Elective Total Knee Replacement Research Articles

The clinical and cost-effectiveness of elective primary total knee replacement with PAtellar Resurfacing compared to selective patellar resurfacing: a pragmatic multicentre randomized controlled Trial (PART).

During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon's decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing. The PAtellar Resurfacing Trial (PART) is a patient- and assessor-blinded multicentre, pragmatic parallel two-arm randomized superiority trial of adults undergoing elective primary TKR for primary osteoarthritis at NHS hospitals in England, with an embedded internal pilot phase (ISRCTN 33276681). Participants will be randomly allocated intraoperatively on a 1:1 basis (stratified by centre and implant type (cruciate-retaining vs cruciate-sacrificing)) to always resurface or selectively resurface the patella, once the surgeon has confirmed sufficient patellar thickness for resurfacing and that constrained implants are not required. The primary analysis will compare the Oxford Knee Score (OKS) one year after surgery. Secondary outcomes include patient-reported outcome measures at three months, six months, and one year (Knee injury and Osteoarthritis Outcome Score, OKS, EuroQol five-dimension five-level questionnaire, patient satisfaction, postoperative complications, need for further surgery, resource use, and costs). Cost-effectiveness will be measured for the lifetime of the patient. Overall, 530 patients will be recruited to obtain 90% power to detect a four-point difference in OKS between the groups one year after surgery, assuming up to 40% resurfacing in the selective group. The trial findings will provide evidence about the clinical and cost-effectiveness of always patellar resurfacing compared to selective patellar resurfacing. This will inform future NICE guidelines on primary TKR and the role of selective patellar resurfacing.

Barriers and enablers to the implementation and sustainability of short-stay arthroplasty programs for elective primary total hip and knee replacement: A systematic review with qualitative evidence synthesis.

We aimed to systematically review contemporary evidence on the barriers and enablers to implementing and sustaining short-stay arthroplasty programs for elective primary total hip and knee replacement from the perspectives of patients, health professionals, carers, healthcare administrators, funders and policymakers and to map the findings to the Theoretical Domains Framework (TDF). Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (up to 19 August 2023). Primary qualitative or mixed-methods studies reporting on perspectives relating to the review aims that utilised a short-stay programme were eligible for inclusion. Study quality was assessed using the qualitative critical appraisal tool from the Joanna Briggs Institute. Data were analysed inductively. The final themes were mapped to the TDF. The confidence in the findings was assessed using GRADE CERQual. Fifteen studies were included. Twelve barrier themes and twelve enabler themes were identified. Three themes were graded with high confidence, 10 were graded with moderate confidence, three were graded with low confidence, and eight were graded with very low confidence. The most pertinent domains that the themes were mapped to for patients were beliefs about capabilities, reinforcement, and the environmental context and resources. Health professionals identified knowledge, environmental context and resources as important domains. Two domains were identified for carers: (1) social/professional role and identity and (2) memory, attention, and decision processes. We identified key barrier and enabler themes linked to the TDF that can be used to guide implementation initiatives and promote the sustainability of short-stay arthroplasty programs.

Evaluation of pain levels of and pain management in patients after elective total knee replacement surgery

Evaluation of pain levels of and pain management in patients after elective total knee replacement surgery

The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients

This systematic review and meta-analysis aimed to determine the impact of presurgical waiting times on pre-/post-operative joint specific pain and function, health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements. MEDLINE, EMBASE, PUBMED, and CENTRAL databases were searched from inception until 30th January 2023 (CRD42022288128). Secondary literature and unpublished datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded. PRISMA 2020 reporting and GRADE certainty of evidence guidelines were followed. Residual maximum likelihood meta-analysis and linear meta-regression was performed to elucidate the influence of presurgical waiting time. Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, capturing 89,996 patients (60.6% female, mean age 67.4 years) between 2001 and 2022. A significant deterioration in joint function (mean difference (MD):0.0575%; 95% CI 0.0064, 0.1086; p = 0.028(4d.p.); I2 = 73.1%) and HRQOL (MD: 0.05%; 95% CI − 0.0001.0009; p = 0.011(4 d.p.); I2 = 80.6%) was identified per additional day of waiting. Despite qualitative evidence, meta-analysis could not observe a relationship with postoperative outcome data. Patient responses to delayed THR and TKR surgery were unanimously negative. Immediate action should seek to reduce the increased patient anxiety and significant reductions in pre-operative joint functionality and HRQOL associated with prolonged pre-surgical waiting time, whilst mitigating any potential deleterious post-operative effects.

