McDonald S, Hetrick SE, Green S - VDCPT · Editorial group: Cochrane Musculoskeletal Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008

Pre-operative education for hip or knee replacement (Review)

McDonald S, Hetrick SE, Green S

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2004, Issue 1

http://www.thecochranelibrary.com

Pre-operative education for hip or knee replacement (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Preoperative education versus routine care, Outcome 1 Preoperative anxiety (Spielberger State-

Trait Anxiety Index). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Analysis 1.2. Comparison 1 Preoperative education versus routine care, Outcome 2 Postoperative anxiety (Spielberger State-

Trait Anxiety Index) (hip). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Analysis 1.3. Comparison 1 Preoperative education versus routine care, Outcome 3 Length of hospital stay (days). . 20

Analysis 1.4. Comparison 1 Preoperative education versus routine care, Outcome 4 Days to standing. . . . . . . 21

Analysis 1.5. Comparison 1 Preoperative education versus routine care, Outcome 5 Days to climb stairs. . . . . . 22

Analysis 1.6. Comparison 1 Preoperative education versus routine care, Outcome 6 Postoperative pain (visual analogue

scale) (hip). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 1.7. Comparison 1 Preoperative education versus routine care, Outcome 7 Patient satisfaction with information

(hip). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

23ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iPre-operative education for hip or knee replacement (Review)


[Intervention Review]

Pre-operative education for hip or knee replacement

Steve McDonald1 , Sarah E Hetrick2, Sally Green3

1Australasian Cochrane Centre, Monash Institute of Health Services Research, Clayton, Australia. 2Centre of Excellence in Youth

Mental Health, Orygen Youth Health Research Centre; Headspace (The National Youth Mental Health Foundation), Melbourne,

Australia. 3Monash Institute of Health Services Research, Monash University, Clayton, Australia

Contact address: Steve McDonald, Australasian Cochrane Centre, Monash Institute of Health Services Research, Monash Medical

Centre, Locked Bag 29, Clayton, Victoria, 3168, Australia. [email protected].

Editorial group: Cochrane Musculoskeletal Group.

Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.

Review content assessed as up-to-date: 22 November 2003.

Citation: McDonald S, Hetrick SE, Green S. Pre-operative education for hip or knee replacement. Cochrane Database of SystematicReviews 2004, Issue 1. Art. No.: CD003526. DOI: 10.1002/14651858.CD003526.pub2.


A B S T R A C T

Background

Hip or knee replacement is a major surgical procedure which can be physically and psychologically stressful for patients. It is hypothesised

that education before surgery reduces anxiety and enhances postoperative outcomes.

Objectives

To determine whether preoperative education improves postoperative outcomes (anxiety, pain, mobility, length of stay and the incidence

of deep vein thrombosis) in patients undergoing hip or knee replacement surgery.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2003), MEDLINE (1966 to April

2003), EMBASE (1980 to June 2002), CINAHL, PsycINFO and PEDro until May 2003. We handsearched the Australian Journal of

Physiotherapy (1954 to 2001) and reviewed the reference lists.

Selection criteria

Randomised trials of preoperative education (verbal, written or audiovisual) delivered by a health professional within six weeks of

surgery to patients undergoing hip or knee replacement.

Data collection and analysis

Two reviewers independently assessed study quality and extracted data. Continuous outcomes were combined using weighted mean

difference (WMD) and 95% confidence intervals (CI).

Main results

Nine studies involving 782 participants met the inclusion criteria. Four studies involving 365 participants assessed length of hospital

stay (days) but detected no significant difference between preoperative education and usual care (WMD -0.97; 95% CI -2.67 to 0.73).

However, one study of 133 participants with more complex needs, indicated that individually tailored programmes of education and

support were beneficial in reducing length of stay. The four studies reporting length of stay did not find any significant effect of

preoperative education on days to standing and days to climb stairs. Three trials found preoperative education was beneficial in reducing

preoperative anxiety (WMD -5.64; -7.45 to -3.82) on a scale of 0 to 100. No significant effect on postoperative anxiety was detected

1Pre-operative education for hip or knee replacement (Review)


mailto:[email protected]

either on the day following surgery , or at discharge. None of the five studies reporting postoperative pain detected any difference

between the groups.

Authors’ conclusions

There is little evidence to support the use of pre-operative education over and above standard care to improve postoperative outcomes

in patients undergoing hip or knee replacement surgery, especially with respect to pain, functioning and length of hospital stay. There

is evidence that preoperative education has a modest beneficial effect on preoperative anxiety. There may also be beneficial effects when

preoperative education is tailored according to anxiety, or targeted at those most in need of support (e.g. those who are particularly

disabled, or have limited social support structures).

P L A I N L A N G U A G E S U M M A R Y

Pre-operative education for hip or knee replacement

How well does information and education given before hip or knee replacement surgery improve recovery?

To answer this question, scientists analysed 9 studies testing over 750 people, 58 to 71 years old. These people had hip or knee

replacement surgery because of arthritis, an accident or another reason. Some people received written information, discussed the surgery

with a health professional, watched a video or received no information. These studies provide the best evidence we have today.

Why might education before surgery help with recovery?

Often when other treatments do not work to provide relief in diseases such as osteoarthritis, hip or knee replacement surgery may be

necessary. But, surgery can be stressful - emotionally and physically. It is thought that people who receive information and are educated

about their surgery and recovery before their surgery, will be less anxious, be able to handle pain better and not have to stay in hospital

long.

Does it improve recovery?

Studies showed that people with or without education before surgery had about the same amount of pain, were just as satisfied with

their surgery, started walking and climbing stairs at about the same time after surgery and stayed in hospital for about the same amount

of time. One study did show that in people who could not move well and didn’t have support, the ones that had education before

surgery did not stay in hospital as long as those who did not have education.

Three studies showed that people with education before surgery were less anxious before surgery, but two other studies found that

anxiety was the same. Four studies showed that people with or without education before surgery had about the same amount of anxiety

after surgery.

One study showed that people with education before surgery had fewer complications, but another study showed people had about

the same amount. Whether it improved the risk of blood clots or Deep Vein Thrombosis (DVT) was not tested.

What is the bottom line?

There is “Silver” level evidence that education before surgery does not seem to decrease pain, improve function or decrease the number

of days in hospital after surgery. But education before surgery may decrease anxiety before surgery. Education and information that is

individually geared to a person and given before surgery may improve recovery in people who need support or do not move well.

Future research should find out which people need education before surgery, what type of education (pamphlets, videos, etc.) works

best and whether education before and after surgery is better.



B A C K G R O U N D

Hip replacement and knee replacement are commonly performed

surgical procedures, with more than 800,000 hip operations car-

ried out worldwide each year (Knutsson 1999). The main indi-

cators for hip or total knee replacement are intractable pain and/

or limitation of function that cannot be managed by conservative

treatment alone (Brady 2000). Leading causes of such pain include

osteoarthritis, rheumatoid arthritis, trauma, congenital abnormal-

ities, dysplasia and osteochondritic disease. In the absence of treat-

ments that provide a cure for conditions such as osteoarthritis,

management is directed primarily towards relieving pain and re-

ducing functional limitation. Joint replacement is one surgical op-

tion when medical treatment has failed to provide adequate symp-

tom relief (Creamer 1998).

Hip or knee replacement is a major surgical procedure that requires

in-patient physiotherapy and out-patient rehabilitation following

a stay in hospital (Palmer 1999). These surgical procedures can

be stressful, compromising the patient both physically and psy-

chologically (Gammon 1996a). Perception of pain and anxiety is

often heightened when patients feel a lack of control over their

situation, and is very common around surgery (Bastian 2002). If a

patient 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 pa-

tients will be less anxious, have a shorter hospital stay and be better

able to cope with postoperative pain.

