Running Head: EFFECTIVENESS OF HIP PRECAUTIONS 1

In patients with total hip replacements, are hip precautions more effective than no hip
precautions in preventing dislocation post surgery?

Jaclyn Strangie
NURS 612
May 6, 2014
Dr. Fetzer










EFFECTIVENESS OF HIP PRECAUTIONS 2
P: Total Hip Replacement Patients
I: Hip Precautions
C: No Hip Precautions
O: Dislocations Post-operatively

Background and Rationale
Total hip replacements (THR) or total hip arthroplasty means that a non-working or
diseased hip joint is being replaced with an artificial joint (Hip Replacements, 2014).
This procedure is typically done in patients with joint damage in their hip from previous
injury or from arthritis. With a total hip replacement, patients can regain full function of
their hip, including range-of-motion, which essentially improves their activities of daily
living.
During this procedure, an incision is made over the front or side of the hip, the
damaged bone and/or cartilage is then removed, and a prosthetic ball is attached to a stem
that fits into the patients thigh (Hip Replacements, 2014). Since this surgery involves
a great deal of work, there is an extensive recovery period with a lot of restrictions that
patients may need to follow. Hip precautions are the restrictions that post-op THR
patients must adhere to in order to prevent dislocation of the new hip. These restrictions
include no driving or riding in a car, refraining from bending the affected hip greater than
ninety degrees or forty-five degrees internally or externally, and no crossing their legs at
the thighs (Ververeli, Lebby, Tyler, & Fouad, 2009, p. 1). In addition, an elevated toilet
seat and chair must be used to prevent bending and patients must sleep supine with an
EFFECTIVENESS OF HIP PRECAUTIONS 3
abductor pillow or regular pillows between their legs. The pillows help to prevent the
affected hip from rotating inward.
Hip precautions have been used in practice for many years following post-op THR.
However, do these precautions prevent post-op dislocations more effectively than no hip
precautions at all? These restrictions are intended to allow the tissue to heal properly by
protecting soft-tissue repairs and to prevent dislocation by restricting patient activity
(Restrepo, Mortazavi, Brothers, Parvizi, & Rothman, 2011, p.4). Dislocations are one of
the most common complications following a total hip replacement. The answer to this
question is important to nursing because it could affect patient care, including the post-
surgery education that patients receive.
If these precautions are determined to be less effective or no more effective than
having no precautions, then its important to incorporate this finding into practice.
Ultimately, the use of hip precautions needs to be evaluated in order to achieve an
optimal outcome for these patients. The rate of recovery and comfort level of THR
patients post-operatively can be affected by the use of hip precautions or not. Along with
implementing best practice, nurses must be up-to-date on these findings so that patient
education can be provided properly. For example, if hip precautions are not necessary,
nurses may need to alter their teaching strategies to educate patients on post-op
dislocation and the signs to look for. Therefore, its imperative to implement evidence-
based practice when caring for total hip replacement patients.
Search Methods
Using CINAHL, the phrase Hip Precautions was searched through the University of
New Hampshires library database, conducted through the search engine EBSCO. This
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search yielded eleven total results. However, the results were not specific to nursing and
related more to an occupational therapy approach. The search was limited to peer-
reviewed, English-language articles published within the last ten years. The studies also
had to be specific to nursing and conducted in the United States. After applying these
limits, the search presented eleven results. The study chosen from those results evaluated
the reduction of hip precautions post-operatively in THR patients. The abstract revealed
that the study was pertinent to this paper. This study meets all the criteria in evaluating
hip precautions, no hip precautions, post-op dislocations, as well as the pace of recovery
amongst THR patients, and whether they implemented post-op restrictions or not.
