Hip Precautions

Issues of Concern

Several surgical approaches to total hip arthroplasty have been described in the literature: 

Posterolateral

The posterolateral approach is the most commonly used approach for primary and revision total hip arthroplasty. This dissection does not use a true internervous plane. The intermuscular interval involves blunt dissection of the gluteus maximus fibers and sharp incision of the fascia lata distally. The deep dissection involves meticulous release of the short external rotators and joint capsule. Clinicians carefully protect these structures because they are subsequently repaired to the proximal femur through transosseous tunnels.

A major advantage of this approach is preservation of the hip abductors. Other benefits include excellent exposure of both the acetabulum and femur and the option for proximal or distal extensile conversion. Historically, results from some studies comparing this approach with the direct anterior approach showed higher dislocation rates with the posterolateral approach. However, the findings remain inconclusive and controversial because the literature has not established a definitive consensus, particularly when the posterior approach includes optimal soft tissue repair at the completion of total hip arthroplasty.[3]

Direct Anterior 

The direct anterior approach is becoming increasingly popular among surgeons who perform total hip arthroplasty. The superficial internervous interval is between the tensor fasciae latae and sartorius, whereas the deep interval is between the gluteus medius and rectus femoris. Advocates of direct anterior total hip arthroplasty cite theoretically lower postoperative hip dislocation rates and preservation of the hip abductor musculature.

The disadvantages include a substantial learning curve, with results from the literature showing lower complication rates only after a surgeon has performed more than 100 procedures. Other disadvantages include increased wound complications, particularly in patients with obesity and a large pannus when an abdominal binder is not used, difficult femoral exposure, the risk of lateral femoral cutaneous nerve paresthesia, and a potentially higher rate of intraoperative femoral fractures. Finally, many surgeons require access to a specialized operating table and appropriately trained personnel and surgical technicians to assist with the procedure. Although a specialized table is not always necessary, performing the procedure on a standard operating table also involves a substantial learning curve.

Anterolateral

Compared with the other approaches, the anterolateral approach is the least commonly used because it disrupts the hip abductor mechanism. The surgical interval lies between the tensor fasciae latae and gluteus medius musculature. Disruption of this interval may contribute to a postoperative limp, although the approach may theoretically reduce the dislocation rate.

Hip Precautions

Hip precautions were created to theoretically reduce the risk of early total hip arthroplasty dislocation. These protocols standardize positions that place the hip at risk after total hip arthroplasty and tailor the restrictions to the surgeon’s specific technique and approach. The overall clinical efficacy remains controversial and uncertain throughout the literature. Moreover, results from reports indicated that some patients received instructions about these protocols but did not adhere to the postoperative restrictions.[5]

Most institutions implement a general preoperative and postoperative patient education component that often incorporates hip precaution protocols. Nurses, physical therapists, or clinicians typically provide the education. Patients receive verbal instruction and, in some cases, videos that demonstrate hip precautions and body movements to avoid after the surgical procedure. Patients also frequently receive paper handouts that list precautions, illustrate prohibited movements, and describe safer alternative movements. Supervised mobility training is also commonly provided. The primary movements to avoid are hip adduction, hip flexion, and external or internal rotation. These precautions are often prescribed for at least 6 weeks or until the soft tissue surrounding the hip has at least partially healed.[6]

Trends in Implementation

Results from a 2018 electronic survey of American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society members showed that 44% of surgeons universally prescribed precautions, whereas approximately one-third never prescribed them. Use of the posterior approach for total hip arthroplasty was significantly associated with implementation of postoperative hip precautions.[7]

Examples of hip precautions include but are not limited to:

Posterior Approach Total Hip Arthroplasty Precautions

• Provocative position: hip flexion, adduction, internal rotation
  • Do not bend the hip more than 90°
  • Do not cross legs or feet
  • Do not roll or lie on your unoperated side for the first 6 weeks
  • Do not twist the upper body when standing
  • Sleep on the back for the first 6 weeks
  • The patient may benefit from a shower chair or elevated seat for home use
  • Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub)
  • Use aids to put on underwear/socks/shoes for 6 weeks to avoid deep hip flexion angles

Anterior Approach Total Hip Arthroplasty Precautions

• Provocative position: hip extension, external rotation

Various assistive devices can help patients adhere to newly prescribed hip precautions. Some patients purchase raised toilet seats and chairs to prevent hip flexion beyond 90°. Sock aids and dressing sticks are often used to simplify dressing and changing clothes. Reachers or grasping devices can help patients retrieve items from the floor or other areas without violating hip precautions. Environmental modifications can also reduce the risk of hip dislocation. Recommended changes include removing tripping hazards, rearranging furniture to minimize turning, and installing grab rails throughout the home.[6]

Adherence to hip precautions can be challenging. Many previously simple activities become more complicated, and activities of daily living may be significantly affected. Affected activities include bathing, grooming, dressing, toileting, and transferring. Loss of independence may leave patients distressed or discouraged, which can further reduce adherence.[8] Additionally, the restrictions may cause discomfort and frustration.

Clinical Significance

The incidence of hip dislocation following primary total hip arthroplasty ranges from 2% to 10%.[4] Furthermore, revision hip arthroplasty significantly increases the risk of postoperative dislocation, with results from some reports showing dislocation rates approaching 28%. Approximately 70% of total hip arthroplasty dislocations occur within the first year after the surgical procedure, and revision arthroplasty is often required after 2 or more dislocation events.

Risk Factors for THA Dislocation

Risk factors include:

• Prior hip surgery (the most significant independent risk factor for dislocation)
• Advanced age (older than 70 years)
• Component malpositioning: Excessive anteversion results in anterior dislocation, and excessive retroversion results in posterior dislocation
• Neuromuscular disorders such as Parkinson disease
• Drug or alcohol use disorders

Nursing, Allied Health, and Interprofessional Team Interventions

Clinicians and other healthcare professionals, including specialists, nurses, and physical therapists, who care for patients undergoing hip arthroplasty should understand preoperative and postoperative hip precautions. These precautions are designed to reduce the risk of complications and support healing and functional recovery after arthroplasty procedures. Clear interprofessional communication and coordinated patient education can improve adherence, strengthen counseling, and enhance clinical outcomes.