HippityHop: Hip Precautions After Hip Operation Protocol Courtney J Lightfoot

1. HippityHop: Hip Precautions After Hip Operation Protocol Courtney J Lightfoot PhD student, University of Nottingham courtney.lightfoot@nottingham.ac.uk Lightfoot C J, Sehat K R, Drury G, Brewin C, Coole C, and Drummond A

2. Total Hip Replacement (THR) • Surgical treatment considered when the hip joint becomes damaged and causes persistent problems • Effective method to relieve pain, improve functional ability, and quality of life (QoL) • >83,000 performed in 20151 • Dislocation recognised complication with incidence rates 1-15%2 1. National Joint Registry, 2016; 2. Resptrepo et al., 2011

3. Hip Precautions ↓ • To protect new joint and ↓ risk of dislocation Hip precautions Avoidance of specific movement 6 weeks Impact on daily life

4. Hip Precautions • Although routinely provided there are large discrepancies in the provision of hip precautions • Movements to avoid • Length of time to follow • Reasons for teaching • Equipment provision Drummond et al., 2012

5. Hip Precautions • Although routinely provided there are large discrepancies in the provision of hip precautions Adduction Flexion • Movements to avoid Internal/external rotation Drummond et al., 2012

6. Hip Precautions • Although routinely provided there are large discrepancies in the provision of hip precautions 6 weeks 12 weeks • Length of time to follow Drummond et al., 2012

7. Hip Precautions Smith and Sackley, 2016

8. Hip Precautions • Although routinely provided there are large discrepancies in the provision of hip precautions OT practice Surgical approach used Surgical opinion • Reasons for teaching Team decision Hospital policy length of stay Evidence based Drummond et al., 2012

9. Hip Precautions • Although routinely provided there are large discrepancies in the provision of hip precautions Chair / bed raisers Raised toilet seat • Equipment provision Dressing aids Perching stools Long handled reachers Drummond et al., 2012

10. Hip Precautions Smith and Sackley, 2016

11. Literature Review • Current research is equivocal, with conflicting evidence Not needed Long term use Counselling patients to avoid bending and to be vigilant during functional transfers2 Dislocations occur due to undesirable movements that cannot be avoided1 1. Gromov et al., 2015. 2. Smith et al., 2012.

12. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates ↓

13. Literature Review ↓ • No additional benefit for ↓dislocation rates Barnsley et al., 2015; van der Weegan et al., 2016

14. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates ↓ • Slower return to ADLs

15. Literature Review • Slower return to ADLs Ververeli et al., 2009

16. Literature Review • Slower return to ADLs Peak et al., 2005

17. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates ↓ • Slower return to ADLs ↓ • ↓patient satisfaction

18. Literature Review ↓ • ↓patient satisfaction Peak et al., 2005

19. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates ↓ • Slower return to ADLs ↓ • ↓patient satisfaction • Sleep deprivation

20. Literature Review • Sleep deprivation 68.4% patients in restricted group and 65.6% patients in unrestricted group rated sleeping fully supine “uncomfortable” Peak et al., 2005 ‘Sleep deprivation leads to increased anxiety and decreased satisfaction’ O’Grady et al., 2003

21. Literature Review • Sleep deprivation 14% patients in unrestricted group began side-sleeping on night of surgery Significant differences in side-sleeping were noted at all follow-up time periods Peak et al., 2005

22. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates ↓ • Slower return to ADLs ↓ • ↓patient satisfaction • Sleep deprivation • Significant £

23. Literature Review • Significant £ Cost savings of $655 … abduction pillow ($120) elevated toilet seat ($65) elevated chair ($955 to purchase, $15/day to rent) Peak et al., 2005 Mean (Range) Drummond et al., 2012

24. Literature Review ↓ Hip precautions = • No additional benefit for ↓dislocation rates 1 ↓ • Slower return to ADLs 2 ↓ • ↓patient satisfaction 3 • Sleep deprivation 4 • Significant £5 1. Barnsley et al., 2015; van der Weegan et al., 2016 2. Ververeli et al., 2009; Peak et al., 2005 3. Peak et al., 2005 4. Peak et al., 2005; O’Grady, 2003; 5. Peak et al., 2005; Drummond et al., 2012

25. Literature Review • Strong opposing clinical opinions • Main difficulties in evaluating key literature: Lack of robust methodology 1. 2. Underpowered studies 3. Focus on dislocation

26. Research Aims HippityHop 1. To compare outcomes of hip precautions vs. no hip precautions To explore patients’ experiences of the regimes To explore staff members’ perceptions of the service To assess the costs of providing each regime 2. 3. 4.

27. Study Design RCT Impractical – service based Potential for widespread contamination and protocol infringement Unrealistic provision Number of participants required to demonstrate a difference would be very large

28. Study Design Using a local Trust who are moving to a no precautions model of care as an opportunity to model the study around this service change After Before

29. Intervention ‘Routine’ (previous) treatment • Hip precautions taught • Patients provided with ‘safe height’ • Equipment routinely provided ‘New’ treatment strategy • Patients encouraged to move as they are able • Equipment only provided to those who require it

30. Sample Size Treatment regimes Recruit = 342 participants (171 per group/ treatment regime) • Pre-defined margin of equivalence = 0.5SD • Confounding factors • 25% attrition rate Interviews Recruit = 40 participants (20 staff & 20 patients) • Sufficient diversity

31. Population and Recruitment • Elective THR patients • Approached at preoperative assessment

32. Pre-op Baseline Surgery Outcomes 1 week 6 weeks 3 months Oxford Hip Score (pain and function) QoL Sample of cohort ADLs equipment mood time sleep satisfaction dislocation

33. Qualitative Interviews • Sample of patients from phase one and two, and orthopaedic staff • Selected using maximum variation purposive sampling • Interview guidelines developed as study progresses

34. 304 letters sent out Results 302 approached 182 consented To date … 9 non returners 173 baseline completed Phase One 8 withdrawn 3 late returners 162 baseline for analysis 8 cancelled surgery 9 unfit for surgery

35. Results 145 baselines and surgery Phase One / Two 27 baselines complete 4 missed 6 to contact 17 one week complete Phase One 10 awaiting return 8 to send out 118 baselines complete 1 non returner 3 missed 115 one week complete 8 six weeks complete 2 awaiting return 4 non returners 112 six weeks complete 23 awaiting return 1 non returner 20 to send out 74 three months complete

36. 84 letters sent out Results 62 approached 42 consented To date … 17 baseline completed Phase Two

37. Next Steps Treatment regimes Recruitment ends = February 2018 Interviews Recruit: • 10 clinical staff (November 2017 – January 2018) • 10 patients (January 2018 – May 2018) Cost Assess 10 patients

38. Thank you Courtney J Lightfoot courtney.lightfoot@nottingham.ac.uk CourtneyJLight

39. Literature Review Key reviews Key papers Talbot et al., 2002 Peak et al., 2005 Restrepo et al., 2011 Sharma et al., 2009 Barnsley et al., 2015 van der Weegan et al., 2016 Smith et al., 2016

40. Peak et al., 2005

41. Drummond et al., 2012