After choosing the first resource, the search terms were refined to include Dislocation
following total hip replacement. With this search, which also used CINAHL, the same
limits were imposed as identified in the first search. These key words along with the
limitations yielded seven results. From these seven results, the second resource
discussing the role of hip precautions and patient restrictions following a total hip
replacement was selected. After evaluating the quality of the study and briefly reading
the abstract, its relevant to this PICO question. This source analyzes the effectiveness of
hip precautions in relation to the prevalence of early dislocation following a total hip
arthroplasty. This study was also noted to have a large population size and analyzed
patients over a longer period of time, possibly leading to more accurate results.
The next step was to find a final resource to help evaluate this topic. The final search
criteria included the same limitations and the same key words, hip precautions as the
initial search, again using CINAHL. After going back through these eleven results from
the first search, another one of these resources could be implemented into this paper. The
EFFECTIVENESS OF HIP PRECAUTIONS 5
final resource examined whether hip precautions were needed to prevent and control
post-op complications, specifically hip dislocation.
Critical Appraisal of the Evidence
Ververeli, et al., (2009) conducted a study evaluating the reduction of postoperative
hip precautions among patients who underwent a total hip replacement. To best conduct
this study, the researchers chose to use a randomized approach. Patients were randomly
placed into the standard group or the early group prior to their surgery. In order to
randomize this study appropriately, group assignments were generated using a random-
numbers table and these numbers were sealed in numbered envelopes (Ververeli et al.,
2009, p.1). These envelopes were then given randomly to any patient who provided
informed consent for this study during their preoperative visit. This study consisted of 81
consenting patients who were seeking elective total hip replacements from the VSAS
Orthopedics office from 2004-2008. The standard group consisted of 43 patients: 16
women with a mean age of 59.8 and 27 men with a mean age of 57.4. The early group
was made up of 38 total patients: 16 women with a mean age of 60.8 and 22 men with a
mean age of 58.8.
To get an accurate sample for this study, the researchers had to exclude patients based
on a certain criteria. The study excluded patients with a previous total hip replacement,
hearing impairment, dementia, Alzheimers or no family support at home (Ververeli et
al., 2009, p.2). Patients who were younger than twenty-one years old, weighed more
than 275 pounds, were unable to ambulate more than thirty feet without the use of an
assistive device or were unable to attend post-op outpatient physical therapy, were also
excluded from the study (Ververeli, et al., 2009, p.2).
EFFECTIVENESS OF HIP PRECAUTIONS 6
The patients in the standard group had to follow the restrictions that went along with
hip precautions. According to this study, the hip precautions for this group included
refraining from bending at the affective hip more than ninety degrees, bending their legs
at the thighs. In addition, this group was not allowed to drive or ride in a car. Along with
these restrictions, the patients in the standard group were required to use elevated toilet
seats and chairs along with sleeping supine with the use of an abductor pillow in between
their legs (Ververeli et al., 2009, p.1). These precautions were implemented for the first
postoperative month. With the conclusion of the first postoperative month, patients in
this group were still limited to flexion of less than ninety degrees but were allowed to get
in and out of a vehicle. These restrictions lasted for the duration of the second and third
postoperative months.
Patients in the early group had no post-operative restrictions, besides refraining
from crossing their legs at the thighs (Ververeli et al., 2009, p.1). Therefore these
patients could remain in any position they deemed comfortable immediately post-op and
also had the privilege of riding in a car at their leisure and comfort. They early group
was also instructed to use a regular toilet seat, regular chair, and could sleep comfortably
in any position, without the use of the abductor pillow between their legs (Ververeli et al.,
2009, p.1).
Two weeks post-op, patients in both groups were assessed. The assessment for the
early group was done in a healthcare office, whereas the assessment for the standard
group was done via telephone call. All participants were advised to keep a journal
documenting when they first walked with and without a cane, when they drove, and at
what time they first walked without a limp (Ververeli et al., 2009, p.1).
