Early Recovery Outcomes in Patients Undergoing Total Hip Arthroplasty Through a Posterior Approach With Modified Postoperative Precautions

Early Recovery Outcomes in Patients Undergoing Contemporary Posterior Approach Total Hip Arthroplasty: Each Week Shows Progress

Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis

BACKGROUND

Return to work (RTW) and sports (RTS) are critical gauges to improvement among patients after total hip arthroplasty (THA). This study aimed to determine rates, timelines, and prognostic factors associated with RTW and RTS outcomes after primary THA.

METHODS

A systematic review was conducted on MEDLINE, EMBASE, and CENTRAL databases with 57 studies meeting inclusion/exclusion criteria. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions and risk of bias in randomized trials (RoB2) tools. Meta-analysis and pooled analysis were conducted, with forest plots to summarize odds ratios and 95% confidence interval (CI).

RESULTS

The pooled RTW rate across all studies was 70% (95% CI, 68%-80%), with rates varying significantly from 11% to 100%. The mean time to RTW was 11.2 weeks (range 1-27). A time point analysis showed increasing RTW rates with a maximum rate at 2 years of 90%. Increased age (p < 0.001) and preoperative heavy labor (p = 0.005) were associated with lower RTW rates. The RTS rate ranged from 42% to 100%, with a pooled rate of 85% (95% CI, 74%-92%). The mean time to RTS was 16.1 weeks (range 8-26). The RTS ranged from 20% to 80% with a pooled proportion of 56% (95% CI, 42%-70%, I2 = 90%) for high-intensity sports and from 75% to 100% for low-intensity sports with a pooled proportion of 97% (95% CI, 83-99, I2 = 93%).

CONCLUSION

Most patients RTW and RTS after THA in an increasing manner as time passes with rates more than 85% after 1 year. These rates may be greatly affected by various factors, most notably age, the intensity of the sport, and the type of work performed. In general, young patients, low-demand work or sports can be resumed as soon as 4 to 6 weeks after surgery, but with increased restrictions as the intensity increases. This information should be used by practitioners to manage postoperative expectations and provide appropriate recommendations to patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous bilateral versus unilateral total hip arthroplasty: Pain and physical function in a one- and five-year follow-up - retrospective patients record study

BACKGROUND

Total hip arthroplasty (THA) decreases pain and improves function in patients with osteoarthritis. In some cases, both hips have been operated simultaneously. Our aim was to report patients' pain and physical function after one- and five-years post-operatively among patients who underwent unilateral THA and those who underwent bilateral THA at the same time in one orthopaedic hospital in Finland.

METHODS

The study group consisted of 488 patients retrospectively selected patients from a single centre; 421 of them underwent unilateral THA and 67 underwent simultaneous bilateral THA. The patients had two clinical examinations one and five years postoperatively. Systematic data about pain and physical function were collected using the scaled Orton Hip Score (sOHS). Register data on revisions and mortality events were from the Finnish Institute of Health and Welfare.

RESULTS

At the one-year follow-up, total sOHS was improved remarkably from the preoperative situation, both in the unilateral THA (age and gender adjusted mean improvement 42 points (95% CI: 40 to 44, p < 0.001) and in the bilateral THA groups (age and gender adjusted mean improvement 45 [95% CI: 41 to 49], p < 0.001), with no group differences after five-years of operation (age and gender adjusted p = 0.19). Total sOHS was statistically higher in the bilateral THA compared to the unilateral THA after one year (98 vs. 95, p < 0.001) and five years (97 vs. 95, p = 0.003) of operation.

CONCLUSIONS

Patients in unilateral THA and bilateral THA groups had increased their physical function, and pain had decreased after one-year follow-up of the primary THA operation, and condition remained after five years of operation. At follow-ups, patients who underwent bilateral THA had slightly better physical function compared to patients who underwent unilateral THA at follow-up; however, this difference had no clinical relevance.

