Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients


  • Christoffer B Korfitsen Danish Health Authority, Evidence-based Medicine, Copenhagen; Cochrane Denmark & Centre for Evidence-Based Medicine Odense (CEBMO), Department of Clinical Research, University of Southern Denmark; Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense https://orcid.org/0000-0003-2159-7662
  • Lone R Mikkelsen Department of Clinical Medicine, Aarhus University; Elective Surgery Centre, Silkeborg Regional Hospital https://orcid.org/0000-0003-3540-7874
  • Marie-Louise Mikkelsen Danish Health Authority, Evidence-based Medicine, Copenhagen
  • Jeanett F Rohde Danish Health Authority, Evidence-based Medicine, Copenhagen; The Parker Institute, Bispebjerg and Frederiksberg Hospital, Capital Region, Frederiksberg
  • Pætur M Holm The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse- Ringsted Hospitals; The Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark
  • Simon Tarp Danish Health Authority, Evidence-based Medicine, Copenhagen https://orcid.org/0000-0001-5254-6580
  • Holger-Henning F Carlsen Særslev Medical Center, Søndersø
  • Kirsten Birkefoss Danish Health Authority, Evidence-based Medicine, Copenhagen
  • Thomas Jakobsen Department of Orthopaedics, Aalborg University Hospital
  • Erik Poulsen Department of Sports Science and Clinical Biomechanics, University of Southern Denmark https://orcid.org/0000-0002-3837-5452
  • Jane S Leonhardt Department of Orthopedics, Lillebaelt Hospital, Vejle
  • Søren Overgaard Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg; University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Sciences https://orcid.org/0000-0001-6829-4787
  • Inger Mechlenburg Department of Clinical Medicine, Aarhus University; Department of Public Health, Aarhus University; Department of Orthopaedics, Aarhus University Hospital, Denmark https://orcid.org/0000-0001-5432-8691




Hip, Meta-analysis, Movement precautions, Osteoarthritis, Systematic review, Total hip arthroplasty


Background and purpose: Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.
Materials and methods: We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.
Results: 4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6–5.2; NRS: RR 0.9, CI 0.3–2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).
Conclusion: The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.


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Hermansen L L, Viberg B, Hansen L, Overgaard S. “True” cumulative incidence of and risk factors for hip dislocation within 2 years after primary total hip arthroplasty due to osteoarthritis: a nationwide population-based study from the Danish Hip Arthroplasty Register. J Bone Jt Surg 2021; 103(4): 295-302. doi: 10.2106/JBJS.19.01352. DOI: https://doi.org/10.2106/JBJS.19.01352

Hermansen L L, Viberg B, Overgaard S. Patient-reported outcome after dislocation of primary total hip arthroplasties: a cross-sectional study derived from the Danish Hip Arthroplasty Register. Acta Orthop 2022; 93: 29-36. doi: 10.1080/17453674.2021.1983973. DOI: https://doi.org/10.1080/17453674.2021.1983973

Mechlenburg I, Knak J, Mosegaard S B, Axelsen M, Krarup Jensen N, Hansen T B, et al. Effectiveness of a bandage to prevent re-dislocation after total hip arthroplasty in patients with a previous hip dislocation: a randomized controlled trial with 12-week follow-up. Clin Rehabil 2022; 36(6): 767-75. doi: 10.1177/02692155221081462. DOI: https://doi.org/10.1177/02692155221081462

Hermansen L L, Viberg B, Overgaard S. Large hospital variation in the risk of dislocation after primary total hip arthroplasty for primary osteoarthritis: 31,105 patients in 59 hospitals from the Danish Hip Arthroplasty Register. Acta Orthop 2022; 93: 503-8. doi: 10.2340/17453674.2022.2754. DOI: https://doi.org/10.2340/17453674.2022.2754