EFFECTIVENESS OF HIP PRECAUTIONS 7
To best analyze the data in each patients journal, the researchers used a two-tailed
test. This evaluation suggested that there were no incidents of dislocation in either the
standard or early group. However, the study concluded, Patients in the early group were
faster to ambulate with only a cane (Ververeli et al., 2009, p.3). Also, the patients in
the early group were found to walk sooner without a cane and were found to be driving
sooner than the standard group. Lastly, the early group was confirmed to be walking
much sooner than those with hip precautions (Ververeli et al., 2009, p.3).
This study concluded that the group with no hip precautions (early) were able to
recover faster and participate in their normal activities of daily living at a quicker pace
than those patients who were on hip precautions (standard). However, no dislocations
were found in either group. The researchers concluded that based on these results
postoperative hip restrictions provide no additional benefit and limit patients from
activities that theyre capable of doing (Ververeli et al., 2009, p.4). It is not possible to
conclude from this study if hip precautions are needed to prevent hip dislocations because
there were no incidents of dislocations in the sample.
This study successfully presented and evaluated the effects of hip precautions versus
no hip restrictions on the pace of recovery among total hip replacement patients. Even
the patients without restrictions did not experience dislocations, as shown by the lack of
dislocations among all participants in the study. However, the incidence of no
dislocations throughout this study cant determine the effectiveness of precautions versus
no precautions due to the finding of no dislocations. This study would have been more
accurate if it had a larger sample size. Due to this limitation, the belief that hip
precautions preventing dislocation may not be valid. Along with the small sample size,
EFFECTIVENESS OF HIP PRECAUTIONS 8
this study included a strict exclusion criteria. With this criteria, the overview of these
results may be challenged.
Restrepo et al., (2011) conducted a large prospective cohort study on hip dislocations
in a population of patients who didnt use hip precautions for a period of six months.
Any patient who had a total hip replacement from January 2005 through December 2007
at one specific institution was included in this study. The sample consisted of 2,532
patients (2,764 hips). Of this total, 1,541 were women and 1,223 were men, both with a
mean age of 63.2 years (Restrepo et al., 2011, p.2). This group of patients was followed
for six months post-operatively. However, 146 patients (152 hips) did not follow-up at
the end of the six-month period, disqualifying them from this study (Restrepo et al., 2011,
p.2).
The patients in this study were allowed to move their operated hip as tolerated, with
no restrictions. These patients did not need to use abduction pillows, elevated toilet seats
or chairs. They could sleep on the operated side if it was comfortable for them and did
not need to put pillows between their legs during sleep. Despite there being no functional
restrictions during this study period, patients with a left hip replacement were allowed to
start driving around two weeks after surgery, and those with a right hip replacement were
allowed to drive around the third or fourth post-op week (Restrepo et al., 2011, p.2). A
nurse practitioner followed up with patients at two weeks, six weeks, and then finally at
six months. During these visits, the nurse practitioner looked for any signs of dislocation
and what could have contributed to the dislocation if present.
Four dislocations were diagnosed, occurring roughly five days after the total hip
replacement surgery (Restrepo et al., 2011). Therefore, this study found a dislocation
EFFECTIVENESS OF HIP PRECAUTIONS 9
rate of 0.15%, or a total of four dislocations out of 2,612 total hip replacements. All of
these dislocations were of an unknown cause, meaning none of them were from a
traumatic event. With such a low dislocation rate, Restrepo et al., (2011) reported that
with the removal of hip precautions, there was no increase in the incidence of early
dislocation. This was a significant finding of this study because the population consisted
of a normalized curve and studied a larger population of patients undergoing total hip
replacements over a period of two years. Since the dislocation rate of 0.15% was so low
the investigators concluded that that having no hip precautions or restrictions following a
total hip replacement does not mean there will be an increase in the number of
dislocations amongst these patients.
One significant limitation of this study was that the final follow-up occurred only six
months after surgery. Six months may not be long enough to monitor these patients
because many dislocations can occur after six months. Its understood that most
physicians dont extend hip precautions for more than six weeks; however, some of the
patients in this study may have been implementing hip precautions on their own, for
comfort measures. Therefore, hip precautions may have been used amongst these
patients in fear of dislocation (Restrepo et al., 2011, p.4). Another limitation of this study
is the loss of 146 patients who didnt follow through with their follow-up visits. Several
of those patients could have suffered from a dislocation but may have not reported it.
