The Decision to Have Surgery

Part of The Joint Replacement Guide — Phase 2: Considering Surgery · Article 8 of 44 · Hip & Knee

Key Points

  • Referral for joint replacement should be based on symptoms, function and quality of life—not an X-ray, questionnaire score or personal characteristic alone.
  • NICE advises considering referral when symptoms substantially affect quality of life and appropriate non-surgical management has been ineffective or is unsuitable.
  • Referral for a surgical opinion does not mean that an operation has been agreed or that the person must proceed.
  • The decision to have surgery is shared between the patient and the clinical team after discussing reasonable options, likely benefits, material risks and the option of not having surgery.
  • Patient-reported outcome measures, or PROMs, can help describe pain and function, but they should not be used as the sole test of whether someone qualifies for referral or surgery.
  • Joint replacement helps many people, but no surgeon can guarantee complete pain relief, a particular level of function or a specific recovery time.

When Might Referral Be Appropriate?

There is no single pain score, walking distance or X-ray grade at which joint replacement automatically becomes appropriate.

NICE advises considering referral for hip, knee or shoulder replacement when:

  • symptoms such as pain, stiffness, reduced function or progressive deformity are having a substantial effect on quality of life; and
  • appropriate non-surgical management has been ineffective or is unsuitable.[1]

The impact of osteoarthritis may include:

  • disturbed sleep
  • difficulty walking or using stairs
  • loss of independence
  • difficulty working or carrying out caring responsibilities
  • reduced ability to exercise or participate in social activities
  • difficulty with dressing, washing or other everyday tasks
  • effects on mood and emotional wellbeing

What represents a substantial impact differs between people. Two individuals with similar X-rays may experience very different symptoms and limitations.

An X-ray remains important when joint replacement is being considered because it helps confirm structural changes and supports surgical planning. However, imaging should be interpreted alongside symptoms, examination findings and the person’s circumstances.

Referral Is Not the Same as Agreeing to Surgery

A referral provides an opportunity for specialist assessment and discussion. It does not commit the patient or surgeon to an operation.

During the specialist assessment, the team may consider:

  • whether osteoarthritis is the main cause of the symptoms
  • the severity and pattern of symptoms
  • examination and imaging findings
  • which treatments have already been tried
  • the likely benefits and limitations of surgery
  • individual medical and anaesthetic risks
  • whether another treatment would be more appropriate
  • whether the patient wishes to proceed

A surgeon may conclude that replacement is not currently appropriate, that further assessment is needed, or that the expected risks outweigh the likely benefits. If so, the reasons and available alternatives should be explained clearly.

The patient may also decide not to have surgery or to defer the decision. Consent is voluntary and can be withdrawn before the procedure.

Shared Decision-Making

Shared decision-making is a structured conversation in which clinical evidence and professional judgement are considered alongside the patient’s priorities, values and preferences.

The clinical team should explain:

  • the reasonable treatment options
  • the option of continuing non-surgical care
  • the likely benefits of surgery
  • material and individual risks
  • important uncertainties
  • what surgery and recovery involve
  • the possibility of persistent symptoms
  • the possible need for further surgery in the future

The patient contributes:

  • how symptoms affect everyday life
  • which activities matter most
  • what improvement they hope to achieve
  • which risks concern them
  • their willingness and ability to undertake rehabilitation
  • their preference to proceed, wait or continue without surgery

A useful way to structure the conversation is BRAN:

  • Benefits: What benefits might this option provide?
  • Risks: What are the important risks for me?
  • Alternatives: What other reasonable options are available?
  • Nothing: What is likely to happen if I do not have surgery now?

NHS England provides decision-support tools for hip and knee osteoarthritis. These are designed to support—not replace—a conversation with a clinician.[3]

The Role of PROMs

Patient-reported outcome measures are questionnaires completed by patients to describe their health, pain and ability to carry out everyday activities.

The Oxford Hip Score and Oxford Knee Score each contain 12 questions about pain and function. In England, condition-specific scores and general health measures are collected before and after NHS-funded hip and knee replacement to measure changes reported by patients.[4]

PROMs can help:

  • describe symptoms in a consistent way
  • support discussion about the impact of osteoarthritis
  • monitor change over time
  • compare outcomes before and after treatment
  • evaluate outcomes across healthcare services

They also have important limitations:

  • a score cannot describe every aspect of an individual’s life
  • people with the same score may have different priorities
  • scores can be influenced by other health conditions
  • no score can predict an individual result with certainty
  • a threshold should not replace clinical assessment

NICE specifically advises using clinical assessment when deciding whether to refer someone for joint replacement rather than relying on numerical severity-scoring systems.[1]

A PROM score may therefore inform the discussion, but it should not independently determine whether referral or surgery is appropriate.

