The Impact of Preoperative Education on Knee and Hip Replacement: A Systematic Review

: This review aims to evaluate the usefulness of preoperative education in the orthopedic patient undergoing knee and total hip replacement. The systematic review was conducted by searching the PubMed, Cochrane, CINAHL, and Embase databases from inception to April 2021. Keywords and combinations of keywords were organized according to the PICOs approach to identify relevant studies. Thirty-seven studies involving 5185 patients were included. Preoperative education was associated with decreased postoperative pain compared to the control group. Preoperative anxiety and length of stay were reduced in most studies through preoperative education compared to the control group. Furthermore, other topics such as sleep, mental status, compliance, knowledge, and patient expectations generally showed improvement in the experimental group. For future investigations, it would be imperative to augment the patient sample size to enhance the research’s reliability and incorporate the most up-to-date literature.


Introduction
Osteoarthritis (OA) is a leading cause of disability, pain, and major utilization of healthcare resources worldwide, affecting more than 14 million people [1]. The prevalence of OA is increasing due to an aging population [2]. Cartilage degradation, subchondral sclerosis, and synovial inflammation can damage other joint structures, such as ligaments and menisci. Diagnosis of OA is based on clinical and radiological findings (e.g., radiography, X-ray, MRI). Osteoarthritis is most observed in the knees and hips, followed by the hands and spine. Treatment options range from patient education, weight loss, exercise and physical therapy, and medications to more invasive options, such as intra-articular corticosteroid injections and arthroplasty. When conservative methods are unsuccessful, total joint replacement (TJR) surgery may be necessary [3].

Preoperative Education
There is an increasing demand for preoperative education for patients undergoing joint replacement surgery. Research has demonstrated that preoperative education can improve patient outcomes and satisfaction with the surgical experience [4,5]. Furthermore, a patient who is well-informed is more likely to be satisfied and take a more active role in their treatment. Preoperative education for surgery requires not only physical preparation of the patient, but also psychological and emotional preparation. The most effective preparation involves patient preparation pathways that are tailored to the patient's pathology, type of procedure, literacy level, and cultural background. In addition to the traditional verbal interview, various educational support materials can be employed, including one item of printed information: each patient was given a handout with all the key information regarding the surgery [6]. Two websites; three audio-visual media, such as videotapes; four digital video discs with illustrative films; and PowerPoint presentations were very useful because they can be sent to the patient who can view them at any time at their convenience. Of these modalities, the most effective is a personal interview with the educator [6], as this allows the operator to anticipate the user's feelings and behaviors and allows the patient to ask active questions that the nurse or health care figure can answer. During preoperative education, information is provided regarding preparation procedures for surgery, the type of surgery, and the techniques used, as well as associated risks and potential complications. Furthermore, information is given regarding anticipated levels of pain and management strategies, restrictions in daily activities, recovery periods, and potential post-surgical health conditions. Several randomized controlled trials have demonstrated that preoperative education for surgical patients can lead to a decrease in length of hospital stay, a reduction in the need for postoperative pain medication, and an increase in patient and family satisfaction with the surgical process [7,8]. The implementation of this educational program would be beneficial in developing effective strategies to provide guidance and instruction to patients before, during, and after hospitalization. As the frequency of these interventions is increasing and the length of hospital stays is decreasing, patients need this kind of information to make informed decisions. Nurses, working together with a group of healthcare professionals from different areas of expertise, are essential for providing preoperative education to patients, their families, and caregivers (individuals outside of the family who provide care, support, and companionship in an informal capacity). The individual plays an important role in the patient's illness experience and assists in daily caregiving tasks, forming a "dyad": something that consists of two elements or parts and, in this case, represents the relationship between patient and caregiver. Currently, there is a lack of systematic research exploring the educational needs of patients and their families undergoing hip and knee replacement [9,10]. The aim of this review is to evaluate the efficacy of orthopedic patient education in identifying, understanding, managing, and resolving issues related to the joint replacement process from preoperative to postoperative periods.

