Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation

Hip-spine parameters change with increasing age

Aims

Spinopelvic pathology increases the risk for instability following total hip arthroplasty (THA), yet few studies have evaluated how pathology varies with age or sex. The aims of this study were: 1) to report differences in spinopelvic parameters with advancing age and between the sexes; and 2) to determine variation in the prevalence of THA instability risk factors with advancing age.

Methods

A multicentre database with preoperative imaging for 15,830 THA patients was reviewed. Spinopelvic parameter measurements were made by experienced engineers, including anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence (PI). Lumbar flexion (LF), sagittal spinal deformity, and hip user index (HUI) were calculated using parameter measurements.

Results

With advancing age, patients demonstrate increased posterior APPT, decreased standing LL, decreased LF, higher pelvic incidence minus lumbar lordosis (PI-LL) mismatch, higher prevalence of abnormal spinopelvic mobility, and higher HUI percentage. With each decade, APPT progressed posteriorly 2.1°, LF declined 6.0°, PI-LL mismatch increased 2.9°, and spinopelvic mobility increased 3.8°. Significant differences were found between the sexes for APPT, SPT, SS, LL, and LF, but were not felt to be clinically relevant.

Conclusion

With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility. Surgeons should consider the higher prevalence of instability risk factors in elderly patients and anticipate changes evolving in spinopelvic biomechanics for young patients.

Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty

The prevalence of total hip arthroplasty (THA) for advanced hip osteoarthritis (OA) is both increasing and shifting toward a younger average age. However, THA alone does not typically normalize function in these patients. Postoperative rehabilitation is often recommended to optimize joint motion, strength, and function. To date, there are no peer-reviewed clinical practice guidelines for postoperative rehabilitation following THA. Thus, optimal postoperative rehabilitation requires consideration of the existing literature and clinical expertise. This review article summarizes current recommendations for postoperative management of THA, including phases of rehabilitation, postoperative hip precautions, the effect of rehabilitation setting and mode of delivery on postoperative outcomes, and gait mechanics.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients

BACKGROUND AND PURPOSE

Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.

MATERIALS AND METHODS

We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.

RESULTS

4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).

CONCLUSION

The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.

An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used

BACKGROUND

The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA).

METHODS

A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge.

RESULTS

Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days.

CONCLUSION

There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.

Patient compliance with hip precautions 12 weeks following primary elective total hip arthroplasty

INTRODUCTION

Patients are routinely advised to follow hip precautions following their total hip arthroplasty (THA) surgery. There is lack of evidence regarding compliance with these precautions and when patients return to activities of daily living following their surgery.

MATERIALS AND METHODS

We designed a new questionnaire to discover when patients return to their activities of daily living. Two hundred and ninety seven consecutive patients who attended 12 week follow up arthroplasty clinic following their primary elective THA were asked to complete the questionnaire.

RESULTS

All patients who attended the follow up clinic at 12 weeks responded to the questionnaire. Only 6.3% (n = 19) of the patients reported that they restricted their daily activities, as prescribed for the full 12 week period, while 50% (n = 148) of patients stopped using prescribed adaptive equipment by 6 weeks after their operation. There were no dislocations recorded among the study group.

CONCLUSION

We found that the majority of patients do not adhere to hip precautions advice. They return to their activities of daily living prior to the end of prescription period based on their pain and activity level. Lack of adherence to hip precautions do not predispose to hip dislocation in the immediate post-operative period.

The ability and factors related with floor sitting after total hip arthroplasty with a posterolateral approach

Background

Prosthesis dislocation following total hip arthroplasty (THA) is one complication that affects treatment outcome and increases the cost of treatment. Currently, many surgeons prohibit patients from performing floor-based activities; however, these prohibitions might affect the lifestyle of a number of patients.

Objective

This study aimed to evaluate the ability of floor sitting after THA, and factors associated with this ability.

Methods

This study was a retrospective cohort study, evaluating 240 patients who underwent THA with a posterolateral approach, in a single tertiary hospital. Patient demographic data, preoperative clinical data, prostheses type, and postoperative radiographic were extracted from the electronic medical records. Postoperative ability to perform floor sitting was evaluated at 6 months postoperatively.

Results

There were 52 patients (21.66%) who were able to sit on the floor postoperatively. Multivariate logistic regression analysis showed independent association between three factors with ability to sit on the floor after surgery: pre-operative external rotation range of motion (OR 1.03; 95% CI, 1.01-1.06; P = 0.01), pre-operative Harris Hip Scores (OR 1.05; 95% CI, 1.01-1.10; P = < 0.01), pre-operative ability to sit on the floor (OR 10.2; 95% CI, 3.65-28.5; P = < 0.01).

Conclusion

There were a number of patients who could sit on the floor after THA. However, there were factors which were associated with this ability. Hence, these results could be useful for adjusted patient preoperative expectations, and did not preclude all patients to perform floor activities.

Does Preoperative Activity Level Affect Postoperative Outcomes Following Total Hip Arthroplasty?

BACKGROUND

Many patients electing to undergo total hip arthroplasty (THA) value continuing active lifestyles when considering treatment options. Addressing these concerns requires evaluating the effect of preoperative activity level on patient-reported outcomes and improvement following THA.

