Team Management of
Hip Revision Patients Using A Post-Op Hip Orthosis
Dulcey Lima, CO
Robert Magnus, MD
Wayne G. Paprosky, MD, FACS
ABSTRACT
Eighty patients who underwent cementless hip revision surgery were managed
postoperatively with a prefabricated,
adjustable range-of-motion hip-abduction orthosis. Four patients had both
hips revised. The orthosis was incorporated into the patients' nursing and occupational and physical therapy during
hospitalization. Patients continued to
wear the orthosis whenever they were
out of bed for an average of eight weeks
after surgery.
The hip orthosis was used to prevent
postoperative dislocation, which some
reports have indicated can occur on as
many as 20 percent of all revisions. Seven of the 84 hips (8.3 percent) dislocated. The average length of hospitalization was 10 days.
This article identifies patients most at
risk of dislocation, discusses the orthotic management of anterior and posterior dislocation patients, and provides
specific team protocol.
Introduction
Each year thousands of hip arthroplasties are performed in the United
States, usually on patients with osteoarthritis and other degenerative diseases (1). Total hip arthroplasties have
been performed since 1959 when Sir
John Charnley first used polymethylmethacrylate for cementing the components (2). To this day, fixing components to the skeleton remains one of the
most difficult surgical problems, and
aseptic loosening of either the acetabular or the femoral component is the main
cause of total hip implant failure (3).
When aseptic loosening occurs, the patient experiences pain and instability,
and revision surgery is recommended.
Studies by Mallory et al., Rao and
Bronstein, and Clayton and Thirupathi
cite dislocation as a complication of
both primary and revision surgery at
the hip (4-6). Dislocation is attributed
to several variables, including soft tissue weakness secondary to the former
and current surgical procedure, poor
patient compliance for hip precautions,
component malposition, and poor
bone stock (5). The risk of dislocation
after revision surgery is higher than after primary hip surgery, and this tendency to dislocate increases with each
revision (7). Dislocations require immediate medical intervention, increase
hospitalization costs, and cause patients pain and suffering.
Studies by Williams and others show
that using a post-op hip orthosis reduces dislocations, which could occur
in as many as 20 percent of revision
cases (7). The study described in this
article was undertaken to determine
which patients are most at risk to dislocate and to determine if use of a postoperative hip orthosis reduces the
number of dislocations in this population. Figure 1
shows the distribution of
patient problems that necessitated hip
revision surgery.
Method
The revision surgery used in this study
a cementless procedure followed by
specific orthotic, nursing, and physical
and occupational therapy management This study followed 84 hip revision surgeries in 80 patients over 33
months. All patients have been seen
For at least 12 months following surgery This study does not involve any
primary patients.
Forty-nine of the hips were operated
on once before; 21 of the hips were
operated on twice; and 14 of the hips
were operated on three, four or five
times.
All patients were fit with the same
type of prefabricated, adjustable
range-of-motion hip-abduction orthosis following surgery.a This hip orthosis
is used routinely as a prophylactic device to prevent dislocation after surgery by restricting motion that could
lead to dislocation, providing a favorable environment for graft incorporation, training patients in total hip precautions and reducing the tendency of
stronger hip adductors to override hip
abductors (see Figure 2
).
Demographics
Study participants included 39 females
and 41 males ranging in age from 31 to
84. The average age was 61.9 years.
The average length of brace wear was
8.5 weeks, and the average length of
hospitalization was 10 days. Follow-up
ranged from 12 to 33 months.
Before revision surgery, the patient's acetabulum and femur are analyzed through roentgenographic evaluation. Acetabular classification is
based on the stability of the acetabular
rim and its ability to support an acetabular component.
Type 1 defects still contain cancelous bone and have minimal deformity.
With rim fixation the acetabulum can
support a component, and the columns
will support a prosthesis.
Although Type 2 defects demonstrate more medial bone loss and cavitary defects, structural grafts are unnecessary in all but the most involved
defects. These require particulate
graft.
Type 3 defects show severe bone
loss, component migration and a rim
that will not support a component unless structural allografting is used.
In this study, the patients had seven
Type 1 defects, 53 Type 2 defects and
22 Type 3 defects. The high number of
Type 2 and Type 3 defects with their
corresponding bone loss and instability
strongly influenced the decision to
orthoticly manage all patients after revision surgery (8). Every patient had
an acetabular defect.