Kunutsor S K, Barrett M C, Beswick A D, Judge A, Blom A W, Wylde V, et al. Risk factors for dislocation after primary total hip replacement: a systematic review and meta-analysis of 125 studies involving approximately five million hip replacements. Lancet Rheumatol 2019; 1(2): e111-21. doi: 10.1016/S2665-9913(19)30045-1. DOI: https://doi.org/10.1016/S2665-9913(19)30045-1

Skoogh O, Tsikandylakis G, Mohaddes M, Nemes S, Odin D, Grant P, et al. Contemporary posterior surgical approach in total hip replacement: still more reoperations due to dislocation compared with direct lateral approach? An observational study of the Swedish Hip Arthroplasty Register including 156,979 hips. Acta Orthop 2019; 90(5): 411-16. doi: 10.1080/17453674.2019.1610269. DOI: https://doi.org/10.1080/17453674.2019.1610269

Rosenlund S, Broeng L, Holsgaard-Larsen A, Jensen C, Overgaard S. Patient-reported outcome after total hip arthroplasty: comparison between lateral and posterior approach. Acta Orthop 2017; 88(3): 239-47. doi: 10.1080/17453674.2017.1291100. DOI: https://doi.org/10.1080/17453674.2017.1291100

Gromov K, Troelsen A, Modaddes M, Rolfson O, Furnes O, Hallan G, et al. Varying but reduced use of postoperative mobilization restrictions after primary total hip arthroplasty in Nordic countries: a questionnaire-based study. Acta Orthop 2019; 90(2): 143-7. doi: 10.1080/17453674.2019.1572291. DOI: https://doi.org/10.1080/17453674.2019.1572291

Smith T O, Sackley C M. UK survey of occupational therapist’s and physiotherapist’s experiences and attitudes towards hip replacement precautions and equipment. BMC Musculoskelet Disord 2016; 17: 228. doi: 10.1186/s12891-016-1092-x. DOI: https://doi.org/10.1186/s12891-016-1092-x

Carli A V, Poitras S, Clohisy J C, Beaulé P E. Variation in use of post-operative precautions and equipment following total hip arthroplasty: a survey of the AAHKS and CAS membership. J Arthroplasty 2018; 33(10): 3201-5. doi: 10.1016/j.arth.2018.05.043. DOI: https://doi.org/10.1016/j.arth.2018.05.043

Crompton J, Osagie-Clouard L, Patel A. Do hip precautions after posterior-approach total hip arthroplasty affect dislocation rates? A systematic review of 7 studies with 6,900 patients. Acta Orthop 2020; 91(6): 687-92. doi: 10.1080/17453674.2020.1795598. DOI: https://doi.org/10.1080/17453674.2020.1795598

van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil 2016; 30(4): 329-39. doi: 10.1177/0269215515579421. DOI: https://doi.org/10.1177/0269215515579421

Smith T O, Jepson P, Beswick A, Sands G, Drummond A, Davis E T, et al. Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty. Cochrane Database Syst Rev 2016; 7: CD010815. doi: 10.1002/14651858.CD010815.pub2. DOI: https://doi.org/10.1002/14651858.CD010815.pub2

Barnsley L, Barnsley L, Page R. Are hip precautions necessary post total hip arthroplasty? A systematic review. Geriatr Orthop Surg Rehabil 2015; 6(3): 230-5. doi: 10.1177/2151458515584640. DOI: https://doi.org/10.1177/2151458515584640

Coole C, Edwards C, Brewin C, Drummond A. What do clinicians think about hip precautions following total hip replacement? Br J Occup Ther 2013; 76(7): 300-7. doi: 10.4276/030802213X13729279114898. DOI: https://doi.org/10.4276/030802213X13729279114898

NKR: Hofteartrose - ikke-kirurgisk behandling og genoptræning efter total hoftealloplastik [Internet]. [cited 2021, Oct 30]. Available from: https://www.sst.dk/da/udgivelser/2021/nkr-hofteartrose--ikke-kirurgiskbehandling-og-genoptraening-efter-tha.

