What are the recommended hip precautions and management strategies post Total Hip Arthroplasty (THA)?

Hip Precautions Post Total Hip Arthroplasty

Hip precautions are not necessary after posterior approach THA when adequate intraoperative stability is achieved and meticulous soft-tissue repair is performed, as eliminating precautions does not increase dislocation rates and may improve patient satisfaction.

Evidence Against Routine Hip Precautions

The most compelling evidence comes from recent high-quality studies demonstrating safety without precautions:

• Patients achieving 90° flexion with 45° internal rotation at 0° adduction intraoperatively had zero dislocations when precautions were eliminated (0/172), while the precautions group had 4 dislocations (4/174,2.29%) 1

• Minimal precautions protocols show no increased dislocation risk - one prospective study found zero dislocations in the unrestricted group versus one dislocation in the restricted group (p=0.32) 2

• A systematic review of 6,900 patients found no statistical difference in dislocation rates between restricted (2.2%) and unrestricted (2.0%) groups 3

• Shortening precautions from 6 to 4 weeks resulted in only 1% dislocation rate, with 75% of dislocations occurring after the 4-week period anyway 4

Recommended Approach Algorithm

For Posterior Approach THA:

If intraoperative stability criteria met (90°/45°/0°):

• No hip precautions required 1
• Use femoral head diameter ≥28mm 2
• Ensure meticulous posterior soft-tissue repair 4, 2

If intraoperative stability NOT achieved:

• Consider minimal precautions for 4 weeks maximum 4
• Avoid extreme flexion >90°, adduction past midline, and internal rotation 5

Equipment prescription:

• Not routinely necessary when precautions are eliminated 2
• Very low quality evidence suggests patients are more satisfied without equipment restrictions (NNTB=7) 5

Key Technical Requirements

The safety of eliminating precautions depends on:

• Meticulous posterior soft-tissue repair - this is non-negotiable 4, 2
• Adequate femoral head size (28-36mm) 4, 2
• Confirmed intraoperative stability testing at 90° flexion, 45° internal rotation, 0° adduction 1
• Experienced surgeon using standardized posterior approach 2

Pain Management Protocol

Focus should shift from mechanical precautions to optimal analgesia for early mobilization:

Preoperative/Intraoperative:

• Paracetamol plus NSAIDs or COX-2 inhibitors 6
• Intravenous dexamethasone 8-10mg 6
• Fascia iliaca block or local infiltration analgesia 6

Postoperative:

• Continue paracetamol and NSAIDs/COX-2 inhibitors 6
• Opioids as rescue only 6
• Avoid femoral nerve blocks, lumbar plexus blocks, and epidural analgesia due to adverse effects outweighing benefits 6

Common Pitfalls to Avoid

• Do not prescribe routine equipment (raised toilet seats, chairs) as very low quality evidence shows no benefit and may reduce patient satisfaction 5

• Do not extend precautions beyond 4 weeks - most dislocations occur after this period regardless 4

• Do not use precautions as substitute for proper surgical technique - soft-tissue repair quality is more important than postoperative restrictions 4, 2

• Surgical approach has minimal impact on pain compared to analgesic regimen, so approach selection should not be based primarily on pain considerations 7

Patient Education Focus

Rather than restrictive precautions, emphasize:

• Early mobilization facilitated by optimal multimodal analgesia 6
• Preoperative exercise and education (Grade A recommendation) 6
• Functional reintegration rather than activity avoidance 5