Influence of build orientation and support structure on additive manufacturing of human knee replacements: a computational study.

Developing patient-specific implants has an increasing interest in the application of emerging additive manufacturing (AM) technologies. On the other hand, despite advances in total knee replacement (TKR), studies suggest that up to 20% of patients with elective TKR are dissatisfied with the outcome. By creating 3D objects from digital models, AM enables the production of patient-specific implants with complex geometries, such as those required for knee replacements. Previous studies have highlighted concerns regarding the risk of residual stresses and shape distortions in AM parts, which could lead to structural failure or other complications. This article presents a computational framework that uses CT images to create patient-specific finite element models for optimizing AM knee replacements. The workflow includes image processing in the open-source software 3DSlicer and MeshLab and AM process simulations in the commercial platform 3DEXPERIENCE. The approach is demonstrated on a distal femur replacement for a 50-year-old male patient from the open-access Natural Knee Data. The results show that build orientations have a significant impact on both shape distortions and residual stresses. Support structures have a marginal effect on residual stresses but strongly influence shape distortions, whereas conical support exhibits a maximum distortion of 18.5 mm. Future research can explore how these factors affect the functionality of AM knee replacements under in-service loading.

Individual Factors Modifying Postoperative Pain Management in Elective Total Hip and Total Knee Replacement Surgery.

Total hip and knee replacements are the most common orthopedic procedures performed due to osteoarthritis. Pain is an intrinsic symptom accompanying osteoarthritis, persisting long before surgery, and continuing during the preoperative and postoperative periods. Appropriate pain management after surgery determines the comfort, duration, and cost of hospitalization, as well as the effectiveness of postoperative rehabilitation. Individual differences in pain perception and tolerance in orthopedic patients remain an important research topic. Therefore, the aim of this study was to investigate the predictors of analgesic requirements (morphine, acetaminophen, and ketoprofen), including individual pain threshold and tolerance, body mass index (BMI), diabetes, and beliefs about pain control in patients undergoing elective hip or knee arthroplasty using a multilevel regression model (N = 147, 85 women, 62 men, 107 after hip replacement, and 40 after knee replacement). Results: Higher pain tolerance was associated with a lower dose of morphine per kg after surgery. Patients undergoing hip surgery received a lower dose of ketoprofen than patients undergoing knee surgery. The more the patient believed in personal pain control, the stronger the negative relationship between pain tolerance and morphine requirement. The lowest doses were given to patients with the highest pain tolerance and the greatest belief in personal control. Factors such as belief in pain control and pain tolerance should be considered in comprehensive postoperative pain management in orthopedic patients to reduce opioid doses and, thus, side effects.

Functional Outcome of Subvastus versus Medial Parapatellar Approaches for Total Knee Replacement in Patients with Knee Osteoarthritis: A Prospective Cohort Study.

