This document discusses an evaluation of changing practice from routinely using hip precautions after hip replacement surgery to not routinely using them. The evaluation found: 1) Most patients (97.5% of elective and 95% of trauma patients) were not prescribed hip precautions after surgery. 2) The dislocation rate was low at 2% and comparable to other studies, suggesting not using precautions did not negatively impact outcomes. 3) Occupational therapy assessment and equipment provision was still provided based on functional ability rather than precautions. Equipment was used for shorter periods on average. 4) The change coincided with a reduced hospital length of stay, though other factors also contributed to this.

1. Opinion
508 International Journal of Therapy and Rehabilitation, November 2014, Vol 21, No 11
©2014MAHealthcareLtd
OpinionOpinion
Occupational therapy in orthopaedics:
An alternative to hip precautions?
P
rimary total hip replacement
is a general orthopaedic pro-
cedure, with 76 448 surgeries
completed in England
and Wales in 2011 (National Joint
Registry, 2012). Traditional post-
operative dislocation prevention
involves using hip precautions for six
to 12 weeks. These restrict: internal
and external rotation; hip adduction
and abduction; and flexion beyond 90
degrees. Restrepo et al (2011) sug-
gested that the surgical approach, soft
tissue repair and femoral head size
may also contribute to dislocation.
Blom et al (2008) reported a 3.4%
dislocation rate following total hip
replacement, of which 77.3% occurred
within the first 12 weeks. Others sug-
gest a dislocation rate closer to 6%
(Paterno et al, 1997), occurring within
the first three months post-surgery.
This early dislocation rate supports the
traditional use of hip precautions.
Despite occupational therapists
having a recognised role following
elective hip surgery (British
Orthopaedic Association (BOA),
2006), the use of hip precautions
varies, with practice being guided by
local policies and protocols (College
of Occupational Therapists (COT),
2012). Occupational therapists can
advise on performing activities
safely while avoiding movements
and maintaining hip precautions
through the use of equipment. More
than a decade ago, McMurray et al
(2000) reported national variations
in occupational therapy practice
following hip surgery; as a result,
controversy exists about whether
hip precautions are used routinely.
Recognising this inconsistency, the
COT (2012) has highlighted the need
for practice guidelines in this area.
An alternative service
The BOA (2006) no longer requires
hip precautions for hemiarthroplasty
surgery completed using an anterior
lateral approach. However, uncertainty
remains as to whether precautions are
an essential aspect of postoperative
dislocation prevention, particularly for
primary and revision surgery. There is
a lack of robust research supporting
the use of precautions upon which to
build an evidence base.
In March 2011, a revised orthopae-
dic pathway was instigated, which
included a consultant-led decision
to terminate the use of routine hip
precautions. This decision had an
impact on the entire multidisciplinary
team, requiring careful communica-
tion from all disciplines to ensure
patients received accurate and con-
sistent information. The removal of
hip precautions, which had previously
been standard practice with this client
group, has had an impact on equip-
ment provision and how activities
of daily living are carried out; how-
ever, postoperative pain and fatigue
continue to be limiting factors for
patients recovering from hip surgery.
This article is a report on how the
use of hip precautions influenced an
occupational therapy and orthopaedic
service. This development in service
differs from standard practice
throughout the UK, and allows
opportunity for discussion on the
controversial issue of hip precautions.
Reviewing a change in service
All patients who received total hip
replacement, revision hip replacement
or hemiarthroplasty surgery in trauma
and elective wards between April and
October 2013 were included in the
service evaluation, which underpins
the discusison of this opinion piece.
The inclusion and exclusion criteria
related solely to the dates of surgery,
with all patients within the specified
timescale being included and all
patients whose surgery occurred
before and after being excluded.
A convenience sample of patients
(n=100) was recruited from the
181 patients undergoing elective and
65 undergoing post-traumatic hip
surgery. The data from all patients
who were not available when
contacted at 12 weeks were removed;
this left 80 elective and 20 post-
trauma participants. The average age
for the elective patients was 60 years,
and 78 years for the trauma patients.
Seventy-eight (97.5%) of the elective
and 19 (95%) of the trauma patients
did not use hip precautions (Figure 1).
After 12 weeks, a structured telephone
interview was conducted by therapists.
Following an explanation on the use
of the data for influencing local and
national practice, participation in the
survey was taken as implied consent.
The study documented whether
adaptive equipment was provided, how
long this was used for and whether hip
dislocation occurred.
