NICE Hip, Knee, and Shoulder Op Guidance Includes 'Stop Moments'

Nicky Broyd

June 05, 2020

Editor's note, 9th June 2020: This article was updated to include comment from the British Orthopaedic Association.

The National Institute for Health and Care Excellence (NICE) has issued final guidance on care before, during, and after planned hip, knee or shoulder replacement operations. 

The guidance includes 'stop moments' designed to check that the right implant components have been selected and to reduce the chances of the wrong implant being used (a so-called 'never event'). It says intraoperative real-time data entry to the National Joint Registry database, which provides alerts on mismatched components, should be considered.

Patella resurfacing is now an option to be offered to candidates for total knee replacements. NICE cited strong economic evidence for this procedure - to fit an artificial surface to the back of the kneecap - based on fewer readmissions over a 10-year period.

Also covered in the guidance:

  • Tranexamic acid to minimise blood loss during surgery

  • Infection prevention

  • Types of surgical procedure to be provided

  • Postoperative rehabilitation and longer-term care

  • Anaesthesia and analgesia options

  • Preoperative rehabilitation, including weight management, diet, exercise, and smoking cessation advice

British Orthopaedic Association Welcomes New Guidance

The British Orthopaedic Association (BOA) responded to the new guidance in an emailed statement: "The BOA fully supports the new NICE guidance on hip, knee, and shoulder replacement. We believe that the process and evidence review has been of high quality, robust and transparent. Many of the findings support continuation of existing good  practices. Patients can be assured that in the UK, patient outcomes for hip, knee and shoulder replacement are already very good. NICE have suggested  some improvements and a number of areas for Research into the best pre surgery preparation and post-surgery rehabilitation to further improve patients’ treatment, experience and outcomes."

The statement continued: "Stop moments have been used for some time in surgery as an important mechanism to avoid the 'never events' where incorrect  components are used. Never events just should not happen. Already the practice of holding stop moments was used in the UK, but we welcome the inclusion of this recommendation by NICE to further support its use in all joint replacement procedures. We would like to reiterate that never events involving incorrect implants in orthopaedic surgery are extremely rare. However, even one never event is too many and anything that helps to eliminate this rare but global problem is to be applauded and fully supported. We will highlight this aspect of the guidance to all our members."

The NICE guidance committee made a future recommendation for research into providing decision aids for patients offered elective joint replacement.

Replacement (primary): hip, knee and shoulder. NICE guideline [NG157] Published date: 4th June 2020.

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