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THA precautions

 
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THA precautions - June 22, 2007 7:16:00 AM   
JSPT

 

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How long do post-THA patients have to observe their precautions?

Assuming a healthy 60-80 y/o who golfs 3 days/week, with no surgical complications? He is 2 years post-op at this point.

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Re: THA precautions - June 22, 2007 8:40:00 AM   
FLAOrthoPT

 

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theoretically for life. which hip and is he right handed or left. For example if he is right handed and right hip, he will be forced in IR on the back swing, easilly corrected by having him ER his right hip in the set up, and if he is left hip you have him ER his left hip to minimize IR on the follow through and even encourage a moving pivot. have him get one of those ball grabbers to fasten to the end of his putter so he doesn't bend over all the way to get the ball out of the cup.

but realistically, if he is in good shape and healthy, i wouldn't worry too too much about it

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Re: THA precautions - June 22, 2007 10:26:00 AM   
garyd

 

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The duration of time the precautions remain in effect is dependent on the type of replacement and the surgeons thoughts. We work (hospital system) with an Ortho who if doing a traditional small diameter femoral head replacement will have precautions for life.

If using a large diameter femoral head, precautions are for 3 months, give or take a little depending on the stability of the joint, strength of surrounding musculature and individuals lifestyle.

Different guidelines for different surgical procedures!!

Gary

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Re: THA precautions - June 22, 2007 11:23:00 AM   
JSPT

 

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Yeah, that's what I've heard as well. However, I've also been told that the only way a new hip could dislocate is if there was a posteriorly directed force through the when it was less than 90 degrees from the trunk.

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Re: THA precautions - June 22, 2007 1:13:00 PM   
buckeye

 

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I recommend asking the surgeon who performed the procedure since there is considerable variability in duration of precautions for THA.

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Re: THA precautions - June 22, 2007 5:24:00 PM   
Nicole Matoushek PT MPH CSHE CEES

 

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If this gentleman really enjoys golfing, it is unlikely he will stop golfing independent of the precautions, even if the surgeon enforces the precautions. Quite possibly referring him to a PT that specializes in golfing biomechanics may be a good solution to ensure his golfing technique does not stress his surgery. I see several of the golfing courses and programs in rehab magazines.

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Re: THA precautions - June 22, 2007 5:54:00 PM   
Tom Reeves DPT ATC

 

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My understanding is that you treat the hip after THA like you do a shoulder after dislocation. If you avoid the "loose packed" position for at least 6 weeks then gradually approach it in funcitonal positions, my opinion, they should be fine. However, you have to clear it with the surgeon before you give the green light.

Food for thought, I tell all of my THA patients that they do not have to follow the precautions when bearing full weight. In other words, if they drop a pencil while sitting, they should not pick it up, however if they stand up, their body weight drives the femoral component into the acetabular component and maintains stability.

The precautions are to prevent dislocations afterall, and 160 pounds of weight is going to keep the hip stabile nicely. Every time you take a step you are adducting your hip across the midline, and every time you sit down you break 90 degrees of flexion.

Do you have your traumatic shoulder dislocations follow precautions forever??

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Re: THA precautions - June 22, 2007 6:33:00 PM   
SJBird55

 

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http://eprints.qut.edu.au/archive/00007153/01/7153.pdf

Factors predisposing to dislocation after primary total hip arthroplasty.
The Journal of Arthroplasty, Volume 17, Issue 3, Pages 282-288
B. Jolles

Clin Orthop Relat Res. 2006 Jun;447:28-33.
Increased surgical volume is associated with lower THA dislocation rates.

Battaglia TC, Mulhall KJ, Brown TE, Saleh KJ.

