Total Hip Precautions

[AJ Lievre]

Any Docs you know of making these recommendations? What are your thoughts on this? http://www.csp.org.uk/news/2015/12/04/icsp-helps-therapist-change-surgeons-advice-post-hip-replacement

[omikutin]

During one of my rotations at a SNF, one of my patients re-dislocated her posterior approach hip. She was about 85 years old and osteoporotic. The patients that I have seen in the past most MDs prescribe precautions for the posterior and no precautions for anterior hip replacement. Both types of patients had difficulty moving and were cautious with gross movement. Patients are worried about their surgery in fear of dislocation, we need to instill motivation (within proper limits) not fear. Those who get hip replacements are motivated to walk, or else they wouldn’t have had the surgery. I’m thankful those surgeons changed their practice, I wonder what our surgeons will have to say about this?

[Myra Pumphrey]

Hi guys – I have had a lot of conversations with my surgeon about this (I had a right, then left posterior approach THR in 2014). First, I think there is some incentive to decrease precautions and limitations if they are not indicated because these are the main ‘con’s’ to the posterior approach when competing with the anterior approach. I have a great deal of respect for my surgeon. He is nationally known and all about the evidence, great ethics and best outcomes. He is strongly contemplating changing the precautions at VCU (He is head of the department). He says these precautions were created in the 60’s and the THR has changed significantly since that time. The hospital pre-op class, the PT’s in the hospital and the home health PT’s continue to follow the precautions, but he believes they are much too conservative. He came into my room on day 1 after the surgery and adducted my leg well past midline. From my experience, I believe (i.e., no evidence, just personal experience!) it is the combined position of flexion/add/IR that puts the posterior approach pt. at greatest risk, not any of the motions in isolation. When I am working on improving flexion, I have patients rock in quadriped in relative hip ER to decrease risk. I also believe it is helpful to teach patients the concept of end-feel and educate them to avoid pushing into resistance in combined movements. In addition, I think having a surgeon who repairs the deep hip rotators and comprehensive PT to strengthen all layers of hip musculature likely significantly decreases risk for dislocation. My surgeon agrees. Unfortunately, one study shows that, with the anterior approach, 25% of patients end up with a torn deep external rotator during dislocation for surgery which is not repaired. This was one of the main reasons I chose the posterior approach.

Another opinion: Many surgeons and PT’s tend to take away assistive devices when the patient does not have adequate strength to ambulate in normal biomechanics. I would rather keep them on the AD a little longer if using the AD helps to facilitate normal dynamic strength in normal biomechanics.

Would love to see some research on dislocation incidence in those with less conservative precautions…..

[Laura Thornton]

Those are really good points and I can appreciate keeping patients on ADs longer to facilitate normal gait mechanics. Myra and I have incorporated this with a few patients and have seen really good results. Once the patients can understand the importance of good mechanics and neuromuscular re-education, they come around to keep the AD a little longer.

It’s interesting in the article they state that the conservative precautions can actually be counterproductive in recovery and they can increase the risk of dislocations due to decrease movement in the initial stages.

I found a few articles that might be of interest. First, a retrospective study on dislocation rates with posterior approach THA for just 4 weeks:

Minimal invasive posterior total hip arthroplasty: are 6 weeks
of hip precautions really necessary?
Schmidt-Braekling T, Waldstein W, Akalin E, Benavente P, Frykberg B, Boettner F.
Arch Orthop Trauma Surg. 2015 Feb;135(2):271-4.
http://link.springer.com/article/10.1007%2Fs00402-014-2146-x

They found a 1% dislocation rate out of 797 patients (total of 8). A few were caused from trauma and a few were caused from sitting on a low surface in the home.

A systematic review also found 2 RCT’s looking at anterolateral approach. Unrestricted protocols (without precautions) found no dislocations and better/faster recovery. I attached the tables.

Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review
Barnsley, Barnsley, Page.
Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):230-5
http://www.ncbi.nlm.nih.gov/pubmed/26328242

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[AJ Lievre]

To me it is similar to ACL rehab. You need to stress the graft in order to make it grow stronger (wolfs law), but recognize when there is too much stress. If we continue to avoid stressing the posterior aspect of the capsule altogether it will likely not develop the tensile strength it needs.
I do believe that it plays into a fear factor and possibly movement avoidance that Eric will talk about next weekend.

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