Life Without Hip Precautions &
Review of an Elective Orthopaedic
Enhanced Recovery Program
Jade Cope
Clinical Specialist Occupational Therapist
Guys & St Thomas Hospital
Hip precautions are not routinely implemented
within Guys and St Thomas Trust for elective
and trauma patients receiving total, hemi or
revision hip replacement surgery. This has
been standard practice since March 2011.
Why?
• Extensive MDT discussion and service review
• Limited evidence base to support use of hip
precautions
• Introduction of enhanced recovery programme
National Figures
No. hip
replacements
2012
% antero-lateral
approach
% posterior
approach
86,488
33%
61%
• Average LOS for elective THR is 5 days, 15.7 days for
patients following hip fracture (National Joint Registry, 2013)
• The use of hip precautions varies nationally, lack of
direction and evidence base (Drummond et al, 2012)
Reasons for OT’s implementing hip precautions
(Drummond et al, 2012, pg. 5)
Response
Yes (%)
No (%)
Missing (%)
Surgical approach 42.5
56.9
0.6
Surgical opinion
72.4
27.0
0.6
Hospital policy
28.7
70.0
0.60.6
Occupational
Therapy Policy
53.4
46.0
0.6
Team decision
40.8
58.6
0.6
Evidence base
21.8
77.6
0.6
Reduce length of
stay
9.6
90.2
0.6
Other
12.1
86.8
0.6
Reasons for Hip Dislocation
• Multiple factors e.g. surgical approach, component mal-position and
Soft tissue imbalance (Malik et al, 2002)
Study identified reasons for 24 dislocations following THR: 11
due soft tissue imbalance, 5 malposition of acetabulum implant,
3 exaggerated posterior tilting of pelvis, and 5 multifactorial
(Kawano et al, 2013)
• Higher incidence in posterior approach compared to anterior
(SIGN,2009)
Surgical Approach and Dislocation Rate
Anterior Approach
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Front of the joint
Smaller incision
Muscle splitting approach
Lower dislocation rate
Posterior Approach
• Back of the joint
• Often removes and
reattaches muscle
• Studies suggest posterior
dislocations account for
80-95% of dislocations
(Davenport, 2012)
Advancements in surgical procedure
• The National Joint Registry for England and Wales has
highlighted a statistically significant increase in the use of
femoral head size (>36mm) from 5% 2005 to 26% 2009
(NJR, 2013)
Larger femoral head size ie >36mmreduces risk of
dislocation compared to smaller ie 28mm after THR
(Kostensalo et al (2013)
• The dislocation rate has decreased from 1.25% in 2005
to 0.96% in 2009 (Jameson et al, 2011)
The research summarised…
Lack of robust evidence to support/reject the use of
hip precautions following THR
Limited research into the use of precautions for
revision surgery and for THR in trauma patients
Existing guidelines suggest hip fractures
are unnecessary following hemiarthroplasty
via an anterolateral approach (BOA, 2007)
Lack of direction and
consensus amongst OTs on
the use of hip precautions
(Drummond, 2012)
Occupational therapy for
adults undergoing total hip
replacement: Practice
guidelines
Published in 2012 to guide
OT practice (COT, 2012)
“It is suggested that due to uncertainty
surrounding the need for hip precautions and
the potential for an increase in satisfaction
and early functional independence when hip
precautions are relaxed or discontinued,
occupational therapists engage in local
discussion/review of the emerging evidence
with their surgical and multidisciplinary
teams” (COT, 2012 pg51)
GSTT current practice
• 445 elective and 230 trauma hip replacements in 2013
• Largely use cement-less fixations with ceramic on
ceramic prosthesis
• Range of approaches to suit patient
• OT practice guided by operative note
Impact of removing precautions on OT
practice
Coole et al (2013) looked at OT clinicians
perspectives on relaxing precautions following hip
replacement:
• Relaxing hip precautions would likely benefit
patients i.e. reduced anxiety and LOS
• Concerns over loss of jobs and role for OT
• Some felt it would allow time to treat more to
address other occupations eg work related
Impact on OT role at GSTT
Pre
Assessment
Hospital
Ward
Discharge
home
• Increased clinical reasoning; less prescriptive equipment provision
• Greater need for qualified staff
• ‘Joint school’ patient education
• Occupation focused functional assessment
• Reduced delay due to equipment
• Equipment provision for comfort and safety – 40% increase activity with same
budget
• Rehabilitation on trauma wards within short acute ward LOS
• Introduction of Guys Orthopaedic Outreach Team
• Reduced LOS; 2.7 in elective and 12 in trauma
• Increase from 15% to 60% trauma patients home independent without social
services
Hip precautions and anxiety
“…because I feel
very good now,
the hardest part is
remembering
what I can’t do”
Dave NHS choices
“She's frightened to
death that she won't
cope (can't have a
bath, can't bend
down to put the TV
on etc) and I'm
extremely concerned
about her welfare”
Claire NHS choices
Data Collection at GSTT
• To observe the dislocation rate after 12weeks following
THR, hemiarthroplasty or revision surgery for all trauma
and elective patients
• Recording the surgical approach
• If hip precautions prescribed
• Phone call at 12 weeks
Preliminary Data
• 1.6% of elective and 4% of trauma patients have been
prescribed hip precautions since data collection began in
April 2013
• Of the 328 patients who have been contacted, two have
dislocated
• Both elective without precautions, one on table and the
other at two weeks post op
• Aim to complete data collection for 400 patients by
August
In conclusion…
• GSTT have found no increase in dislocation rate since
ceasing to implement standard hip precautions in 2011 for
THR, hemiarthroplasty and revision surgery
• Lack of robust evidence to support their use
• Variation in OT practice nationally
• Advice to implement COT practice guidelines
recommendations and speak to MDT re use of hip
precautions in your area
YES!
