Hip replacement

Low-risk patients undergoing a total hip replacement with a posterior approach can skip the standard hip precautions; currently recommended for post-surgical recovery; according to a new study conducted at Hospital for Special Surgery (HSS). Eliminating standard precautions in this population did not increase the risk of hip dislocation; In the last ten years, surgeons have started favoring the anterior approach (through the back of the hip); for total hip replacement over the posterior approach, because it doesn’t involve standard hip precautions.
Little data, however, back the standard hip precautions recommended for the posterior approach. For a posterior approach, standard precautions are not flexing your hip past 90 degrees; not internally rotating your hip more than 10 degrees; using an elevated seat cushion at all times and a grabber for anything that is on the ground; sleeping on your back for six weeks. “The precautions can be limiting and cause fear in patients.

The hip precautions

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. The literature showing that hip precautions make a difference in hip dislocation is poor. “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 have given us more confidence in the stability of our hips.
“Their understanding of the dynamic movement of the pelvis and how they put the parts it is much different. The quality of our soft tissue repair and closure at the end of surgery is much more robust.” When patients are on stringent precautions, they are not as active, which can hamper recovery. “If you minimize the hip precautions in an appropriate way, patients focus more on their mobility and recovery and less on the fear of how they turn their leg ten degrees,” said Dr. Sculco.
Researchers retrospectively reviewed all patients undergoing a posterior primary uncemented total hip replacement (total hip arthroplasty). Surgeons had the choice to put patients on standard precautions or a pose avoidance protocol, to avoid a single pose, a flexed external rotation position that occurs when a person puts on their shoe or shaves their leg.

A historical cohort of patients

A total of 1,311 patients met the inclusion criteria for the pose avoidance cohort; the minimum followup was six weeks. Researchers then matched patients 1:1 in this group to a historical cohort of patients based on age, gender, and body mass index that treated with standard posterior hip precautions. Therefore the study was limited in that it is not a randomized controlled trial; usually the gold standard for dictating a change in practice.

“The bottom line of the study is in recent years; they have learned more about interventions that matter after joint replacement and those that do not really have efficacy. In most patients, they got rid of powerful anticoagulants, for example, and we are moving toward a shorter stay and even outpatient arthroplasty for total hip replacement.

“Minimizing precautions and simplifying the postoperative recovery is part of the larger simplification of surgery where they are using more selected resources and interventions for people; so instead of blanketing everyone with the same kind of protocols.” Dr. Sculco noted that there is an increasing demand for hip replacement in the United States. “In 2010, there were 310,000 hip replacements in the United States and that number is increasing. It is probably 350,000 if not more now,” said Dr. Sculco.