THR Precautions

[raafox]

Dear All

we are currently investigating whether there is any research regarding the use of post operative precautions and risk/rate of dislocation in primary total hip replacement for OA hip as instructed by physiotherapists/OTs.

I was interested whether anyone has any research looking at this or any views about precautions, are they important or does it just come down to the surgeon's skill?

Thanks for your time

Rob Fox

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[poboy62]

I work in acute care with several physicians, I'm a PT. One of our physicians believes adamately that precautions make no difference and he does not use them and feels it scares the pt. so much that they worry all the time. He says his dislocation rate is the same as physicians that do use precautions.

[mbrownless]

Yep, agree (almost) totally.

I know of colleagues who essentially set-out to scare the pants off patients so they won't have a chance of dislocating. What you've got to ask yourself is where the evidence comes from that says that after a certain period of time, an activity will be 'safe'. Essentially, as long as a patient is sensbile and doesn't do sudden movements of, say, flexion way beyond 90 degrees with rotation, they will almost certainlt be okay.

The only caveat to this is what the OS finds when they operate. Get them to document on their op notes what range they got on the table post-op. If they only get 100 degrees of flexion before the femur starts to get levered out of joint by contact of the neck of femur on bony rim of the acetabulum / pelvis, then 100 degrees would be a strict maximum amount of range.

[bikash63]

Hi,I am closely involved with THR,TKR at India with famous Orthopaedics.Yes, the post operative complications must be narrated to the patients with TKR and THR.Although the patient can walk on the same evening of surgery, the body takes its own time to heal.God has never gave us full capacity to go at a straight mile.
the Orthopaedic Surgeon makes all the seting on the OT table itself and explains to us for further PT procedures to the patient immediately the patient is out of OT.the anesthetist,Orthopaedics and we form the team to bring the patient to great convince of new life.As we become part of their freedom to walk painfree,we need to win them.All the contra indications must be explained to them freely.because litle mistake may lead to astroy.. its money matter and health matter.The advises must not be shocking to the patient.
If the Ortho Surgeon does a rotator palteform TKR, he may do flexion at 110Degree.But we need to start from 90 Degree at the first day with CPM.this has been practicing by me at Bangalore with my Orthopaedic.Thanks.
bikuda2003@yahoo.co.in

[kempo1981]

Hi there, i am a final year student and have been asked this question by one of my patients in the community.
Since searching the evidence base all i can find is one particularly interesting article regarding late dislocations following THR. this article was published in 2002 and is one of the most up to date i can find. there are also a couple of articles from around 2005 links are all at the bottom of this msg.

I must say that the evidence does seem to show that the hip precautions are most problematic for the majority of patients with regards to sleep in the acute stages which in itself may hinder the healing process!! furthermore in the sub acute stages restrictions are found with activities of daily living and this further frustrates the patient and reduces satisfaction. However despite there being significant problems encountered in this area, the precautions are necessary to help TO REDUCE THE RISK OF DISLOCATION.... This is what i understand the precautions aims to be. some patients will dislocate even if/when they do adhere to the precautions some will not... it is the responsibility of the clinicians to decide in each individual case whether a strict regimen is to be followed or whether the patient can be allowed to infringe on the precautions.
Finally, from what i have experienced clinically as a PTassistant and student i would say that hip precautions are required for all patients as the long term benefit of a stable but slightly restricted hip joint outweighs the problems caused by recurrent dislocations, instability or revisions of surgery endured through non adherence to precautions.

sleep and patient satisfaction.....
SLEEP DEPRIVATION FOLLOWING TOTAL HIP ARTHROPLASTY -- O’Grady et al. 85-B (2004): 133 -- The Journal of Bone and Joint Surgery (Proceedings)

Late dislocations
Late Dislocation After Total Hip Arthroplasty -- von Knoch et al. 84 (11): 1949 -- Journal of Bone and Joint Surgery

Consultant advice
Log In Problems

Late instability 2007!
Late Instability Following Total Hip Arthroplasty

Hope this helps

Chris

[jwpt2010]

How about strength testing and hip precautions? Can you test flex, add, and IR??

[kempo1981]

You can test the muscle strength in flex, add and internal rotation. although I would advise against it. However the patient will be restricted by pain in the early stages and to the patient it may feel as though the hip is going to dislocate and they will stop resisting the test. I would recommend testing in standing for hip extension, abduction and flexion. I also suggest functional testing rather than physical resistance testing. For example to look for Trendelemburg gait as an indication of Gluteus medius weakness and to follow strengthening guidlines for Hip extension, Abduction and flexion. As the patient progresses you will be more able to test for strength using a resistance method although you may find that this still provokes a pain response. In addition i would just reitterate that you will find functional testing easier and more suitable to these patients as the majority of them want to regain function you can also have the patient perform the Hip extension, abduction and flexion exercises in standing and test using a resistance method while they attempt the exercises. this will give a great indication to thier strength and stage of rehabilitation.

[Josephine]

This is an awfully old thread! Never the less, I'll add my two penn'orth!

I've worked with a lot of hip surgeons over the years and to be honest, this is a relatively recent protocol (recent as in since the last 15-20 years - yes, I'm old!!).

When McKee and Charnley were doing hip replacements back in the 60s and 70s, the thought never crossed their minds! Nor for all the thousands who had hemiarthroplasties as well. And their dislocation rates were no more or less then than they are these days.

I currently continue to have acquaintanceships with many hip surgeons and in a straw poll, less than half of them confessed to imposing these restrictions on their patients. Last September I attended a symposium on THR in Edinburgh and this was a general consensus there also - the majority do not impose them.