METHODS

Three hundred thirty-five patients (368 hips) who underwent THA with a minimum 6-month (mean 533 ± 271 days) follow-up completed preoperative and postoperative University of California, Los Angeles (UCLA) activity score along with various patient-reported measures of function, pain, and mental state. Preoperative UCLA score divided patients into inactive, mild, and active groups. Analysis of covariance controlling for age, sex, body mass index, surgical approach, implant, bilateral cases, conversions, and follow-up time evaluated differences among groups for postoperative outcomes with subsequent Tukey-Kramer pairwise comparisons.

RESULTS

Mildly active patients (73:139 male:female) had better postoperative outcomes than inactive patients (40:70 male:female) for UCLA score, EuroQol Visual Analog Scale (EQVAS), Hip Outcome Score (HOS), 12-item Short-Form (SF-12) Physical, and Visual Analog Pain Scale (average/now/worst) (P values <0.001/<0.001/<0.001/<0.001/0.003/<0.001/<0.001). Active patients (32:14 male:female) had better postoperative outcomes than inactive patients for UCLA score, EQVAS, HOS, SF-12 Physical, and Visual Analog Pain Scale Worst (P values <0.001/0.024/0.001/0.001/0.017). No postoperative outcome differences existed between active and mild patients. Inactive patients displayed greater outcome improvements than mildly active patients for UCLA score, Harris Hip Score, and International Hip Outcome Tool (P values <0.001/<0.001/0.013) and active patients for UCLA score, EQVAS, HOS, International Hip Outcome Tool, and SF-12 Physical (P values <0.001/0.008/0.013/0.022/0.004).

CONCLUSIONS

Inactive patients achieve greater measure improvements following THA. Active patients achieve better absolute outcomes than inactive patients; however, increasing activity levels do not incrementally improve patient-reported outcome measures. Patients similarly improve pain and mental health regardless of activity level.

Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions

Background

Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted.

Methods

The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014–2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used.

Results

PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43–68) and 47 (31–61); other symptoms, 50 (40–65) and 36 (19–50); function in daily living, 54 (41–65) and 44 (31–55); function in sports and recreation, 56 (38–75) and 40 (15–64); joint-related quality of life, 69 (50–81) and 56 (38–75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients.

Conclusions

We found excellent PROM results after fast-track HA and KA with no postoperative restrictions. We believe that a fast-track program focusing on mobilization without any postoperative restrictions is superior for most patients, but further comparative studies are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05276-y.

Inpatient dislocation after primary total hip arthroplasty: incidence and associated patient and hospital factors

INTRODUCTION

Inpatient dislocation following total hip arthroplasty (THA) may incur substantial financial penalties for hospitals in the United States. However, limited studies report on current incidence and variability of dislocations. We utilised a large national database to evaluate inpatient hip dislocation trends regarding: (1) yearly incidences; (2) lengths of stay (LOS); (3) demographic factors; and (4) hospital metrics.

METHODS

The National Inpatient Sample was queried from 2012 to2016 for primary THA patients (n = 1,610,155), identifying 2490 inpatient dislocations. Various patient demographics and hospital characteristics were assessed. Multivariate regression analyses were conducted to identify dislocation risk factors.

RESULTS

Dislocation rates increased from 0.11% in 2012 to 0.18% in 2016 (p < 0.001). Dislocated patients experienced significantly longer LOS (p < 0.001). Patient demographic factors associated with dislocation were sex, race, Medicaid insurance, alcohol use disorder, psychosis, hemiparesis/hemiplegia, chronic renal failure, and obesity. Spinal fusion was not associated with inpatient dislocation. Dislocations were likeliest in the South and least likely in teaching hospitals.

CONCLUSION

Inpatient dislocation has increased in recent years. Optimised management and recognition of the patient and hospital factors outlined in this study may help decrease inpatient dislocation risks following THA, thus avoiding hospital reimbursement penalties for this preventable complication.

Is convention hip precaution necessary after total hip arthroplasty?

Background:

Dislocation is one of the most common causes of revision after total hip arthroplasty (THA). Standard hip precautions are thought to enhance soft-tissue healing and reduce dislocations. However, lifestyle restrictions affect a patient’s rehabilitation, quality of life (QOL), and satisfactions. We aim to compare conventional (CP) and minimal hip precautions (MP) after THA.

Methods:

Retrospective review of prospectively collected data in posterolateral approach THA. Chief surgeon assigns patients to CP or MP group. CP group had to sleep supine, used elevated toilet seats and chairs, avoid hip flexion greater than 90°, and no internal rotation or adduction for 6 weeks. MP group had no restrictions in hip movements, except for the combined flexion, adduction and internal rotation. All had a minimum 1-year follow-up. The number of dislocations, length of stay (LOS), time to independent toileting, Harris Hip Scores, QOL, and health perceptions, assessed by EuroQol 5D-5L, was compared between CP and MP groups.

Results:

Fifty-five THAs were included. CP group consisted of 17 primary and 12 revision THAs; MP group consisted of 21 primary and 5 revision THAs. There were two dislocations and both are revisions in CP group. Overall rate of dislocation was 6.9% in CP group and no dislocation in MP group (p-value > 0.05). MP group had shorter LOS (12 vs 19 days, p-value 0.04), higher EQ5D-5L health perception scores at 1-year (81.7 vs 70.9, p-value 0.01).

Conclusion:

MP group had shorter LOS and better health perceptions 1-year after THA with no increase in dislocation rates.

