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The 2020 NICE guidelines for primary hip, knee and shoulder replacement: key recommendations and the ongoing need for better quality evidence in orthopaedics Paul Baker, Ananth Ebinesan, John Skinner, Andrew Metcalfe and Jonathan Rees Why should orthopaedic surgeons engage in the development of NICE Guidelines?
Paul Baker is an Orthopaedic Surgeon specialising in primary and revision hip and knee replacement surgery. He is also the Director of Research and Innovation for the South Tees Hospitals NHS Foundation Trust. Paul is the current Royal College of Surgeons Speciality lead for Orthopaedics and a member of the BOA research committee.
Ananth Ebinesan is a Consultant Orthopaedic Surgeon at Manchester University Hospitals NHS Trust. He is an active BESS member and is currently the Clinical Lead for Orthopaedics at Manchester Royal Infirmary.
The development of a NICE guideline is viewed as rigorous and independent. As such published guidelines are supported and endorsed by NHS England and have a greater impact than guidelines from specialist societies. For this reason, when a new orthopaedic NICE guideline is proposed, it is critical we engage to ensure there is orthopaedic expertise on the guideline committee. However, this can be challenging as there are no ‘nominations’ and surgeons do not represent the BOA or their specialist society. The surgeon must apply independently, fulfil various criteria, pass an interview and be prepared for guideline commitments that take 2-3 years to compete. Despite these hurdles, we would encourage BOA members looking for new challenges and wishing to make a national contribution to patients and the health service to apply. In the instance of the new hip, knee and shoulder replacement guidelines, the sheer breadth of a combined guideline encouraged the authors to apply as we recognised the importance of the topic, and the need to ensure correct clinical interpretation of the evidence in making recommendations that could have profound effects on patients and joint replacement services. Once appointed to a NICE guideline committee, a detailed scope is first developed. Many will ask why this guideline complicates matters by combining all three joints. This topic was picked by NHS England, not NICE, and not the committee. Due to the large remit of this guideline, we structured it as a patient pathway from the point of offering joint replacement. The scope went out for public consultation in March 2018 and was finalised by NICE in April 2018.
22 | JTO | Volume 08 | Issue 04 | December 2020 | boa.ac.uk
Multiple systematic evidence reviews were then conducted for each question assessing clinical and cost effectiveness. It is worth noting that while some of us are involved in large joint registry data research, this is not considered in the NICE process even though many will consider registry data to be highly relevant to this topic. NICE deal with RCT evidence and the evidence reviews are detailed and of high quality. The meetings we attended were intense and long with many challenging discussions. In total it took 2.5 years to complete this guideline which has produced 24 final recommendations. Importantly for those of you active in high quality research, it has also produced 16 research recommendations. The full guidelines and committee discussions can be found at www.nice.org.uk/guidance/ ng157, but we present the main highlights for you by speciality.
How will these guidelines effect you and your Trust? For hip, knee, shoulder surgeons and hospital trusts Preventing infection in all patients: No evidence was identified to justify adding antiseptics or antibiotics to saline wash for wound washouts and so NICE guidance NG125 (www.nice.org.uk/guidance/ng125) on surgical site infection should be followed. A recommendation to use ultraclean air theatre ventilation systems for primary hip, knee and shoulder replacement surgery was also made. Avoiding implant selection errors in all patients: It is recommended that surgeons now use two intraoperative stop moments, one before implantation and one before wound closure to ensure correct implant details and compatibility. A recommendations was also
