The Decision to Have Surgery

Part of The Joint Replacement Guide — Phase 2: Considering Surgery · Article 8 of 42 · Hip & Knee

Key Points

  • Deciding to have joint replacement surgery is a shared decision between you and your clinical team — not something dictated by an X-ray result.
  • The right time is when symptoms are significantly affecting your quality of life despite trying non-surgical measures, not a fixed severity threshold.
  • Structured questionnaires (PROMs) help make this conversation more objective, but don’t replace it.
  • No surgeon can guarantee a completely pain-free result, so realistic expectations are part of a good decision.

What “Ready for Surgery” Actually Means

Patients often assume there is a specific pain score, or a particular appearance on X-ray, that marks the point at which surgery becomes appropriate. In reality, the decision is based much more on how the condition is affecting your day-to-day life — your sleep, your independence, your ability to work, exercise, and do the things that matter to you — than on any single number. Two people with very similar X-rays can have very different levels of disability, and the decision to proceed with surgery should reflect your actual experience, not just the imaging.

Shared Decision-Making

Good surgical decision-making is a genuine two-way conversation. Your surgeon brings clinical judgement, experience, and an honest account of the likely benefits and risks for someone in your specific situation; you bring an understanding of how your symptoms actually affect your life, what matters most to you, and your own tolerance for risk. Decision aids — structured tools that walk through the benefits, risks and alternatives — are increasingly used to support this conversation and help ensure it isn’t rushed.

The Role of PROMs

Patient-Reported Outcome Measures, such as the Oxford Hip Score or Oxford Knee Score, are structured questionnaires that quantify your pain and function in a standardised way. They’re collected as part of a national NHS programme both before and after surgery, which allows outcomes to be tracked and compared over time. Some units use PROMs scores to help structure referral pathways, but a low score alone doesn’t automatically mean surgery is the right choice, and a moderate score doesn’t automatically rule it out — the questionnaire is a tool to support the conversation, not a substitute for it.

Trying Non-Surgical Options First

For most people, a genuine trial of the non-surgical measures covered earlier in this guide — exercise, weight management where relevant, and appropriate pain relief — is a reasonable and expected part of the pathway before surgery is considered, both because these measures work for many people and because it helps confirm that surgery is genuinely needed. For more severe structural disease, or where non-surgical measures have clearly failed over a reasonable period, this stage can be shorter.

In More Depth

National guidance is explicit that certain factors — age, sex, smoking status, obesity, or the presence of other health conditions — should not, on their own, be used as a reason to refuse or delay a referral for joint replacement. This doesn’t mean these factors are ignored; they are genuinely relevant to planning a safe operation and are addressed as part of pre-operative optimisation (covered in a later article), but they should inform how and when surgery is planned, not whether the conversation happens at all. If you feel a referral has been declined purely on the basis of one of these factors without a broader discussion, it is reasonable to ask for that decision to be revisited.

This article is general information and does not replace individual clinical advice.

Sources

  • NICE guideline NG157 — Joint replacement (primary): hip, knee and shoulder (2020)
  • NHS Patient-Reported Outcome Measures (PROMs) programme
  • GIRFT (Getting It Right First Time) — National Report on Orthopaedics
  • NHS shared decision-making resources

← Back to the Joint Replacement Guide · Previous: Injections Explained · Next: Your Role, Your Family’s Role, Your Team’s Role