UK survey of occupational therapist's and physiotherapist's experiences and attitudes towards hip replacement precautions and equipment

Factors influencing implementation of assistive technology services for older adults from the perspectives of Thai occupational therapists: a mixed methods study

PURPOSE

Occupational therapists are crucial in providing assistive technology (AT) services for older adults. However, evidence has shown limited provision of such services in Thailand. This study aimed to investigate the factors that influence the implementation of AT services for older adults from the perspectives of Thai occupational therapists.

METHODS

An explanatory sequential mixed-methods design was guided by the measurement instrument for determinants of innovations and literature review. This study was conducted in two phases: quantitative and qualitative. During the quantitative phase, an adapted version of the Measurement Instrument for Determinants of Innovations was administered to 96 occupational therapists (OTs). A subsample of 5 OTs completed a semi-structured interview during the qualitative phase to explain the findings in the quantitative one.

RESULTS

Factors were categorized into three sections: personal, organizational and socio-political context levels. At the personal level, integrating knowledge and experience could contribute to awareness and professional competency. Client satisfaction influenced OTs to utilize AT, based on a client centred manner. With coordinator and performance feedback within the organization, OTs indicated that consultants supported them in their decision-making. In contrast, availability of AT for older adults is determined by time and resources. Moreover, at the socio-political context level, legislation and regulations may permit or prohibit accessibility of assistive devices.

CONCLUSION

In order to address current challenges, education or training programmes are needed to increase the awareness and competence of OTs. In addition, collaboration with other professionals in community settings is necessary to improve access to AT services.IMPLICATIONS FOR REHABILITATIONAT service for older adults is limited by the availability of time and resources. To handle with these challenges, occupational therapists could advocate for village health volunteers to be a part of the AT services for older adults in the community to increase AT accessibility for older adults.Additional education or training programs should be developed to build competencies and increase occupational therapists' awareness of providing AT services to older adults, as well as to strengthen their roles in AT services.Future research and health policies should focus on access to sufficient funding, and resources for occupational therapists relative to their role in implementing AT services.

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.

An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used

BACKGROUND

The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA).

METHODS

A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge.

RESULTS

Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days.

CONCLUSION

There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.

Patient compliance with postoperative precautions in an unrestricted and a supine sleeping position following posterolateral total hip arthroplasty: a randomized controlled trial

PURPOSE

To evaluate compliance with the precaution to sleep in a supine position following total hip arthroplasty (THA) and its impact on the other precautions.

MATERIALS AND METHODS

Single-center, parallel-group, stratified, randomized trial. Patients were allocated to a Restricted Group or an Unrestricted Group. This study focuses on compliance with the precaution to sleep in a supine position, compliance with the remaining set of precautions and the burden of restricted sleeping. Measurements were made using a self-administered diary and questionnaires. Trial registration number: NCT02107248.

RESULTS

During the first 2 weeks, 81% of the patients in the restricted group were compliant with sleeping in a supine position.Patients in the Unrestricted Group significantly kept sleeping fewer days per week in a supine position than patients in the Restricted Group (p = 0.000). No significant differences between the two groups were found regarding compliance with the remaining set of precautions. The burden of the sleeping restriction is significantly lowered in the Unrestricted Group (p = 0.000).

CONCLUSIONS

Compliance with restricting patients to sleep in a supine position is high. Removing this precaution has a significant decrease in burden for patients without affecting compliance with the remaining set of precautions.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02107248 - https://clinicaltrials.gov/ct2/show/NCT02107248?term=anil+peters&draw=2&rank=1IMPLICATIONS FOR REHABILITATIONSleeping precautions cause a high rate of burden to patients, whereas movement precautions do not.By removing sleeping precautions, the burden is significantly reduced without affecting the remaining set of precautions.Compliance with movement precautions is high compared to other more functional precautions.

Patient compliance with hip precautions 12 weeks following primary elective total hip arthroplasty

INTRODUCTION

Patients are routinely advised to follow hip precautions following their total hip arthroplasty (THA) surgery. There is lack of evidence regarding compliance with these precautions and when patients return to activities of daily living following their surgery.

MATERIALS AND METHODS

We designed a new questionnaire to discover when patients return to their activities of daily living. Two hundred and ninety seven consecutive patients who attended 12 week follow up arthroplasty clinic following their primary elective THA were asked to complete the questionnaire.