Alonso-Coello P, Oxman A D, Moberg J, Brignardello-Petersen R, Akl E A, Davoli M, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices 2: Clinical practice guidelines. BMJ 2016; 353: i2089. doi: 10.1136/bmj.i2089. DOI: https://doi.org/10.1136/bmj.i2089

Cochrane Handbook for Systematic Reviews of Interventions [Internet]. [cited 2022, Feb 10]. Available from: https://training.cochrane.org/ handbook/current.

Page M J, McKenzie J, Bossuyt P, Boutron I, Hoffmann T, Mulrow C, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews [Internet]. MetaArXiv; 2020 Sep [cited 2021, Jan 23]. Available from: https://osf.io/preprints/metaarxiv/v7gm2/. doi: 10.31222/osf.io/v7gm2. DOI: https://doi.org/10.31222/osf.io/v7gm2

Guyatt G H, Oxman A D, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines, 2: Framing the question and deciding on important outcomes. J Clin Epidemiol 2011; 64(4): 395-400. doi: 10.1016/j.jclinepi.2010.09.012. DOI: https://doi.org/10.1016/j.jclinepi.2010.09.012

Cuello-Garcia C A, Santesso N, Morgan R L, Verbeek J, Thayer K, Ansari M T, et al. GRADE guidance 24: Optimizing the integration of randomized and non-randomized studies of interventions in evidence syntheses and health guidelines. J Clin Epidemiol 2022; 142:200-8. doi: 10.1016/j.jclinepi.2021.11.026. DOI: https://doi.org/10.1016/j.jclinepi.2021.11.026

Sterne J A C, Savović J, Page M J, Elbers R G, Blencowe N S, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366. doi: 10.1136/bmj.l4898. DOI: https://doi.org/10.1136/bmj.l4898

Sterne J A, Hernán M A, Reeves B C, Savović J, Berkman N D, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919. doi: 10.1136/bmj.i4919. DOI: https://doi.org/10.1136/bmj.i4919

Smith T O, Hawker G A, Hunter D J, March L M, Boers M, Shea B J, et al. The OMERACT-OARSI core domain set for measurement in clinical trials of hip and/or knee osteoarthritis. J Rheumatol 2019; 46(8): 981-9 . doi: 10.3899/jrheum.181194. DOI: https://doi.org/10.3899/jrheum.181194

Nilsdotter A K, Lohmander L S, Klässbo M, Roos E M. Hip disability and osteoarthritis outcome score (HOOS): validity and responsiveness in total hip replacement. BMC Musculoskelet Disord 2003; 4(1): 10. doi: 10.1186/1471-2474-4-10. DOI: https://doi.org/10.1186/1471-2474-4-10

Dobson F, Hinman R S, Roos E M, Abbott J H, Stratford P, Davis A M, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage 2013 Aug; 21(8): 1042-52. doi: 10.1016/j.joca.2013.05.002. DOI: https://doi.org/10.1016/j.joca.2013.05.002

Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines, 3: Rating the quality of evidence. J Clin Epidemiol 2011; 64(4): 401-6. doi: 10.1016/j.jclinepi.2010.07.015. DOI: https://doi.org/10.1016/j.jclinepi.2010.07.015

Higgins J P T, Thomas J, Chandler J, Cumpston M, Li T, Page M J, Welch V A, editors. 12.6.2: Re-expressing SMDs using rules of thumb for effect sizes [Internet]. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. [cited 2022, Mar 14]. Available from: https://handbook-5-1.cochrane.org/chapter_12/12_6_2_re_expressing_smds_using_rules_of_thumb_for_effect_sizes.htm.

Chinn S. A simple method for converting an odds ratio to effect size for use in meta-analysis. Stat Med 2000; 19(22): 3127-31. doi: 10.1002/1097-0258(20001130)19:22<3127::AID-SIM784>3.0.CO;2-M. DOI: https://doi.org/10.1002/1097-0258(20001130)19:22<3127::AID-SIM784>3.0.CO;2-M

Higgins J P T, Thomas J, Chandler J, Cumpston M, Li T, Page M J, Welch V A, editors. Chapter 15: Interpreting results and drawing conclusions [Internet]. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. [cited 2022 Oct 12]. Available from: https://training.cochrane.org/handbook/current/chapter-15.