Femoral defects also can be classified into categories to assist in surgical
planning for revision patients. This
classification is based on the degree of
bone loss in the femur and the amount
of diaphyseal support provided to the
implant. Type 1 defects are similar to
those found in a primary total hip arthroplasty. There is minimal bone loss,
and the diaphysis and metaphysis are
intact. Type 2 femoral defects demonstrate no calcar, and the subtrochanteric bonee provides little or no proximal rotational stability. To prevent rotation and migration of the component, longer stems are used to provide
more distal fixation. Type 3 femoral
defects have extensive metaphyseal
and diaphyseal bone loss, major anteroposterior bone loss and a nonintact
diaphysis. Rotational stability is provided only with an extremely long stem
(9). In this study there were 12 Type 1
femoral revisions, 44 Type 2s and 19
Type 3s (9) (see Figure 3
). Not every
patient had a femoral defect.
Orthotic Protocol
The orthotist measures the patient before surgery or as soon as possible postoperatively. The nurse often takes preliminary measurements. Snug measurements are taken around the waist,
the widest part of the hip and of the
mid-thigh on the affected side. The patient's height and weight are noted to
customize the orthosis.
Based on these measurements the
appropriate pelvic module and thigh
cuff are chosen. The pelvic component
must fit the patient properly around
the waist and hips. Usually men have a
four- to six-inch development between
their waist and hips, and women have a
eight- to 12-inch development. If the
pelvic module does not properly accommodate the development, the patient may experience excessive pressure over the trochanter and gapping at
the waist (not enough development) or
poor purchase over the pelvis (too
much development). Patients with very
weak abductors also have excessive
pressure over the trochanter and must
be trained to position their leg in more
abduction.
The patient is fit the first or second
day after surgery. If the patient is able,
the orthosis is applied at the side of the
bed, and the patient is transferred to a
chair. In other cases, the orthotist fits
the patient in bed and returns when the
patient is ready to ambulate so the
orthosis can be assessed during standing, sitting and walking. The orthosis is
worn only when the patient is out of
bed. Patients are seen after discharge if
an adjustment is required.
Patients responded to questionnaires asking how they put on their
orthoses after leaving the hospital and
whether they found the orthosis comfortable and tolerable. Patients who
wore the orthosis whenever they were
out of bed were determined to be in
compliance. The overall orthotic compliance rate was 90 percent. Twenty-six
percent felt the orthosis was comfortable, 64 percent felt the orthosis was
tolerable, and 10 percent found the
orthosis intolerable. Patients who dislocated and were not compliant with
orthosis wear were included in the intolerable category. All patients were
initially managed to prevent posterior
dislocation, which is the most common
dislocation (see Figure 4
).
During the study it became evident
the orthosis was adequately protecting
the patients from posterior dislocation,
but occasionally a patient dislocated in
bed. Fluoroscopy during the closed reduction of these patients revealed
some were at risk to dislocate anteriorly. The patients with anterior dislocations all had Type 3 acetabular defects
and structural grafting.
Anterior dislocations require different orthotic protocol and management;
extension and external rotation are the
important motions to block. The extension can be blocked by allowing a
hip flexion range of 40 to 70 degrees. To
control rotation a KAFO is added to
the pelvic section. This provides a longer lever arm to block the external rotation. Extending the orthosis to the foot
allows sagittal plane motions of flexion
and extension while controlling undesirable adduction in the coronal plane
and internal and external rotation in
the transverse plane. The patient wears
the hip-knee-ankle-foot orthosis at all
times. Figure 5
describes the protocol
used. Anterior dislocation should be
suspected when the patient has had an
acetabular reconstruction or when a
patient dislocates in bed or while standing and reaching up over the head or
back (see Figure 6
).
Nursing Protocol
Nursing plays a primary role in the care
of hip revision surgery patients. All patients are placed in balanced suspension traction until the middle of the
third post-op day, and nurses monitor
the patient's comfort and position.
Nurses also care for wounds, change
dressings and teach the patient proper
bed mobility that is reinforced by other
team members.
Patients were instructed to get out of
bed toward the affected side to prevent
adduction of that leg. The patient
could sleep only on the affected side for
the same reason. This protocol may be
different than that used by other physicians. Nurses reinforced all hip precautions and transfer techniques. The hip
orthosis was applied while sitting at the
side of the bed whenever the patient
wished to get up. Nurses also monitored patient pain, fatigue, etc., and
leg position (see Figure 7
).
Physical Therapy Protocol
Physical therapists are usually the first
team member to help the patient out of
traction and sit up on the side of the
bed on the first postoperative day. Often they are also the first to apply the
hip orthosis and move the patient to a
chair.
Therapists teach patients bed mobility, hip precautions and isometric exercises. Therapists also help patients increase strength and endurance by having patients walk to the physical therapy department while using appropriate
ambulation aids-often a walker or
crutches. Patients are usually on one-third weightbearing status - able to
place enough weight on the operative
side to advance the sound leg - and
progress to weightbearing as tolerated.