RESULTS

All patients who attended the follow up clinic at 12 weeks responded to the questionnaire. Only 6.3% (n = 19) of the patients reported that they restricted their daily activities, as prescribed for the full 12 week period, while 50% (n = 148) of patients stopped using prescribed adaptive equipment by 6 weeks after their operation. There were no dislocations recorded among the study group.

CONCLUSION

We found that the majority of patients do not adhere to hip precautions advice. They return to their activities of daily living prior to the end of prescription period based on their pain and activity level. Lack of adherence to hip precautions do not predispose to hip dislocation in the immediate post-operative period.

Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions

Background

Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted.

Methods

The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014–2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used.

Results

PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43–68) and 47 (31–61); other symptoms, 50 (40–65) and 36 (19–50); function in daily living, 54 (41–65) and 44 (31–55); function in sports and recreation, 56 (38–75) and 40 (15–64); joint-related quality of life, 69 (50–81) and 56 (38–75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients.

Conclusions

We found excellent PROM results after fast-track HA and KA with no postoperative restrictions. We believe that a fast-track program focusing on mobilization without any postoperative restrictions is superior for most patients, but further comparative studies are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05276-y.

Dual Mobility Cup: Does It Improve Patient's Satisfaction After Total Hip Arthroplasty? A Prospective Comparative Randomized Study

INTRODUCTION

Despite the great success of total hip arthroplasty (THA), many patients were fairly dissatisfied after surgery. Therefore, patient-reported outcome measures have become of an utmost importance in assessing the results after joint replacement. This study was conducted to compare the postoperative patient-reported satisfactions after implantation of two commonly used THA designs.

METHODS

Of 180 patients, who initially fulfilled the study selection criteria and received cementless THA, 165 patients were finally eligible and enrolled in this prospective comparative randomized study. All surgeries were carried out between 2010 and 2018. Two groups of homogenous demographic and clinical data were present. Group A patients (n = 80) were treated by large head THA, whereas group B (n = 85) received dual mobility cup designs. The Western Ontario McMaster Universities Osteoarthritis Index and visual analog scale were used for clinical evaluation. The degree of improvement that the patient expected and hoped before undergoing their surgeries was estimated using the score of the new knee society. The self-administered patient satisfaction scale was used to record the levels of patient satisfaction after surgery, and their values were statistically analyzed in relation to preoperative expectation scores (ie, score of the new knee society) and different clinical and sociodemographic variables.

RESULTS

After a mean follow-up of 79 ± 4.13 months (range 24 to 96 months), both groups recorded a significant improvement (P < 0.05) in Western Ontario McMaster Universities Osteoarthritis Index and visual analogue scale scores. Patients of group B were significantly more satisfied (P < 0.05) than those of group A up to the first postoperative year. Certain studied variables were linked to superior satisfaction results among group B at the last follow-up.

CONCLUSIONS

Dual mobility THA provides better patient satisfaction than their standard large head alternatives specifically among elderly patients, socially unsupported individuals, farmers, heavy manual workers, and those with high levels of expectations.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov identifier: NCT04333316.

Is convention hip precaution necessary after total hip arthroplasty?

Background:

Dislocation is one of the most common causes of revision after total hip arthroplasty (THA). Standard hip precautions are thought to enhance soft-tissue healing and reduce dislocations. However, lifestyle restrictions affect a patient’s rehabilitation, quality of life (QOL), and satisfactions. We aim to compare conventional (CP) and minimal hip precautions (MP) after THA.

Methods:

Retrospective review of prospectively collected data in posterolateral approach THA. Chief surgeon assigns patients to CP or MP group. CP group had to sleep supine, used elevated toilet seats and chairs, avoid hip flexion greater than 90°, and no internal rotation or adduction for 6 weeks. MP group had no restrictions in hip movements, except for the combined flexion, adduction and internal rotation. All had a minimum 1-year follow-up. The number of dislocations, length of stay (LOS), time to independent toileting, Harris Hip Scores, QOL, and health perceptions, assessed by EuroQol 5D-5L, was compared between CP and MP groups.

