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Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study | Orthopedics.

Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study

Prodromos A. Ververeli, MD; Eric B. Lebby, MD; Cheryl Tyler, RN; Carol Fouad

  • Orthopedics

  • December 2009 – Volume 32 · Issue 12:

Abstract

Currently, many rehabilitation protocols for total hip replacements (THRs) include activity restrictions to prevent postoperative dislocation. There is increasing demand for more efficient and safe rehabilitation protocols. This randomized prospective study evaluates the need for hip restrictions following a modified anterolateral procedure. From 2004 to 2008, 81 patients seeking elective THRs were randomly assigned into a standard rehabilitation group or an early rehabilitation group.

The standard group included restrictions to avoid hip flexion >90° and avoidance of riding in a car for the first postoperative month. The early group had no flexion or car riding restrictions. Forty-three patients were in the standard group and 38 patients were in the early group.

There were no significant demographic differences between the 2 groups. All patients completed the Short Form 12-question Health Survey and Harris Hip Score preoperatively and at 4 weeks, 1 month, 3 months, and 1 year postoperatively. The time-points at which the patient first drove and ambulated with a cane, without a cane, and without a limp were also collected.

No incidents of dislocation occurred. Patients in the early group were faster to ambulate with only a cane (P=.03), without a cane (P<.001), and without a limp (P=.003). They also drove earlier (P=.02). Pace of recovery was the only significant difference between the 2 groups. The early rehabilitation protocol increases the pace of recovery compared to a pathway with hip precautions without increasing complications.

Discussion

This article adds to a small number of existing studies testing postoperative hip restrictions for the prevention of early dislocation.

Lifting such restrictions in the early rehabilitation group resulted in an improved speed of recovery.

When compared with the control group, patients observing no restrictions were able to walk with a cane and drive earlier. The same group of patients was also able to walk without a limp and without the aid of any assistive devices at an earlier postoperative interval.

On average, patients in both groups were regaining their full range of motion and functions at the same rate as measured by the Harris Hip Score. This assessment tool was chosen because it is a valid and reliable measure of the outcome of a THR.13 It showed no advantage to standard rehabilitation in terms of subsidized pain and that 94.5% of all THRs were conducted at the same success level.

Based on these results, postoperative hip restrictions provide no additional benefit and limit patients from activities that they are capable of doing.

These findings demonstrate a faster return to activities of daily living following elective THRs.

Without any incidents of dislocation to evaluate, it is not possible to conclude if restrictions are a necessary preventive measure. However, the results may suggest that dislocation can be greatly decreased with proper patient selection and surgical technique alone.14

These conclusions are consistent with previous studies. In their study, Peak et al9concluded that unrestricted patients reported a significantly higher degree of satisfaction with their recovery. This was not statistically observed when the SF-12 was used in the present study. The SF-12 test was chosen because it has been well-validated as a quality of life assessment tool and its results can be widely compared in the field.15 Patients in the early rehabilitation group were equally as likely to feel limited from performing housework or social activities and suffer emotional strain due to a decreased sense of accomplishment in the months following surgery. The 2 groups were found to recover with the same physical strength and mental stamina as tested by the SF-12.

Although one limitation of the present study is the small sample size, the statistically significant differences had a statistical power of at least 0.08 with the exception of the postoperative time-point when the patients started walking with a cane, which had a power of 0.06. Since there were exclusions to patient enrollment, the generalization of these results may be questioned. It is important to note that the exclusions were imposed in an effort to maximize patient compliance and ability to participate in this investigation. Patients who consented might have been less at-risk than the general population. However, patient characteristics and self-reported physical conditions preoperatively were widely varied and the standard and early rehabilitation groups were not found to differ on any preoperative or postoperative physical, emotional, or demographic components.

Interestingly enough, 1 patient was randomly assigned into the standard group for his left hip and then 1 year later into the early rehabilitation group for his right hip. He included in his diary that “depression was a real issue to contend with in the control group.

I was so much happier and the quality of life was so much better in the accelerated group.”

Conclusion

The senior authors (P.V. and E.L.) ended the study before enrolling the target 106 patients to remove the standard hip restrictions and allow all patients to progress to the rapid rehabilitation group without restrictions.

Since the conclusion of the trial, there has been no increase in the prevalence of dislocation at this surgical practice.

Further protocol adjustments should focus on the best preoperative patient education.7 If standard postoperative restrictions are eliminated, patients must rely on proper preoperative education to evaluate the risks they take with activities of daily living.

The performance of a THR with appropriate surgical technique and patient selection can lead to a successful functional recovery at a rapid pace with the elimination of routine hip precautions and restrictions.

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Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study | Orthopedics.

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