay after hip or knee arthroplasty. Canadian Journal of Anesthesia 2002;49(1):109.
Ferrara 2008 {published data only}
  • Ferrara PE, Rabini A, Maggi L, Piazzini DB, Logroscino G, Magliocchetti G, et al. Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty. Clinical Rehabilitation 2008;22(10-11):977-86.
Gammon 1996a {published data only}
Gill 2009 {published data only}
  • Gill SD, McBurney H, Schulz DL. Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2009;90(3):388-94.
Haslam 2001 {published data only}
  • Haslam R. A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip: a randomised controlled trial. Acupuncture in Medicine 2001;19(1):19-26.
Hough 1991 {published data only}
  • Hough D, Crosat S, Nye P. Patient education for total hip replacement. Nursing Management 1991;22(3):80I-80P.
Mancuso 2008 {published data only}
  • Mancuso CA, Graziano S, Briskie LM, Peterson MG, Pellicci PM, Salvati EA, et al. Randomized trials to modify patients' preoperative expectations of hip and knee arthroplasties. Clinical Orthopaedics and Related Research 2008;466(2):424-31.
Mikulaninec 1987 {published data only}
Nuñez 2006 {published data only}
  • Nuñez M, Nuñez E, Segur JM, Macule F, Quinto L, Hernandez MV, et al. The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study. Osteoarthritis and Cartilage 2006;14(3):279-85.
Pour 2007 {published data only}
  • Pour AE, Parvizi J, Sharkey PF, Hozack WJ, Rothman RH. Minimally invasive hip arthroplasty: what role does patient preconditioning play?. Journal of Bone and Joint Surgery. American Volume 2007;89(9):1920-7.
Roach 1995 {published data only}
Ródenas-Martínez 2008 {published data only}
  • Ródenas-Martínez S, Santos-Andrés JF, Abril-Boren C, Usabiaga-Bernal T, Abouh-Lais S, Aguilar-Naranjo JJ. Effectiveness of a pre-surgery rehabilitation program in total knee arthroplasty [Eficacia de un programa de rehabilitación preoperatoria en prótesis total de rodilla]. Rehabilitación 2008;42(1):4-12.
Wong 1985 {published data only}
Yeh 2005 {published data only}
  • Yeh ML, Chen HS, Liu PH. Effects of multimedia with printed nursing guide in education on self-efficacy wand functional activity and hospitalization in patients with hip replacement. Patient Education and Counseling 2005;57:217-24.

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Notes
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Eschalier 2012 {published data only}
  • Eschalier B, Descamps S, Pereira B, Girard MG, Boisgard S, Coudeyre E. Evaluation of a pre operative education approach for patient undergoing total knee replacement. Annals of Physical and Rehabilitation Medicine 2012;55:e117-e8+e20.
Huang 2012 {published data only}
  • Huang SW, Chen PH, Chou YH. Effects of a preoperative simplified home rehabilitation education program on length of stay of total knee arthroplasty patients. Orthopaedics & Traumatology: Surgery & Research 2012;98(3):259-64.
Wilson 2012 {published data only}
  • Wilson RA. A randomized controlled trial of an individualized preoperative education intervention for symptom management following total knee arthroplasty. Dissertation Abstracts International: Section B: The Sciences and Engineering 2012;73(4-B):2123.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Notes
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Bastian 2002
  • Bastian H, Cochrane Collaboration Consumer Network. Reducing anxiety before surgery, 2002. www.wagnerdiasresende.med.br/ANXIETY_SURGERY.htm (accessed 25 April 2014).
Brady 2000
  • Brady OH, Masri BA, Garbuz DS, Duncan CP. Rheumatology: 10. Joint replacement of the hip and knee: when to refer and what to expect. Canadian Medical Association Journal 2000;163(10):1285-91.
Cates 2008
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Creamer 1998
Deeks 2011
  • Deeks JJ, Higgins JPT, Altman DG. Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
DeFrances 2008
  • DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National Health Statistics Reports 2008, issue 5:1-20.
Dwan 2011
Gammon 1996b
  • Gammon J, Mulholland CW. Effect of preparatory information prior to elective total hip replacement on post-operative physical coping outcomes. International Journal of Nursing Studies 1996;33(6):589-604.
Gummesson 2003
Hathaway 1986
  • Hathaway D. Effect of pre-operative instruction on post-operative outcomes: a meta-analysis. Nursing Research 1986;35(5):269-75.
Higgins 2011
  • Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Johansson 2005
Kirkham 2010
  • Kirkham JJ, Dwan KM, Altman DG, Gamble C, Dodd S, Smyth R, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ 2010;340:c365.
Louw 2013
  • Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiotherapy Theory and Practice 2013;29(3):175-94. [PUBMED: 23035767]
NJR 2013
  • NJR StatsOnline, National Joint Registry. www.njrcentre.org.uk (accessed 25 April 2014).
Oshodi 2007a
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