"True" Cumulative Incidence of and Risk Factors for Hip Dislocation within 2 Years After Primary Total Hip Arthroplasty Due to Osteoarthritis: A Nationwide Population-Based Study from the Danish Hip Arthroplasty Register

BACKGROUND

Hip dislocation is one of the leading indications for revision of total hip arthroplasty (THA) implants, and the extent of this complication is often measured by the number of revisions. The exact incidence of dislocation can be difficult to establish as closed reductions may not be captured in available registers. The purpose of this study was to identify the "true" cumulative incidence of hip dislocation (revisions and closed reductions) after primary THA, and the secondary aim was to identify risk factors for dislocation.

METHODS

From the Danish Hip Arthroplasty Register, we identified 31,105 primary THAs indicated by primary osteoarthritis that had been performed from 2010 to 2014 and had 2 years of follow-up. Dislocations were identified through extraction from the Danish National Patient Register. Matching diagnosis and procedure codes were deemed correct while non-matching codes were reviewed through a comprehensive, nationwide review of patient files. Risk factors were analyzed with multiple logistic regression analysis and presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Our review of patient files identified 1,861 dislocations in 1,079 THAs, which corresponds to a 2-year cumulative incidence of 3.5% (CI = 3.3% to 3.7%). This was a 50% increase compared with the correctly coded dislocations captured by administrative register data only. Patients who were <65 years of age had a lower dislocation risk (OR = 0.70; CI = 0.59 to 0.83) and those who were >75 years of age had a higher risk (OR = 1.32; CI = 1.14 to 1.52) compared with those who were 65 to 75. Male sex (OR = 0.86; CI = 0.75 to 0.98), cemented fixation (OR = 0.71; CI = 0.58 to 0.87), and lateral approach (OR = 0.28; CI = 0.16 to 0.49) were all associated with a lower risk. A head size of 32 mm was associated with a higher risk of dislocation (OR = 1.27; CI = 1.10 to 1.46) than 36-mm heads, whereas dual-mobility cups had a reduced risk (OR = 0.13; CI = 0.05 to 0.36).

CONCLUSIONS

We found the "true" cumulative incidence of dislocations within 2 years after primary THAs performed between 2010 and 2014 in Denmark to be 3.5%. Age, sex, American Society of Anesthesiologists (ASA) score, head size and type, fixation method, and surgical approach were independent significant factors for dislocation. Comprehensive search algorithms are needed in order to identify all dislocations so that this complication can be accurately reported in national registers.

Do hip precautions after posterior-approach total hip arthroplasty affect dislocation rates? A systematic review of 7 studies with 6,900 patients

Background and purpose - Hip precautions limiting flexion, adduction, and internal rotation have been prescribed traditionally to minimize dislocation rates following THA. We assessed the prevalence of hip dislocation following posterior approach total hip arthroplasty without postoperative hip precautions. Methods - A systematic review of multiple medical databases was performed using the PRISMA guidelines and checklist. All clinical outcome studies that reported dislocation rates and postoperative instructions following posterior approach, primary surgery, published within the last 6 years, were included. Results - 6,900 patients were included from 7 Level I-IV studies, with 3,517 treated with and 3,383 without precautions. There was no statistically significant difference in the rates of dislocation between groups (2.2% in restricted group vs. 2.0% in unrestricted group). All but 1 study demonstrated no statistically significant differences in patient-reported outcome scores between restricted and unrestricted groups, including those pertaining to return to function, confidence, and pain. Interpretation - The review found no impact on dislocation rates following total hip arthroplasty performed through a posterior approach, regardless of the use of hip precautions. We also found no impact of the prescription of hip precautions on patient-reported outcome scores.

Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning

PURPOSE

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA.

MATERIALS AND METHODS

Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice.

CONCLUSION

This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.IMPLICATIONS FOR REHABILITATIONRedesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

Are hip movement precautions effective in preventing prosthesis dislocation post hip arthroplasty using a posterior surgical approach? A systematic review and meta-analysis

PURPOSE

To determine if hip movement precautions reduce hip prosthesis dislocation rates post hip arthroplasty using a posterior surgical approach compared to minimal or no movement restrictions.

MATERIALS AND METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively. CINAHL, MEDLINE and Embase were searched from inception until September 2020 supplemented by citation tracking. Studies were included if patients had a hip arthroplasty using a posterior surgical approach with comparative data on hip movement precautions or minimal to no movement restrictions. Methodological quality was evaluated using the Downs and Black checklist.

RESULTS

From a yield of 8 studies, meta-analysis of 7 studies and 9599 total hip arthroplasties, there was low quality evidence of no increased risk of dislocation (RR = 0.98, 95%CI 0.58 to 1.67) for patients prescribed minimal or no hip movement restrictions compared with patients prescribed hip movement precautions. There were 121/5440 dislocations (2.2%) in the movement precaution group and 90/4159 dislocations in the minimally restricted group (2.2%).

CONCLUSIONS

Dislocation rates after total hip arthroplasty are low irrespective of movement precaution allocation. Resources allocated to implementing hip movement precautions may be better directed towards other clinical areas.IMPLICATIONS FOR REHABILITATIONThere was no difference in hip prosthesis dislocation rate between patients who received hip movement precautions compared to patients who received minimal or no restrictions after total hip arthroplasty using a posterior surgical approach.Health professionals involved in prescribing and monitoring adherence to hip movement precautions after total hip arthroplasty may be better allocating their resources to other areas of clinical care.Falls were associated with the greatest number of prosthesis dislocations, accounting for 24% of dislocations; resources may be better allocated towards evidence-based strategies to reduce falls.

