According to a new study, patients who have undergone a posterior hip replacement may be able to ignore hip precautions.
In March 2019, at the American Academy of orthopedic surgeons conference in Las Vegas, Dr. Peter Sculco reported that low-risk patients who have undergone posterior hip replacements no longer need to maintain hip precautions in lieu of advancements in hip surgery.
In this article, I’ll further discuss Dr. Sculco’s findings, what this means for post surgical patients, and how physical and occupational Therapy should respond to these new guidelines.
New literature reports why hip precautions may not be necessary
For years, the anterior approach for hip replacements has been preferred by orthopedic surgeries to avoid the stringent precautions associated with the posterior approach.
However, according to Dr. Sculco, “The current precautions are based on hip replacements done 25 years ago, and we have changed a lot in terms of improving how we do hip replacements that has given us more confidence in the stability of our hips,” (Science Daily).
He goes on to say that hip procedures today are greatly improved, and new literature suggest that these improvements reduce the risk of dislocation.
New Study examining the efficacy of standard hip precautions
A new study at HSS, examined the efficacy of hip precautions for patients who had undergone a posterior total hip arthroplasty from January 2014 to June 2016. The study measured outcomes of 1,311 participants who were grouped to follow standard hip precautions or follow an avoidance protocol. The participants following the avoidance protocol where told to avoid a single pose; a flexed hip and external rotated position.
There was a total of 6 dislocations in the avoidance protocol group and 7 dislocations in the group treated with standard hip precautions.
The results did not show a significant difference between groups, but it should be noted this study was not a randomized control trial.
Dr. Sculco Stated “Our results suggest that the standard postoperative precautions in patients undergoing total hip arthroplasty through the posterior approach without known risk factors for instability are unnecessary…We may find that precautions don’t make sense for any of our patients, but we need to look at [it] in a stepwise fashion.”
He concludes by discussing the growing demand for hip replacements and how better outcomes may be achieved by minimized precautions.
Why are standard hip precautions a problem?
Dr. Sculco says that hip precautions are problematic because it causes patients to be less mobile and overly cautious. He states “The precautions can be limiting and cause fear in patients…Sleeping on your back is very uncomfortable for many people. You often hear from physical therapists that patients are relieved when they can finally cross their legs and sleep on their side.” According to Dr. Sculco, this leads to worse outcomes and hinders recovery.
The standard hip precautions for the posterior approach require that recovering patients are not allowed to bend their hip more than 90 degrees, cross their legs, and internally or externally rotate their hip. They may also be required to sleep flat on their back with an abductor pillow between their legs for 4-6 weeks.
As an occupational therapist, I know that these precautions can be incredibly challenging for patients to follow. It’s a challenge to just remember these precautions.
It’s also difficult for these patients to adhere to these precautions when completing basic ADLs, such as getting out of bed, transferring to the toilet, dressing, shaving legs, or standing from a low seated position.
These precautions are especially difficult for taller patients and almost always require that the patient purchase adaptive equipment or DME such as reachers, sock aides, shoe horns, and elevated toilet seats.
How should PT and OT respond to new guidelines for hip precautions
This new study doesn’t say we should skip hip precautions altogether. It’s important that we continue to educate patients on functional mobility with a minimized approach to hip precautions.
This new study makes it clear that we should educate patients to avoid extreme positions such as flexing at the hip with the leg externally rotated.
We can explain this by educating our patients to avoid extreme bending and external rotating. For example, we might explain they try to avoid this position when they tie their shoes, shave their legs, or when bending to get off the toilet.
To avoid these positions, I think it’s still important to educate patients on adaptive equipment such as sock aides, elastic shoe laces, and shoe horns. I would also still advise them to avoid transferring to a low seated position and recommend DME such as elevated toilet seats.
Physical and Occupational therapists should be discussing ways they can incorporate this new study and clarify if these measures are appropriate with their orthopedic surgeons.
The idea behind this study is to help patients feel safe with their new hip and promote functional mobility. As we implement this in our practice and collaborate with our orthopedic specialists, we may find that our patients with hip replacements will recover quicker and feel unrestricted in their ability to become independent.
Source: Science Daily
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David is the lead editor of OT Focus. He has been practicing as an Occupational Therapist since 2013. He specializes in acute care, hand therapy, and ergonomics.