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Mandel R.1, Bruce G.1, Moss R.1, Carrington R.1, Gilbert A.W.1, Jaggi A.1
1Royal National Orthopaedic Hospital, Therapies, Stanmore, United Kingdom
Background: Hip precautions are often advised following primary total hip arthroplasty (THA) for osteoarthritis (OA). Six centres delivering NHS care in the UK have removed standard hip precautions for these patients.
Purpose: The aim of this study was to explore the rationale behind both the continuation and discontinuation of hip precautions following primary THA for OA.
Methods: Qualitative methodology was used. Semi-structured interviews were conducted with therapists and surgeons at centres no longer using hip precautions and at centres that continue to use them following THA. All interviews were recorded and transcribed verbatim. An inductive framework analysis was used to identify and explore themes generated from the data.
Results: Thirty-three clinicians across 12 centres in the UK were interviewed. Qualitative data was collected from 6 centres still using precautions (9 surgeons and 10 therapists) and 6 centres no longer using precautions (6 surgeons and 8 therapists). The posterolateral approach was the most common approach used.
All clinicians interviewed acknowledged the importance of reducing the risk of dislocation through avoiding extreme movements. Clinicians recognised that although the use of hip precautions is historical and the exact angle of precautions an arbitrary designation, the avoidance of dislocation is of paramount importance. Where precautions are still used, this is to avoid dislocation by creating a rigid boundary to movement, particularly important when dealing with patients who push these boundaries.
Clinicians stopped using precautions because of their negative impact on patients and the lack of supporting evidence. It is thought that advances in surgical techniques and implant positioning have increased post-operative stability. In the absence of a rise in dislocation rates for pioneering centres, others have now dropped restrictions with unaffected dislocation rates and, anecdotally reported, enhanced patient experience.
Conclusion(s): The majority of hospitals in the UK continue to use hip precautions for patients following primary THA for OA. Six centres have discontinued precautions and have seen unchanged dislocation rates. It is accepted that the use of hip precautions for this patient group is a historical practice with little published literature supporting their use. Clinicians distrust of patient behaviours and fear of increased dislocation rates and litigation are barriers to changing clinical practice. Anecdotally, adhering to precautions is challenging and can lead to longstanding avoidance of functional activities due to an ongoing fear of dislocation. The use of precautions causes clinician anxiety about dislocation. It is thought that putting unnecessary functional restrictions on patients inhibits their return to full function and can be costly. Further work investigating the effectiveness of hip precautions for preventing dislocation is needed as widespread clinical practice is unlikely to change in the absence of robust evidence.
Implications: This study found that hip precautions for primary THA are historical with little supporting evidence. Their use is associated with anxiety and fear of dislocation, which might lead to negative patient experience after surgery. Centres that have discontinued hip precautions have seen unchanged dislocation rates.
The ongoing use of hip precautions after THA therefore needs to be questioned.
Funding acknowledgements: The authors are grateful to receive funding from the Association of Trauma and Orthopaedic Chartered Physiotherapists (ATOCP).
Topic: Orthopaedics
Ethics approval: Ethical approval was not sought as this research interviewed clinical staff only. Local R&D approval was sought and obtained.
All authors, affiliations and abstracts have been published as submitted.