Educating patients about postoperative routines may reduce the

incidence of postoperative complications, the most serious of

which is pulmonary embolism resulting from deep vein thrombo-

sis (Brady 2000). A second cause of early stage injury and disease

for hip replacements is dislocation, which may result when post-

surgical recommendations and protocols are not followed. It is es-

sential that patients undergoing hip replacement know the posi-

tions to avoid, and this understanding is potentially enhanced by

preoperative education.

Reviews of psychological and educational preparation for surgery

support the effectiveness of interventions in reducing pain, anxiety

and length of stay (Devine 1983). However, evidence from more

recent reviews suggests the additional benefit derived from preop-

erative education, particularly with respect to length of hospital

stay, is being eroded as standard preoperative procedures improve

and post-surgical guidelines and protocols are adopted as standard

care (Devine 1992).

O B J E C T I V E S

To determine whether preoperative education in patients under-

going total hip replacement or total knee replacement improves

postoperative outcomes with respect to anxiety, pain, mobility,

length of stay, compliance with exercise routines and the incidence

of deep vein thrombosis.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Randomised or quasi-randomised studies comparing educational

interventions given preoperatively to patients undergoing total hip

or total knee replacement surgery.

Types of participants

All patients undergoing planned total hip or total knee replace-

ment. We originally planned to include only studies of patients

undergoing surgery for osteoarthritis or rheumatoid arthritis (or

where non-osteoarthritis and non-rheumatoid arthritis patients

accounted for less than 10% of the entire study population) to

avoid clinical heterogeneity. However, few studies reported these

data so we included all trials of patients undergoing planned hip

or knee replacement surgery.

Types of interventions

Any preoperative education regarding the surgery and its postop-

erative course that is delivered by a health professional within six

weeks of surgery. Education could be given verbally or in any writ-

ten or audiovisual form, and could include preoperative instruc-

tion of postoperative exercise routines.

All comparators were considered, although we excluded studies

comparing various methods of delivery of preoperative education

in the absence of a control group receiving standard or routine

care. We also excluded studies that incorporated some form of

postoperative intervention (e.g. use of reminder systems to per-

form exercises).

Types of outcome measures

(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

We added preoperative anxiety to the list of outcome measures

originally appearing in the protocol. Although our focus was on

the effect of preoperative education on postoperative recovery, in-

terventions that successfully lower preoperative anxiety are impor-

tant. Preoperative anxiety, for example, may interfere with a per-

son’s ability to retain information. Postoperative anxiety and pain

may also be lessened if patients are less anxious before surgery.

Search methods for identification of studies

We searched the Cochrane Central Register of Controlled Trials

(The Cochrane Library issue 2, 2003), MEDLINE (1966 to April

week 4 2003), PreMEDLINE (19 May 2003), EMBASE (1980 to

week 24 2002), CINAHL (1982 to May week 2 2003), PsycINFO

(1872 to May week 2 2003) and PEDro - Physiotherapy Evidence

Database (www.pedro.fhs.usyd.edu.au/ accessed 16 May 2003).

We handsearched the Australian Journal of Physiotherapy (1954

to 2001) and reviewed the reference lists of retrieved articles. No

language restrictions were applied.

The following strategy was used to search the Cochrane Central

Register of Controlled Trials (CENTRAL):

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 arthro-

plast*))

4. ((knee* near replac*) or (knee* near prosthe*) or (knee* near

arthroplast*))

5. PATIENT EDUCATION 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* or (pre next operativ*))

9. (#1 or #2 or #3 or #4)

10. (#5 or #6 or #7 or #8)

11. (#9 and #10)

The other search strategies are included as Additional Tables:

MEDLINE (Appendix 1), EMBASE (Appendix 2), CINAHL

(Appendix 3) and PsycINFO (Appendix 4).

Data collection and analysis

STUDY SELECTION

One reviewer (SM) conducted the searches and identified a pool

of potentially eligible studies. Two reviewers (SM and SG) inde-

pendently assessed these studies against the inclusion criteria and

any disagreement was resolved through discussion.

METHODOLOGICAL QUALITY

The methodological quality of included studies was assessed inde-

pendently by all three reviewers and disagreements were resolved

through discussion. Instead of using a formal quantitative quality

assessment scale, we assessed methodological quality against the

following criteria (see Table of Included Studies):

(1) Was the study described as randomised?

(2) Was the allocation concealment adequate?

(3) Were the participants blinded?

(4) Was there blinded outcome assessment?

(5) Was there a description of withdrawals and drop-outs?

(6) Were the results analysed according to intention-to-treat prin-

ciples?

DATA ANALYSIS

Data were extracted independently by two reviewers (SM and SG)

and checked by the third reviewer (SH). With the exception of

preoperative anxiety, we only extracted data for outcomes specified

in the protocol. Continuous outcomes were collected as means

and standard deviations, and dichotomous outcomes as number

of events. We requested additional trial details and data from study

authors when the data reported were incomplete.

Continuous data were combined using weighted mean difference

(WMD) and 95% confidence intervals (CI). Dichotomous data

were not pooled. When there was significant heterogeneity be-

tween studies, we used a random effects model for the meta-anal-

ysis because it is more conservative and results in wider confidence

intervals than the fixed effect model. We used a random effects

model to calculate all effect sizes since the pooled estimates cal-

culated by the random effects and fixed effect models are similar

when there is minimal between-study heterogeneity.

There were insufficient studies to carry out sensitivity analyses

based on quality. Sub-group analyses were performed for outcomes

that included data for both hip and knee replacement patients. In

these cases, we presented the results for hips and knees separately,

and then combined them to provide an overall estimate.

GRADING THE STRENGTH OF THE EVIDENCE

The common system of grading the strength of scientific evi-

dence for a therapeutic agent that is described in the CMSG mod-

ule scope and in the Evidence-based Rheumatology BMJ book

(Tugwell 2003) was used to rank the evidence included in this sys-

tematic review. Four categories are used to rank the evidence from

research studies from highest to lowest quality: Platinum, Gold,

Silver, and Bronze. The ranking is included in the synopsis of this

review.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.



After excluding records that were clearly not relevant to the re-

view, we identified nine studies involving 782 participants from

a pool of 17 potentially eligible studies. Seven of the included

studies involved only patients undergoing hip replacement, with

the remaining two studies (Daltroy 1998; Crowe 2003) including

both hip and knee replacements. Eight studies were published in

English and one in Dutch (Wijgman 1994). The median num-

ber of participants in each study was 78 (range 42 to 170), with

all studies having a similar mean age (range 58 to 71 years). All

outcomes were measured preoperatively and/or until discharge,

except for Santavirta 1994 which followed patients two to three

months after discharge.

Studies were excluded for the following reasons: information was

not specific to hip or knee surgery (Mikulaninec 1987; Bondy

1999); study was not randomised (Hough 1991; Roach 1995);

patients received a combined pre and postoperative intervention

(Wong 1985; Gammon 1996b); study investigated the effect of

preoperative depression on postoperative recovery and was not a

randomised trial of preoperative education (Brull 2002); and the

study did not investigate postoperative outcomes (Haslam 2001)

(see Table of Excluded Studies).

The timing and methods used to deliver preoperative education

varied considerably. Written information was provided before ad-

mission in Butler 1996. Santavirta 1994 combined the provi-

sion of preadmission written information with a teaching ses-

sion on admission that was planned according to the needs of

each participant. Four studies included an audiovisual compo-

nent: 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 pro-

gramme of education before admission; and Daltroy 1998 and

Doering 2000 showed participants a video after admission in the

presence of the investigator. In the remaining three studies, in-

formation was provided in teaching sessions delivered by physio-

therapists (Wijgman 1994; Cooil 1997) or nurses (Cooil 1997)

after admission but before surgery. All studies provided some form

of standardised information for participants, consisting mainly of

printed materials, thus ensuring all participants (including those

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 Appendix 5.