Results:

Fifty-five THAs were included. CP group consisted of 17 primary and 12 revision THAs; MP group consisted of 21 primary and 5 revision THAs. There were two dislocations and both are revisions in CP group. Overall rate of dislocation was 6.9% in CP group and no dislocation in MP group (p-value > 0.05). MP group had shorter LOS (12 vs 19 days, p-value 0.04), higher EQ5D-5L health perception scores at 1-year (81.7 vs 70.9, p-value 0.01).

Conclusion:

MP group had shorter LOS and better health perceptions 1-year after THA with no increase in dislocation rates.

Do hip precautions after posterior-approach total hip arthroplasty affect dislocation rates? A systematic review of 7 studies with 6,900 patients

Background and purpose - Hip precautions limiting flexion, adduction, and internal rotation have been prescribed traditionally to minimize dislocation rates following THA. We assessed the prevalence of hip dislocation following posterior approach total hip arthroplasty without postoperative hip precautions. Methods - A systematic review of multiple medical databases was performed using the PRISMA guidelines and checklist. All clinical outcome studies that reported dislocation rates and postoperative instructions following posterior approach, primary surgery, published within the last 6 years, were included. Results - 6,900 patients were included from 7 Level I-IV studies, with 3,517 treated with and 3,383 without precautions. There was no statistically significant difference in the rates of dislocation between groups (2.2% in restricted group vs. 2.0% in unrestricted group). All but 1 study demonstrated no statistically significant differences in patient-reported outcome scores between restricted and unrestricted groups, including those pertaining to return to function, confidence, and pain. Interpretation - The review found no impact on dislocation rates following total hip arthroplasty performed through a posterior approach, regardless of the use of hip precautions. We also found no impact of the prescription of hip precautions on patient-reported outcome scores.

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

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 REHABILITATIONRedesign 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.

Are hip movement precautions effective in preventing prosthesis dislocation post hip arthroplasty using a posterior surgical approach? A systematic review and meta-analysis

PURPOSE

To determine if hip movement precautions reduce hip prosthesis dislocation rates post hip arthroplasty using a posterior surgical approach compared to minimal or no movement restrictions.

MATERIALS AND METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively. CINAHL, MEDLINE and Embase were searched from inception until September 2020 supplemented by citation tracking. Studies were included if patients had a hip arthroplasty using a posterior surgical approach with comparative data on hip movement precautions or minimal to no movement restrictions. Methodological quality was evaluated using the Downs and Black checklist.

RESULTS

From a yield of 8 studies, meta-analysis of 7 studies and 9599 total hip arthroplasties, there was low quality evidence of no increased risk of dislocation (RR = 0.98, 95%CI 0.58 to 1.67) for patients prescribed minimal or no hip movement restrictions compared with patients prescribed hip movement precautions. There were 121/5440 dislocations (2.2%) in the movement precaution group and 90/4159 dislocations in the minimally restricted group (2.2%).

CONCLUSIONS

Dislocation rates after total hip arthroplasty are low irrespective of movement precaution allocation. Resources allocated to implementing hip movement precautions may be better directed towards other clinical areas.IMPLICATIONS FOR REHABILITATIONThere was no difference in hip prosthesis dislocation rate between patients who received hip movement precautions compared to patients who received minimal or no restrictions after total hip arthroplasty using a posterior surgical approach.Health professionals involved in prescribing and monitoring adherence to hip movement precautions after total hip arthroplasty may be better allocating their resources to other areas of clinical care.Falls were associated with the greatest number of prosthesis dislocations, accounting for 24% of dislocations; resources may be better allocated towards evidence-based strategies to reduce falls.

Risk of Dislocation After Total Hip Arthroplasty in Patients with Crowe Type IV Developmental Dysplasia of the Hip

Objective

To investigate whether the risk of dislocation after total hip arthroplasty (THA) in patients with Crowe type IV developmental dysplasia of the hip (DDH) is high and to further identify the risk factors for postoperative dislocation in these patients.

Methods

This retrospective cohort study reviewed Crowe type IV DDH patients undergoing THA between January 2009 and December 2017 in our institution. Each Crowe type IV DDH patient was matched with three Crowe type I, II, or III DDH patients according to gender, side and date of operation. The primary outcome of this study was postoperative dislocation after THA. Occurrence, rate, classification, treatment and outcome of dislocation were documented in detail for all patients. The dislocation rates were compared between Crowe type IV DDH patients and Crowe type I, II, or III DDH patients. Demographic data, implant factors, and surgical factors were compared between the dislocation and no dislocation groups. Multiple logistic regression analysis was used to determine the independent risk factors for dislocation in Crowe type IV hips.