Materials and Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were employed to enhance the reporting of the review. The most recent revision on this topic was published in 2017 [11], and the following article has incorporated recent literature to ensure the results are up to date.

Eligibility Criteria
This study aimed to identify articles describing patients (P) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) [12] who had received different types of preoperative education (I), and to compare the outcomes (O) between those who had received preoperative training and those who had not (C). Keywords and combinations of keywords were used to search electronic databases, and the research question was formulated using a PICOS-approach: Patient (P), Intervention (I), Comparison (C), Outcome (O), and Study design (S).
The aim of this study was to quantify the outcomes of preoperative education for orthopedic patients and caregivers, as well as to assess the qualitative outcomes and dyad characteristics (e.g., age, social context, and cost) associated with these outcomes. To achieve this, randomized controlled trials, prospective studies, retrospective analyses, pilot randomized controlled trials, prospective longitudinal cohort studies, feasibility studies, and pilot studies were included in the analysis.

•
Studies involving employed individuals of all ages with no restrictions. • Studies that measure outcomes of patients who have undergone total hip arthroplasty (THA) and total knee arthroplasty (TKA) using generic scales administered to specific groups or at specific times, such as before and after preoperative education, and studies that report scores related to functionality and psychological aspects.

Search Strategy
A comprehensive search of Medline, Cochrane, CINAHL, and Embase databases was conducted from inception to April 2021 using a combination of keywords connected by the Boolean operators "AND" and "OR" to screen articles for inclusion in the study. The search process was conducted in an iterative and adaptive manner, considering the capabilities of the search engines of each database. The search strategy for this study was conducted by two reviewers (C.R. and I.P.) using a combination of Medical Subject Heading (MeSH) keywords and free terms, including: preoperative, presurgical care, education, education programs, arthroprotesis, total knee arthroplasty, total hip arthroplasty, total knee replacement, total hip replacement, joint arthroplasty, joint replacement, knee prosthesis, and hip prosthesis.

Study Selection and Data Collection
We accepted only English publications and conducted a search of the literature using the CADIMA software. The search was performed by two reviewers (I.P. and C.R.) following a previously described protocol. The researchers followed a research order of screening titles first, then abstracts and full papers. If the two independent reviewers could not exclude a paper based on its title and abstract, its full text was reviewed. The number of articles excluded or included were recorded and reported in a PRISMA flowchart (Figure 1), which was designed according to the rules by Moher et al.

Quality Assessment
Two reviewers (C.R. and I.P.) independently assessed the potential risk of bias in the included studies using the Methodological Index for Non-randomized Studies.
(MINORS) and the Cochrane Risk-of-Bias Tool for Randomized Controlled Trials (RCTs). The items of MINORS were scored 0 if not reported, 1 if reported but inadequate, and 2 if reported and adequate. The Cochrane Risk-of-Bias Tool was used to assess the quality of randomized controlled trials, with criteria including selection, performance, detection, attrition, reporting, and other biases. Each criterion was evaluated by assigning 0 points for low risk, 1 point for unclear risk, and 2 points for high risk of bias. The total score ranged from 0 to 14. A score of 0-1 indicated high quality, 2-3 indicated moderate quality, and a score greater than 3 indicated.

Data Synthesis and Analysis
Data were extracted and synthesized using Microsoft Excel 365. Characteristics of the study extracted included author, year of publication, country of origin, study design, aim, mean age, sex (Female/Male), joint analyzed, intervention program for the intervention group, follow-up period, outcome measure, outcome results, and conclusion. The codes of the scales and other abbreviations used in the tables were explained in the legend. Additionally, a comment and the prevalence of the values were expressed as a percentage below.

Study Selection
The selection process is depicted in Figure 1. After conducting a search strategy, 668 articles were identified. Duplicates were removed and titles, abstracts, and full-texts were reviewed. Of these, 37 studies met the criteria for methodological quality and were eligible for review. Only articles in English were included in the initial filter; thus, the number of articles excluded due to being in other languages is not shown in Figure 1.