Are Postoperative Hip Precautions Necessary After Primary Total Hip Arthroplasty Using a Posterior Approach? Preliminary Results of a Prospective Randomized Trial

BACKGROUND

It is unclear whether posterior hip precautions after primary total hip arthroplasty (THA) reduce the incidence of early postoperative dislocation.

METHODS

We performed a prospective randomized study to evaluate the effect of hip precautions on incidence of early dislocation after primary THA using a posterior approach. Between January 2016 and April 2019, 587 patients (594 hips) were consented and randomized into restricted or unrestricted groups. No significant demographic or surgical differences existed between groups. The restricted group was instructed to refrain from hip flexion >90°, adduction across midline, and internal rotation for 6 weeks. 98.5% (585 of 594) of hips were available for minimum 6-week follow-up (291 restricted and 294 unrestricted). Power analysis showed that 579 hips per group are needed to demonstrate an increase in dislocation rate from 0.5% to 2.5% with 80% power.

RESULTS

At average follow-up of 15 weeks (range, 6-88), there were 5 dislocations (incidence, 0.85%). Three posterior dislocations occurred in the restricted group at a mean of 32 days (range, 17-47), and 2 posterior dislocations occurred in the unrestricted group at a mean of 112 days (range, 21-203), with no difference in dislocation rate between groups (1.03% vs 0.68%; odds ratio, 0.658; 95% confidence interval, 0.11-3.96; P = .647). At 6 weeks, unrestricted patients endorsed less difficulty with activities of daily living, earlier return to driving, and more time spent side sleeping (P < .05).

CONCLUSION

Preliminary analysis suggests that removal of hip precautions after primary THA using a posterior approach was not associated with early dislocation and facilitated return to daily functions. Investigation to appropriate power is warranted.

It is safe to use minimal restrictions following posterior approach total hip arthroplasty: results from a large cohort study

BACKGROUND

To prevent early postoperative dislocation following a total hip arthroplasty (THA) procedure, patients must adhere to restrictions. Restrictive protocols are common if THA surgery is performed using the posterior approach, but scientific evidence form larger studies that supports these restrictions are scarce. In this large cohort study we compare the <90-days dislocation rate between patients receiving posterior approach THA managed with minimal versus extensive restrictions.

METHODS

Prospective cohort (n = 1049) of consecutive elective primary hip replacement surgery procedures (September 2014-July 2017) managed with minimal postoperative restrictions. Hospital charts were prospectively reviewed for patient demographics, risk factors and any hip dislocation. Control (n = 1102) consecutive primary elective THAs (January 2011-August 2014) managed with a traditional restrictive protocol. A posterior surgical approach was used in all procedures.

RESULTS

Minimal restrictions group: 17 dislocations <90 days (1.6%); Restricted group: 28 (2.5%), chi-square p = 0.1. Testing the hypothesis of inferiority by a minimum of 1% increase in ⩽90 days dislocation risk: p = 0.14 (test for difference) and p < 0.001 (non-inferiority test), allowing us to discard the null hypothesis (absolute increase in risk of ⩾1% with minimal restrictions). The proportion of surgeries performed with a femoral head size ⩾32 mm was higher in the minimal restrictions group.

CONCLUSIONS

Patients can be managed safely with minimal restrictions following posterior approach THA if combined with frequent use of larger femoral heads.

Less Postoperative Restrictions Following Total Hip Arthroplasty With Use of a Posterolateral Approach: A Prospective, Randomized, Noninferiority Trial

BACKGROUND

Patient restrictions are prescribed after total hip arthroplasty (THA) to ensure proper healing and prevent early dislocation. It has been suggested that less or nonrestrictive protocols following THA do not lead to higher dislocation rates. Nonetheless, restrictions are still widely used. The aim of this study is to evaluate the rate of early dislocations when patients were restricted to supine sleeping or unrestricted sleeping in the first 8 weeks after THA using a posterolateral approach.

METHODS

The study design was a single-center, parallel-group, stratified, randomized, noninferiority trial in which primary THA patients were allocated to either a restricted group or a nonrestricted group. The primary outcome was early (<8 weeks) dislocation rate. Secondary outcomes include pain (visual analog scale [VAS]), function in activities of daily living (Hip Disability and Osteoarthritis Outcome Score [HOOS]), and quality of life (EuroQoL 5 Dimension [EQ-5D]).

RESULTS

A total of 408 patients were randomized into 2 groups: those who were restricted in their sleeping position (n = 203) and those who received no restrictions in sleeping position (n = 205). Three patients (1.48%) from the restricted group and 3 patients (1.46%) from the unrestricted group had a dislocation. The noninferiority of the restricted group compared to the nonrestricted group was established for early dislocation. In addition, no statistically significant differences were found for VAS, HOOS, and QoL-5D between both groups. Both groups showed a significant improvement in VAS, HOOS, and QoL-5D.

CONCLUSION

Early dislocation rates in patients who were advised to comply to an unrestricted sleeping position following THA were not inferior to the dislocation rates in patients who were advised to sleep in a supine position following THA. The results of the present study strengthen the discussion regarding the relevance of providing patients with restrictions following THA.

