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Three Part Question

In [adults who have sustained a # NOF] what [factors attribute] to [hip dislocations]?

Clinical Scenario

Therapists assess and treat patients following surgery for fractured neck of femur (NOF). Hip precautions (no hip flexion above 90 degrees, no adduction beyond midline and no rotation of the operated leg) are routinely adhered to in those having undergone hemiarthroplasty and total hip replacement. This has time and cost implication for example waiting for equipment delivery for discharge can increase length of stay. To ensure that following hip precautions is evidenced based practice, the orthopaedic therapy team wanted to conduct a BestBETs.

Search Strategy

Medline: exp FEMORAL NECK FRACTURES and HIP DISLOCATION
Limit to: publication year 2004-2014: English Language and (Age Groups All Adult 19 plus years)

CINAHL : exp (fractur* AND neck AND femur) or (femoral AND neck AND fracture) AND HIP DISLOCATION
Limit to publication year 2004-2014: (Language English) and (Age Groups All Adult)

Embase
exp FEMORAL NECK FRACTURES and HIP DISLOCATION. Limit to publication year 2004-2014: English Language and (Human Age Groups Adult 18 to 64 years or Aged 65+ years)

Search Outcome

The literature search returned 249 journals of which 42 full text articles were considered appropriate for critical appraisal. The 4 journals below were relevant for inclusion. The other 39 journals were not included for a variety of reasons including; duplication, not relevant to the clinical question, data collected was pre 2004 or they were of very poor methodological quality.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Enocson et al (2009) Sweden	42 patients having undergone hemiarthroplasty for a # NOF	Prospective study (Level 3)	Risk of dislocation with anterolateral approach vs posterolateral approach.	Clinically significant reduction in risk of dislocation with an anterolateral surgical approach.	No documentation that hip precautions were followed. No discussion of how many different surgeons operated
Conroy et al (2008) Australia	428 patients having dislocated following THR for # NOF	Prospective review of Austrailian National Joint Registry (Level 3)	Risk factors associated with dislocation with cemented vs uncemented prosthesis	Increased risk of revision surgery following dislocation with 26mm head cementless acetabular component.	Retrospective study over 5 years.
Adam et al (2012) France	214 patients treated with a THR for fractured NOF with a dual mobility cup	Multi-centre prospective study (Level 3)	Dislocation rate	3 dislocations occurred of which all of these patients had undergone a posterior approach. However, results were not statistically significant	Patients were not gender matched. No long term follow up Doesn’t discuss limitations of the study
Skoldenberg et al (2010) Sweden	372 cases in two groups (199 in 2007 and 173 in 2008) underwent fixation with either anterolateral or posterolateral approach	A prospective study (Level 3)	Dislocation rate	There was a statistically significant reduction in rate of dislocation with the anterolateral approach. Overall dislocation rate for AL approach was 1% and PL approach was 9%	27 different surgeons operated Both study groups had a mixture of AL and PL approaches. Groups were not matched.

Comment(s)

5 papers were included in this report. All were prospective studies completed within Europe or Australasia. There were no studies satisfactory for inclusion completed within the UK. No studies looked directly at the effect of hip precautions on dislocation rate. All studies either compared different surgical approaches or different prostheses used. No studies mentioned whether hip precautions were followed post-operatively. An anterolateral surgical approach was associated with reduction in rate of dislocation compared to a posterolateral approach. Smaller head sizes in patients having received a THR was associated with lower dislocation rates than a larger head size. All studies were categorised as level 3 evidence. There were no randomised controlled trials relevant for inclusion.

Clinical Bottom Line

There is no evidence to suggest that following hip precautions following a hemiarthroplasty or THR has an effect on dislocation rate.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Enocson, A., Lapidus, G., Tornkvist, H., Tidermark, J. & Lapidus, L.J. Direction of hip arthroplasty dislocation in patients with femoral neck fractures Springer-Verlag 2010; 641-647
2. Conroy, J.L., Whitehouse, S.L., Graves, S.E., Pratt, N.L., Ryan, P. & Crawford,S. Risk factors for revision for early dislocation in total hip arthroplasty Elsevier Inc 2008; 867-872
3. Adam, P., Philippe, R., Ehlinger, M., Roche, O., Bonnomet, F., Mole, D. & Fessy, M.H. Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. Elsevier Masson 2012; 296-300
4. Skoldenburg, O., Ekman, A., Salemyr, M. & Boden, H. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach Taylor adn Francis Ltd 2010; 583-587