With these limitations, the significance of the studys results could be questioned.
The final study conducted by Peak et al., 2005 looked into the role of patient
restrictions in reducing the prevalence of early dislocation following a THR. Before
conducting this prospective, randomized study, the researchers hypothesized that
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dislocation was more likely to occur in patients who were not placed on hip restrictions
(Peak et al., 2005, p. 247). The population of this study was made up of 265 patients
(303 total hips). These patients were randomly selected from a specific institution
between the months of March and December 2002, and were studied for a minimum of
six months post-operatively. The patients who consented to be a part of this study
consisted of 139 males and 126 females with a mean age of 58.3 years (Peak et al., 2005,
p. 248). During the study, March to December, there were a total of 630 patients who
underwent a total hip arthroplasty at the institution where the study was conducted.
Therefore, 365 patients chose not to be in this study or were excluded from being an
eligible participant (Peak et al., 2005, p. 248).
The exclusion criteria for this study was similar to those in the previous studies analyzed.
Peak et al., (2005) excluded any patient with a history of surgery on a hip, hyper
flexibility syndromes or neuromuscular compromise, and most importantly patients who
didnt give consent. Once the final population was determined, the patients were
randomly assigned to two groups, the restricted group or the unrestricted group. All
participants, no matter which group they were assigned to, had some precautions to
follow. Each group was asked to refrain from flexing the hip more than 90 degrees and
to avoid more than 45 degrees of rotation both internally and externally for the first six
weeks after the procedure (Peak et al., 2005, p. 247). Along with these restrictions, the
restricted group had to abide by additional precautions. The additional precautions for
the restricted participants included the use of an abductor pillow or pillows between their
legs while in bed, used elevated toilet seats and chairs. In addition, they could not sleep
on their affected side and had to refrain from driving or riding a car due to the bending it
EFFECTIVENESS OF HIP PRECAUTIONS 11
involved getting in and out of a vehicle (Peak et al., 2005, p. 247). Although the
unrestricted group had no further precautions, they were free to use additional
precautions if and when they experienced discomfort (Peak et al., 2005, p. 249).
Patient education was provided to both groups prior to discharge, including written
instructions. Each participant completed surveys at each follow-up visit, six weeks post-
op and roughly six months post-op. These surveys were intended to gauge how
accurately the participants followed the range-of-motion limitations, whether either group
used additional equipment for comfort, and finally to note at which point in time they
stopped using additional equipment (Peak et al., 2005, p. 249). With the completion of
these surveys and relevant activity-related questions, the researchers could determine if
there were any dislocations in this six-month period.
After careful analysis, Peak et al., (2005) confirmed that there was only one
dislocation in the entire study. This dislocation was present in the restricted group,
resulting in a 0.33% overall dislocation rate. It was confirmed that this dislocation
occurred during a transfer from the operating table to a bed with the use of an abduction
pillow in place (Peak et al., 2005, p. 249). This result was significant to this study as it
demonstrates no dislocations among the patients complying with no hip precautions, and
confirms that the only dislocation was prior to the restrictions.
Further significant findings of this prospective, randomized study was that there were
no difference between the two groups when it came to the presence of a limp. The return
to activities of daily living was reached earlier in the unrestricted group (Peak et al.,
2005, p. 250). It was also confirmed that patients were more satisfied with fewer
restrictions. These patients felt a sense of autonomy, had better sleep habits, returned to
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driving sooner, returned to work earlier, and ultimately felt back to being themselves
again, but most importantly had no dislocations (Peak et al., 2005, p. 251).
