• It is recognised that the requirements for follow up of Total Joint Arthroplasty have evolved over recent years and need to be customised to the patient, surgeon, hospital and implant.  

• Modern hip and knee replacements deliver consistent and excellent clinical outcomes. Failure through implant breakage or loosening is rare. Local audits and peer-reviewed literature have supported stopping routine arthroplasty review after the first postoperative visit for high volume surgeons using the best performing implants (ODEP10A).

• Units are encouraged to use implants that have satisfactory clinical outcomes and assurance of good long-term survivorship. This is usually achieved through the implantation of devices with ODEP10A ratings or better. If implants with lower ratings are used, more planned follow-up may be required depending on the joint and implant. This year’s procurement contracts with industry mandate the use of an ODEP minimum 3A* rating with suppliers assuming all costs for follow up of implants rated 3A* to 7A. It should be noted that although the Scottish Arthroplasty Project is an invaluable resource, it is not a joint registry. The National Joint Registry (NJR) and post-market surveillance projects such as “Beyond Compliance” do not cover Scottish patients.

• There must be a system in place for self-referral and review (Patient Initiated Review [PIR]) if a patient develops problems at any point following arthroplasty. This must be in place prior to any change to existing practice. The patient must be aware of these arrangements and warning signs.

• The post-operative visit is important and should take place within 12 weeks following surgery. At that stage the trajectory of recovery is assessed. If it is below expectation then investigation, rehabilitation and further review should be considered. Education, both written and verbal, should be provided regarding anticipated ongoing recovery. This includes symptoms that might raise concern and need investigation. The PIR arrangements should be communicated verbally and written information provided. 

• It is recognised that although universal follow-up is of reducing benefit, the audit of outcomes is important for quality assurance, training and teaching purposes. Some units have ongoing programmes of review and audit that are of value to the wider orthopaedic communities.

• In the absence of a joint registry, units should ensure that they have the ability to retrospectively identify the implants placed into individual patients. This would be important in case of a post-market recall.

• Specific implants such as hip resurfacing and metal-on-metal THRs have follow-up regimen as specified by the BHS/BOA

• Revision and complex primary arthroplasty will require a bespoke approach to follow-up and surveillance. 

•  Arthroplasty surgeons should be aware of the outcomes from their own surgery.

If the above action points are adopted, universal follow-up beyond the first post-operative visit is not routinely required.

Ed Dunstan, Consultant Orthopaedic Surgeon, Chair – SCOT

Matthew Moran, Consultant Orthopaedic Surgeon, Chair – SAP

Mark Blyth, Consultant Orthopaedic Surgeon, Chair – SOSDG

Dr Catherine Calderwood, Chief Medical Officer

Version 1: December 2019