Experience of patients following lower limb joint replacement: a systematic review protocol : JBI Evidence Synthesis

Secondary Logo

Journal Logo


Experience of patients following lower limb joint replacement: a systematic review protocol

Makimoto, Kiyoko1,2; Fujita, Kimie2,3; Konno, Rie2,4

Author Information
JBI Database of Systematic Reviews and Implementation Reports 16(12):p 2248-2252, December 2018. | DOI: 10.11124/JBISRIR-2017-003669
  • Free



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.


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.


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.


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


We thank Kelly Zammit, BVSc, from Edanz Group (www.edanzediting.com/ac), for editing this manuscript.


1. Kremers HM, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015; 97 17:1386–1397.
2. Ethgen O, Bruyère O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am 2004; 86-A 5:963–974.
3. Litwic A, Edwards M, Dennison E, Cooper C. Epidemiology and burden of osteoarthritis. Br Med Bull 2013; 105:185–199.
4. National Institute for Health and Care Excellence. Osteoarthritis: care and management Clinical guideline [CG177] Published date: February 2014. https://www.nice.org.uk/guidance/CG177/uptake (cited 2018 March 11).
5. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Rese 2012; 64:465–474.
6. American Joint Replacement Registry 2016 Annual Report 1. http://www.ajrr.net/images/annual_reports/AJRR_2016_Annual_Report_final.pdf (cited 2018 March 11).
7. Canadian Institute for Health Information. Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry 2015 Annual Report. https://secure.cihi.ca/free_products/CJRR_2015_Annual_Report_EN.pdf (cited 2018 March 11).
8. Shan L, Shan B, Grahamx D, Saxena A. Total hip replacement: a systematic review and meta-analysis on mid-term quality of life. Osteoarthritis Cartilage 2014; 22 3:389–406.
9. Verra WC, Kernkamp WA, van Hilten JA, van de Watering L, Chander B, Bloem RM, et al. Patient satisfaction and quality of life at least 10 years after total hip or knee arthroplasty. Int J Orthop Sci 2016; 2 2:5–9.
10. Fujita K, Makimoto K, Hotokebuchi T. Qualitative study of osteoarthritis patients’ experience before and after total hip arthroplasty in Japan. Nur Health Sci 2006; 8 2:81–87.
11. Marcinkowski K, Wong VG, Dignam D. Getting back to the future a grounded theory study of the patient perspective of total knee joint arthroplasty. Orthop Nur 2005; 24 3:202–209.
12. Hawker GA. Who, when, and why total joint replacement surgery? The patient's perspective. Curr Opin Rheumatol 2006; 18 5:526–530.
13. Barlow T, Griffin D, Barlow D, Realpe A. Patients’ decision making in total knee arthroplasty systematic review of qualitative research. Bone Joint Res 2015; 14 4:163–169.
14. O’Neill T, Jinks C, Ong BN. Decision-making regarding total knee replacement surgery: a qualitative meta-synthesis. BMC Health Serv Res 2007; 7:52.
15. Clark JP, Hudak PL, Hawker GA, Coyte PC, Mahomed NN, Kreder HJ, et al. The moving target: a qualitative study of elderly patients’ decision-making regarding total joint replacement surgery. J Bone Joint Surg Am 2004; 86-A 7:1366–1374.
16. Reay PA, Horner B, Duggan R. The patient's experience of early discharge following total hip replacement. Int J Orthop Trauma Nurs 2015; 19 9:131–139.
17. Webster F, Perruccio AV, Jenkinson R, Jaglal S, Schemitsch E, Waddell JP, et al. Understanding why people do or do not engage in activities following total joint replacement: a longitudinal qualitative study. Osteoarthritis Cartilage 2015; 23 6:860–867.
18. Causey-Upton R, Howell DM. Patient experiences when preparing for discharge home after total knee replacement. Internet J Allied Health Sci Pract 2017; 5 1: 11; Article 5.
19. Kennedy D, Wainwright A, Pereira L, Robarts S, Dickson P, Christian J, et al. A qualitative study of patient education needs for hip and knee replacement. BMC Musculoskelet Disord 2017; 18:413–420.
20. Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Hans J, et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg 2008; 51 6:428–436.
21. van Egmond JC, Verburg H, Vehmeijer SB, Mathijssen NM. Early follow-up after primary total knee and total hip arthroplasty with rapid recovery: Focus groups. Acta Orthop Belg 2015; 81:447–453.
22. The Joanna Briggs Institute, Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, Loveday H, Carrier J, Stannard D. Aromataris E, Munn Z. Chapter 2: Systematic reviews of qualitative evidence. Joanna Briggs Institute Reviewer's Manual 2017.
23. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc 2015; 13 3:179–187.
24. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol 2014; 14 108:1–7.

Patient education; patients’ experience; post-surgical period; total hip replacement; total knee replacement