No precautions, no impact?
Dislocation rate
Two dislocations (2%) were reported,
potentially implying the non-use
of hip precautions did not influence
dislocation rate (Table 1). This dis-
location rate is lower than the 3.4%
reported by Blom et al (2008), one
of the largest multi-surgeon audits of
dislocation in the UK, although this
included a greater sample size.
One dislocation occurred before
the patient returned to the ward
post-surgery, and was subsequently
prescribed hip precautions. The
Scottish Intercollegiate Guidelines
Network (SIGN) (2009) and Blom
(2008) described a higher dislocation
Table 1. Analysis of dislocations for
elective total hip replacement surgery
Precautions used Surgical approach
No Posterior
Yes Antero-lateral
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2. ©2014MAHealthcareLtd
International Journal of Therapy and Rehabilitation, November 2014, Vol 21, No 11 509
rate associated with using a posterior
surgical approach. Such a finding was
not observed in this evaluation, and is
likely due to surgical advancements
using the posterior transosseous
capsular tendinous repair technique.
This method is routinely used in the
evaluated service and has been shown
to provide superior stability of joint
replacement and, consequently, a
lower dislocation rate than traditional
posterior approaches (Sioen et al,
2002). Both dislocations occurred
following total hip replacement,
which SIGN (2009) has suggested as
having a higher dislocation rate than
hemiarthroplasty.
Reduced equipment use
Equipment can be issued by occupa-
tional therapists to assist with main-
taining hip precautions post-surgery;
for example, raising furniture to
ensure a 90-degree angle is main-
tained when seated and to promote
functional independence. Coole et al
(2013) highlighted a concern from
some therapists that the occupational
therapists’ role might be reduced with
this client group if precautions were
relaxed. However, since the removal
of routine hip precautions in 2011,
the therapist’s rationale for equip-
ment provision has mainly been
based on postoperative pain manage-
ment and functional ability. Despite
not using hip precautions, all patients
received occupational therapy assess-
ment and 89% required equipment
provision to facilitate independence
and a safe discharge (Figure 2).
Precautions may impede recovery
by imposing non-essential restrictions
on occupational performance, thus
disabling patients and creating
dependence on equipment or carers.
Issuing equipment to address
occupational need rather than hip
precaution requirements facilitates
a quicker transition back to baseline
without the use of equipment
(Figure 3). Hip precautions are
traditionally maintained between
six and 12 weeks following surgery;
however, in this study, elective
patients used equipment for a shorter
period on average. Trauma patients
had a higher average age than that of
the elective group, which accounts
for the longer duration of use of
equipment as an older individual may
have a slower recovery from surgery.
Reduced length of stay
A notable change that coincided with
the removal of standard hip precau-
tions, but is not solely attributable to
it, has been a reduction in the length
of stay of elective patients. The length
of stay was reduced from 7.1 days in
2010/11 to 3.9 days in 2012/13, reflect-
ing an average cost saving of £183 per
day in terms of bed day costs.
Surgical and anaesthetic advance-
ments, as well as improved pre-
operative preparation, contributed
to achieving an accelerated and cost-
effective rehabilitation programme.
The reduced length of stay has required
occupational therapists to predict func-
tional outcomes and equipment needs
in order for the home environment to
be set up before surgery. This method
of practice requires a higher level of
clinical reasoning as the ‘prescriptive’
issuing of equipment is removed along
with precautions, adding value to the
profession’s role. Therapists working in
a service without precautions can dis-
cuss returning to activities without the
use of adaptive equipment at an earlier
stage due to the allowance for greater
range of movement and function.
Results and discussion
No detrimental effects from relaxing
the use of hip precautions were high-
lighted by this study, suggesting that
the non-routine use of hip precautions
was a safe method of practice in this
service. This development has enabled
occupational therapy interventions to
become more individualised, facili-
tating regained joint range and func-
tional independence at an earlier stage.
Occupational therapy assessment was
still required due to the pain, joint
stiffness and initial reduced function
associated with major surgery.
Additionally, as the reduction in
length of stay required patients to be
discharged from hospital as early as
day one post-surgery, occupational
therapists helped to facilitate a
smooth transition back to the home,
educating patients and their carers
on maintaining independence during
postoperative recovery.
Limitations
Not all patients were willing or able
to respond, and recall bias may have
influenced the findings as patients
were questioned 12 weeks after
surgery. In some cases, third party
data was provided where patients
could not answer themselves either
due to sensory or cognitive deficits.