The nature of the intervention and the types of participants dif-

fered most markedly in Crowe 2003. In this study, an array of

interventions tailored to individual needs was offered to partici-

pants in addition to the educational material (a 50 minute video

and booklet). In contrast to other included studies, the inclusion

criteria targeted participants with poor functioning, limited so-

cial support and existing comorbidities. Furthermore, there was

an imbalance between the groups at baseline with respect to type

of replacement (hips: intervention group 36; control group 29,

knees: intervention group 29; control group 39) and disability (the

control group was significantly more disabled).

The outcomes assessed also varied considerably. Most studies mea-

sured anxiety (Butler 1996; Clode-Baker 1997; Daltroy 1998; Lilja

1998; Doering 2000; Crowe 2003) and two also measured cortisol

levels (Lilja 1998; Doering 2000). Length of hospital stay was re-

ported in five studies (Wijgman 1994; Butler 1996; Clode-Baker

1997; Daltroy 1998; Crowe 2003), hip function and mobilisa-

tion in four (Wijgman 1994; Clode-Baker 1997; Doering 2000;

Crowe 2003) and patient satisfaction in five (Santavirta 1994;

Butler 1996; Clode-Baker 1997; Cooil 1997; Daltroy 1998).

Pain was measured either through self-reporting (Clode-Baker

1997; Lilja 1998) or by charted medication (Wijgman 1994;

Daltroy 1998; Doering 2000). Other outcomes included depres-

sion (Clode-Baker 1997; Doering 2000; Lilja 1998), recall and

recognition (Cooil 1997), compliance (Santavirta 1994; Butler

1996) and postoperative complications (Daltroy 1998; Crowe

2003).

Risk of bias in included studies

The included studies were of varying methodological quality (see

Table of Included Studies). All studies were reported as randomised

but half had inadequate reporting of the study methods. Trial pop-

ulations were generally moderate in size. Most studies reported

clear, though sometimes brief, inclusion and exclusion criteria ex-

cept for two studies where the exclusion criteria were not stated

(Clode-Baker 1997; Lilja 1998).

Allocation was reported as being adequately concealed in two stud-

ies (Butler 1996; Crowe 2003), was unclear in one (Clode-Baker

1997) and was not reported in the remaining six. Blinded outcome

assessment, an important indicator of quality in procedural trials

with subjective outcomes, was carried out in four studies (Cooil

1997; Daltroy 1998; Lilja 1998; Crowe 2003); was achieved for

some outcomes in two others (Butler 1996; Doering 2000); and

was not done in the remaining three (Santavirta 1994; Wijgman

1994; Clode-Baker 1997). Participants were blinded in two stud-

ies (Cooil 1997; Lilja 1998). Blinding of participants was unclear

in the remaining studies, although in two studies participants were

randomised and given the educational intervention before they

were informed about the study or had given consent to partici-

pate (Butler 1996; Clode-Baker 1997). In the six studies reporting

postoperative function and length of hospital stay, loss to follow-

up at discharge was minimal (range 0.5% to 1.5%) except for

Butler 1996 (12.5%). Most studies failed to report if an intention-

to-treat analysis was undertaken.

Effects of interventions

Nine studies involving 782 participants (median size 78, range

42 to 170) were included in the review. Five studies presented

data in a form that could be extracted and combined in a meta-

analysis (Santavirta 1994; Wijgman 1994; Butler 1996; Doering



2000; Crowe 2003). The data from one other study (Clode-Baker

1997) were reported as medians and ranges and are included as

an additional table (Table 1). The remaining three studies did not

present data in a form that could be included in the review (Cooil

1997; Daltroy 1998; Lilja 1998). Despite attempts to contact all

authors, we were only able to secure additional data for three stud-

ies (Butler 1996; Doering 2000; Crowe 2003). Two studies in-

cluded participants undergoing knee replacements (Daltroy 1998;

Crowe 2003). In the meta-analysis the data for hips and knees are

presented as separate subgroups and then combined to provide an

overall estimate.

ANXIETY

The three studies involving 301 patients that presented data for

preoperative anxiety (Butler 1996; Doering 2000; Crowe 2003)

found preoperative education to be beneficial in reducing anxiety.

The WMD for hip and knees combined was -5.64 (95% CI -7.45

to -3.82) as measured on the State-Trait Anxiety Index (scale 0

to 100). However, in contrast to these studies, Clode-Baker 1997

and Lilja 1998 failed to detect a significant effect on preoperative

anxiety.

Two studies also looked at postoperative anxiety at different time

periods. Neither showed any significant benefit of preoperative

education. In Doering 2000 (n = 95) the WMD on the first post-

operative day was -3.81 (95% CI -7.75 to 0.13). Postoperative

anxiety measured at discharge was WMD -9.58 (95% CI -19.28

to 0.12) in Butler 1996 (n = 70). Clode-Baker 1997 and Lilja 1998

also concluded that preoperative education had no significant ef-

fect on postoperative anxiety.

LENGTH OF HOSPITAL STAY

Data on length of hospital stay were reported in four studies in-

volving 365 patients (Wijgman 1994; Butler 1996; Doering 2000;

Crowe 2003). Overall, there was no significant difference between

the groups (WMD -0.97; 95% CI -2.67 to 0.73), although Crowe

2003 detected a significant difference among those undergoing

hip replacement in their study of intensive education and support

among poorer functioning participants. Clode-Baker 1997 and

Daltroy 1998 also concluded that information provision did not

have any significant effect on length of stay. This was the only out-

come that exhibited significant heterogeneity. A sensitivity analy-

sis revealed that this was due entirely to Crowe 2003. The WMD

changed to 0.40 days (95% CI -0.10 to 0.90) when Crowe 2003

was excluded from the analysis.

MOBILITY OUTCOMES

The same four studies that reported length of hospital stay also

presented data for days to standing and days to climb stairs. There

was no discernible difference between the groups for days to stand-

ing (WMD -0.12; 95% CI -0.65 to 0.42) and days to climb stairs

(WMD 0.23; 95% CI -0.31 to 0.76).

POSTOPERATIVE PAIN

None of the five studies reporting postoperative pain detected any

difference between the groups. In Doering 2000, the only study

for which data could be extracted for this outcome, the WMD was

-2.43 (95% CI -14.41 to 9.55) as measured on a visual analogue

scale.

PATIENT SATISFACTION

Data on patient satisfaction were presented in two studies

(Santavirta 1994; Butler 1996) using a five point rating scale where

one corresponded to ’very dissatisfied’ and five to ’very satisfied’.

No significant differences were found between the groups (WMD

0.19; 95% CI -0.02 to 0.39). In Butler 1996, the satisfaction rat-

ings were taken once both groups had received the same informa-

tion even though the treatment group had received the informa-

tion before admission which may explain the lack of difference

between the groups.

EXERCISE COMPLIANCE

None of the studies presented data for exercise compliance, so the

effect of preoperative education on postoperative exercise cannot

be determined.

POSTOPERATIVE COMPLICATIONS

Reporting of postoperative complications was generally poor.

Santavirta 1994 found there was no statistical difference in the

number of early complications, whereas Crowe 2003 found there

were significantly fewer postoperative complications in the inter-

vention group (p = 0.007). Neither study referred specifically to

incidence of deep vein thrombosis.