Subvastus approach and medial parapatellar approach are two major approaches for total knee replacement (TKR). There is no global consensus on the superiority of either approach in terms of functional outcomes. The present study aimed to evaluate the functional outcome of TKR through subvastus approach and medial parapatellar approach by using patient-reported scores at 3-, 6-, and 12-month post-operative follow-ups. This prospective cohort follow-up study included patients with knee osteoarthritis who underwent elective primary TKR either through the subvastus or medial parapatellar approaches at King Abdullah Medical City, Makkah city, Kingdom of Saudi Arabia, from January 2019 to December 2022. Scores from the self-reported Oxford Knee Score (OKS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were compared in the two groups of patients at 3-, 6-, and 12-month post-operative follow-ups. A total of 98 patients were included, of which 37 underwent TKR through the subvastus approach and 61 through the medial parapatellar approach. There was an overall significant change over time in both WOMAC and OKS scores (P < 0.001). Patients who underwent the subvastus approach had significantly higher mean of WOMAC and OKS than patients with the medial parapatellar approach at the 3- and 6-month follow-ups (P < 0.05), but not at the 12-month follow-up. For TKR, the medial parapatellar approach results in better functional outcomes at the 3- and 6- month follow-up periods compared with the subvastus approach.

Perioperative Intra-articular Infiltration of Tranexamic Acid and Ropivacaine Cocktail in Bilateral Total Knee Replacement

Objective: This study evaluated the efficacy and safety of perioperative intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in patients undergoing bilateral total knee replacement (TKR). Methods: A randomized controlled trial was conducted involving 50 patients scheduled for elective bilateral TKR. Participants were randomly assigned to receive either intra-articular infiltration of a tranexamic acid and ropivacaine cocktail (intervention group) or standard care (control group). Outcome measures included postoperative blood loss, pain scores, range of motion, and adverse events. Results: Among the enrolled patients (n=50), the intervention group demonstrated reduced postoperative blood loss, evidenced by higher hemoglobin levels and lower drain output than the control group. Additionally, the intervention group exhibited consistently lower pain scores at various postoperative time points and greater improvements in range of motion. Conclusion: Intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in bilateral TKR patients showed promising outcomes, including reduced blood loss, improved pain control, and enhanced range of motion. These findings suggest the potential of this adjunctive therapy in optimizing perioperative care for patients undergoing bilateral TKR. However, further research with larger sample sizes is warranted to validate these preliminary results and establish this intervention’s long-term efficacy and safety.

Translated article] Are frailty scores superior to the ASA score in predicting complications, hospital stay, and readmissions in total knee replacement? A comparative study between octogenarian and septuagenarian patients

Background and objectiveFrailty scores have not been standardised for the preoperative assessment of patients undergoing total knee replacement (TKR). The aim of this study was to compare the efficacy of the American Society of Anesthesiology (ASA) score, the Charlson comorbidity index (ICC) and the simple frailty score (SSF) in predicting complications, hospital stay, readmissions and mortality after elective TKR. Materials and methodsWe retrospectively studied 448 patients who underwent TKR for osteoarthritis at our institution between 2016 and 2019. They were divided into two groups: Group A (263 patients, <80 years) and Group B (185 patients, >80 years).). All were classified by ASA, ICC and SSF scores. ResultsThe ICC was higher in Group B (median 5 [RI: 4–6] vs. 4 [RI: 3–5]; p<.001); however, it was not associated with a higher number of complications. When performing a logistic regression analysis we found, for complications: OR SSF=0.67; ICC=1.11; ASA 3 & 4=0.89 and age=1.04; while for readmissions: OR SSF=2.09; ICC=1.01; ASA 3 & 4=0.79 and age=1. ConclusionsThe ICC and SSF scales showed no differences to the ASA scale in the prediction of readmissions, complications and hospital stay. However, the SSF seems to have a better correlation in predicting unplanned readmission.

Retention of Urine after Elective Total Hip and Knee Replacement Surgeries - A Literature review

Urinary retention postoperatively is alarming complication that happened after elective hip and knee replacement surgeries. This literature review examined the incidence, risk factors, and management of postoperative urinary retention (POUR) in elective total hip and knee replacement surgery over the last five years.