Posterior Hip Precautions Do Not Impact Early Recovery in Total Hip Arthroplasty: A Multicenter, Randomized, Controlled Study

BACKGROUND

Posterior hip precautions have been routinely prescribed to decrease dislocation rates. The purpose of this study was to determine whether the absence of hip precautions improved early recovery after total hip arthroplasty via the posterolateral approach.

METHODS

Patients undergoing total hip arthroplasty via the posterolateral approach at 3 centers were enrolled. Patients meeting the selection criteria were randomized to standard hip precautions (SHP) or no hip precautions (NHP) for 6 weeks following surgery. HOOS Jr, Health State visual analog score, and rate of pain scores were recorded preoperatively and in subsequent postoperative visits; dislocation episodes were also noted. Standard statistical analysis was performed.

RESULTS

From 2016 to 2017, 159 patients were randomized to SHP and 154 patients were randomized to NHP. Controlling for the center at which the surgery was performed, the only difference in outcome scores between the 2 groups was at 2 weeks; the NHP group had a lower HOOS Jr score when compared to the SHP group (P = .03). There was no difference in outcome scores at any other time points when compared to preoperative assessments. In the SHP group, there were 2 recorded dislocations (1.3%) and 1 in the NHP group (0.7%; P = .62).

CONCLUSION

In this multicenter, randomized, controlled study, the absence of hip precautions in the postoperative period did not improve subjective outcomes which may be explained by the self-limiting behavior of NHP patients. Furthermore, with the numbers available for the study, there was no difference in the rate of dislocation between the 2 groups.

Varying but reduced use of postoperative mobilization restrictions after primary total hip arthroplasty in Nordic countries: a questionnaire-based study

Background and purpose - Mobilization has traditionally been restricted following total hip arthroplasty (THA) in an attempt to reduce the risk of dislocation and muscle detachment. However, recent studies have questioned the effect and rationale underlying such restrictions. We investigated the use of postoperative restrictions and possible differences in mobilization protocols following primary THA in Denmark (DK), Finland (FIN), Norway (NO), and Sweden (SWE). Patients and methods - All hospitals performing primary THA in the participating countries were identified from the latest national THA registry report. A questionnaire containing questions regarding standard surgical procedure, use of restrictions, and postoperative mobilization protocol was distributed to all hospitals through national representatives for each arthroplasty registry. Results - 83% to 94% (n = 167) of the 199 hospitals performing THA in DK, FIN, NO, and SWE returned correctly filled out questionnaires. A posterolateral approach was used by 77% of the hospitals. 92% of the hospitals had a standardized mobilization protocol. 50%, 41%, 19%, and 38% of the hospitals in DK, FIN, NO, and SWE, respectively, did not have any postoperative restrictions. If utilized, restrictions were applied for a median of 6 weeks. Two-thirds of all hospitals have changed their mobilization protocol within the last 5 years-all but 2 to a less restrictive protocol. Interpretation - Use of postoperative restrictions following primary THA differs between the Nordic countries, with 19% to 50% allowing mobilization without any restrictions. There has been a strong tendency towards less restrictive mobilization over the last 5 years.

Variation in Use of Postoperative Precautions and Equipment Following Total Hip Arthroplasty: A Survey of the AAHKS and CAS Membership

BACKGROUND

A traditional method to reduce dislocation risk following total hip arthroplasty involves prescribing postoperative precautions and ambulatory equipment to patients. The purpose of this study was to determine the prevalence of postoperative precaution and equipment use among North American arthroplasty surgeons for patients undergoing primary total hip arthroplasty.

METHODS

We conducted a survey of American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society members using an electronic questionnaire format to determine how often precautions and equipment were prescribed, and whether their use was associated with surgical approach and other surgeon demographics.

RESULTS

Of the respondents, 44% universally prescribed precautions while 33% never prescribed precautions. Use of the posterolateral approach, surgeon experience, and larger head size use were significantly associated (P < .01) with precaution and equipment use. Direct anterior approach surgeons were significantly less likely to prescribe precautions (P < .0001) and significantly less likely to prescribe equipment (P < .0001).

CONCLUSION

Although postoperative precautions continue to be used to some degree by the majority of members, their consumption of healthcare resources through utilization of additional care providers and purchasing of equipment, known association with reduced patient satisfaction, and lack of supporting evidence make them a target for future scrutiny.

The effect of precautions on early dislocations post total hip arthroplasty: a retrospective cohort study

INTRODUCTION

The efficacy of hip precautions in preventing dislocation post total hip arthroplasty (THA) has been questioned in recent literature. From 2014 our centre ceased routinely prescribing them due to lack of evidence. We investigate the effect of stopping these precautions on dislocation rate, patient satisfaction and Oxford hip score (OHS).

METHODS

Patients who underwent primary total hip arthroplasty prior to this change in protocol ( n = 2551) and for 1 year subsequently ( n = 673) were identified. Operative records were used to identify key demographic and operative data. Incidence of dislocation, OHS and patient satisfaction were extracted from the centre's electronic database. Subset analysis of those patients dislocating within 6 weeks was performed.

RESULTS

Rate of dislocation at 6 weeks in those prescribed and not prescribed precautions was 0.71% and 0.89% respectively ( p = 0.618). At 1 year this rose to 1.25% and 1.49% ( p = 0.406). Satisfaction ( p = 0.332) and OHS ( p = 0.441) at 1 year was not significantly different between cohorts.

CONCLUSIONS

Cessation of prescribing routine hip precautions post primary THA does not appear to significantly affect overall dislocation rate, patient satisfaction or functional status at 1 year post-operatively.