Study Characteristics
This study included 5185 patients. The details of the sample size, study design, and purpose of the studies are provided in Table 1. All quantitative studies were reported in Tables 2 and 3. Data reported included mean age, female-male ratio, joint analyzed, type of educational intervention, follow-up, scores used, score results, and conclusions. The results included statistically insignificant data (p-value > 0.05). The conclusions in the table were based on statistically significant data (p < 0.05) and allowed for an accurate estimation of the effectiveness of each aspect analyzed. The percentages in the final conclusions were derived from statistically significant data only. Table 4 displays the qualitative studies, which are similar to those in Tables 2 and 3, except that Outcome Measures are not included. The conclusions are consistent with those in Table 3. Hypothesize that patients receiving standard information plus additional medical information through audiovisual video discs would modify their preoperative expectations more than those only receiving the standard information through medical interviews Lewis [31] 1997 Australia Not RTC 87 (38,49) Determine the value of orthopaedical education in a pre-admission clinic for patients who were undergoing total knee and total hip replacements.
Lichtenstein [ Use the program to attempt to prevent complications, decrease anxiety, and decrease pain and hospital length of stay      Table 3. Outcome results.
Biau [14] 65 The median time to reach complete independence was five days in all groups. There was no significant effect of either education (HR:

Author Outcome Results
Daltroy [19] LOS: patients who received information had shorter LOS than controls (0.67 days less, on average); patients in the bottom quartile (least denial) who received information had greater length of stay (1.94 days) than controls. The average anxiety level 4 days postoperatively was 1.9 (scaled 1 = low to 4 = high; SD 0.56). The average pain level 4 days postoperatively was 2.4 (scaled 1 to 5; SD 0.85). General linear models analysis indicated that 24% of the variance in pain was explained by the covariates and intervention effects (F = 6.55, 10,207 df; p < 0.0001). The average patient used the equivalent of 9.9 units of morphine during the first 4 days postoperatively (range 0.0-62.1; median 8.0; SD 8.3). Neither the information intervention (p = 0.059) nor the relaxation intervention (p = 0.52) nor their interaction (p = 0.51) was associated with better mental status, although the trend was favorable for information provision.
Doering [20] Trait anxiety (stanine value) 5.0 ± 1.9 5.3 ± 1.9. Depression (stanine value) 6.1 ± 1. Huang [25] S-E (T4 Kearney [28] Patients who had attended the structured preoperative class felt significantly better prepared for surgery (mean 1.2 vs. 1.4, p 0.002, where 1 corresponded to very much so and 2 to somewhat) and they also felt better able to control their pain after surgery (mean 1.4 vs. 1.7, p 0.001, where 1 corresponded to very much so and 2 to somewhat). Leal-Blanquet [30] Knee ROM c: 0.  Medina-Garzon [37] The mean score of preoperative anxiety was equal in the pre-intervention evaluation in both groups (19. [42] Average LOS i: 8.0 days, c: 8.7 days. Santavirta [43] The experimental group had followed the instructions for the exercise program more often than the control group (p = 0.02, Chi-square). Patients who received information increased fruit consumption (p = 0.05, McNemar test). The intervention group's knowledge of symptoms and complications were not statistically better than that of the controls (p = 0.2, Mann-Whitney U-test).
The experimental group showed more satisfied with the information they had received. There was no statistical difference in the number of early complications and the two-to three-month rehabilitation results between the two groups. Confusing or controversial information from different health care professionals/groups t: 422.5 p: 0.2519. Teaching and verbal information presented clearly t: 475.0 p: 0.0913. Teaching and information always adjusted to individual situation t: 305.0 p: 0.3132. At home, many items remained unclear t: 332.5 p: 0.3293.
Siggeirsdottir [44] Mean hospital stay was shorter for the SG than for the CG (6.4 days and 10 days, respectively; p < 0.001).
During the 6-month study period, there were nine non-fatal complications in the SG and 12 in the CG (p = 0.3). The difference in Oxford Hip Score between the groups was not statistically significant before the operation, but was better for the SG at 2 months (p = 0.03), and this difference remained more or less constant throughout the study.