An elective total knee replacement in a patient with a recent history of cardiac arrest: A case report

Performing surgery on a patient with a previous history of a major cardiac event, such as a myocardial infarction or cardiac arrest, is inherently risky and requires specific anesthetic and surgical-related measures to avoid perioperative complications. Our patient is a 63-year-old male who is a known case of chronic knee osteoarthritis with a history of myocardial infarction leading to cardiac arrest. He was resuscitated and transferred to the catheterization laboratory and the occluded artery was stented. Within the 1st year after the cardiac arrest, he presented to the orthopedic clinic complaining of worsening knee pain and a reduced range of movement that affected his quality of life. We performed the surgery 2 months later and the patient was discharged with satisfactory results and no complications. This case reports how we prepared a patient with a recent history of cardiac arrest for a total knee replacement from an anesthetic and surgical point of view.

USING THE CAPABILITY, OPPORTUNITY, AND MOTIVATION MODEL OF BEHAVIOUR (COM-B) TO IMPLEMENT A PATHWAY TO REDUCE 30-DAY ELECTIVE EMERGENCY ADMISSIONS

AbstractIntroduction30-day emergency readmission is an indicator of treatment related complication once discharged, resulting in readmission. A board-approved quality improvement pathway was introduced to reduce elective re-admissions.MethodThe pathway involved telephone and email contact details provision to patients for any non-life threatening medical assistance, allowing for initial nurse led management of all issues. A new clinic room available 7 days, and same day ultrasound scanning for DVT studies were introduced. A capability, opportunity and behavior model of change was implemented.Readmission rates before and six months after implementation were collected from Model Hospital. A database used to document patient communications was interrogated for patient outcomes.ResultsPrior to implementation, readmission rates following elective primary total knee replacement (TKR) at the 1st business quarter of 2021 (April – June 2021), was 8.7%, (benchmark 3.8%). Following implementation, readmission rates decreased to 4.1% (October – December 2021). 54% of patients making contact were managed with telephone advice. 15% of patients required face-to-face clinic. 32% of those required a same day scan to exclude DVT (1/4).20 out of 684 TKRs performed following protocol introduction were re-admitted within 30 days. Readmissions were 41% surgical, 29% medical. 52% were unaware of the newly implemented protocol. Further improvements have been made to the protocol based on these findings.Implementation of a suitable pathway can significantly reduce re-admission rates in our center and could be used to reduce readmission rates in other national elective treatment centers.

Effective VTE prophylaxis with enoxaparin after elective THR or TKR: a retrospective observational study.

Orthopedic patients are at the highest risk for venous thromboembolism (VTE). Nowadays, with VTE prophylaxis as a routine in patients undergoing total hip replacement (THR) and total knee replacement (TKR), fatal pulmonary embolism (PE) is rare and the rates of symptomatic VTE within 3 months dropped to 1.3%-10%, compared with the rates of 50%-70% before VTE prophylaxis implementation. In this study, we aim to evaluate the VTE prophylaxis and incidence in patients who underwent THR and TKR in Centro Hospitalar Universitário de Santo António (CHUdSA). We included 483 patients who underwent elective THR or TKR in CHUdSA from March 2019 to February 2020 and who were under enoxaparin as a VTE prophylaxis drug. All data related to prescribed enoxaparin were collected from the nationwide common electronic drug prescription system (PEM). Of the 483 eligible patients, 192 (39.75%) underwent elective THR and 291 (60.25%) underwent TKR. Enoxaparin was prescribed for 31.86 ± 5.98 and 30.28 ± 5.97 days, on average, for the THR and TKR groups, respectively (P = .005). Patients completed, on average, 29.38 ± 8.12 days and 28.20 ± 7.32 days of VTE prophylaxis with enoxaparin in the THR and TKR groups, respectively (P = .098). The incidence of VTE was approximately 3.13% and 0.69% in the THR and TKR groups, respectively (P = .064). In CHUdSA, we usually prescribe enoxaparin 40 mg once daily for up to 35 days for VTE prophylaxis after THR or TKR. High therapeutic compliance rates resulted in very few events.

