Lightfoot, Courtney Jane
(2019)
Hip precautions after hip operation (HippityHop): a
before and after study evaluating hip precautions following total hip replacement.
PhD thesis, University of Nottingham.
Abstract
Background
Total hip replacement (THR) is a common surgical intervention for treating painful osteoarthritis, especially with end-stage joint deterioration. A well-recognised complication of THR surgery is hip dislocation. To reduce the risk of dislocation, patients are often asked to observe ‘hip precautions’ (that is to restrict certain movements) for several weeks post-surgery. Hip precautions are routinely used despite conflicting evidence regarding their efficacy in reducing dislocation, and divergent clinical opinions as to whether they are detrimental or beneficial to patient recovery.
Aim
The overarching aim of this study, therefore, was to evaluate the effectiveness of hip precautions following THR by comparing a regime of routine hip precautions with a regime of no routine precautions, in order to: 1. compare patient outcomes in functional performance, pain, sleep, mood, satisfaction, and quality of life; and 2. ascertain staff and patient perceptions and experiences of the two regimes.
Method
A before and after study was conducted. In the ‘before’ phase patients received education on hip precautions, while in the ‘after’ phase patients received no advice on routine precautions. Data were collected from participants at baseline, and at one week, six weeks, and three months postoperatively. The primary outcome was the Oxford Hip Score (OHS) at three months; other outcomes measures were the Nottingham Extended Activities of Daily Living Scale, the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, EQ-5D-5L, and rate of hip dislocation at the different time points. Equivalence analysis was conducted to determine whether patients’ OHSs were equivalent at three months postoperatively. Statistical analyses were conducted to determine any differences in the other patient outcomes.
Semi-structured interviews were conducted with staff and patients who participated in the before and in the after phases of the study. Interviews included experiences and opinions of the service provided, provision of information, equipment prescription, and the impact on patients’ recovery. Thematic analysis was used to identify and report themes.
Results
In the before and after study, 367 participants were recruited, of these a total of 237 participants successfully underwent THR surgery during the study period and were followed-up. Outcome data were obtained for 221 participants at six weeks and 212 at three months. The results indicated that patients who received hip precautions had similar outcomes to those who did not at six weeks and three months postoperatively. In addition, patients who did not receive precautions had equivalent levels of pain and function at three months as patients who received precautions. The rate of dislocation observed was comparable for both groups.
Interviews were conducted with 19 members of staff and 22 patients across both phases of the study. Findings from the interviews suggested that diverging clinical opinions remained amongst staff about the use of hip precautions and their impact on patients’ recovery. Whilst therapists were more willing to withdraw precautions from practice, surgeons were more concerned about the change. Even following the change in service, some surgeons remained sceptical about the potential benefits that the relaxed regime may have on the patients’ recovery and were concerned about the effects on dislocation rates. Patients in the before phase also had mixed views about the use of hip precautions, with varying adherence and perceived impact upon their daily lives and recovery following THR. Some felt that they were restrictive whilst others believed that precautions provided reassurance and decreased their risk of dislocation. Following the withdrawal of precautions, some patients were less fearful about dislocating their hip but were unsure how to perform certain movements and progress their rehabilitation.
Conclusion
The principal conclusion was that patients who did not receive hip precautions had similar outcomes to those who did receive them, at six weeks and three months postoperatively, in terms of pain, function, mood, sleep quality and health-related quality of life. In addition, the rate of dislocation observed was similar for both groups. Although this study demonstrated that hip precautions provided no additional benefit, some surgeons interviewed believed that precautions should continue to be provided to patients. The study findings support the removal of precautions following primary THR but highlighted that mixed opinions about this remain.
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