Most patients continue receiving physical therapy - usually in their homes -
for eight weeks after discharge (see
Figure 8
).
Occupational Therapy Protocol
Like all other team members, occupational therapists reinforce hip precautions and bed mobility. Therapists
teach patients how to apply the hip abduction orthosis and manage clothing
that is applied over the orthosis. Occupational therapists also teach patients
how to manage sponge baths and toilet
transfers. Showers are allowed after
the staples are removed, but baths are
not permitted.
The occupational therapy staff provides and teaches patients how to use
adaptive equipment such as long-handled shoe horns, a leg lifter, raised toilet seat and elastic laces. Compression
hosiery is not worn after the patient
leaves the hospital because application
requires too much forward flexion (see
Figure 9
).
Results
Eighty-four hip revision procedures
were performed and treated prophylactically with the adjustable range-of-motion hip-abduction orthosis. Of
these, three patients dislocated in an
anterior direction (3.5 percent). The
three patients' hips were repositioned
with closed reduction and controlled
after restraining extension and external
rotation with a hip-knee-ankle-foot
orthosis worn at all times.
Two of these patients were casted into
a modified hip spica using the hip-knee-ankle-foot orthosis as a base. The patients wore the orthosis for three
months, and neither patient dislocated
again after orthosis wear was completed.
Casting tape was used only on patients who dislocated while wearing the
orthosis and on those who were suspected of being noncompliant. No patient casted into his or her hip-knee-ankle-foot orthosis dislocated.
Four patients (4.8 percent) dislocated in a posterior direction. Two of
these patients discontinued the brace
against medical advice and dislocated
at four and five weeks. They both had a
closed reduction and wore the orthosis
12 more weeks with no recurrence of
dislocation. The third patient fell and
dislocated his hip after completing orthotic management. He had a closed
reduction and remained dislocation-free after 12 more weeks of wearing the
hip orthosis. The last patient dislocated
the 14th week after orthotic management concluded. This patient had a
closed reduction and wore the orthosis
12 more weeks without dislocation. All
patients who dislocated were treated
with closed reduction and did not require additional surgery.
The records of the seven patients
who dislocated were analyzed to determine what characteristics might have
predisposed dislocation. Several high risk factors have been identified and
are listed in Figure 10
.
Discussion
After studying 84 hip revision treatments, the following protocol is recommended. First, the team approach
should be employed because it provides consistent patient training. Many
patients in this study were in their 70s,
and a few were in their 80s. Patients in
this age group often have physical and
cognitive deficits preventing them from
learning easily.
When all staff use the hip orthosis
during the patient's hospital stay, there
is a greater chance for patient compliance at home. This was verified by the
90 percent compliance rate. No data
exist to prove the compliance rate is
higher than it would be without the
team approach, but experience using
the hip orthosis without the team benefits has been less successful.
Second, the orthosis should be used
on all revision patients to lessen the
chance of dislocation, allow soft tissue
to tighten and create the optimal environment for bone graft incorporation.
If a decision is made not to use the
orthosis on all revision patients, the
orthosis should at least be used on patients most at risk to dislocate.
Third, patients at risk for anterior
dislocation should be identified during
surgery if possible so that they can be
managed immediately to block external rotation and extension with a hip-knee-ankle-foot orthosis. Other high-risk patients should wear the orthosis
for four to six months rather than the
customary eight-week period.
Conclusion
Use of an adjustable range-of-motion
hip-abduction orthosis has proven a
useful adjunct to the team management of hip revision patients. This is
evidenced by the orthosis wear dislocation rate of 8.3 percent as compared to
the data of Williams and Mallory,
which was 20 percent without orthotic
management (5).
It is well documented that prolonged
bed rest has detrimental effects on the
elderly. With the orthosis in place, patients are now mobilized within one
day of major surgery. The team can
work with the patient to increase endurance, teach safety precautions and
begin activities of daily living within
the precautionary range-of-motion
provided by the orthosis. With third-party payers demanding shorter hospital stays for joint revision patients, the
hip orthosis provides a cost-effective
method of promoting earlier ambulation when administered with a team approach to treatment.
Dulcey Lima, CO, is an orthotist and office manager for Oakbrook Orthopedic Services in Aurora, Ill.
Dr. Robert Magnus practices in Davenport, Iowa.
Dr. Wayne G. Paprosky, FACS, is a clinical professor at Loyola University Medical Center in Maywood, Ill., and specializes in total joint replacements.
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