D I S C U S S I O N

We found insufficient evidence to support or refute the use of pre-

operative education to improve postoperative outcomes in peo-

ple undergoing hip and knee replacement surgery, especially with

respect to functioning and length of hospital stay. This finding

needs to be interpreted in light of several factors. Firstly, only a

small number of studies contributed data to the pooled analyses.

Secondly, the use of an active comparator in the majority of stud-

ies (whereby participants in the control group also received some

form of preoperative education) is likely to result in smaller effect

sizes in comparison to control groups that receive no preoperative

education. And thirdly, the use of standardised postoperative pro-

tocols in hospital is likely to limit the variation between groups

with respect to length of stay and mobility outcomes. The small

sample size of many of the studies also means that rare but poten-

tially important postoperative complications are less likely to be

detected. It should also be noted that only two studies included

patients undergoing total knee replacement, and thus the results

should be applied cautiously to this group of patients.

For length of stay, established ward routines often determine when

patients are mobilised and discharged, and the pressure on hospi-

tal beds means that patients 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 patient’s level of anxiety and knowledge may deter-

mine how much time staff spend with them but may not prevent

hospital staff mobilising the patient on the prescribed day. Dif-

ferences between the studies regarding length of hospital stay and

days to standing and climbing stairs may be more of a reflection of

when and where these studies were conducted and the guidelines

and protocols in place at the time.

Only one study (Crowe 2003) showed that preoperative education

was beneficial in reducing length of stay. However, the results of

this study should be interpreted in context. The participants were

required to have poor social support and/or be functioning at a

low level, and they received a mixture of content that included

procedural information, education, skills training and individu-

ally tailored support programmes. Furthermore, the groups were

unbalanced at baseline, with those in the control group being sig-

nificantly more disabled. Thus, the benefits of preoperative edu-

cation may be increased in patients with greater need.

Our finding for length of hospital stay contradicted the results of

reviews that have considered the impact of preoperative education

for surgery in general. In a wide-ranging review, Shuldham 1999

concluded that psycho-educational preparation of patients before

surgery reduced length of hospital stay, and that larger effect sizes

were identified when a mixture of content was included. Despite

the heterogeneous nature of the interventions included in this

review, we found no evidence (with the exception of Crowe 2003)

that a mixture of content had a significant effect. For the other two

measures of postoperative functioning, days to standing and days

to climb stairs, there was no statistically significant heterogeneity,

and only small non-significant differences between the groups were

detected.

Education was beneficial in reducing preoperative anxiety. Anxi-

ety is clinically important not only because it is an uncomfortable

psychological state, but also because of its interaction with pain

and coping, which are thought to influence functional outcomes.

Being very anxious before surgery does not necessarily mean a per-

son will have worse outcomes, or find it harder to recover from the

operation, but it may have an effect on a person’s ability to under-

stand and retain important information (Wallace 1986; Bastian

2002). The meta-analysis showed that preoperative education is

effective in reducing preoperative anxiety, however, these results

should be treated with caution as the effect was small and was not

supported by some studies.

The impact on postoperative anxiety was inconclusive. Sample

sizes were small and none of the included studies showed any sta-

tistically significant difference between the groups. Daltroy 1998

went further and investigated the interaction with baseline denial

and anxiety for several outcomes. He concluded that the provi-

sion of preoperative education was not as important as the abil-

ity to identify the most and least anxious patients. High preop-

erative anxiety was associated with greater postoperative anxiety,

pain, medication requirement and length of stay. Preoperative in-

formation was only found to be beneficial among the least anxious

patients, and only in relation to a reducing pain medication. This

concurs with the review by Hathaway 1986, which concluded that

the focus should be on procedural aspects of care among patients

with lower levels of anxiety or fear and on psychological aspects

among those with high anxiety and fear. Thus when preoperative

education is individually tailored, for example according to anxi-

ety or functional status, there may be an effect on outcomes.

The main methodological issue concerned the variety of methods

used to deliver preoperative education in the included studies and

whether it was appropriate to pool the data. Despite this between-

study heterogeneity, the effect across trials was remarkably con-

sistent. We excluded two studies because they incorporated some

form of postoperative intervention designed to supplement the

provision of preoperative education. It is more likely that such

strategies will have a beneficial effect on postoperative outcomes.

Wong 1985, for example, combined the preoperative instruction

of rehabilitation exercises with postoperative behavioural strate-

gies (positive reinforcement and reminder systems). This resulted

in significantly improved patient compliance with postoperative

exercises. Gammon 1996b showed that postoperative teaching, in

addition to preoperative education, reduced anxiety and depres-

sion and increased patient’s sense of coping. In addition, patients

were mobilised more quickly and had shorter hospital stays. Sim-

ply educating or informing patients preoperatively may not be suf-

ficient to reduce postoperative anxiety and improve functioning.

Future research and practice needs to consider the use of multi-

faceted interventions combined pre and postoperative interven-

tions, and the assessment of individual patient requirements.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

For patients undergoing hip or knee replacement surgery, there is

insufficient evidence from the available studies to support the use

of preoperative education over and above standard care to improve

postoperative outcomes, especially with respect to pain, function-

ing and length of hospital stay. There may be beneficial effects

when preoperative education is tailored according to anxiety, or

targeted at those most in need of support (e.g. those who are par-

ticularly disabled, or have limited social support structures). There

is evidence that preoperative education has a modest beneficial

effect on preoperative anxiety.

Implications for research

Educating and informing patients preoperatively without consid-

ering individual needs is not sufficient to improve postoperative

outcomes. Future research should investigate how to incorporate

assessments of patient requirements (e.g. psychological condition)



in tailoring individual programmes of pre and postoperative care.

Research could also assess which method (or combination of meth-

ods) is best for delivering education, and how preoperative educa-

tion can be reinforced by postoperative care.

A C K N O W L E D G E M E N T S

We thank Amrita Williams for assistance in drafting the back-

ground section and Cristel Dunshea for help with extracting data

from Wijgman 1994. Thanks also to Gordon Butler, Stephan Do-

ering and Jean Crowe for providing additional trial data.

R E F E R E N C E S

References to studies included in this review

Butler 1996 {published and unpublished data}

Butler GS, Hurley CA, Buchanan KL, Smith-VanHorne

J. Prehospital education: effectiveness with total hip

replacement surgery patients. Patient Education &

Counseling 1996;29(2):189–97.

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}

Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH.

Preoperative education for total hip and knee replacement

patients. Arthritis Care & Research 1998;11(6):469–78.

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.

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.

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.

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

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.

Gammon 1996b {published data only}

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.∗ Gammon J, Mulholland CW. Effect of preparatory

information prior to elective total hip replacement on

psychological coping outcomes. Journal of Advanced Nursing

1996;24(2):303–8.



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.

Mikulaninec 1987 {published data only}

Mikulaninec CE. Effects of mailed preoperative

instructionson learning and anxiety. Patient Education and

Counselling 1987;10(3):253–65.

Roach 1995 {published data only}

Roach JA, Tremblay LM, Bowers DL. A preoperative

assessment and education program: implementation and

outcomes. Patient Education & Counseling 1995;25(1):

83–8.

Wong 1985 {published data only}

Wong J, Wong S. A randomized controlled trial of a new

approach to preoperative teaching and patient compliance.

International Journal of Nursing Studies 1985;22(2):105–15.

References to studies awaiting assessment

Cunado 1999 {published data only}

Cunado Barrio A, Gil ML, Caston JR, De La Torre JS,

Martinez LC, Garcia Lopez F. The effect of a structured,

individualized ’nursing visit’ on the anxiety of surgical

patients. A randomized clinical study [Spanish]. Enfermeria

Clinica 1999;9(3):98–104.

Additional references

Bastian 2002

Bastian H. Reducing anxiety before surgery (Hot topic).

Cochrane Database of Systematic Reviews May 2002, Issue 1.