Capsular Ligament Function After Total Hip Arthroplasty

BACKGROUND

The hip joint capsule passively restrains extreme range of motion, protecting the native hip against impingement, dislocation, and edge-loading. We hypothesized that following total hip arthroplasty (THA), the reduced femoral head size impairs this protective biomechanical function.

METHODS

In cadavers, THA was performed through the acetabular medial wall, preserving the entire capsule, and avoiding the targeting of a particular surgical approach. Eight hips were examined. Capsular function was measured by rotating the hip in 5 positions. Three head sizes (28, 32, and 36 mm) with 3 neck lengths (anatomical 0, +5, and +10 mm) were compared.

RESULTS

Internal and external rotation range of motion increased following THA, indicating late engagement of the capsule and reduced biomechanical function (p < 0.05). Internal rotation was affected more than external. Increasing neck length reduced this hypermobility, while too much lengthening caused nonphysiological restriction of external rotation. Larger head sizes only slightly reduced hypermobility.

CONCLUSIONS

Following THA, the capsular ligaments were unable to wrap around the reduced-diameter femoral head to restrain extreme range of motion. The posterior capsule was the most affected, indicating that native posterior capsule preservation is not advantageous, at least in the short term. Insufficient neck length could cause capsular dysfunction even if native ligament anatomy is preserved, while increased neck length could overtighten the anterior capsule.

CLINICAL RELEVANCE

Increased understanding of soft-tissue balancing following THA could help to prevent instability and improve early function. This study illustrates how head size and neck length influence the biomechanical function of the hip capsule in the early postoperative period.

Analyzing the characteristics of rising from the bed in patients having undergone total hip arthroplasty immediately after surgery

BACKGROUND

Immediately after patients undergo total hip arthroplasty (THA), they are often coached through the process of rising from the bed to prevent dislocation. However, motion analysis of this process, which can guide coaching methods, has not been conducted. The purpose of this study was to clarify whether there is a difference in hip joint angle, rise time, pain, and difficulty based on the method of rising from the bed in postoperative patients, immediately after THA.

METHODS

Twenty patients who underwent THA were enrolled in this study. Seven days after surgery, 3-D motion analysis was performed while subjects rose from the bed using six different methods that include rising from the bed using either the affected or non-affected side either with or without assistance. Hip joint angle, rise time, pain, and difficulty were evaluated.

RESULTS

In all six methods, the maximal hip joint angle of the affected side was in the safe range. The maximal hip adduction angle and adduction angle at maximum flexion of the affected side were significantly lower in patients who rose from the bed using their affected side than in those who rose using their non-affected side. There were no differences in maximal hip flexion angle, internal rotation angle, internal rotation angle at maximum flexion of the affected side, rise time, pain, or difficulty regardless of the direction of rising from the bed or the use of assistance.

SIGNIFICANCE

Coaching patients to rise from the bed is better performed when using the most optimal method that takes into consideration the movement direction and patient's individuality.

Prevention of Dislocation After Total Hip Arthroplasty

BACKGROUND

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

METHODS

We performed a literature search to assess historical perspectives and current strategies to prevent dislocation after primary THA. The search yielded 3458 articles, and 154 articles are presented.

RESULTS

Extremes of age, body mass index >30 kg/m², lumbosacral pathology, surgeon experience, and femoral head size influence dislocation rates after THA. There is mixed evidence regarding the effect of neuromuscular disease, sequelae of pediatric hip conditions, and surgical approach on THA instability. Sex, simultaneous bilateral THA, and restrictive postoperative precautions do not influence the dislocation rates of THA. Navigation, robotics, lipped liners, and dual-mobility acetabular components may improve dislocation rates.

CONCLUSIONS

Risks for dislocation should be identified, and measures should be taken to mitigate the risk. Reliance on safe zones of acetabular component positioning is historical. We are in an era of bespoke THA surgery.

Hip precautions after hip operation (HippityHop): Protocol for a before and after study evaluating hip precautions following total hip replacement

Introduction

Hip precautions are routinely used despite inconclusive evidence that they reduce dislocations and concern that they impede activities of daily living. This study compares a change in practice locally from implementing routine hip precautions to no routine precautions, in order to: 1. Compare patient outcomes in quality of life, functional performance, pain, sleep, mood, and satisfaction. 2. Ascertain staff and patient perceptions of the two regimes. 3. Determine the cost of precautions.

Method

Phase one patients will receive hip precautions, while phase two patients will receive no routine precautions. We propose to collect data from 342 participants at baseline, and at one week, six weeks, and three months postoperatively. Interviews will be conducted with 20 staff and 20 patients, and data collected relating to costs.

Results

Statistical analysis will be conducted to compare the two groups to determine any differences in patient outcomes. Thematic analysis will be used to identify and report themes within the interview data.

Conclusion

If there are no additional advantages to hip precautions, patients could resume everyday activities more quickly, potentially improving their quality of life. Conversely, if withdrawing hip precautions is detrimental, evidence for precautions will be provided.