We think there is a life without hip
precautions
(But it must be consultant lead)
References
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British Orthopaedic Association, British Geriatrics Society. (2007)The Care Of Patients with Fragility fractures.
London: BOA
College of Occupational Therapists, Specialist Section Trauma and Orthopaedics (2012) Occupational Therapy
for adults undergoing total hip replacement: Practice guideline. COT: London
Coole, C., Edwards, C, Brewin, and Drummond A (2013) What do clinicians think about hip precautions following
total hip replacement? The British Journal of Occupational Therapy: London. 76(7 300-307
Drummond A, Coole C, Brewin C, Sinclair E (2012) Hip precautions following primary total hip replacement: a
national survey of current occupational therapy practice. British Journal of Occupational Therapy, 75(4), 164-70.
Davenport, M (2012) Joint Reduction, Hip Dislocation, Posterior, Medscpare Reference: Drugs diseases and
Procedures. Available at www.emedicine.medscape.com Accessed on 01/11/13
Fox, R., Halliday, R., Barnfield, S., Roxburgh, J., Dunford, J and Chesser, T (2011). Hip precautions after
hemiarthroplasty: what is happening in the UK and at what cost? The Royal College of Surgeons of England 93(5)
396-397
Jameson, S., Lees, D., James, P., Serrano-Pedraza, I., Partington, P., Muller, S., Meek, R and Reed, M (2011)
Lower rates of dislocation with increased femoral head size after primary hip replacement: a five year analysis of
NHS patients in England. The Bone and Joint Journal, 93(7) 876-880.
Kawano, S., Sonohata, M., Takayama G., Tsukamoto, M., Kiajima, M and Mawatari, M. Revision Total Hip
Arthroplatsy for recurrent dislocation. The Bone and Joint Journal 2013. vol. 95-B no. SUPP 15 214
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Malik, M, Lovell, M, Jones, M (2002) Patient-related Factors leading to Total hip
Replacement Dislocation: A Case Series. Advances in Physiotherapy: Taylor &
Franics, (4), 85-86
National Joint Registry (2013) National Joint Registry for England Wales and
Northern Ireland 10th Annual Report. Hemel Hempstead: NJR Available at
www.njrcentre.org.uk
NHS Choices Department of Health www.nhs.co.uk/conditiond/Hip-repacement
Accessed on 28/10/13
Restrepo C, Mortazavi SMJ, Brothers B, Parvizi J, Rothman R (2011) Hip
dislocation: are hip precautions necessary in anterior approaches? Clinical
Orthopaedics and Related Research, 469(2), 417– 422.
Scottish Intercollegiate Guidelines Network (2009) Management of hip fracture in
older people. A national clinical guideline Number 111. Edinburgh: SIGN
Stewart, L & McMillan, I (2011) How necessary are hip restrictions for avoiding
dislocation following hemiarthroplasty or total hip arthroplasty in older patients with a
hip fracture? The British journal of Occupational Therapy, 74(3) 110-118
Accelerated Discharge Program - Elective
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Guys Hospital
Primary and revision hip and knee replacements
Redesign of old pathway
Introduction of interdisciplinary extended scope
rehab outreach team (GOOT)
• Aim Discharge day 2 hips, day 3 knees
• Commenced June 2013
Opportunity for change at GSTT
• In 2010
• Previous LOS Hips 5.5 days and knees 6.4
• Pressing need to improve efficiency and patient
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experience.
Wait for surgery 9- 12 months
Predicted 60% increase in throughput with no bed
increase
Make it happen!
Enhanced recovery – difference for all services
GSTT ERP….What changed…..?
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7DW – joint MDT Rota
Mandatory attendance at Pre-op Education Class (hips and knees)
Education Class MDT (Physio, OT & Nursing)
All hips and knees seen by OT in PAC
Written Patient information PAC
Access to electronic patient information – website
OT PAC – home set up and negotiation of having carer stay post
op.
• Guys Orthopaedic Outreach Team (GOOT) input if eligible
• Extended scope – GOOT (Physio, nursing & OT competencies)
Guys Orthopaedic Outreach Team
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Eligibility
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Geographical location
Support at home
Home environment set up
Patient consent
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Eligibility
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Geographical location
Support at home
Home environment set up
Patient consent
GOOT Home Rehab Goals
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Progress Mobility
Stairs
Knee and hip Joint range
Functional transfers
Equipment provision
Wound dressings
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Observations taken each visit, documentation on IPAD Ap.
Outcomes
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1 year later 1000 plus patients through pathway
Fantastic patient feedback
Staff satisfaction improved, greater interest in orthopaedics due to extended
scope
• LOS now Hips GOOT 2.4 NON GOOT 4.4 average all 3.4
Knees GOOT 3.3 and NON GOOT 5.9 average all
• Wait for surgery – 1 week. Contracting other trust wait lists.
GOOT Specific
• Nil SSI or dislocations
• X 1 readmission
• Most don’t need visits – now aiming for day 1 hips and 2 knees. Either
home on time meeting milestones or unwell
Other influencing factors……
• Hip Precautions
• Anesthetic protocols
• GPs educated and giving more accurate
information
• Advancements in surgery technique /
prosthetics