[DOI: DOI: 10.1002/14651858.CD003526.pub2]

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.

Creamer 1998

Creamer P, Flores R, Hochberg MC. Management of

osteoarthritis in older adults. Clinics in Geriatric Medicine

1998;14(3):435–54.

Devine 1983

Devine EC, Cook TD. A meta-analytic analysis of effects of

psychoeducational interventions on length of postsurgical

hospital stay. Nursing Research 1983;32:267–74.

Devine 1992

Devine EC. Effects of psychoeducational care for adult

surgical patients: a meta-analysis of 191 studies. Patient

Education and Counseling 1992;19:129–42.

Gammon 1996a

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.

Hathaway 1986

Hathaway D. Effect of pre-operative instruction on post-

operative outcomes: a meta-analysis. Nursing Research

1986;35(5):269–75.

Knutsson 1999

Knutsson S, Engberg IB. An evaluation of patients’ quality

of life before, 6 weeks and 6 months after total hip

replacement surgery. Journal of Advanced Nursing 1999;30

(6):1349–59.

Palmer 1999

Palmer LM. Management of the patient with a total

joint replacement: the primary care practitioner’s role.

Lippincott’s Primary Care Practice 1999;3(4):419–27.

Shuldham 1999

Shuldham C. A review of the impact of pre-operative

education on recovery from surgery. International Journal of

Nursing Studies 1999;36:171–7.

Tugwell 2003

Tugwell P, Shea B, Boers M, Simons L, Strand V, Wells G.

Evidence-based Rheumatology. London: BMJ Books, 2003.

Wallace 1986

Wallace LM. Pre-operative state anxiety as a mediator of

psychological adjustment to and recovery from surgery.

British Journal of Medical Psychology 1986;59:253–61.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Butler 1996

Methods Randomised parallel group trial with allocation concealed by an admissions clerk (information from

author). Participant blinding: unclear. Outcome assessment blinding: achieved for time in postoperative

physiotherapy but not for other outcomes. Description of withdrawals: no. Intention-to-treat analysis:

not stated

Participants 80 participants aged 17 to 85 (mean 63, SD 13) undergoing total hip replacement. Intervention group

18 female, 14 male (mean age 64, SD 13); control group 22 female, 26 male (mean age 62, SD 13).

Inclusion criteria: ability to read English. Exclusion criteria: previous hip replacement.

Location: Canada.

Interventions Intervention group (n = 32) mailed an 18 page teaching booklet as part of the preadmission package 4 to

6 weeks before surgery.

Control group (n = 48) mailed preadmission package only (containing information of a general nature)

Outcomes Anxiety at admission and discharge (Spielberger State-Trait Anxiety Inventory); length of hospital stay;

practising of prehospital preparatory exercises; attendance at physiotherapy and occupational therapy

sessions; patient satisfaction

Notes On admission, both groups were treated the same. Patient satisfaction ratings were only taken just before

discharge, by which time both groups had received the same information. An overall satisfaction rating

was not obtained. Instead, ratings were given for each of six questions. The data entered in the review for

patient satisfaction relate to the question “How satisfied were you with the amount of information you

received about your hip joint and what a total hip replacement is?”

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Clode-Baker 1997

Methods Randomised parallel group trial stratified by age. Randomisation performed by an independent statistician,

but unclear if allocation was concealed. Participant blinding: unclear. Outcome assessment blinding: no.

Description of withdrawals: no. Intention-to-treat analysis: not stated

Participants 78 people undergoing total hip replacement (52 female, 26 male; aged 65 years and younger (n = 25), 66

to 74 (n = 27), 75 and over (n = 27)).

Exclusion criteria: none stated.

Location: United Kingdom.



Clode-Baker 1997 (Continued)

Interventions Intervention group (n = 41) mailed information about the hospital stay and postoperative recovery,

consisting of a 20 minute video, booklet and set of life-size plastic model bones approximately 4 weeks

before surgery.

Control group (n = 37) received no preadmission information but were seen routinely on admission by

nursing staff who provided information about the hospital stay

Outcomes Hip function evaluation; general health state (Nottingham Health Profile); stress and arousal (Stress Arousal

Checklist); anxiety and depression (Hamilton Anxiety and Depression Scale); days to mobilisation; length

of hospital stay; pain (descriptive ordinal scale); sleep disturbance; patient satisfaction

Notes 24% of patients were undergoing their second primary total hip replacement: “nearly all” of these patients

were in the intervention group

Risk of bias


Allocation concealment? Unclear B - Unclear

Cooil 1997

Methods Randomised parallel group trial with randomisation within matched pairs based on age, gender and

socio-economic status. Allocation concealment not stated. Participant blinding: yes. Outcome assessment

blinding: yes. Description of withdrawals: unclear. Intention-to-treat analysis: not stated

Participants 42 participants (30 female, 12 male) undergoing total hip replacement. Intervention group aged 54 to 84

years (mean 69, SD 8); control group aged 56 to 84 years (mean 69, SD 8).

Exclusion criteria: previous hip replacement.

Location: United Kingdom.

Interventions Intervention group (n = 21) given an information sheet containing instructions regarding postoperative

protocol and list of ecercises as well as verbal explanation of contents; exercises and activities taught through

demonstration by a physiotherapist.

Control group (n = 21) given the same information sheet, asked to read and follow instructions but

received no further contact with demonstrator

Outcomes Recall of exercises and recognition of advice on the first postoperative day; patient satisfaction (with

content and delivery of information)

Notes

Risk of bias





Crowe 2003

Methods Randomised parallel group trial with allocation concealed using a random number table and a system

of sealed envelopes. Participant blinding: not stated. Outcome assessment blinding: yes. Description of

withdrawals: yes. Intention-to-treat analysis: yes

Participants 133 participants undergoing total hip replacement (n = 65) or total knee replacement (n = 68). Intervention

group 51 female, 14 male (mean age 67, SD 12); control group 55 female, 13 male (mean age 71, SD

11).

Inclusion criteria: admission for elective hip or knee replacement, participants not functioning well,

limited social support and/or comorbid medical conditions. Exclusion criteria: functioning well, managing

activities of daily living and access to good care-giver support, limited English, undergoing a revision or

second joint replacement within two years.

Location: Canada.

Interventions Intervention group (n = 65) provided with a preoperative education package consisting of a 50 minute

video and a booklet giving information on length of stay, discharge criteria, respite care and diet. Some

patients given tour of the hospital unit, demonstration of equipment, dietician counselling and social

work input. All participants received individualised counselling from an occupational therapist.

Control group (n = 68) received one standard preoperative clinic visit (lasting about 7 hours) 1 to 2 weeks

before surgery. Participants were informed about the hospital stay and the immediate postoperative phase

Outcomes Days to eligibility for discharge; preoperative anxiety (Spielberger State-Trait Anxiety Inventory); length

of hospital stay; days to mobilisation (out of bed, walking and climbing stairs)

Notes Randomisation resulted in uneven numbers of hip and knee replacements in each group

Risk of bias


Allocation concealment? Yes A - Adequate

Daltroy 1998

Methods Randomised trial using a 2 x 2 factorial design stratified by joint (hip or knee) and age (18 to 70 years

or >70 years). Allocation concealment not stated. Participant blinding: not stated. Outcome assessment

blinding: yes. Description of withdrawals: unclear. Intention-to-treat analysis: not stated

Participants 222 participants (146 female, 76 male; mean age 64, SD 12) undergoing total hip replacement (n = 104)

or total knee replacement (n = 118).

Exclusion criteria: previous hip or knee replacement, inability to speak English or fill out questionnaires.

Location: USA.

Interventions Information group (n = 58) received a 12 minute audio-tape slide programme on the postoperative in-

hospital rehabilitation experience.

