Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning

Abstract

Purpose

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA.

Materials and methods

Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed.

Results

Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who “push” these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice.

Conclusion

This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.

IMPLICATIONS FOR REHABILITATION

• Redesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.

• Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.

• Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.

• Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

Keywords:

• Hip dislocation
• occupational therapy
• orthopaedic surgery
• physical therapy modalities
• rehabilitation
• total hip replacement

Acknowledgements

The authors are grateful for the support of the Inpatient and Outpatient Orthopaedic Therapy Teams at the Royal National Orthopaedic Hospital during the initial planning stages. The authors are grateful for the support and mentorship received from Anju Jaggi, Dr Mindy Cairns and Prof John Skinner throughout this project.

Disclosure statement

The authors report no conflicts of interest.

Additional information

Funding

This work was supported by receiving sponsorship from the Association of Trauma and Orthopaedic Chartered Physiotherapists (ATOCP).