An Update on Hip
Precautions following
Elective Surgery
.
Avril Drummond
University of Nottingham
Three parts
1.
National survey of occupational therapy
2.
Interviews with key staff
3.
Evaluation of hip literature for patients
1. National survey
Question
What is routine practice in occupational
therapy in advising on hip precautions
following THR?
Hip precautions following PRIMARY total hip
replacement; a national survey of current
occupational therapy practice.
Drummond A, Coole C, Brewin C & Sinclair E.
British Journal of Occupational Therapy 2012;
75(4) 164-170.
Movements to avoid
flexion (173; 99%),
 adduction (166; 95%)
 internal/external rotation (156; 90%)
 other movements to avoid (14%) as twisting [13
respondents], certain sleeping positions [5],
crossing legs [4], bending [2], sitting on low
furniture [2], active abduction [1], stretching [1],
lifting [1] and driving [1].

Activities discussed
The most common activities discussed were
 kitchen activities (163; 94 %),
 bath/shower transfers (161; 93%),
 car transfers (160; 92%),
 strip washing (159; 91%)
 dressing techniques (140; 82%)
Activities practised
The most common activities practised
were;
 bed transfers (169; 97%),
 chair transfers (167; 96%),
 toilet transfers (165; 95%),
 and dressing practise (144; 83%).
Time precautions observed
Many occupational
therapists supplied a range
of time; responses reflect
this and varied from 6 to
over 12 weeks.
The majority of OTs
recommended precautions
were followed for 12 weeks
post op (84: 48 %).
Why does your service/department teach
hip precautions?
Response
Yes n (%)
No n (%)
Missing n (%)
Surgical
approach
Surgical
opinion
Hospital
policy
OT
policy
74 (42.5)
99 (56.9)
1 (0.6)
126 (72.4)
47 (27)
1 (0.6)
50 (28.7)
123 (70.7)
1 (0.6)
93 (53.4)
80 (46)
1 (0.6)
Team
decision
Evidence
base
Reduce LOS
71 (40.8)
102 (58.6)
1 (0.6)
38 (21.8)
135 (77.6)
1 (0.6)
16 (9.6)
21 (12.1)
157 (90.2)
151 (86.8)
1 (0.6)
1 (0.6)
Other
2. Staff interviews
The purpose of this study was to report the
views and experiences of clinicians on the
use of hip precautions by occupational
therapists.


16 semi-structured telephone interviews with
surgeons, nurses and therapists. (6 regions; 4
using precautions; 6 occupational therapists, 4
orthopaedic surgeons, 3 physiotherapists and 3
nurses)
Data was analysed thematically.
Themes



the rationale, and disadvantages of, routine hip
precautions;
the barriers and facilitators to relaxing hip
precautions;
the contextual factors of service change and
support for further research.
Hip precautions- what do the clinicians
think?
Submitted and under review
Rationale
“You need the posterior capsule to try to repair
up, so there is a little bit of logic in not wanting to
stress the posterior capsule, which is – sort of
worse in flexion, internal rotation, until the
piriformis heals up… so there is some logic in
restricting their movement early on, trying to get
some soft tissue, to tether down”
(168, surgeon)
Historical reasons
“…..and although procedures have moved
forward, we’ve stuck to exactly the same postoperative routines with them”
(163, nurse)
Negative aspects
“I think if you’re telling them don’t do this don’t
do that…we’d often have patients sat there doing
nothing, and it’s not good for them. I think we
treated them still as an invalid”
(163, nurse)
Equipment
“We did a bit of a survey and I think about 25% of
the equipment never got touched and that’s a lot
of money and it’s a bit of a waste of time”.
(172, occupational therapist)
Change
“I’m sure changing physios’ mind-set would be
vastly easier than changing senior consultants’
mind-set, and I suspect OTs are on the whole a
very sensible bunch, so I suspect if you gave them
the rationale for change, I think they’d probably be
happy to change as well”
(168, surgeon)
3. Patient literature
Aim
To analyse the literature provided to patients after
elective hip surgery in the UK
What do we tell patients after their elective
total hip replacement in the UK?
Paper submitted and under review.
Three areas
A.
B.
C.
Accessibility of information to a lay
audience.
Scope of information.
Specific activities of daily living (ADLs)
presented.
Results
 121
leaflets / information booklets examined.
 10 excluded; 9 were duplicates, 1 not specific to
hip replacement.
 10 further leaflets were noted to be paired with
one or more other documents (a total of 21
leaflets).
A. Accessibility of information
to a lay audience.
Checklist
Everyday language
 Overall size
 Overall lay out
 Typeface
 Diagrams
 Patient
involvement

Person/department
 Contact details
 Language help
 Space for notes
 Referenced
statements

A. Accessibility of information
to a lay audience.

The shortest publication was a single side of
paper and the longest was a 50 page booklet.

The overall scores ranged from 13% to 83%
(mean 45%; SD 15).
The highest total score was 83%,
followed by 71%.






clear text
useful diagrams
headings including clear title
logical order
contact details for help, guidance for obtaining
copies in another language or Braille.
one had space for own notes
Lowest score was 13% ( 2)




one and two pages long respectively
poor quality diagram in each.
one had handwritten text inserted on the final
copy- which was difficult to read.
title of one was ‘Precautions’ and it was not
initially clear that this referred to hip
precautions.
B. Scope of information.



49 (44%) described the actual operation,
39 (35 %) advice on pre-operative care
40 (36 %) covered medical aspects such as pain
relief, complications e.g. DVT, wound infection.
Scope of information.






49 (44%) described the actual operation,
39 (35 %) advice on pre-operative care
40 (36 %) covered medical aspects such as pain
relief, complications eg DVT, wound infection.
46 (41 %) advice on general health issues e.g.
keeping fit before and after surgery,
44 (40 %) included specific exercises
109 ( 98 %) generic advice on hip precautions such as not bending or twisting.
C. Specific activities of daily
living (ADLs) presented.
Activities
Sitting
Bathing
Driving a car
Sleeping
Dressing/ undressing
Being a (car) passenger
Using the toilet
General domestic activities
Modifying the home environment
Sex
Bed transfers
Stairs
Leisure
Walking
Social support
Bending down/ picking something
up from the floor
Work
No n (%)
12
(11)
Yes n (%)
99
(89)
24
(22)
87
(78)
26
(23)
85
(77)
27
(24)
84
(76)
29
(26)
82
(74)
29
(26)
82
(74)
39
(35)
72
(65)
41
(37)
70
(63)
47
(42)
64
(58)
49
(44)
62
(56)
51
(46)
60
(54)
62
(56)
49
(44)
65
(59)
46
(44)
66
(60)
45
(41)
69
(62)
42
(38)
81
(73)
30
(27)
85
(77)
26
(23)
Messages

National picture- variations even regionally in
activities taught and practised and in time
recommendations.

Differing opinions on hip precautions

Literature produced- range in scope and quality
Hip studies/trials to date

No control or inadequate comparator

Under powered

Outcome of hip dislocation at expense of
patient satisfaction, pain, quality of life, function,
mood.
Bigger question is still- do we
need hip precautions?