Relaxation group (n = 58) received training in Benson’s Relaxation Response with a bedside audiotape.

Information and relaxation group (n = 52) received the information intervention followed by relaxation

training.

Control group (n = 54) received neither intervention.



Daltroy 1998 (Continued)

Outcomes Anxiety at day four (Spielberger State-Trait Anxiety Inventory); pain (charted medication); length of

hospital stay; mental status (Mini-Mental State Exam) on day 4; use of continuous passive motion machine;

postoperative complications; usefulness of intervention materials

Notes Data from the Information and relaxation group (n = 52) were excluded from the analyses because our

inclusion criteria specified that the education/information intervention should be the sole component of

the intervention

Risk of bias



Doering 2000

Methods Randomised parallel group trial with unstated allocation concealment. Participant blinding not stated.

Outcome assessment blinding: for physiotherapy measures and use of analgesics but not for other out-

comes. Description of withdrawals: pre-randomisation only. Intention-to-treat analysis: not stated

Participants 100 participants undergoing total hip replacement. Intervention group 21 female, 25 male (mean age 59,

SD 11); control group 17 female, 31 male (mean age 60, SD 9).

Inclusion criteria: admission for total hip replacement surgery, age > 17 years, osteoarthritis of the hip.

Exclusion criteria: previous hip surgery, comorbidity associated with severe pain, scheduled elective hip

replacement, comorbidity that might alter cortisol and catecholamine excretion, psychiatric comorbidity.

Location: Austria.

Interventions Intervention group (n = 46) shown a 12 minute videotape in the presence of an investigator the night

before surgery containing procedural information (pre and postoperative), behavioural instructions and

information about the sensory experiences a patient is likely to have.

Control group (n = 54) received preoperative information delivered by a surgeon and anaesthetist, and

routine information sheets

Outcomes Anxiety (Spielberger State-Trait Anxiety Inventory); depression (von Zerssen Depression Scale); days to

mobilisation (standing and climbing stairs); length of hospital stay; pain (postoperative analgesics); blood

pressure; cortisol excretion

Notes

Risk of bias





Lilja 1998

Methods Randomised parallel group trial with unstated allocation concealment. Participant blinding: yes. Outcome

assessment blinding: yes (all self-reported). Description of withdrawals: yes. Intention-to-treat analysis:

not stated

Participants 55 participants (17 female, 33 male; median age 65) undergoing total hip replacement.

Inclusion criteria: < 75 years of age. Exclusion criteria: none stated.

Location: Sweden.

Interventions Intervention group (n = 22) given extended formalised information concerning pre and postoperative

procedures by an anaesthetic nurse for 30 minutes the day before surgery.

Control group (n = 28) informed about pre and postoperative routines by a ward nurse

Outcomes Anxiety (Hospital Anxiety and Depression Scale); stress and pain (visual analog scale); serum cortisol

(radioimmunoassay)

Notes Aim of the study was to evaluate effects of extended preoperative information on perioperative stress

Risk of bias



Santavirta 1994

Methods Randomised parallel group trial with unstated allocation concealment. Participant blinding: not stated.

Outcome assessment blinding: no. Description of withdrawals: to point of surgery only. Intention-to-

treat analysis: not stated

Participants 60 participants undergoing total hip replacement. Intervention group 19 female, 8 male (mean age 59

years, SD 6); control group 19 female, 14 male; (mean age 58, SD 5).

Inclusion criteria: age > 17 years. Exclusion criteria: previous major orthopaedic surgery, severe disabilities.

Location: Finland.

Interventions Intervention group (n = 27) before admission received an 18 page patient guide information booklet

on total hip replacement surgery and rehabilitation. On admission, had a 20 to 60 minutes teaching

session delivered by one of the investigators concerning total hip replacement and rehabilitation planned

according to each participant’s situation.

Control group (n = 33) received the 18 page booklet only.

Outcomes Patient knowledge (disease, treatment and rehabilitation); patient satisfaction; patient compliance (ques-

tionnaire)

Notes Measurements taken on admission to hospital and 2 to 3 months postoperatively

Risk of bias




Santavirta 1994 (Continued)


Wijgman 1994

Methods Randomised parallel group trial with unstated allocation concealment. Participant blinding: no. Outcome

assessment blinding: no. Description of withdrawals: yes. Intention-to-treat analysis: unclear

Participants 64 participants (48 female, 16 male; mean age 65) undergoing cemented or uncemented total hip replace-

ment.

Inclusion criteria: primary coxarthrosis confirmed by X-ray. Exclusion criteria: pathological malformations

(other than hip problems) which could interfere with rehabilitation.

Location: Netherlands.

Interventions Intervention group (n = 31) received preoperative instructions (30 minutes) in groups of 4 to 6 delivered

by two physiotherapists as well as preoperative exercise therapy including muscle-setting exercises.

Control group (n = 32) not described.

Outcomes Function/disability (Harris Hip Score); days to mobilisation (standing, walking and climbing stairs);

length of hospital stay; pain (medication)

Notes Original publication in Dutch.

Risk of bias



SD: standard deviation

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Bondy 1999 Studied the effects of anaesthetic patient education on preoperative anxiety. Although the patients were under-

going total hip replacements, the information was not specific to hip or knee replacement surgery

Brull 2002 Not a trial of preoperative education. Anxiety and depression were measured in a randomly selected group of

patients undergoing elective hip or knee replacement with the aim of measuring the effects of preoperative

anxiety and depression on postoperative recovery

Gammon 1996b In addition to receiving preoperative education, patients in the intervention group were also exposed to a

postoperative teaching programme before discharge. The study was excluded because nce it is not possible to

isolate the effects of the preoperative education



(Continued)

Haslam 2001 A trial to detect differences between acupuncture and advice/exercise in the symptomatic treatment of os-

teoarthritis of the hip. Patients were on a waiting list for hip replacement but did not have surgery as part of the

study. Advice given was not related to surgery for hip replacement

Hough 1991 Not a randomised trial.

Mikulaninec 1987 Preoperative instruction was of a general nature and not specific to hip or knee replacement. It was designed

for patients undergoing a range of general surgical procedures including abdominal, thoracic, perineal and

orthopaedic surgery

Roach 1995 Not a randomised trial.

Wong 1985 The intervention combined preoperative instruction of rehabilitation exercises with postoperative behavioural

strategies (including an alarm clock reminder to do exercises and verbal reinforcement from nurses)



D A T A A N D A N A L Y S E S

Comparison 1. Preoperative education versus routine care

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Preoperative anxiety (Spielberger

State-Trait Anxiety Index)

3 301 Mean Difference (IV, Random, 95% CI) -5.64 [-7.45, -3.82]

1.1 Hip 3 233 Mean Difference (IV, Random, 95% CI) -5.75 [-8.40, -3.11]

1.2 Knee 1 68 Mean Difference (IV, Random, 95% CI) -5.52 [-8.34, -2.70]

2 Postoperative anxiety

(Spielberger State-Trait Anxiety

Index) (hip)

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

2.1 Day 1 1 95 Mean Difference (IV, Random, 95% CI) -3.81 [-7.75, 0.13]

2.2 Discharge 1 70 Mean Difference (IV, Random, 95% CI) -9.58 [-19.28, 0.12]

3 Length of hospital stay (days) 4 365 Mean Difference (IV, Random, 95% CI) -0.97 [-2.67, 0.73]

3.1 Hip 4 297 Mean Difference (IV, Random, 95% CI) -0.58 [-2.35, 1.18]

3.2 Knee 1 68 Mean Difference (IV, Random, 95% CI) -2.97 [-6.06, 0.12]

4 Days to standing 3 286 Mean Difference (IV, Random, 95% CI) -0.12 [-0.65, 0.42]

4.1 Hip 3 218 Mean Difference (IV, Random, 95% CI) 0.03 [-0.41, 0.48]


5 Days to climb stairs 3 275 Mean Difference (IV, Random, 95% CI) 0.23 [-0.31, 0.76]

5.1 Hip 3 207 Mean Difference (IV, Random, 95% CI) 0.27 [-0.27, 0.82]


6 Postoperative pain (visual

analogue scale) (hip)

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

6.1 Day 1 1 94 Mean Difference (IV, Random, 95% CI) -2.43 [-14.41, 9.55]

7 Patient satisfaction with

information (hip)

2 139 Mean Difference (IV, Random, 95% CI) 0.19 [-0.02, 0.39]



Analysis 1.1. Comparison 1 Preoperative education versus routine care, Outcome 1 Preoperative anxiety

(Spielberger State-Trait Anxiety Index).