Results

A total of 131 Crowe type IV hips were followed up for a mean of 76.5 ± 28.1 months. Three hundred and ninety‐three Crowe type I, II and III hips, including 261 type I hips, 94 type II hips, and 38 type III hips, were identified as controls and followed up for a mean of 76.4 ± 28.2 months. No significant difference was observed in follow‐up time between two groups (P = 0.804). One or more dislocations occurred in 22 of the 524 dysplasia hips (4.20%). Of the 22 dislocated hips, 20 hips (90.9%) were successfully managed with non‐operative treatment. Two patients (9.1%, one Crowe type I and one Crowe type IV) experienced recurrent dislocation and required revision surgery. Crowe type IV hips had a significantly higher postoperative dislocation rate than type I, II, and III hips (11.45% vs 1.78%, P < 0.001). The use of a 22‐mm femoral head (odds ratio [OR] = 23.55, 95% confidence interval [CI] = 1.901–291.788, P = 0.014), older age (OR = 1.128, 95% CI = 1.037–1.275, P = 0.031), and absence of false acetabulum (OR = 12.425, 95% CI = 1.982–77.879, P = 0.007) were identified as independent risk factors for dislocation in Crowe type IV hips.

Conclusions

Crowe type IV DDH patients were at a high risk of dislocation after THA, and using large femoral heads and improving abductor muscle strength may help decrease the rate of postoperative dislocation in such patients.

Less Postoperative Restrictions Following Total Hip Arthroplasty With Use of a Posterolateral Approach: A Prospective, Randomized, Noninferiority Trial

BACKGROUND

Patient restrictions are prescribed after total hip arthroplasty (THA) to ensure proper healing and prevent early dislocation. It has been suggested that less or nonrestrictive protocols following THA do not lead to higher dislocation rates. Nonetheless, restrictions are still widely used. The aim of this study is to evaluate the rate of early dislocations when patients were restricted to supine sleeping or unrestricted sleeping in the first 8 weeks after THA using a posterolateral approach.

METHODS

The study design was a single-center, parallel-group, stratified, randomized, noninferiority trial in which primary THA patients were allocated to either a restricted group or a nonrestricted group. The primary outcome was early (<8 weeks) dislocation rate. Secondary outcomes include pain (visual analog scale [VAS]), function in activities of daily living (Hip Disability and Osteoarthritis Outcome Score [HOOS]), and quality of life (EuroQoL 5 Dimension [EQ-5D]).

RESULTS

A total of 408 patients were randomized into 2 groups: those who were restricted in their sleeping position (n = 203) and those who received no restrictions in sleeping position (n = 205). Three patients (1.48%) from the restricted group and 3 patients (1.46%) from the unrestricted group had a dislocation. The noninferiority of the restricted group compared to the nonrestricted group was established for early dislocation. In addition, no statistically significant differences were found for VAS, HOOS, and QoL-5D between both groups. Both groups showed a significant improvement in VAS, HOOS, and QoL-5D.

CONCLUSION

Early dislocation rates in patients who were advised to comply to an unrestricted sleeping position following THA were not inferior to the dislocation rates in patients who were advised to sleep in a supine position following THA. The results of the present study strengthen the discussion regarding the relevance of providing patients with restrictions following THA.

A Protocol of Pose Avoidance in Place of Hip Precautions After Posterior-Approach Total Hip Arthroplasty May Not Increase Risk of Post-operative Dislocation

BACKGROUND

Post-operative rehabilitation after posterior-approach total hip arthroplasty (P-THA) includes the use of standard hip precautions, defined as no hip flexion beyond 90°, hip adduction, or hip internal rotation for 6 to 12 weeks after surgery (sometimes for life). Since they were first implemented in the 1970s, subsequent advances may have made standard hip precautions no longer necessary, although little evidence supports that hypothesis. A modified set of precautions, a "pose avoidance protocol," could be effective in enhancing recovery, but its effectiveness on early dislocation and post-surgical outcomes is not known.