The hypothesis of this study was not confirmed as the researchers theorized that
dislocations were more likely to occur in patients in the unrestricted group. From these
findings, Peak et al., (2005) recommended that all patients should conform to the range-
of-motion restrictions that were placed on both groups and that further restrictions are not
necessary in preventing dislocation. One limitation of this study is that it evaluated
uncomplicated patients undergoing a total hip replacement. Therefore anyone with
predisposing factors stated in the exclusion criteria were not eligible participants.
Excluding these participants could have altered the results, lowering the rate of
dislocation. Patients with predisposing factors may have been more likely to suffer a hip
dislocation than those considered uncomplicated. The way the researchers gathered
their data could also be a weakness in this study. Peak et al., (2005) gathered their
information via word of mouth or through the surveys. They then confirmed the
accuracy of the patient-reported information by having discussions with the patients
family members and health-care personnel (Peak et al., 2005, p. 249). This would be
considered a limitation because its not a significant enough way to confirm data; perhaps
direct observation may have been a preferred method of data collection.
Evidence Synthesis
The analysis of the evidence indicated that there is not a significant increase in post-op
dislocations when hip precautions are not used among total hip replacement patients. As
discussed and confirmed in these studies, patients who didnt comply with hip
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precautions, thus having no restrictions, had a higher satisfaction level and ultimately had
a quicker recovery than those who were placed on hip precautions.
Each study observed these patients for a minimum of six months, which is when the
majority of hip dislocations may be diagnosed. During this time, as stated in all three
studies, the rate of dislocation was very minimal, if a dislocation was present at all. The
dislocations in these studies occurred in patients on hip precautions who were complying
with significant restrictions. These patients may feel more uncomfortable, cautious, and
in fear of dislocation, leading them to unintentionally cause an early dislocation.
Therefore, it has been determined from these studies that there is no evidence to suggest
that hip precautions are more effective than no hip precautions post-operatively in total
hip replacement patients.
Clinical and Research Recommendations
Based on the clinical appraisal of this research, it would be considered evidence-based
practice to refrain from implementing hip precautions. If hip precautions are not
implemented, that doesnt mean these restrictions should not be mentioned in the
teaching of these patients received at discharge. Since evidence showed no significant
increase in dislocation without restrictions/precautions, its safe to remove these from
practice. If any precautions are necessary, it should be the range-of-motion limitations as
discussed by Peak et al., (2005). With the large satisfaction level, low dislocation rate,
and increase in pace of recovery among the unrestricted patients, it can be concluded that
patients have a more desirable outcome when not having to comply with restrictions.
In the future, its important for the health care team to provide adequate patient
teaching regarding the signs of dislocation and to progress through the post-operative
EFFECTIVENESS OF HIP PRECAUTIONS 14
period at their own pace. With this teaching, THR patients may be more apt to
implement their own precautions, but may not implement all of the restrictions that would
be termed hip precautions. A major nursing implication among this patient population
is discharge teaching, Therefore, in future research, it would be valuable to explore and
determine the effectiveness of discharge teaching in this patient population, regardless of
whether hip precautions are implemented.

















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References
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Peak, E., Parvizi, J., Ciminiello, M., Purtill, J., Sharkey, P., Hozack, W., & Rothman, R.
(2005). The role of patient restrictions in reducing the prevalence of early
dislocation following total hip arthroplasty: a randomized, prospective study.
Journal Of Bone & Joint Surgery, American Volume, 87A(2), 247-253.
Restrepo, C., Mortazavi, S., Brothers, J., Parvizi, J., & Rothman, R. (2011). Hip
dislocation: are hip precautions necessary in anterior approaches?. Clinical
Orthopaedics & Related Research, 469(2), 417-422. doi:10.1007/s11999-010-
1668-y
Ververeli, P., Lebby, E., Tyler, C., & Fouad, C. (2009). Evaluation of reducing
postoperative hip precautions in total hip replacement: a randomized
prospective study. Orthopedics, 32(12), doi:10.3928/01477447-20091020-
09