Stepping Beyond Counts in Recovery of Total Hip Arthroplasty: A Prospective Study on Passively Collected Gait Metrics

Gait quality parameters have been used to measure recovery from total hip arthroplasty (THA) but are time-intensive and previously could only be performed in a lab. Smartphone sensor data and algorithmic advances presently allow for the passive collection of qualitative gait metrics. The purpose of this prospective study was to observe the recovery of physical function following THA by assessing passively collected pre- and post-operative gait quality metrics. This was a multicenter, prospective cohort study. From six weeks pre-operative through to a minimum 24 weeks post-operative, 612 patients used a digital care management application that collected gait metrics. Average weekly walking speed, step length, timing asymmetry, and double limb support percentage pre- and post-operative values were compared with a paired-sample t-test. Recovery was defined as the post-operative week when the respective gait metric was no longer statistically inferior to the pre-operative value. To control for multiple comparison error, significance was set at p < 0.002. Walking speeds and step length were lowest, and timing asymmetry and double support percentage were greatest at week two post-post-operative (p < 0.001). Walking speed (1.00 ± 0.14 m/s, p = 0.04), step length (0.58 ± 0.06 m/s, p = 0.02), asymmetry (14.5 ± 19.4%, p = 0.046), and double support percentage (31.6 ± 1.5%, p = 0.0089) recovered at 9, 8, 7, and 10 weeks post-operative, respectively. Walking speed, step length, asymmetry, and double support all recovered beyond pre-operative values at 13, 17, 10, and 18 weeks, respectively (p < 0.002). Functional recovery following THA can be measured via passively collected gait quality metrics using a digital care management platform. The data suggest that metrics of gait quality are most negatively affected two weeks post-operative; recovery to pre-operative levels occurs at approximately 10 weeks following primary THA, and follows a slower trajectory compared to previously reported step count recovery trajectories.

Return to work following primary total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is increasingly common in younger patients, who are more likely to be working preoperatively. There is a need for an updated review of the literature regarding the rate and time to return to work (RTW), which is important when counseling patients, and also from an economic standpoint.

METHODS

A systematic review and meta-analysis of the literature was performed on January 20, 2022, and studies reporting the rate and/or time to RTW after THA were included. Two authors independently selected relevant papers. RTW was extracted and analyzed using fixed-effects or random-effects models where appropriate.

RESULTS

A total of 48 studies were included in the final analysis. We found that 70.7% of patients were working after primary THA. Among patients who were working before surgery, this rate increases to 87.9%, while 28.1% of patients who were not working preoperatively started working after surgery. Younger patients were more likely to RTW, while patients with a physically demanding job were less likely to RTW. Minimally invasive techniques were reported to yield a higher rate of RTW and an earlier time to RTW.

CONCLUSION

We found that the majority of patients return to work after THA, and some patients are able to start working after surgery. Compared to previous reviews, patients seem to have a higher rate and earlier RTW. The overall trend of the literature suggests that patients are returning to work earlier and at a higher rate compared to previous reviews.

A Systematic Review of the Use of Commercial Wearable Activity Trackers for Monitoring Recovery in Individuals Undergoing Total Hip Replacement Surgery

The innovation of wearable devices is advancing rapidly. Activity monitors can be used to improve the total hip replacement (THR) patients' recovery process and reduce costs. This systematic review assessed the body-worn accelerometers used in studies to enhance the rehabilitation process and monitor THR patients. Electronic databases such as Cochrane Database of Systematic Reviews library, CINAHL CompleteVR, Science Citation Index, and MedlineVR from January 2000 to January 2022 were searched. Due to inclusion criteria, fourteen eligible studies that utilised commercial wearable technology to monitor physical activity both before and after THR were identified. Their evidence quality was assessed with RoB 2.0 and ROBINS-I. This study demonstrates that wearable device technology might be feasible to predict, monitor, and detect physical activity following THR. They could be used as a motivational tool to increase patients' mobility and enhance the recovery process. Also, wearable activity monitors could provide a better insight into the individual's activity level in contrast to subjective self-reported questionnaires. However, they have some limitations, and further evidence is needed to establish this technology as the primary device in THR rehabilitation.