Patient compliance with the implementation of a decolonization strategy for Staphylococcus aureus in hip and knee replacements

A preoperative, in-community antimicrobial decolonization protocol combining chlorohexidine gluconate (CHG) sponges and mupirocin ointment to reduce surgical site infections amongst hip and knee replacement patients has been adopted in Alberta, Canada. Patient compliance with the protocol is essential for effectiveness. It is, therefore, important to understand patterns, and reasons why, patients do, and do not, comply. A descriptive survey of patients having elective total hip or knee replacement at seven clinics in Alberta was conducted to determine patient compliance and reasons for noncompliance. Descriptive statistics and multivariate logistic regression were computed. Patient compliance was assessed in 3,427 patients. There were no differences in compliance based on the baseline protocols and enhanced protocols, but there was a difference based on clinic location. The odds of compliance with three CHG sponges were 4.47 times higher in rural versus urban clinics (P<.001). The most common reason for noncompliance for patients instructed to use 3 CHG sponges was "patient forgot". Compliance did not change when enhanced protocols were introduced; however, compliance differed by clinic location. Reasons for noncompliance included "sponges not provided", "patient forgot", and "surgery date moved". Results may inform clinics on areas where improvements could be made to increase patient compliance.

Low Correlation between Gait and Quality of Life in Advanced Knee Osteoarthritis

Advanced knee osteoarthritis patients’ gait usually undergoes alterations leading to decreased mobility and lower functional performance, which can result in a worsening of their quality of life (QoL). While several authors have reported a moderate correlation between gait parameters and QoL assessed by generic questionnaires, the literature is scarce. This study aimed to explore the relationship between gait and QoL parameters assessed by a generic and a disease-specific questionnaire in patients with advanced knee osteoarthritis. In this single-centre, prospective, observational study, 129 patients with advanced knee osteoarthritis scheduled for elective total knee replacement were selected. The patients’ gait was evaluated by means of a validated wireless device while they walked 30 m at a comfortable speed. Patient function was also analysed using the Knee Society Score (KSS). QoL was measured with the EQ-5D and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires. Patients showed a mean walking speed of 0.95 ± 0.19 m/s, a mean cadence of 105.6 ± 9.9 steps/min, and a mean stride length of 1.25 ± 0.17 m on both legs. They presented poor knee status (KSS &lt; 60) and poor QoL, with an EQ-5D of 0.44 ± 0.24 and a total KOOS of 29.77 ± 13.99. Positive low correlations (r &lt;0.5, p &lt;0.5) were found only between the speed, propulsion and stride length of both legs, and the overall and ADLs subscale scores of the total KOOS questionnaire. In conclusion, several gait parameters have a significant low correlation with the QoL of patients with advanced knee osteoarthritis, as assessed by an osteoarthritis-specific questionnaire.

¿Son las escalas de valoración de fragilidad superiores a la escala de valoración ASA en la predicción de complicaciones, estancia hospitalaria y readmisiones en prótesis total de rodilla? Un estudio comparativo entre pacientes octogenarios y septuagenarios

Background and objectiveFrailty scores have not been standardized for the preoperative assessment of patients undergoing total knee replacement (TKR). The aim of this study was to compare the efficacy of the American Society of Anesthesiology (ASA) score, the Charlson comorbidity index (ICC) and the simple frailty score (SSF) in predicting complications, hospital stay, readmissions and mortality after elective TKR. Materials and methodsWe retrospectively studied 448 patients who underwent TKR for osteoarthritis at our institution between 2016 and 2019. They were divided into two groups: Group A (263 patients, <80 years) and Group B (185 patients, >80 years).). All were classified by ASA, ICC and SSF scores. ResultsThe ICC was higher in Group B (median 5 [RI: 4-6] vs. 4 [RI: 3-5]; P<.001); however, it was not associated with a higher number of complications. When performing a logistic regression analysis we found, for complications: OR SSF=0.67, ICC=1.11; ASA 3 & 4=0.89 and age=1.04; while for readmissions: OR SSF=2.09; ICC=1.01; ASA 3 & 4=0.79 and age=1. ConclusionsThe ICC and SSF scales showed no differences to the ASA scale in the prediction of readmissions, complications and hospital stay. However, the SSF seems to have a better correlation in predicting unplanned readmission.

