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

No need for hip precautions after total hip arthroplasty with posterior approach: A systematic review and meta-analysis

BACKGROUND

Nowadays, total hip arthroplasty (THA) is one of the most successful procedures in the field of orthopedics and trauma. The posterior approach has historically been associated with a higher rate of hip dislocation. To reduce the rate of hip dislocation in the posterior approach, most orthopedic surgeons would recommend hip precautions (HP) for their patients postoperatively based on previous theories. However, recent randomized controlled trials have shown no significant difference in hip dislocation rates with or without HP, in contrast to previous theories. Based on these, this study conducted a meta-analysis of these randomized controlled trials to try to get qualitative conclusions.

METHODS

Randomized controlled trials of HP after THA up to July 28, 2023, were searched in 3 databases, PubMed, Embase, and the Cochrane Library. Data extraction and literature quality assessment were performed by 2 independent authors and extracted hip dislocation, hip disability and Osteoarthritis Outcome Score, joint replacement (HOOS JR) scores over 6 weeks, and time to discontinuation of mobility aids. Stata software and Revman software were used to perform this meta-analysis.

RESULTS

Following screening, 3 papers with a total of 1215 participants were included in the analysis. This meta-analysis showed that there was no statistically significant difference in hip dislocation rates with or without HP after THA undergoing the posterior approach and that the without HP group instead showed better outcomes in terms of HOOS JR scores and time to discontinuation of mobility aids.

CONCLUSION

THA with a posterior approach does not require hip precautions.

Recommendations on the use of restrictions and assistive devices after total hip arthroplasty: an adolopment of guidelines

PURPOSE

Movement restrictions and assistive devices have traditionally been recommended to prevent hip dislocation after total hip arthroplasty (THA). Considering the advancements in THA surgery, a review of treatment recommendations is worthwhile. The aim of this study was to investigate whether unrestricted protocol (without movement restrictions and assistive devices) should be recommended for THA patients.

METHODS

A multiprofessional panel used the GRADE-Adolopment to develop the present recommendations, following the GIN-McMaster-Guideline-Development-Tool. We selected guideline topic and target audience, formulated clinical questions and prioritised outcomes. For the first question, a source guideline was identified and adoloped, whereas the second question required a de-novo recommendation. Therefore, the GRADE-Evidence-Profile and the Evidence-to-Decision framework were completed. Finally, the panel discussed and formulated the final recommendations.

RESULTS

Hip dislocation was defined as critical outcome. No between-groups differences in the early dislocation rates were found: without movement restrictions, 1623 patients, RR 0.44 (CI95 0.16-1.20); without assistive devices, 4426 patients, RR 0.75 (CI95 0.52-1.08). Finally, considering small desirable health effects and trivial undesirable health effects of the intervention, we integrated two "conditional-recommendations" in favour of an unrestricted protocol.

CONCLUSION

Through GRADE-adolopment approach new recommendations to provide an evidence-based guidance after THA have been formulated.

Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients

BACKGROUND AND PURPOSE

Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.

MATERIALS AND METHODS

We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.

RESULTS

4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).

CONCLUSION

The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.

Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty

BACKGROUND

Postoperative dislocation is considered the main drawback of posterior approach total hip arthroplasty (THA). Thinner highly cross-linked polyethylene and dual-mobility bearings allow maximizing femoral head diameter per a given cup size. This study evaluated dislocation rates as large femoral head bearings were introduced into a practice over an 11-year period.

METHODS

A total of 1,511 consecutive primary THAs were retrospectively reviewed. Demographics, implant sizes, femoral head-acetabular cup ratio, and dislocation status were collected from the electronic medical record. Data were evaluated using time series analysis techniques as larger femoral heads, thinner polyethylene liners, and dual-mobility bearings were introduced. The cohort was 57% women with mean age and body mass index of 62 years (range, 13 to 93) and 31 kg/m² (range, 13 to 54), respectively.

RESULTS

The overall dislocation rate was 0.98%. Use of femoral head sizes ≥ 40 millimeters increased from 4% in the years 2010 to 2016 to 51% in the years 2017 to 2021, correlating with a 50% reduction in dislocation rate from 1.4% to 0.7% (P = .279). Also, no dislocations occurred in patients who had dual-mobility bearings or ≥ 40-millimeter femoral heads (P = .007). Twelve of 14 dislocations occurred in cases with head-cup ratio < 0.7 (P = .013). Thirteen of 14 dislocations were in women (P = .005).

CONCLUSION

Maximizing the femoral head diameter per given cup size correlated with a decrease in dislocation rate in modern posterior approach THA. Furthermore, these results suggest that dual-mobility articulations should be reserved for high-risk patients or patients in whom a 40-millimeter femoral head is not possible.

LEVEL OF EVIDENCE

IV-consecutive case series; no control group.