Introduction
As the aging population grows, the number of patients with osteoarthritis (OA) is increasing. Osteoarthritis results in deterioration of the joint cartilage, leading to chronic pain and disability, and is the most common cause of disability in older adults.1 Major risk factors for OA are obesity, metabolic diseases, old age and the female sex.2 A population-based epidemiological study of symptomatic OA reported that the incidence of OA was 0% at the age of 20 years and increased with increasing age, peaking at the age of 70 years.3 Guidelines for the management of OA recommend exercise and weight loss as self-management therapy, and the use of local and topical analgesics for pain management.4,5 However, non-surgical treatments gradually become ineffective for relieving pain, stiffness and reduced function, and these symptoms substantially decrease quality of life in patients with OA. At this point, joint replacement surgeries are considered.4,5 Osteoarthritis accounted for 70% of the joint replacement surgeries performed in the US in 2014.6
In the US alone, it was estimated that 4.7 million people underwent total knee replacement (hereafter referred to as knee replacement) in 2010, while 2.6 million underwent total hip replacement (hereafter referred to as hip replacement).1 In the US and Canada, the mean age of patients who have undergone these lower limb joint replacements ranges from 65 to 67 years.6,7 Most research on patients undergoing lower limb joint replacement is quantitative, and focuses on the improvement of health-related quality of life and physical function following the surgery.2 Systematic reviews report substantial improvements in the health-related quality of life and physical function by six months after joint replacement, and that these parameters continue to improve for up to 10 years postoperatively.8,9 In contrast, less attention has been paid to the patients’ views on joint replacement.
From the patients’ perspective, pain is a major reason for joint replacement surgery. The pain is generally described as severe and disabling, and patients often report that they have tried many alternative therapies in addition to Western medicine.10,11 However, some studies found that only a third of lower limb joint replacement surgery candidates expressed interest in undergoing the surgery.12 Two systematic reviews of qualitative studies summarized the experiences of patients who were on the waiting list for knee replacement, focusing on the patients’ decisions as to whether to undergo lower limb joint replacement. Patient decision was affected by pain, expectation of the surgical outcome, relationships with healthcare professionals and coping strategies for pain.13,14 Patients compared the problem of pain/disability with the perceived benefit of surgery, which was affected by their relationships with clinicians and the information received from their social network.13,14 Perceived support from family members in the post-surgical period also is found to play an important role in decision-making.13,15
Once patients decide to undergo joint replacement, they face the challenge of coping with the new joint after the surgery. Recent qualitative research reported on the problems resulting from shortening the length of stay for patients who underwent lower limb joint replacement.16,17,18 With the shortening of the hospital stay, the pain management and rehabilitation exercise program managed by healthcare professionals in hospital became the patients’ responsibility. Patients were mostly unprepared and undereducated about pain medication management and use of assistive devices,17,11 and those who lived alone felt isolated due to limited mobility.17 These studies suggest that healthcare professionals have not adapted to the shortened length of hospital stay and are not adequately preparing patients to undertake self-care after discharge. Understanding of the patients’ experiences after joint replacement surgery is critical for healthcare professionals to better understand how to educate patients to prepare for and cope with difficulties in the post-surgical period.
Some quantitative13,14 and qualitative research17,19 has treated hip replacement and knee replacement as one procedure within a study; this trend is the same in qualitative19 and quantitative systematic reviews.20 However, there are some differences between the two procedures in the underlying conditions and outcomes.13 For example, obesity is less prevalent in those undergoing hip replacement than in those undergoing knee repacement.13 Furthermore, functional recovery is greater for hip replacement than knee replacement,2 and dissatisfaction with the surgical outcome is less common in hip replacement patients than in knee replacement patients.13 A study in the Netherlands explored problems experienced during the six-week discharge period by patients who had undergone hip or knee joint replacement, and identified pain, physical therapy, sleep and the use of assistive devices as major problems.21 They reported only minor differences in the problems encountered by patients who had undergone hip replacement versus knee replacement, such as sleeping positions.21 Furthermore, most of the problems related to self-care were resolved by the end of six weeks.21
A search of the Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, and PubMed did not reveal any previous or planned systematic reviews of qualitative evidence on the problems encountered by patients during the early post-surgical period after hip or knee replacement. A review of the relevant studies evaluating patients’ experiences related to lower limb joint replacement will add to the understanding of the difficulties that patients face in the post-surgical period, and may provide healthcare professionals with important information for patient education.
