Hip Precautions After Hemiarthroplasty
Hip precautions are not necessary after hemiarthroplasty for hip fracture when performed through an anterolateral or direct lateral approach, as they do not reduce dislocation rates and may delay functional recovery.
Evidence-Based Approach to Hip Precautions
No Precautions Protocol (Recommended)
The current evidence strongly supports eliminating traditional hip precautions after hemiarthroplasty:
- Dislocation rates remain extremely low (0.15-0.33%) without precautions when anterolateral or direct lateral approaches are used 1, 2, 3
- A cluster-randomized study of 394 hemiarthroplasty patients found identical dislocation rates (one patient in each group) whether precautions were used or not 1
- Patients without restrictions achieve faster return to daily functions, higher satisfaction with recovery pace, and earlier return to work 2
Surgical Approach Considerations
The surgical approach is the critical determinant for precaution decisions:
- The American Academy of Orthopaedic Surgeons states that current evidence does not show outcome differences between surgical approaches in the general population 4
- However, in high-risk patients with neurological or cognitive impairment, the posterior approach may carry increased dislocation risk, and surgeons should consider alternative approaches 4
- When the direct lateral or anterolateral approach is used, meticulous capsular repair minimizes dislocation risk, making precautions unnecessary 4
What to Avoid Teaching Patients
Do not prescribe the following traditional restrictions:
- Elevated toilet seats and elevated chairs 1, 2
- Abduction pillows while in bed 2
- Restrictions on side-sleeping 2
- Restrictions on driving or being a passenger in automobiles 2
- Mandatory assistive equipment 1
Benefits of Eliminating Precautions
Removing restrictions provides measurable advantages:
- Patients return to side-sleeping sooner (p < 0.001) 2
- Patients ride in and drive automobiles more often (p < 0.026 and p < 0.001) 2
- Patients return to work sooner (p < 0.001) 2
- Higher patient satisfaction with recovery pace (p < 0.001) 2
- Cost savings of approximately $655 per patient 2
- Significantly shorter work effort required from rehabilitation personnel during hospital stay (p < 0.001) 1
Critical Caveat: Posterior Approach Exception
If a posterior approach was used in a high-risk patient (neurological impairment, cognitive dysfunction, or dementia), consider maintaining precautions as this population may have elevated dislocation risk 4. However, the evidence base for this is limited, and the general principle of no precautions still applies to most patients.
What to Actually Teach Patients
Focus education on:
- Early mobilization with weight-bearing as tolerated to reduce DVT risk and improve functional recovery 4, 5
- Recognition of dislocation symptoms (sudden pain, inability to bear weight, leg length discrepancy, abnormal rotation)
- Importance of interdisciplinary care programs involving orthopedics, geriatrics, and physical therapy 6, 5
Quality of Evidence Note
The systematic review examining 6,900 THA patients found no statistically significant difference in dislocation rates between restricted (2.2%) and unrestricted (2.0%) groups 7. While this evidence comes from THA rather than hemiarthroplasty specifically, the hemiarthroplasty-specific studies demonstrate even lower dislocation rates without precautions 1, 2.