The incidence of hip dislocation after posterior approach primary total hip arthroplasty: comparison of two different posterior repair techniques

INTRODUCTION

Total hip arthroplasty (THA) remains one of the most successful orthopedic surgical procedures. The posterior approach is associated with a higher incidence of post-operative dislocations than others. Adequate posterior soft tissue repair techniques, including capsulorrhaphy and transosseous bone sutures in the greater trochanter effectively reduce the dislocation rate. Post-operative "posterior hip precautions" were historically believed to reduce dislocation risks, although not clearly proven. The first protocol consists of capsulorrhaphy with the prescription of post-operative posterior hip precautions (TT) and the second, transosseous bone sutures without precautions (TB). This study aims to determine the optimal protocol to decrease the dislocation rate following posterior approach primary THA.

MATERIALS AND METHODS

A 10-year retrospective case-control chart review analyzed demographic, pre-, intra-, and post-surgical parameters. Primary outcomes were the difference in dislocation and revision surgery rates between protocols. Secondary outcomes included the incidence of recurrent dislocations and the identification of predictors of dislocation.

RESULTS

2,242 THAs were reviewed and 26 (1.2%) resulted in dislocation. Increased age (p = 0.04) ASA score (p = 0.03) and larger acetabular cup size (p < 0.001) were associated with heightened risk. Tendon to tendon (TT) repair saw a 1.62% dislocation rate versus 0.98% for tendon-to-bone (TB) repair, although statistically insignificant (p = 0.2). Transosseous repair resulted in recurrent dislocations for 8/16 (50%) patients compared to 6/10 (60%) in the suture group (p ≤ 0.001). No significance was found for prescription of posterior hip precautions.

CONCLUSIONS

To our knowledge, this is the first study to perform a direct comparison of TT repair with posterior precautions to TB repair without posterior precautions. Similarity in dislocation rate, decreased recurrent events and the alleviated patient burden from precautions leads the authors to recommend the TB repair without precautions for a successful THA.

Patients Achieving 90°/45°/0° Intraoperative Stability Do Not Require Hip Precautions Following Posterior Approach Total Hip Arthroplasty: A Prospective Randomized Study

BACKGROUND

Hip precautions are traditionally employed after posterior total hip arthroplasty (THA). The primary purpose was to investigate the necessity of hip precautions after posterior approach THA. We hypothesized that eliminating precautions in patients that achieved appropriate intraoperative stability would not increase the dislocation rate.

METHODS

Randomized controlled trial of 346 consecutive eligible patients undergoing primary THA with a mean follow-up of 2.3 years (range 11 months to 3.7 years).

EXCLUSION CRITERIA

lumbar fusion, scoliosis, abductor insufficiency, inability to achieve intraoperative stability with combined 90° flexion and 45° internal rotation in 0° adduction. Fisher's exact test was used to compare dislocation rates between the hip precaution (HP) control group and no hip precaution (NP) study group. In addition, Mann-Whitney U test was used to compare differences in HOOS JR scores at 2, 6, 12 weeks between groups.

RESULTS

The dislocation rate was not increased in the NP (0/172: 0%) group compared to the HP group 4/174 (2.29%) (P = .418). All dislocations occurred in the precautions group, two of which required revision. There were no differences in mean HOOS Jr. scores at any 2, 6, or 12 weeks (P > .05 at all timepoints) (secondary outcome).

CONCLUSION

Eliminating hip precautions in patients undergoing posterior approach THA that achieve 90°/45°/0° intraoperative stability does not increase the rate of dislocation. In fact, every dislocation occurred in patients receiving hip precautions. Short-term patient-reported outcome measures were not affected by hip precautions. Surgeons may discontinue the use of hip precautions as the standard of care in patients achieving 90°/45°/0° stability.