Inclusion criteria
The review will consider any qualitative studies that describe the after discharge experiences of adult/elderly patients who have undergone lower limb joint replacement. The proposed review will include studies of both knee and hip replacements.
Participants
The proposed review will consider studies that have evaluated adult patients who have undergone lower limb joint replacement surgery. Patients aged 20 years and over will be included.
Phenomena of interest
The proposed review will consider studies that explore the experiences in the first six weeks after discharge of adult patients who have undergone lower limb joint replacement surgery. The exclusion criterion will be studies that only deal with rare experiences, such as major surgical complications.
Context
The proposed review will consider research conducted in any setting, i.e. at home and/or in an outpatient clinic.
Types of studies
The proposed review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research. Data collection methods will include, but are not limited to, face-to-face interviews, phone interviews and focus group interviews.
Methods
Search strategy
The search strategy will aim to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL has been undertaken, followed by analysis of the text words contained in the titles and abstracts, and of the index terms used to describe relevant studies. A full search strategy for MEDLINE is detailed in Appendix I. The reference lists of all studies selected for critical appraisal will be screened for additional studies.
Information sources
The databases to be searched include: MEDLINE via Ovid, CINAHL and PsycINFO via EBSCO, and Scopus via ScienceDirect.
The search for unpublished studies will include: MedNar and GreyNet International.
The search will include studies published in English from 2002 to the current date in 2018 to reflect the current practice of orthopedic care.
Study selection
Following the search, all identified citations will be collated and uploaded into bibliographic software or a citation management system, and duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers to determine whether the studies meet the inclusion criteria for the review. Studies that meet or could potentially meet the inclusion criteria will be retrieved in full, and their details will be imported into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail in accordance with the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded, and the reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full and presented in a PRISMA flow diagram in the final report. Any disagreements that arise between the reviewers will be resolved through discussion, or consultation with a third reviewer.
Assessment of methodological quality
Selected studies will be critically appraised by two independent reviewers for methodological quality using the JBI Critical Appraisal Checklist for Qualitative Research.22 Any disagreements that arise between the reviewers will be resolved through discussion, or consultation with a third reviewer. The results of critical appraisal will be reported in narrative and tabular forms.
All studies, regardless of methodological quality, will undergo data extraction and synthesis (where possible).
Data extraction
Two independent reviewers will extract qualitative data from included studies using the standardized data extraction tool from JBI SUMARI.22 The extracted data will include specific details about the populations, context, culture, geographical location, study methods and phenomena of interest relevant to the review question and specific objectives. The major focus of the review will be experiences in the post-discharge period, such as pain and sleep. Study findings, and their illustrations, will be extracted and assigned a level of credibility.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.23 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing certainty in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis, and will be presented in a Summary of Findings generated by ConQual methods.24 The Summary of Findings will include the major elements of the review, and details how the ConQual score is developed. Included in the table will be the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research that has provided the finding, a score for dependability, credibility and the overall ConQual score.
Appendix I: MEDLINE search strategy
- 1. arthroplasty, replacement, hip/ or arthroplasty, replacement, knee/ or after joint replacement.mp. or after knee replacement.mp. or after THA.mp. or after TkA.mp. or exp hip joint/ or exp knee joint/
- 2. exp qualitative research/ or “Interviews as Topic”/ or “qualitative study”.ti.
- 3. exp Patient Satisfaction/ or experience∗.mp.
- 4. exp adult or exp middle aged or exp aged
- 5. limit 1 to yr = 2002-current date in 2018
- 6. 1 and (2 or 3) and 4 and 5
Acknowledgments
We thank Kelly Zammit, BVSc, from Edanz Group (www.edanzediting.com/ac), for editing this manuscript.
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