Review: Pre-operative education for hip or knee replacement

Comparison: 1 Preoperative education versus routine care

Outcome: 1 Preoperative anxiety (Spielberger State-Trait Anxiety Index)

Study or subgroup Preop. education ControlMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Hip

Butler 1996 30 27.93 (25.24) 40 42.65 (29.06) 2.0 % -14.72 [ -27.47, -1.97 ]

Crowe 2003 36 39.97 (4.86) 29 45.73 (6.51) 40.5 % -5.76 [ -8.61, -2.91 ]

Doering 2000 44 38.43 (11.16) 54 42.91 (11.67) 16.0 % -4.48 [ -9.01, 0.05 ]

Subtotal (95% CI) 110 123 58.5 % -5.75 [ -8.40, -3.11 ]

Heterogeneity: Tau2 = 0.66; Chi2 = 2.20, df = 2 (P = 0.33); I2 =9%

Test for overall effect: Z = 4.26 (P = 0.000020)

2 Knee

Crowe 2003 29 40.17 (5.03) 39 45.69 (6.83) 41.5 % -5.52 [ -8.34, -2.70 ]

Subtotal (95% CI) 29 39 41.5 % -5.52 [ -8.34, -2.70 ]

Heterogeneity: not applicable


Total (95% CI) 139 162 100.0 % -5.64 [ -7.45, -3.82 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 2.21, df = 3 (P = 0.53); I2 =0.0%

Test for overall effect: Z = 6.09 (P < 0.00001)

-10 -5 0 5 10

Favours education Favours control



Analysis 1.2. Comparison 1 Preoperative education versus routine care, Outcome 2 Postoperative anxiety

(Spielberger State-Trait Anxiety Index) (hip).



Outcome: 2 Postoperative anxiety (Spielberger State-Trait Anxiety Index) (hip)



Difference


1 Day 1

Doering 2000 43 35.77 (10.32) 52 39.58 (9) 100.0 % -3.81 [ -7.75, 0.13 ]

Subtotal (95% CI) 43 52 100.0 % -3.81 [ -7.75, 0.13 ]



2 Discharge

Butler 1996 30 21.57 (18.44) 40 31.15 (22.93) 100.0 % -9.58 [ -19.28, 0.12 ]

Subtotal (95% CI) 30 40 100.0 % -9.58 [ -19.28, 0.12 ]



-10 -5 0 5 10




Analysis 1.3. Comparison 1 Preoperative education versus routine care, Outcome 3 Length of hospital stay

(days).



Outcome: 3 Length of hospital stay (days)



Difference


1 Hip

Butler 1996 30 10.28 (4.74) 40 10.38 (5.53) 18.5 % -0.10 [ -2.51, 2.31 ]

Crowe 2003 36 6.77 (7.03) 29 12.89 (6.83) 13.6 % -6.12 [ -9.50, -2.74 ]

Doering 2000 46 11.5 (1.53) 53 11.15 (1.17) 28.5 % 0.35 [ -0.19, 0.89 ]

Wijgman 1994 31 15.7 (3.4) 32 14.8 (2.1) 24.5 % 0.90 [ -0.50, 2.30 ]

Subtotal (95% CI) 143 154 85.1 % -0.58 [ -2.35, 1.18 ]



2 Knee

Crowe 2003 29 6.21 (2.27) 39 9.18 (9.5) 14.9 % -2.97 [ -6.06, 0.12 ]

Subtotal (95% CI) 29 39 14.9 % -2.97 [ -6.06, 0.12 ]



Total (95% CI) 172 193 100.0 % -0.97 [ -2.67, 0.73 ]



-10 -5 0 5 10




Analysis 1.4. Comparison 1 Preoperative education versus routine care, Outcome 4 Days to standing.



Outcome: 4 Days to standing



Difference


1 Hip

Crowe 2003 36 4.44 (3.53) 29 5.46 (2.04) 12.3 % -1.02 [ -2.39, 0.35 ]

Doering 2000 43 1.21 (0.71) 47 1.06 (0.25) 56.6 % 0.15 [ -0.07, 0.37 ]

Wijgman 1994 31 7.3 (2.2) 32 7.2 (1.4) 22.3 % 0.10 [ -0.81, 1.01 ]

Subtotal (95% CI) 110 108 91.3 % 0.03 [ -0.41, 0.48 ]



2 Knee

Crowe 2003 29 5.03 (3.31) 39 6.16 (3.78) 8.7 % -1.13 [ -2.82, 0.56 ]

Subtotal (95% CI) 29 39 8.7 % -1.13 [ -2.82, 0.56 ]



Total (95% CI) 139 147 100.0 % -0.12 [ -0.65, 0.42 ]



-10 -5 0 5 10




Analysis 1.5. Comparison 1 Preoperative education versus routine care, Outcome 5 Days to climb stairs.



Outcome: 5 Days to climb stairs



Difference


1 Hip

Crowe 2003 36 5.67 (7.57) 29 5.94 (2.36) 4.2 % -0.27 [ -2.89, 2.35 ]

Doering 2000 41 6.71 (1.27) 38 6.39 (1.5) 75.3 % 0.32 [ -0.30, 0.94 ]

Wijgman 1994 31 11.7 (2.9) 32 11.5 (2.6) 15.4 % 0.20 [ -1.16, 1.56 ]

Subtotal (95% CI) 108 99 94.9 % 0.27 [ -0.27, 0.82 ]



2 Knee

Crowe 2003 29 6.04 (5.5) 39 6.66 (3.99) 5.1 % -0.62 [ -2.98, 1.74 ]

Subtotal (95% CI) 29 39 5.1 % -0.62 [ -2.98, 1.74 ]



Total (95% CI) 137 138 100.0 % 0.23 [ -0.31, 0.76 ]



-10 -5 0 5 10




Analysis 1.6. Comparison 1 Preoperative education versus routine care, Outcome 6 Postoperative pain

(visual analogue scale) (hip).



Outcome: 6 Postoperative pain (visual analogue scale) (hip)



Difference


1 Day 1

Doering 2000 43 41.65 (31.44) 51 44.08 (27.06) 100.0 % -2.43 [ -14.41, 9.55 ]

Subtotal (95% CI) 43 51 100.0 % -2.43 [ -14.41, 9.55 ]



-10 -5 0 5 10


Analysis 1.7. Comparison 1 Preoperative education versus routine care, Outcome 7 Patient satisfaction

with information (hip).



