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Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: The UK SAFE evidence synthesis and recommendations

Kingsbury, Sarah R; Smith, Lindsay K; Czoski Murray, Carolyn J; Pinedo-Villanueva, Rafael; Judge, Andrew; West, Robert; Smith, Chris; Wright, Judy M; Arden, Nigel K; Thomas, Christine M; Kolovos, Spryos; Shuweihdi, Farag; Garriga, Cesar; Bitanihirwe, Byron KY; Hill, Kate; Matu, Jamie; Stone, Martin; Conaghan, Philip G

Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: The UK SAFE evidence synthesis and recommendations Thumbnail


Sarah R Kingsbury

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Dr Lindsay Smith
Senior Lecturer in Physiotherapy (Academic Clinical Research)

Carolyn J Czoski Murray

Rafael Pinedo-Villanueva

Andrew Judge

Robert West

Chris Smith

Judy M Wright

Nigel K Arden

Christine M Thomas

Spryos Kolovos

Farag Shuweihdi

Cesar Garriga

Byron KY Bitanihirwe

Kate Hill

Jamie Matu

Martin Stone

Philip G Conaghan


Background: Joint replacement surgery has revolutionised the management of degenerative joint disease. Increasing demand for surgery and post-surgical reviews has overwhelmed orthopaedic services and, consequently, many centres have reduced or stopped follow-up. Such disinvestment is without an evidence base and raises questions regarding the consequences to patients. Objectives: To produce evidence-and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Our research question was ‘Is it safe to disinvest in mid-to late-term follow-up of hip and knee replacement?’. Methods: The study comprised three complementary evidence synthesis work packages to inform a final consensus process. Work package 1 was a systematic review of the clinical effectiveness and cost-effectiveness literature. Work package 2 used routine national data sets (i.e. the Clinical Practice Research Datalink–Hospital Episode Statistics, Hospital Episode Statistics–National Joint Registry–patient-reported outcome measures) to identify pre, peri and postoperative predictors of mid-to late-term revision, and prospective data from 560 patients to understand how patients present for revision surgery. Work package 3 used a Markov model to simulate the survival, health-related quality of life and NHS costs of patients following hip or knee replacement surgery. Finally, evidence from work packages 1–3 informed a face-to-face consensus panel, which involved 32 stakeholders. Results: Our overarching statements are as follows: (1) these recommendations apply to post primary hip and knee replacement follow-up; (2) the 10-year time point in these recommendations is based on a lack of robust evidence beyond 10 years; and (3) in these recommendations, the term ‘complex cases’ refers to individual patient and surgical factors that may increase the risk of replacement failure. Our recommendations are as follows: for Orthopaedic Data Evaluation Panel 10A* (ODEP-10A*) minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided that there is rapid access to orthopaedic review; (2) for ODEP-10A* minimum implants in complex cases or non-ODEP-10A* minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years; (3) at 10 years post hip and knee replacement, clinical and radiographic evaluation is recommended; and (4) after 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment (note that ongoing rapid access to orthopaedic review is still required) [Stone M, Smith L, Kingsbury S, Czoski-Murray C, Judge A, Pinedo-Villanueva R, et al. Evidence-based follow-up recommendations following primary hip and knee arthroplasty (UK SAFE). Orthop Proc 2020;102–B:13.]. Limitations: The current absence of data beyond 10 years restricted the evidence base. Conclusions: For ODEP-10A* prostheses, the UK SAFE programme demonstrated that it is safe to disinvest in routine follow-up in the 1-to 10-year period after non-complex hip and knee replacement. At 10 years, clinical and radiographic review is recommended. Complex cases, implants not meeting the 10A* criteria and follow-up after revision surgery are not covered by this recommendation.

Journal Article Type Article
Acceptance Date May 6, 2022
Online Publication Date Jun 28, 2022
Publication Date Jun 28, 2022
Deposit Date Jun 28, 2022
Publicly Available Date Jun 29, 2022
Journal Health and Social Care Delivery Research
Print ISSN 2755-0060
Electronic ISSN 2755-0079
Publisher NIHR Journals Library
Peer Reviewed Peer Reviewed
Volume 10
Issue 16
Pages 1-172
Keywords orthopaedic services; Joint replacement surgery; orthopaedic services; orthopaedics; arkov mode; complex cases; hip replacement; knee replacement; degenerative joint disease; UK SAFE evidence synthesis
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Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: The UK SAFE evidence synthesis and recommendations (2.4 Mb)


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