QUESTIONS/PURPOSES

We sought to determine the functional recovery of patients on a pose avoidance protocol after P-THA according to levels of pain and patient satisfaction, rates of dislocation, the use of assistive devices, and a return to driving.

METHODS

We conducted a retrospective, descriptive study of data from a consecutive case series of 164 patients treated by a single surgeon between January 2014 and December 2015. Patients who had undergone a primary uncemented P-THA were prescribed a pose avoidance protocol and followed for a minimum of 6 weeks. Exclusion criteria were patients with congenital hip dysplasia, revision THA, femoral neck fracture, rheumatoid arthritis, or neuromuscular disease. Changes to the rehabilitation protocol included elimination of the requirements to use elevated chairs, raised toilet seats, and abduction pillows for sleeping. Patients could resume driving at 2 and 3 weeks for left and right P-THA, respectively. The only motion restriction was avoiding the combination of hip flexion past 90°, hip adduction, and hip internal rotation. Patients could perform all other movements and to bear weight and stop using walking aids as tolerated. Patients completed a biweekly questionnaire to assess their functional recovery, opioid use, and pain levels.

RESULTS

At 2 weeks after surgery, 80% of patients reported no pain, 86% did not require walking aids, and 92% were satisfied with their recovery. At 6 weeks after surgery, 89% of patients reported no pain. Patients returned to driving at a mean of 2.7 weeks after surgery. No patients had experienced a dislocation at 6 weeks of follow-up.

CONCLUSION

A pose avoidance rehabilitation protocol in this P-THA population was found to be safe and was associated with accelerated functional recovery and high patient satisfaction without increased risk of early post-operative dislocation.

Posterior Hip Precautions Do Not Impact Early Recovery in Total Hip Arthroplasty: A Multicenter, Randomized, Controlled Study

BACKGROUND

Posterior hip precautions have been routinely prescribed to decrease dislocation rates. The purpose of this study was to determine whether the absence of hip precautions improved early recovery after total hip arthroplasty via the posterolateral approach.

METHODS

Patients undergoing total hip arthroplasty via the posterolateral approach at 3 centers were enrolled. Patients meeting the selection criteria were randomized to standard hip precautions (SHP) or no hip precautions (NHP) for 6 weeks following surgery. HOOS Jr, Health State visual analog score, and rate of pain scores were recorded preoperatively and in subsequent postoperative visits; dislocation episodes were also noted. Standard statistical analysis was performed.

RESULTS

From 2016 to 2017, 159 patients were randomized to SHP and 154 patients were randomized to NHP. Controlling for the center at which the surgery was performed, the only difference in outcome scores between the 2 groups was at 2 weeks; the NHP group had a lower HOOS Jr score when compared to the SHP group (P = .03). There was no difference in outcome scores at any other time points when compared to preoperative assessments. In the SHP group, there were 2 recorded dislocations (1.3%) and 1 in the NHP group (0.7%; P = .62).

CONCLUSION

In this multicenter, randomized, controlled study, the absence of hip precautions in the postoperative period did not improve subjective outcomes which may be explained by the self-limiting behavior of NHP patients. Furthermore, with the numbers available for the study, there was no difference in the rate of dislocation between the 2 groups.

Varying but reduced use of postoperative mobilization restrictions after primary total hip arthroplasty in Nordic countries: a questionnaire-based study

Background and purpose - Mobilization has traditionally been restricted following total hip arthroplasty (THA) in an attempt to reduce the risk of dislocation and muscle detachment. However, recent studies have questioned the effect and rationale underlying such restrictions. We investigated the use of postoperative restrictions and possible differences in mobilization protocols following primary THA in Denmark (DK), Finland (FIN), Norway (NO), and Sweden (SWE). Patients and methods - All hospitals performing primary THA in the participating countries were identified from the latest national THA registry report. A questionnaire containing questions regarding standard surgical procedure, use of restrictions, and postoperative mobilization protocol was distributed to all hospitals through national representatives for each arthroplasty registry. Results - 83% to 94% (n = 167) of the 199 hospitals performing THA in DK, FIN, NO, and SWE returned correctly filled out questionnaires. A posterolateral approach was used by 77% of the hospitals. 92% of the hospitals had a standardized mobilization protocol. 50%, 41%, 19%, and 38% of the hospitals in DK, FIN, NO, and SWE, respectively, did not have any postoperative restrictions. If utilized, restrictions were applied for a median of 6 weeks. Two-thirds of all hospitals have changed their mobilization protocol within the last 5 years-all but 2 to a less restrictive protocol. Interpretation - Use of postoperative restrictions following primary THA differs between the Nordic countries, with 19% to 50% allowing mobilization without any restrictions. There has been a strong tendency towards less restrictive mobilization over the last 5 years.