Outcome: LOS
Of fourteen studies, nine [19,22,28,31,36,38,42,44,45,49] demonstrated a decrease in the length of stay (LOS) in comparison to the control group, while the remaining five trials [14,17,18,28,46] reported no significant difference from the hospital average. According to the MINORS scale, the overall quality of evidence for these studies was rated between "low" and "high". In addition to these topics, sleep, mental state, compliance, knowledge, and patient expectations were all observed to have improved in the experimental group. The results of this are presented in Tables 2 and 3. 3.4. Quality Assessment 3.4.1. Risk of Bias Assessment with MINOR for Non-Randomized Studies Two authors (C.R., I.P.) independently assessed the potential risk of bias for nonrandomized studies using MINOR (Methodological Index for Non-Randomized Studies). Items were scored as 0 for unreported, 1 for inadequate, and 2 for reported and adjusted. Studies that met all MINOR criteria were classified as having a low risk of bias, while those that did not meet all criteria were classified as having a high risk of bias (Table 5). The quality assessment of the RCTs' risk of bias instrument was performed by two authors (C.R., I.P.) independently, using a quantitative score for each item. Unreported items were scored with a 0, inadequate items with 1, and reported and corrected items with 2. An overall quality score was calculated by summing up the values of the different items using the following scale: score ≤1 (high quality), score ≤3 (moderate quality), and score >3 (low quality) ( Table 6).  High quality ≤ 1: N = 7 (28%); Moderate quality ≤ 3: N = 9 (36%); Low quality > 3: N = 9 (36%).

Synthesis of Results
A total of 8129 patients were enrolled in the included studies; 24.5% were female, 20.6% were male, and the remaining 54.9% were unspecified. Most studies analyzed patients undergoing hip replacement (40.5%), 43.3% analyzed patients undergoing either hip or knee replacement, and 16.2% analyzed only knee replacement. Most studies (64.9%) were randomized controlled trials (RCTs), 8.1% were qualitative studies, 13.5% were nonrandomized controlled trials (NRCTs), 10.8% were prospective cohort studies, and the remaining 2.7% were descriptive comparative studies. The measured outcomes were highly varied.

