Hip Precautions Suck

Intro
For therapists working with hip replacements,  precautions have been the standard recommendation for decades.  But just how effective are these practices and what does the evidence say? 

Today's Papers
Barnsley, L., Barnsley, L., & Page, R. (2015). Are hip precautions necessary post total hip arthroplasty? A systematic review. Geriatric orthopaedic surgery & rehabilitation, 6(3), 230-235.
Systematic review

  • 2 RCTs investigating anterolateral approach to surgery were included

  • 346 patients total, just 1 dislocation notes

  • No obvious benefit of using precautions (and several benefits noted for NOT following precautions)

Lee, G. R., Berstock, J. R., Whitehouse, M. R., & Blom, A. W. (2017). Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty. Acta orthopaedica, 88(5), 496-499.
Questionnaire based study

  • 97 patients responded (91 posterior approach, 6 lateral approach)

  • No dislocations noted (in the response group)

  • Less than 25% of patients adhered to all precautions

Allen, F. C., Skinner, D. L., Harrison, J., & Stafford, G. H. (2018). The effect of precautions on early dislocations post total hip arthroplasty: a retrospective cohort study. HIP International, 1120700018762175.
retrospective cohort study

  • Studied patients before and after the centre stopped prescribing precautions in 2014

  • 2551 patients (precautions) vs. 673 patients (no precautions)

  • Rate of dislocation was low in both groups (0.71% with precautions and 0.89% without)

What does this mean?

  • Hip precautions don’t offer more safety for patients and are largely unnecessary

  • Most people don’t follow the precautions anyway

  • Precautions might be detrimental in that they slow patient’s return to activities, reduce QOL and satisfaction and actually end up costing the system more (estimated US$655 per patient)

  • Patients who don’t follow precautions return to activity more quickly, are more comfortable, functional and sleep better

  • Many surgical centres around the world have discontinued using hip precautions  

Summary
There is mounting evidence that hip precautions are not helpful and are probably detrimental to patient outcomes.  This scenario is a great example of how good intentions are not sufficient for good care and integrating evidence is absolutely essential.