The presumed correlation between an increasing volume of health care procedures and an improvement in outcomes is sometimes referred to as the practice-makes-perfect effect. Growing interest in outcomes-based research has led to numerous papers examining this relationship for various surgical procedures, including total hip arthroplasty. The results of these studies have important implications for consumers, providers, and healthcare financers. Accordingly, we review the literature to date examining surgeon and hospital volume effects on hip arthroplasty outcomes, with a specific focus on the effects of volume on dislocation. A systemic review of the literature demonstrates a substantial positive association between surgical volumes and improvement in most THA outcomes, including dislocation; that is, increasing surgical volume is associated with lower dislocation rates. This correlation appears to be stronger and is more clearly established for surgeon volumes than it is for hospital volumes.

http://www.asbweb.org/conferences/2001/pdf/001.pdf

http://www.hipsoc.org/openmeet02162002.html

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Re: THA precautions - June 22, 2007 7:15:00 PM   
Dr.Wagner


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I see multiple post arthroplasty hip dislocations a year...sub acute and chronic. ALL of them have been in the standing position and flexing at the hips.
While not a scientific study, I agree with those that state "precautions are essentially for life".
Hip dislocations are NOT fun to put back in...I would like to try and avoid them if I can.

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Re: THA precautions - June 22, 2007 9:31:00 PM   
PTupdate.com


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I got with the "for life" program as well, unless the surgeon tells me/them otherwise

Tom: You note some interesting ideas with regards to stability of the hip with movements, but is there anything research-wise to back that up? I distinctly remember two dislocations that occurred when just "bending to pick something up", and Wags has obviously seen them as well

Duffy

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Re: THA precautions - June 22, 2007 9:38:00 PM   
jma

 

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I also agree with the "life program", unless the surgeon tells the patient otherwise.

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Re: THA precautions - June 22, 2007 10:15:00 PM   
Tom Reeves DPT ATC

 

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No, I don't know of any research, weak on my part. Personally, I haven't seen a dislocation that occurred with weight bearing. We see about 50 THAs per year (I know that does not a study make). I also do almost exclusively functional weight bearing exercise for their rehab. I stop doing SLRs etc . . . once they can get their leg into and out of bed.

Wagner, those dislocations that you have seen, is there a general profile of the person? Are they generally active or not? fittish or unfit? The only dislocations that I have encountered were people who totally ignored the NWB precautions that were instructed and dislocated while getting out of a VW or some such low slung chair or bed.

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Re: THA precautions - June 22, 2007 10:25:00 PM   
PTupdate.com


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Why not do SLR and other open chain exercises? Functional is fine, but does not isolation of specific muscle groups carry over into the functional activity? What if the person has a compensation strategy that inhibits a certain muscle group, which ends up being neglected if not isolated?

Don't offensive linemen work on bench and triceps seperately, which carry over into offensive blocking? Don't WR's work on specific leg musculature which carries over into their performance on the field?

Duffy

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Re: THA precautions - June 23, 2007 7:58:00 AM   
Jon Newman

 

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I've seen/met many folks with hip dislocations. Some were chronic and some were first timers. I can remember two that were drying feet/ankles after a shower(standing), two during sex (I didn't have the guts to ask position), and one getting up from sitting to yell "BINGO" after winning.

I know a physician that recommends that patients keep their hips abducted as much as possible when flexing at the hips as this provides some biomechanical protection of the joint.

I think the safest course of action (for the therapist for sure) is to refer the patient to the person who placed them on the restrictions in the first place (as has been mentioned by others.)

As long as we're on the topic of dislocations, I've read (if needed I can provide the reference)that hip abduction braces are not effective at preventing further dislocations. My clinical experience has not shed much light on the topic but I'm not surprised by the findings of the article. These braces certainly don't prevent adduction or flexion (but they might provide a reminder) especially with certain body shapes. Compliance is also an issue. It seems that patient behavior in combination with predisposing factors at the hip joint are most important.

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Re: THA precautions - June 24, 2007 8:40:00 AM   
jma

 

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Agree with you on that one. Haven't seen the abduction brace make any difference in the hospital setting and they eventually dislocated the hip again. Of course, I'm talking about those who somehow keep dislocating the hip.

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Re: THA precautions - June 24, 2007 12:48:00 PM   
Tom Reeves DPT ATC

 

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Duffy, It seems that you and I have had this discussion before. My stance on isolated exercise is the same. In my view, it is a relatively inefficient use of my patient's time to do single plane isolated exercise for the hip flexors, then of the abductors, then of the extensors, then of the adductors etc . . .