This information reflects a small
Elective Trauma
Number of patients prescribed precautions
90
80
70
60
50
40
30
20
10
0
n Yes
n No
Equipment provided following surgery
n Yes
n No11%
89%
Figure 1. Precaution prescription
Figure 2. Equipment required and issued
following hip surgery
Elective Trauma
Average number of weeks equipment
used following surgery
10
9
8
7
6
5
4
3
2
1
0
5.8
8.7
Figure 3. Number of weeks of equipment
use following hip surgery
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3. Opinion
510 International Journal of Therapy and Rehabilitation, November 2014, Vol 21, No 11
©2014MAHealthcareLtd
sample, looking at only one service
where the change in practice was
consultant-led and filtered to therapy
and the wider multidisciplinary
team. This study offers an opinion
that the current service without hip
precautions is a safe one. However,
it can only stimulate discussion for
other services and professionals, and
does not provide a standard that can
be directly replicated.
Conclusions
The use of hip precautions is a
controversial topic, with varying
practice across the UK. This service
evaluation suggests a consultant-led
removal of routine hip precautions
can be a safe method of practice
and provides a continuing role for
occupational therapists. Following on
from this, more robust information
is needed in order to draw reliable
conclusions for changing future
practice elsewhere. In light of these
findings, services are invited to
evaluate their practice and discuss the
need for precautions locally. IJTR
British Orthopaedic Association (2006)
Primary Total Hip Replacement: A Guide
to Good Practice. http://almacen-gpc.
dynalias.org/publico/Total%20Hip%20
R e p l a c e m e n t % 2 0 B OA % 2 0 2 0 0 7 . p d f
(accessed 28 October 2014)
Blom AW, Rogers M, Taylor AH, Pattison
G, Whitehouse S, Bannister GC (2008)
Dislocation following total hip replacement:
the avon orthopaedic centre experience.
Ann R Coll Surg Engl 90(8): 658–62. doi:
10.1308/003588408X318156
College of Occupational Therapists (2012)
Occupational Therapy for Adults
Understanding Total Hip Replacement:
Practice Guideline. http://www.cot.co.uk/sites/
default/files/general/public/P171-Total-Hip-
Replacement.pdf (accessed 28 October 2014)
Coole C, Edwards C, Brewin C, Drummond,
A (2013) What do clinicians think about hip
precautions following total hip replacement?
Br J Occup Ther 76(7): 300–7
McMurray R, Heaton J, Sloper P, Nettleton S
(2000) Variations in the provision of occu-
pational therapy for patients undergoing pri-
mary elective total hip replacement in the
United Kingdom. Br J Occup Ther 63(9):
451–5
National Joint Registry (2012) 10th Annual
Report 2013. National Joint Registry for
England, Wales and Northern Ireland. http://
www.njrcentre.org.uk/njrcentre/Portals/0/
Documents/England/Reports/10th_annual_
r e p o r t / N J R % 2 0 1 0 t h % 2 0 A n n u a l % 2 0
Report%202013%20B.pdf (accessed
28 October 2014)
Paterno SA, Lachiewicz PF, Kelley SS (1997)
The influence of patient-related factors and
the position of the acetabular component on
the rate of dislocation after total hip replace-
ment. J Bone Joint Surg Am 79(8): 1202–10
Restrepo C, Mortazavi SM, Brothers J, Parvizi
J, Rothman RH (2011) Hip dislocation:
are hip precautions necessary in anterior
approaches? Clin Orthop Relat Res 469(2):
417–22. doi: 10.1007/s11999-010-1668-y
Scottish Intercollegiate Guidelines Network
(2009) Management of Hip Fracture in Older
People. A National Clinical Guideline. SIGN
guideline 111. http://www.sign.ac.uk/pdf/
sign111.pdf (accessed 28 October 2014)
Sioen W, Simon JP, Labey L, Van Audekercke
R (2002) Posterior transosseous capsulo-
tendinous repair in total hip arthroplasty:
a cadaver study. J Bone Joint Surg Am
84-A(10): 1793–8
Leona McQuaid is a specialist occupational
therapist at Guy’s and St Thomas’ NHS
Foundation Trust, UK;
Jade Cope is a clinical specialist occupational
therapist at Guy’s and St Thomas’ NHS
Foundation Trust, UK;
Anne Fenech is an international fellow in
recreation and leisure at the University of
Southampton, UK.
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