Reduced length of uninterrupted institutional stay after implementing a fast-track protocol for primary total hip replacement

Background and purpose - Fast-track protocols have been successfully implemented in many hospitals as they have been shown to result in shorter length of stay (LOS) without compromising results. We evaluated the effect of fast-track implementation on the use of institutional care and results after total hip replacement (THR). Patients and methods - 3,193 THRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast-track (Hospital A) and non-fast-track (Hospitals B, C, and D). We analyzed LOS, length of uninterrupted institutional care (LUIC, including LOS), discharge destination, readmission, revision rate, and mortality in each hospital. We compared these outcomes for THRs performed in Hospital A before and after fast-track implementation and we also compared outcomes, excluding readmission rates, with the corresponding outcomes for the other hospitals. Results - After fast-track implementation, median LOS in Hospital A diminished from 5 to 2 days (p < 0.001) and (median) LUIC from 6 to 3 (p = 0.001) days. No statistically significant changes occurred in discharge destination. However, the reduction in LOS was combined with an increase in the 42-day readmission rate (3.1% to 8.3%) (p < 0.001). A higher proportion of patients were at home 1 week after THR (p < 0.001) in Hospital A after fast-tracking than before. Interpretation - The fast-track protocol reduces LUIC but needs careful implementation to maintain good quality of care throughout the treatment process.

Can Surgeons Reduce the Risk for Dislocation After Primary Total Hip Arthroplasty Performed Using the Posterolateral Approach?

BACKGROUND

Hip dislocation is one of the most common postoperative complications after total hip arthroplasty (THA). Potential contributors include patient- and surgical-related factors. We performed a retrospective cohort study to identify risk factors for postoperative dislocation in patients receiving THA via the posterolateral approach.

METHODS

We assessed 1326 consecutive primary THAs performed between 2010 and 2015. Patient information was documented, and plain radiographic films were used to evaluate cup positioning, hip offset, and hip length change. A multiple logistic regression was used to identify risk factors for dislocation. Follow-up was coordinated by the Danish National Patient Registry.

RESULTS

Age and American Society of Anesthesiologists scores were higher in dislocating THA compared with those in the nondislocating THA. Cup anteversion was less in dislocating THA compared with that in nondislocating THA. Independent risk factors for cup dislocation were increased age, body mass index <25 and >30 kg/m², and leg shortening of >5 mm.

CONCLUSION

Surgeons should aim for a shortening of leg length <5 mm to reduce the risk of postoperative dislocation in primary THA. Although anteversion was reduced for dislocating THA, there is likely no universal safe zone for cup positioning. Hip stability is multifactorial, and optimal cup positioning may vary from patient to patient.

Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty

Background and purpose - There is a lack of evidence to support the role of hip precautions in preventing dislocation following total hip arthroplasty (THA). We report an exploratory study which assesses recall, adherence, and the impact of precautions on activities of daily living in the first 6 weeks postoperatively. Patients and methods - We designed a new questionnaire based on the education patients receive and refined by professionals within our multidisciplinary team. 129 patients underwent primary elective THA during the study period and received the questionnaire at 6 weeks postoperatively. Results - 97 (75%) patients responded before the 8th week postoperatively. Most of these (83 patients) could remember all the precautions. Of the 97 who responded only 22 claimed to adhere to all of the precautions. 48 admitted to putting their own underwear on without the use of aids or assistance, and 38 had started walking without an aid. Due to the precautions 67 avoided leaving the house at some point and 63 were unable to perform desired activities. 84 stated that their sleep was affected. There were no dislocations among the 97 patients who responded; however, there was 1 dislocation among the 32 non-responders. Interpretation - We found that most patients did not adhere to hip precaution advice. Precautions have a detrimental effect on patient activity and sleep. In view of the limited efficacy in reducing dislocation rate, we question the use of precautions in the primary arthroplasty setting.

Ipsilateral femoral head osteochondral transfers for osteochondral defects of the femoral head

Osteochondral defects of the femoral head are rare. Several treatment options have been described, though there is currently no consensus on the appropriate management of these lesions. Five patients underwent femoral head osteochondral autograft transfer for treatment of ipsilateral femoral head osteochondral defects via surgical hip dislocation between 2011 and 2014 at our institution. The mean age of the patients was 24.8 (16–37) years. There were four females and one male. Mean follow-up was 53.8 (30–64) months. Four patients reported complete resolution of preoperative pain, return to baseline activities and were satisfied with their results. Harris hip scores improved from a mean 60.8 (30–87) to 86.6 (44–100). There was no radiographic evidence of progression of the femoral head defects. There were no operative complications. Osteochondral autograft transfer from the ipsilateral femoral head using a surgical hip dislocation demonstrated good clinical and radiographic outcomes at midterm follow-up in our cohort and may be considered a suitable option for management of these lesions in select patients. Further research and follow-up is warranted to more clearly define the indications and outcomes of this procedure.

Rehabilitation of revision total hip replacement: A multi-centre survey of current practice

BACKGROUND

Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation.

AIMS AND OBJECTIVES

To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery.

METHODS

An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically.

RESULTS

There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably.

CONCLUSIONS

This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.

Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is one of the most common orthopaedic operations performed worldwide. Painful osteoarthritis of the hip is the primary indication for THA. Following THA, people have conventionally been provided with equipment, such as raised toilet seats and chairs, and educated to avoid activities that could cause the hip joint to be in a position of flexion over 90 degrees, or adduction or rotation past the midline. These aspects of occupational therapy have been advocated to reduce the risks of prosthesis dislocation. However, the appropriateness of these recommendations has been questioned.

OBJECTIVES

To assess the effects of provision of assistive devices, education on hip precautions, environmental modifications and training in activities of daily living (ADL) and extended ADL (EADL) for people undergoing THA.