Once they can lift their leg into and out of bed, I NEVER add load to the ankle. They were not weak before the surgery, they are not "weak" immediately post op, they simply can't activate the hip flexors because of pain inhibition etc . . .

You have seen them on post op day one, unable to lift their leg, then on post op day two they can. You can't tell me that they got stronger, only that their brain found a way around the inhibition.

You also mentioned about offensive linemen doing bench and triceps and yes of course they do and it helps. BUT, they have a bit more time to add those isolated activities. Furthermore, if you were to do a study and compare what activity predicted who would be the better offensive lineman, vertical leap, bench press, 40 time, max squat, power cleans etc . . . you would find bench press at the bottom of the list of effective predictors.

Jon mentioned compliance,I know in a different context, but if I can distill most of the movements that a patient needs to do into a 15-20 minute routine (usually more like 10) then they are infinitely more likely to do it than if it takes 45 minutes.

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Re: THA precautions - June 24, 2007 8:21:00 PM   
Dr.Wagner


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Tom, in regards to your question "Wagner, those dislocations that you have seen, is there a general profile of the person? Are they generally active or not? fittish or unfit? The only dislocations that I have encountered were people who totally ignored the NWB precautions that were instructed and dislocated while getting out of a VW or some such low slung chair or bed."

The dislocations that I see are not fresh arthroplasty's...they are months to YEARS old. As for the type of person, they seem to be 60ish year old men...typical guy.

Relocating a hip is not fun for me or any EP, it is also very expensive for the patient...especially if it requires OR time. Seems pretty reasonable to simply maintain easy precautions for life.

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Re: THA precautions - June 24, 2007 10:55:00 PM   
Tom Reeves DPT ATC

 

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What do you think is the percentage of THAs that actually dislocate? And if they are years old, are they approaching the end of the prosthesis' fixation lifespan? Months old, certainly not but the years old ones I wonder.

My point is that if people disregard the precautions when in weightbearing and follow them in NWB for, lets say, one year, are they more likely to dislocate than those who follow them forever. THEN what is the functional cost to them. IF the percentage is very low (granted we don't know this) it may be worth it to run the risk and play golf.

If you said to me that I could live to 95 years if I gave up bacon, beer, and ice cream but that I would die at 90 by continuing to imbibe those particular delicacies, I would live happily to 90.

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Re: THA precautions - June 24, 2007 10:56:00 PM   
PTupdate.com


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Tom:

1. How is it inefficient use of a patients time?
2. How do you know they weren't weak prior to the surgery?

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RE: Re: THA precautions - July 7, 2007 9:47:20 PM   
Tom Reeves DPT ATC

 

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Sorry it took me so long to reply.  Vacation, then couldn't find the new post button, thanks David.  When I say that it is an inefficient use of the pts time I mean simply that they are less likely to do a 40 minute program than a 20 minute program.  Especially when with weight bearing exercises, you not only work on strengthening targeted muscle groups, but also on the timing of those contractions.  I find the timing of the contractions to be much more immediately useful to the patient.  I tell them that if I had to choose between strong and stupid muscles and weak but smart muscles, the smart ones win.  However, strong and smart are most helpful.  I just don't believe (based upon the lack of correlation between outstanding isokinetic scores and functional tests) that straight plane, isolated muscle exercise translates to improved function.

I don't know that they weren't weak before surgery.  It is likely that they were, or in the case of elective hip replacement, they became so after general relative self limitations in activity (Trendelenburg gait causing an avoidance of G.Med contraction for example)  More commonly, I see mechanical issues that probably had more of a rudimentary role in the gradual failure of the hip articular cartilage.  i.e. leg length discrepancy, bad feet causing excessive loads on one part of the joint etc . . .

If I had a greater n I would do a study.  I am trying to get to the faculties of the Universities where I do clinical teaching to get the students (or faculty) to do research with large groups but haven't had any luck yet.  (I live in a small town, 5300 people, that is 20 miles from the nearest PT school.

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