McGuinness L A, Higgins J P T. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods [Internet] 2020 Apr 26 [cited 2020, May 21]; n/a(n/a). Available from: https://doi.org/10.1002/jrsm.1411/.

Sterne J A C, Harbord R M. Funnel plots in meta-analysis. Stata J 2004; 4(2): 127-41. doi: 10.1177/1536867X0400400204. DOI: https://doi.org/10.1177/1536867X0400400204

Higgins J P T, Thompson S G. Quantifying heterogeneity in a metaanalysis. Stat Med 2002; 21(11): 1539-58. doi: 10.1002/sim.1186. DOI: https://doi.org/10.1002/sim.1186

Mikkelsen L R, Petersen M K, Søballe K, Mikkelsen S, Mechlenburg I. Does reduced movement restrictions and use of assistive devices affect rehabilitation outcome after total hip replacement? A non-randomized, controlled study. Eur J Phys Rehabil Med 2014; 50(4): 383-93.

Tetreault M W, Akram F, Li J, Nam D, Gerlinger T L, Della Valle C J, et al. Are postoperative hip precautions necessary after primary total hip arthroplasty using a posterior approach? Preliminary results of a prospective randomized trial. J Arthroplasty 2020; 35(6S): S246-51. doi: 10.1016/j.arth.2020.02.019. DOI: https://doi.org/10.1016/j.arth.2020.02.019

Dietz M J, Klein A E, Lindsey B A, Duncan S T, Eicher J M, Gillig J D, et al. Posterior hip precautions do not impact early recovery in total hip arthroplasty: a multicenter, randomized, controlled study. J Arthroplasty 2019 ; 34(7, Suppl.): S221-S227.e1. doi: 10.1016/j.arth.2019.02.057. DOI: https://doi.org/10.1016/j.arth.2019.02.057

Peters A, Weele K ter, Manning F, Tijink M, Pakvis D, Huis in het Veld R. Less postoperative restrictions following total hip arthroplasty with use of a posterolateral approach: a prospective, randomized, non-inferiority trial. J Arthroplasty 2019; 34(10): 2415-19. doi: 10.1016/j.arth.2019.05.038. DOI: https://doi.org/10.1016/j.arth.2019.05.038

Mounts M R, Turner R A, Patel N B, Snelling E N, Phillips R E, Levesque D A, et al. Patients achieving 90°/45°/0° intraoperative stability do not require hip precautions following posterior approach total hip arthroplasty: a prospective randomized study. J Arthroplasty 2022; 37(8, Suppl.): S876-80. doi: 10.1016/j.arth.2022.01.028. DOI: https://doi.org/10.1016/j.arth.2022.01.028

Lightfoot C J, Sehat K R, Coole C, Drury G, Ablewhite J, Drummond A E R. Evaluation of hip precautions following total hip replacement: a before and after study. Disabil Rehabil 2021; 43(20): 2882-9. doi: 10.1080/09638288.2020.1721575. DOI: https://doi.org/10.1080/09638288.2020.1721575

Brown M L, Ezzet K A. Relaxed hip precautions do not increase early dislocation rate following total hip arthroplasty. J Am Acad Orthop Surg 2020; 28(10): e440-7. doi: 10.5435/JAAOS-D-19-00261. DOI: https://doi.org/10.5435/JAAOS-D-19-00261

Allen F C, Skinner D L, Harrison J, Stafford G H. The effect of precautions on early dislocations post total hip arthroplasty: a retrospective cohort study. HIP Int 2018; 28(5): 485-90. doi: 10.1177/1120700018762175. DOI: https://doi.org/10.1177/1120700018762175

van der Weegen W, Kornuijt A, Das D, Vos R, Sijbesma T. It is safe to use minimal restrictions following posterior approach total hip arthroplasty: results from a large cohort study. Hip Int J Clin Exp Res Hip Pathol Ther 2019; 29(6): 572-7. doi: 10.1177/1120700018823504. DOI: https://doi.org/10.1177/1120700018823504