Outcome: 7 Patient satisfaction with information (hip)



Difference


Butler 1996 32 4.16 (0.68) 47 4.09 (0.75) 41.7 % 0.07 [ -0.25, 0.39 ]

Santavirta 1994 27 4.77 (0.43) 33 4.5 (0.63) 58.3 % 0.27 [ 0.00, 0.54 ]

Total (95% CI) 59 80 100.0 % 0.19 [ -0.02, 0.39 ]



-10 -5 0 5 10

Favours control Favours education



A D D I T I O N A L T A B L E S

Table 1. Results of included studies with data not appropriate for MetaView

Study ID Intervention Outcome Results

Clode-Baker 1997 Preadmission versus no preadmis-

sion information

Preoperative anxiety

(Hamilton Anxiety and Depression

Scale 0 to 21)

Intervention: median 6 (range 1 to

17)

Control: median 8 (range 2 to 21)

No significant difference between

the two groups.

Postoperative anxiety (Hamilton

Anxiety and Depression Scale 0 to

21)


15)



the two groups.

Nottingham Health Profile (post-

operative) (0 to 38)


29)



the two groups.

Days to mobilisation Intervention: median 2 (range 1 to

6)



the two groups.

Length of hospital stay Intervention: median 12 (range 7 to

21)



the two groups.



A P P E N D I C E S

Appendix 1. MEDLINE search strategy (Ovid) <1966 to April Week 4 2003>

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. random$.mp.

13. ((singl$ or doubl$) adj5 (blind$ or mask$)).mp.

14. or/11-13

15. 4 and 10 and 14

Appendix 2. EMBASE search strategy (Ovid) <1980 to 2002 Week 24>

1. exp Total Hip Prosthesis/

2. exp Total Knee Replacement/

3. exp Hip Arthroplasty/

4. exp Knee Arthroplasty/

5. (hip$ adj2 (replac$ or prosthe$ or arthroplast$)).mp.

6. (knee$ adj2 (replac$ or prosthe$ or arthroplast$)).mp.

7. or/1-6


9. exp PHYSIOTHERAPY/

10. (exercise$ or physiotherapy or physical therapy or education or information or brochure$ or video$ or leaflet$ or pamphlet$).

mp.

11. or/8-10

12. Clinical Trial/

13. Randomized Controlled Trial/

14. (random$ or trial$ or double blind$ or placebo$).mp.

15. or/11-14

16. 7 and 11 and 16



Appendix 3. CINAHL search strategy (Ovid) <1982 to May Week 2 2003>

1. exp Arthroplasty, Replacement/

2. exp Orthopedic Prosthesis/

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

4. or/1-3


6. exp PREOPERATIVE EDUCATION/



9. or/5-8

10. Clinical Trials/

11. random$.mp.

12. ((singl$ or doubl$) adj3 (blind$ or mask$)).mp.

13. trial$.mp.

14. or/10-13

15. 4 and 9 and 14

Appendix 4. PsycINFO search strategy (Ovid) <1872 to May Week 2 2003>

1. ((hip$ or knee$) adj5 (replac$ or arthroplast$ or prosthe$)).mp.

2. exp Client Education/



5. or/2-4

6. 1 and 5

Appendix 5. Description of the education intervention

Study Content

Butler 1996 An 18 page teaching booklet ’Total hip replacement: a patient guide’ was sent to participants at home. The

booklet was developed by a multidisciplinary team and contained information on the anatomy of a normal and

diseased hip, total hip prosthesis, exercises to practice before admission, what to expect in hospital, precautions

following surgery and planning for discharge. The booklet has a readability age of Grade 6 to 7 with 22 drawings

and photographs

Clode-Baker 1997 A 20 minute video, booklet and set of plastic models were sent to participants at home. The video followed

the progress of a patient undergoing hip replacement surgery, from difficulties encountered at home through to



(Continued)

the hospital stay, postoperative recovery and exercises. The booklet addressed similar issues and included advice

from previous patients. The booklet described arthritis and backed up information presented in the video. The

life size plastic model bones demonstrated changes of the total hip replacement by comparison with a normal

hip joint, osteoarthritis and an implanted total hip replacement prosthesis

Cooil 1997 An information sheet that was already in clinical use was made available at the participants’ bedside. The

sheet contained instructions on the postoperative protocol, exercises and advice on beneficial and harmful

postoperative activities. In addition, a verbal explanation of the sheet’s contents was given, and the exercises and

activities were taught through demonstration and practiced under supervision

Crowe 2003 A preoperative education package consisting of a 50 minute video and a booklet giving information on length

of hospital stay, discharge criteria, respite care and diet was provided to participants the first time they visited

the clinic following randomisation. The video focused on the participant’s responsibility during the postoper-

ative phase and use of equipment. Some participants were given a tour of the hospital unit, demonstration of

equipment, dietician counselling and social work input. All participants received extensive individualised coun-

selling from an occupational therapist on all aspects of optimising function and independence postoperatively,

including home assessments, and were provided with a telephone contact for additional information. A physical

conditioning programme was available to participants to improve strength and endurance and facilitate post-

operative mobility. Participants also received the same standard preoperative clinic visit as the control patients

Daltroy 1998 A 12 minute audiotape slide programme was presented by a research assistant at the bedside the day before surgery.

The audiotape oriented the participant to the hospital, staff, surgery and rehabilitation. Participants were told

of various stressful aspects of their hospital stay, and reassured that these were normal. The tape complemented

the standard preoperative information. The comparison group received relaxation training consisting of oral

and written instructions and an 18-minute audiotape

Doering 2000 A 12 minute video shown in hospital preoperatively in the presence of the investigator. The video followed an

osteoarthritis patient undergoing hip replacement. Filmed from the patient’s perspective, the video showed what

to expect from hospital, the procedure, the recovery and rehabilitation. It included original dialogue, a narrator

giving procedural information and interviews with the patient

Lilja 1998 In addition to being informed by ward nurses about preoperative routines and what to expect before and after

the operation, participants spent 30 minutes with an anaesthetic nurse. The information provided by the nurse

covered the importance of preoperative preparation and patient participation in recovery, the operating theatre

and mobilisation following surgery

Santavirta 1994 Before admission participants received an 18 page guide on hip replacement surgery and postoperative rehabili-

tation. They also received a 20 to 60-minute teaching session by the investigator which was planned according to

each participant’s situation. Elements covered included safe walking, active exercises, wound care, temperature

taking, rehabilitation and discharge planning

Wijgman 1994 Participants received preoperative instructions for 30 minutes in groups of four to six delivered by two physio-

therapists. They also received preoperative exercise therapy including muscle setting exercises



W H A T ’ S N E W

Last assessed as up-to-date: 22 November 2003.

Date Event Description

10 May 2008 Amended Converted to new review format.

CMSG ID: A017-R

H I S T O R Y

Protocol first published: Issue 1, 2002

Review first published: Issue 1, 2004

C O N T R I B U T I O N S O F A U T H O R S

SM and SG designed and drafted the protocol. SM ran the searches. All reviewers assessed studies for inclusion, assessed methodological

quality and extracted data. SM and SH drafted the text of the review, and all reviewers contributed to interpreting the results and

writing the discussion.

D E C L A R A T I O N S O F I N T E R E S T

None known

S O U R C E S O F S U P P O R T

Internal sources

• Australasian Cochrane Centre, Australia.

External sources

• No sources of support supplied

N O T E S

For Doering 2000 we are waiting for translation of the report published in Zeitschrift Fuer Psychosomatische Medizin Und Psychother-

apie in 2001 that presents three-month follow-up data on mobility.



I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Length of Stay; ∗Patient Education as Topic; Anxiety [∗prevention & control]; Arthroplasty, Replacement, Hip [∗psychology]; Arthro-

plasty, Replacement, Knee [∗psychology]; Early Ambulation; Preoperative Care; Randomized Controlled Trials as Topic

MeSH check words

Humans



Documents

McDonald S, Hetrick SE, Green S - VDCPT · Editorial group: Cochrane Musculoskeletal Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008