SEARCH METHODS

We searched MEDLINE (1946 to April 2016), EMBASE (1947 to April 2016), the Cochrane Library including CENTRAL (Issue 4 of 12, 2016), Database of Reviews of Effects (DARE), Health Technology Assessment (HTA), Economic Evaluations Database (EED), CINAHL, PEDro and CIRRIE from inception to April 2016. In addition we checked Controlled Clinical Trials, Clinicaltrials.gov, the National Institutes of Health Trial Registry, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the OpenGrey database from inception to April 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that evaluated the effectiveness of the provision of assistive devices, education on hip precautions, environmental modifications, or training in ADL and EADL for people undergoing THA. The main outcomes of interest were pain, function, health-related quality of life (HRQOL), global assessment of treatment success, reoperation rate, hip dislocation and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recognised by Cochrane. We conducted a systematic literature search using several databases and contacted corresponding authors, appraised the evidence using the Cochrane risk of bias tool, analysed the data using a narrative analysis approach (as it was not possible to conduct a meta-analysis due to heterogeneity in interventions), and interpreted all outcomes using the GRADE approach.

MAIN RESULTS

We included three trials with a total of 492 participants who had received 530 THA. The evidence presented with a high risk of performance, detection and reporting bias.One study (81 participants) compared outcomes for participants randomised to the provision of hip precautions, equipment and functional restrictions versus no provision of hip precautions, equipment or functional restrictions. Due to the quality of evidence being very low, we are uncertain if the provision of hip precautions, equipment and functional restrictions improved function measured using the Harris Hip Score at 12 month follow-up, or health-related quality of life (HRQOL) measured by the Short Form-12 at four week follow-up, compared to not providing this. There were no incidences of hip dislocation or adverse events in either group during the initial 12 postoperative months. The study did not measure pain score, global assessment of treatment success or total adverse events.One study (265 participants; 303 THAs) evaluated the provision of hip precautions with versus without the prescription of postoperative equipment and restrictions to functional activities. Due to the quality of evidence being very low, we are uncertain if perceived satisfaction in the rate of recovery differed in people who were not prescribed postoperative equipment and restrictions (135/151 satisfied) compared to those prescribed equipment and restrictions (113/152) (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.93; 265 participants, one trial; number needed to treat for an additional beneficial outcome (NNTB) = 7). Due to the low quality evidence, we are uncertain if the incidence of hip dislocation differed between participants provided with hip precautions with (1/152) compared to without providing equipment or restrictions post-THA (0/151) (RR 2.98, 95% CI 0.12 to 72.59). The study did not measure pain, function, HRQOL, re-operation rates or total adverse events.One study (146 participants) investigated the provision of an enhanced postoperative education and rehabilitation service on hospital discharge to promote functional ADL versus a conventional rehabilitation intervention in the community. This study was of very low quality evidence. We were uncertain if the provision of enhanced postoperative education and rehabilitation improved function at six months follow-up, when assessed using the Objective and Subjective Functional Capability Index (146 participants, one trial; P > 0.05; no numerical results provided) compared to conventional rehabilitation. The study did not measure pain score, HRQOL, global assessment of treatment success, hip dislocation, re-operation rate or total adverse events.

AUTHORS' CONCLUSIONS

Very low quality evidence is available from single trials, thus we are uncertain if hip precautions with or without the addition of equipment and functional restrictions are effective in preventing dislocation and improving outcomes after THA. There is also insufficient evidence to support or refute the adoption of a postoperative community rehabilitation programme consisting of functional reintegration and education compared to conventional rehabilitation strategies based on functional outcomes.Further high-quality trials are warranted to assess the outcomes of different occupational therapy interventions both in the short and longer-term for those who undergo THA. An assessment of the impact of such interventions on pain and restriction on personal ADL, EADL and instrumental ADL is needed, and also of functional integration-type interventions rather than just hip precautions, equipment and restrictions.

The rate of dislocation is not increased when minimal precautions are used after total hip arthroplasty using the posterolateral approach

Aims

In order to prevent dislocation of the hip after total hip arthroplasty (THA), patients have to adhere to precautions in the early post-operative period. The hypothesis of this study was that a protocol with minimal precautions after primary THA using the posterolateral approach would not increase the short-term (less than three months) risk of dislocation.

Patients and Methods

We prospectively monitored a group of unselected patients undergoing primary THA managed with standard precautions (n = 109, median age 68.9 years; interquartile range (IQR) 61.2 to 77.3) and a group who were managed with fewer precautions (n = 108, median age 67.2 years; IQR 59.8 to 73.2). There were no significant differences between the groups in relation to predisposing risk factors. The diameter of the femoral head ranged from 28 mm to 36 mm; meticulous soft-tissue repair was undertaken in all patients. The medical records were reviewed and all patients were contacted three months post-operatively to confirm whether they had experienced a dislocation.

Results

There were no dislocations in the less restricted group and one in the more restricted group (p = 0.32).

Conclusion

For experienced surgeons using the posterolateral approach at THA and femoral heads of diameter ≥ 28 mm, it appears safe to manage patients in the immediate post-operative period with minimal precautions to protect against dislocation. Larger studies with adequate statistical power are needed to verify this conclusion. Take home message: Experienced orthopaedic surgeons using the posterolateral approach for THA should not fear an increased dislocation rate if they manage their patients with a minimal precautions protocol. Cite this article: Bone Joint J 2016;98-B:589–94.