Lyman S, Lee Y Y, McLawhorn A S, Islam W, MacLean C H. What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement? Clin Orthop 2018; 476(12): 2432-41. doi: 10.1097/CORR.0000000000000456. DOI: https://doi.org/10.1097/CORR.0000000000000456

Peak E L, Parvizi J, Ciminiello M, Purtill J J, Sharkey P F, Hozack W J, et al. The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty: a randomized, prospective study. J Bone Joint Surg Am 2005; 87(2): 247-53. doi: 10.2106/JBJS.C.01513. DOI: https://doi.org/10.2106/JBJS.C.01513

Peters A, Manning F, Tijink M, Vollenbroek-Hutten M, Huis in ’t Veld R. Patient compliance with postoperative precautions in an unrestricted and a supine sleeping position following posterolateral total hip arthroplasty: a randomized controlled trial. Disabil Rehabil 2021; 0(0): 1-8. doi: 10.1080/09638288.2021.2012606. DOI: https://doi.org/10.1080/09638288.2021.2012606

Jørgensen C C, Kehlet H, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Fall-related admissions after fast-track total hip and knee arthroplasty: cause of concern or consequence of success? Clin Interv Aging 2013; 8:1569-77. doi: 10.2147/CIA.S52528. DOI: https://doi.org/10.2147/CIA.S52528

Gromov K, Troelsen A, Otte K S, Ørsnes T, Ladelund S, Husted H. Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation. Acta Orthop 2015; 86(4): 463-8. doi: 10.3109/17453674.2015.1028009. DOI: https://doi.org/10.3109/17453674.2015.1028009

Lightfoot C J, Coole C, Sehat K R, Drummond A E R. Hip precautions after total hip replacement and their discontinuation from practice: patient perceptions and experiences. Disabil Rehabil 2021; 43(20): 2890-6. doi: 10.1080/09638288.2020.1722262. DOI: https://doi.org/10.1080/09638288.2020.1722262

Okafor L, Chen A F. Patient satisfaction and total hip arthroplasty: a review. Arthroplasty 2019; 1(1): 6. doi: 10.1186/s42836-019-0007-3. DOI: https://doi.org/10.1186/s42836-019-0007-3

Ververeli P A, Lebby E B, Tyler C, Fouad C. Evaluation of reducing postoperative hip precautions in total hip replacement: a randomized prospective study. Orthopedics 2009; 32(12): 889. doi: 10.3928/0147744720091020-09. DOI: https://doi.org/10.3928/01477447-20091020-09

Specht K, Agerskov H, Kjaersgaard-Andersen P, Jester R, Pedersen B D. Patients’ experiences during the first 12 weeks after discharge in fast-track hip and knee arthroplasty: a qualitative study. Int J Orthop Trauma Nurs 2018; 31: 13-19. doi: 10.1016/j.ijotn.2018.08.002. DOI: https://doi.org/10.1016/j.ijotn.2018.08.002

Jansson M M, Harjumaa M, Puhto A P, Pikkarainen M. Patients’ satisfaction and experiences during elective primary fast-track total hip and knee arthroplasty journey: a qualitative study. J Clin Nurs 2020; 29(3-4): 567-82 . doi: 10.1111/jocn.15121. DOI: https://doi.org/10.1111/jocn.15121



How to Cite

Korfitsen, C. B., Mikkelsen, L. R., Mikkelsen, M.-L., Rohde, J. F., Holm, P. M., Tarp, S., Carlsen, H.-H. F., Birkefoss, K., Jakobsen, T., Poulsen, E., Leonhardt, J. S., Overgaard, S., & Mechlenburg, I. (2023). Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients. Acta Orthopaedica, 94, 141–151. https://doi.org/10.2340/17453674.2023.11958





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