AB081. SOH23ABS_016. Is total knee replacement surgery warranted in the obese patient: a systematic review

Background: Obesity is a well-documented risk factor for the development of osteoarthritis. This in turn results in an increase in the need for joint replacement surgery amongst this cohort. The debate persists as to whether obese patients undergoing total knee replacement (TKR) surgery will experience a higher rate of complications. This has resulted in patients with obesity to be deemed unsuitable for elective TKR surgery.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Comparison of dural puncture epidural approach versus conventional epidural approach for anesthesia in patients undergoing total knee arthroplasty: Prospective randomized study

Background: Epidural anesthesia reduces the exposure to other anesthetics and analgesics. The dural puncture epidural (DPE) approach improves caudal spread of analgesia compared with epidural (EPL) approach without the side effects observed with the combined spinal EPL method. The goal of this work was to evaluate the efficacy of DPE method versus standard EPL method as an anesthetic method in cases undergoing Total Knee Arthroplasty (TKA). Methods: This prospective randomized double blinded study was carried out on 70 cases admitted for elective total knee replacement surgery. Cases were subdivided in to two equal groups: group I (EP): received fifeteen millilitres of (0.25% plain bupivacaine and 50 µg fentanyl) over 5 min., there was no dural puncture in this group and group II (DPE): who received fifeteen millilitres of (0.25% plain bupivacaine and 50 µg fentanyl) over 5 min., administered in the epidural space by epidural catheter at L3-L4 interspace, a dural puncture was created. All cases were assessed for time of onset of motor block, duration, number of top-up doses for 24 hours postoperative and adverse events. Results: There was significant decrease in mean value of time till sensory block and time till motor block occurred in group II versus group I (p value <0.001). there was significant decrease in mean value of Breen Modified Bromage scale in group II (p value <0.05) at 5min and 8min versus group I. Intergroup comparison of duration from administration of block till first top up dose and number of top up doses revealed no difference between two approaches. Conclusions: DPE method seemed to have faster onset of sensory and motor block versus standard EPL method.

Barriers, enablers and acceptability of home-based care following elective total knee or hip replacement at a private hospital: A qualitative study of patient and caregiver perspectives.

To facilitate implementation of home-based care following an elective total knee or hip replacement in a private hospital, we explored patient and caregiver barriers and enablers and components of care that may increase its acceptability. Thirty-one patients (mean age 71 years, 77% female) and 14 caregivers (mean age 69 years, 57% female) were interviewed. All themes were developed using thematic analysis, then categorised as barriers or enablers to uptake of home-based care or acceptable components of care. Barrier and enabler themes were mapped to the Theoretical Domains Framework. Eight themes emerged as barriers or enablers: feeling unsafe versus confident; caregivers' willingness to provide support and patients' unwillingness to seek help; less support and opportunity to rest; positive feelings about home over the hospital; certainty about anticipated recovery; trusting specialist advice over family and friends; length of hospital stay; paying for health insurance. Five themes emerged as acceptable components: home visits prior to discharge; specific information about recovery at home; one-to-one physiotherapy and occupational therapy perceived as first-line care; medical, nursing and a 24/7 direct-line perceived as second-line care for complications; no one-size-fits-all model for domestic support. Theoretical domains relating to barriers included emotion (e.g., feeling unsafe), environmental context and resources (e.g., perceived lack of physiotherapy) and beliefs about consequences (e.g., unwillingness to burden their caregiver). Theoretical domains relating to enablers included beliefs about capabilities (e.g., feeling strong), skills (e.g., practising stairs), procedural knowledge (e.g., receiving advice about early mobility) and social influences (e.g., caregivers' willingness to provide support). Multiple factors, such as feeling unsafe and caregivers' willingness to provide support, may influence implementation of home-based care from the perspectives of privately insured patients and caregivers. Our findings provide insights to inform design of suitable home-based care following joint replacement in a private setting.