Trying Non-Surgical Treatment

Most people should be offered appropriate non-surgical treatment before joint replacement is considered. This may include:

  • information and support
  • tailored therapeutic exercise
  • weight-management support where appropriate
  • walking aids when helpful
  • carefully selected pain relief

These treatments may reduce pain, improve function and help some people manage without surgery.

However, every possible treatment does not have to be exhausted. A treatment may be unsuitable because of another medical condition, potential harm, previous lack of benefit or the patient’s informed preferences.

There is no universal minimum duration that applies to every person. What represents an adequate trial depends on the treatment, symptoms, clinical circumstances and whether there has been a reasonable opportunity for benefit.

Non-surgical treatment is not a test that proves whether surgery is needed. Instead, its response forms one part of the overall assessment.

Realistic Expectations

Hip and knee replacements improve pain and function for many people, but outcomes vary.

Surgery cannot guarantee:

  • complete freedom from pain
  • a particular range of movement
  • return to every previous activity
  • a specific recovery time
  • that complications will not occur
  • that the implant will last for the remainder of the patient’s life

Some people continue to experience pain, stiffness, weakness or dissatisfaction despite an operation that is technically successful.

An informed decision should compare the likely benefits with the risks and limitations that matter to the individual. It should not be based on a promise of a perfect result.

Age, Weight, Smoking and Other Health Conditions

NICE advises that people should not be excluded from referral for joint replacement solely because of:

  • age
  • sex or gender
  • smoking
  • another medical condition
  • overweight or obesity, including a particular BMI measurement.[1]

This recommendation concerns access to referral and individual assessment. It does not mean these factors are medically irrelevant.

Smoking, body composition and conditions affecting the heart, lungs, circulation, kidneys or immune system may influence anaesthetic or surgical risk. The clinical team should assess those risks individually, explain them and discuss whether anything could reasonably improve safety or recovery.

Preparation for surgery should be supportive and proportionate. It should not be presented as punishment or as a guarantee that changing a risk factor will prevent complications.

Occasionally, an individual medical risk may be so substantial that surgery is not currently safe or its expected harms outweigh its benefits. That decision should follow an individual clinical assessment and should be explained, rather than being based automatically on one characteristic or numerical threshold.

If a Referral Is Declined

If referral has been declined, it is reasonable to ask:

  • what clinical reasons informed the decision
  • whether the decision was based on an individual assessment
  • which treatment or review is recommended instead
  • what changes should prompt reassessment
  • whether local criteria are consistent with current NICE guidance
  • what options exist for clinical review or a second opinion

This does not mean that referral or surgery must be provided. It supports an informed discussion and gives the patient an opportunity to understand the decision.

Questions to Ask at a Surgical Consultation

You may find it helpful to ask:

  • What improvement is realistically likely for me?
  • Which symptoms is surgery most and least likely to improve?
  • What are my individual risks?
  • What reasonable alternatives do I have?
  • What could happen if I wait?
  • What will recovery and rehabilitation involve?
  • How much help might I need after surgery?
  • What symptoms might remain?
  • Might I need another operation in the future?
  • What happens if I decide not to proceed?

Taking notes or bringing a relative, friend or carer may help, if that is your preference.

Important Information

This article provides general educational information and does not determine whether an individual should be referred for or undergo joint replacement.

Suitability for surgery requires individual assessment by appropriately qualified healthcare professionals. No surgical outcome, recovery time or implant lifespan can be guaranteed. Consent must be voluntary and based on information relevant to the individual patient.

References

  1. National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226. Published 19 October 2022. Available from: https://www.nice.org.uk/guidance/ng226 [Accessed 14 August 2026].
  2. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. NICE guideline NG157. Published 4 June 2020; last reviewed 19 December 2024. Available from: https://www.nice.org.uk/guidance/ng157 [Accessed 14 August 2026].
  3. NHS England. Decision support tools: hip and knee osteoarthritis. Available from: https://www.england.nhs.uk/personalisedcare/shared-decision-making/decision-support-tools/ [Accessed 14 August 2026].
  4. NHS England Digital. Patient Reported Outcome Measures: methodologies. Available from: https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/patient-reported-outcome-measures-proms/proms-methodologies [Accessed 14 August 2026].

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