Prevention of Dislocation After Total Hip Arthroplasty

BACKGROUND

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

METHODS

We performed a literature search to assess historical perspectives and current strategies to prevent dislocation after primary THA. The search yielded 3458 articles, and 154 articles are presented.

RESULTS

Extremes of age, body mass index >30 kg/m², lumbosacral pathology, surgeon experience, and femoral head size influence dislocation rates after THA. There is mixed evidence regarding the effect of neuromuscular disease, sequelae of pediatric hip conditions, and surgical approach on THA instability. Sex, simultaneous bilateral THA, and restrictive postoperative precautions do not influence the dislocation rates of THA. Navigation, robotics, lipped liners, and dual-mobility acetabular components may improve dislocation rates.

CONCLUSIONS

Risks for dislocation should be identified, and measures should be taken to mitigate the risk. Reliance on safe zones of acetabular component positioning is historical. We are in an era of bespoke THA surgery.

Patient Needs for an Ambulant Dislocation Alert System Following Total Hip Arthroplasty

INTRODUCTION

One of the major complications in total hip arthroplasty (THA) is dislocation of the prosthesis. To prevent early dislocation, patients are instructed with movement restrictions. The first goal in this development is to obtain insight in the movement restrictions that are reported to have low levels of self-efficacy during activities of daily life. The second goal is to reveal the design needs for an ambulant hip dislocation alert system (HipDas) and the third goal is to explore its usability among patients.

METHODS

Patient-centered experiences with THA were explored by the use of a questionnaire and a semistructured focus group. The questionnaire was administered among n = 32 THA patients at 1 week preoperative and at 3 and 6 weeks postoperative. The questions addressed self-efficacy, performance and effort expectancy, and usefulness and social influence. The focus group consisted of patient journeys and scenario composition. The usability of a prototype version of the HipDas system was evaluated (n = 5).

RESULTS

Flexion of the hip >90°, bending over while sitting in a chair, and sleeping in a supine position are the restrictions that have the lowest self-efficacy. The majority of patients (>86.6%) believe that a future HipDas is useful. Focus group outcomes suggest there is a gradual decrease in the threshold for feedback. The system is preferably used in the first 6 weeks after surgery and appeared to be usable and highly clinically relevant.

DISCUSSION

HipDas is considered an interesting concept that can accelerate functional recovery of patients following THA by providing support on how to properly apply postoperative movement restrictions to prevent a dislocation.

Towards a situation-and-user-aware multi-modal motorized toilet system to assist older adults with disabilities: A user requirements study

In the recent decades state of the art technologies appeared in many areas to assist older adults with disabilities. However, one very essential activity of daily life, the toileting remained without any relevant development. The iToilet project of the European Union focuses on the development of an intelligent and motorized toilet system to enable independent toilet use for older adults with disabilities. To begin the development, the user requirements of end-users were assessed by means of focus group interviews and questionnaires. The survey was conducted in Austria and Hungary with the participation of 74 persons in total (41 subjects with movement disorders, 21 caregivers and 12 healthcare managers). From the interviews, the ranking of functions and features based on the number of their mentions was derived. The raw ranking was modulated by the average ratings from the questionnaires that resulted in the final list of priorities. Our results suggest that a safe and intelligent motorized toilet system should have foldable handrails on both sides (especially for wheelchair users), motorized height and tilt adjusting mechanism for the toilet bowl, fixed toilet paper holder on both sides and emergency recognition with call function. Simple operation, storage and retrieval of user specific settings including bowl height, and user identification were also deemed as very important features, while the possibility to control functions with gestures was valued rather low.

Rehabilitation of revision total hip replacement: A multi-centre survey of current practice

BACKGROUND

Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation.

AIMS AND OBJECTIVES

To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery.

METHODS

An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically.

RESULTS

There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably.

CONCLUSIONS

This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.