Discussion
Prior to surgery, patients were provided with educational information to enable them to actively participate in the decision-making process and understand the essential elements of the proposed procedure. Furthermore, research has demonstrated that preoperative education is associated with decreased levels of anxiety and stress, as well as reduced postoperative pain and hospital stay. Patients have reported increased understanding and satisfaction with the process [24].
A total of 37 articles were analyzed, which employed various educational techniques. These included the use of brochures, illustrative PowerPoint presentations, and video lessons. The duration of the educational sessions varied, with some receiving only a few hours of instruction, while others attended classes for a longer period. Additionally, the number of patients instructed differed, with some receiving individual programs and others being grouped into large groups and attending classroom lectures [6]. The results of 37 studies suggest that preoperative education may be beneficial in improving patientreported outcomes (PROs), such as quality of life, pain, stress, and satisfaction in patients undergoing hip or knee replacement. Preoperative education was found to reduce preand postoperative anxiety in many of the samples analyzed. This psychological state has been associated with a negative impact on the patient's entire hospital course [50]. Anxiety has been shown to not only affect one's psychological state but also to have an impact on functional outcomes [6]. Medina-Garzon et al. [37]. conducted a study to assess the effect of a nurse-led motivational interview on preoperative anxiety in knee replacement candidates [11]. After six weeks of follow-up, the preoperative anxiety score was lower in the intervention group than in the control group. In another study, videotapes were utilized as an educational tool [20].
The results indicate that preoperative education prior to total hip replacement surgery decreased anxiety and stress (as measured by cortisol excretion). Additionally, the intervention group had lower analgesic consumption during the four postoperative days, despite similar pain levels reported in both groups. Preoperative education was associated with a significant reduction in length of stay, with an average decrease of almost one day, according to Sisak et al. (2019). [45] found that mean length of stay was reduced by 0.37 days for patients who had undergone total hip replacement surgery (95% CI −0.74, −0.01, p = 0.05) and by 0.77 for patients who had undergone total knee replacement (95% CI −1.23, −0.31, p = 0.001). The results of this study can be compared to those reported by Yoon et al. [49], in which patients who participated in a training session had a significantly shorter length of stay than non-participants for both total hip replacement (3.1 (SD 0.9) vs. 3.9 days (SD 1.4); p = 0.001) and total knee replacement (3.1 (SD 0.9) vs. 4.1 days (SD 1.9); p = 0.001). On the other hand, the results of the study by Butler et al. [17] found that the intervention group (which received an educational booklet) had lower levels of anxiety at admission and discharge than the control group; however, there was no significant difference between the two groups in terms of length of stay.
Approximately 30-80% of patients who have undergone surgery report inadequate pain management. Pain is a complex phenomenon that necessitates consideration of multiple factors. Sjöling et al. [46] demonstrated that certain types of information can affect the experience of pain. The treatment group experienced a more rapid decrease in postoperative pain, as well as lower levels of anxiety and greater satisfaction. Postoperative pain decreased more rapidly in the treatment group, accompanied by lower levels of anxiety and greater satisfaction. A separate study demonstrated that providing an educational session 2 to 6 weeks prior to total hip arthroplasty can reduce pain and other factors before surgery [24].
A 1993 study conducted by Wong et al. [48] demonstrated the efficacy of a preoperative education program in preparing patients for surgery and their postoperative needs at home. The sample enrolled revealed significant differences in satisfaction between the groups.
The participants in the experimental group exhibited a greater degree of satisfaction than those in the control group. Furthermore, this study demonstrated that patients' compliance with physician instructions increased following a structured educational program. In 1994, Santavirta et al. [43] found that the experimental group who underwent an intensified education program experienced higher satisfaction and compliance than the control group. In the Oxford English Dictionary, "compliance" is defined as the act of adhering to a desire, request, condition, direction, etc.; consenting to act in accordance with; acceding to; and providing practical assent [51]. Studies have demonstrated that when patients are provided with information regarding the therapeutic process and the rationale for performing certain tasks, patient compliance is improved, which has a positive effect on postoperative recovery [22,23]. Wong et al. [48] observed that patients who received the new approach exhibited a significantly higher level of adherence than those who did not. Generally, patients are considered to be empowered when they possess adequate knowledge to meet their needs. Consequently, it is essential that patients take an active role in the educational process [27]. Pre-admission education appears to result in improved learning outcomes, particularly when concept maps and written material are utilized as opposed to unstructured oral education [27].

Limitation
This review has some limitations. Firstly, a control population with no prior knowledge would be necessary to obtain highly reliable results; however, this is not feasible in the included studies due to ethical considerations. It is likely that patients in the control group sought information on their own and asked questions that were not always declined on ethical grounds. Second, non-randomized, descriptive studies were also included in our work to broaden the search; however, comparing two groups provides better data on the impact of the intervention. Third, some articles only provided preoperative training to the intervention group. This comparison has limitations due to ethical considerations, as the control group cannot be denied information.
Another significant limitation of the following study lies in the fact that THA and TKA interventions have significantly different aspects in the assessment of clinical outcomes, particularly in rehabilitation.

Conclusions
Based on the comprehensive scientific analyses conducted previously, it is evident that 65.4% of the analyzed parameters demonstrated superior outcomes in the intervention group compared to the control group. These findings underscore the crucial role of preoperative education in the trajectory of orthopedic patients. This review highlighted the need for further research into preoperative education for orthopedic patients. In future research, descriptive studies can offer valuable information; however, to accurately determine the effect of an intervention, it is necessary to incorporate a control group. Therefore, future researchers are advised to expand the research dress with randomized controlled trials.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.