By Prodyut Das

Hip Replacement Rehabilitation

The Hip Replacement Rehabilitation protocols mentioned here for are general and should be tailored to specific patients. For example, weight bearing should be limited to toe touch in osteotomy of the femur. Expansion osteotomies allow the insertion of a larger prosthesis, and reduction osteotomies allow narrowing of the proximal femur normally. In patients with these osteotomies, weight-bearing should be delayed until some union is present. These patients should avoid SLR (straight leg raise) and side-leg-lifting until, surgeon agrees that it is safe to do so.

Treatment may also have to be adjusted according to difficulty of initial fixation. In revision surgery, a stable press-fit acetabular component may be difficult to achieve and multiple-screw fixation may be required. Caution should be exercised in rehabilitation in these circumstanses.

Hip Replacement Rehabilitation might also have to be adjusted because of stability. Abduction brace may be used to prevent adduction and flexion of more than 80 degrees for upto 6 months in case of recurrent dislocations. Similarly, leg shortening through a hip at the time of revision with or without a constrained socket should be protected with an abduction brace until the soft tissues tighten up.

Hip Replacement Rehabilitation Protocol- Posterior Approach

Goals of Hip Replacement Rehabilitation

  • Guard against dislocation of the implant.
  • Obtain pain free range of motion within safe limits.
  • Gain functional strength.
  • Strengthen hip and knee musculature.
  • Teach transfers and ambulation independently or with assistive devices.
  • Prevent bedrest hazards (eg. pneumonia, decubitus ulcer, pulmonary embolism, thrombophlebitis).

Rehabilitation Considerations in Cemented and Cementless Techniques

In cemented total hip Weight Bearing To Tolerance (WBTT) with walker should be started immediately after surgery.

Preoperative Instructions

  • Instruct on precautions for hip dislocation (mentioned later).
  • Provide instructions for transfers in and out of bed and chair.
  • Avoid deep chairs. Also instruct the patient to look at the ceiling as they sit down to minimize trunk flexion.
  • Avoid crossing legs while sitting.
  • While rising from a chair scoot to the edge of the chair and then rise.
  • Use elevated commode seat. Elevated seat is placed on commode at a slant, with higher part at the back, to aid in rising.
  • For ambulation instruct on use of anticipated assistive device.

Postoperative Hip Replacement Rehabilitation Regimen

Patient should be made to come out of bed in stroke chair twice a day with assistance within 1 or 2 days postoperatively. Chair should not be of low height. Begin ambulation with assistive device (walker) twice a day.

Weight bearing recommendations in Hip Replacement Rehabilitation

Cemented Prosthesis: Weight bearing as tolerated with walker for at least 6 weeks, then use cane in the contra-lateral hand for 4-6 months.

Cementless Prosthesis: Touch down weight bearing with walker for 6-8 weeks, then use a cane in contra-lateral hand for 6 months. Wheelchair must be used for long distances with careful avoidance of excessive hip flexion greater than 80 degrees while in wheelchair, this can be achieved by placing a cushion in the wheelchair seat with highest cushion point posterior.

Isometric and bed Exercises (Hip Replacement Rehabilitation)

  • Straight Leg Raise (SLR)- Tighten knee and lift leg off the bed, keeping the knee straight. Flex the opposite knee to aid this exercise.
  • Ankle Pumps- Pump ankle up and down repeatedly.
  • Quadriceps Sets- Tighten quadriceps muscles by pushing knee down and holding for a count of 5.
  • Gluteal Sets- Squeeze buttocks together and hold for a count of 5.
  • Isometric hip abduction with self resistance while lying.
  • Hip abduction adduction- (Prevent initially if patient had a trochanteric osteotomy). While lying on the back patient can slide the leg to the side. In standing this can be done by moving the leg out to the side and back. Perform this exercise while lying on one side (5-6 weeks postoperatively). The patient should be turned 30 degree towards prone to utilize gluteus maximus and medius muscles. Most patients would otherwise tend to rotate towards the supine position, thus abducting with the tensor fascia femoris.

ROM and Stretching Exercises (Hip Replacement Rehabilitation)

  • 1 to 2 days postoperative, begin Thomas stretch to avoid flexion contracture of the hip. Pull the uninvolved leg to the chest while lying supine on the bed. At the same time, push the involved leg against the bed. This stretches the anterior capsule and the hip flexors of the involved leg. Perform this stretch 5 times per session, 5-6 times a day.
  • Patient may start with exercising on stationary bicycle depending on trunk stability with a high seat 4-7 day postoperative. Until successful completion of a full arc on the bicycle, the seat should be set as high as possible. The seat may be progressively lowered to increase hip flexion within safe parameters.
  • Perform extension stretching of the anterior capsule in standing by extending the involved leg while the uninvolved leg is mildly flexed at the hip and knee, supported by the walker. Slowly thrust the pelvis forward and the shoulders backward for a sustained stretch of the anterior capsule.

Abduction Pillow

Keep an abduction pillow between the legs while in bed. Use the abductor pillow while asleep or resting in bed for 5-6 weeks, it may then be safely discontinued.

Bathroom Rehabilitation

Permit bathroom privileges with assistance and an elevated commode seat. Teach bathroom transfers when the patient is ambulating 10-20 feet outside of room. Always use elevated commode seats.

Assistive devices used in Hip Replacement Rehabilitation

Use "reacher" or "grabber" to help retrieve objects on the floor. Do not bend to put on slippers. Shoe horn and loosely fittings shoes or loafers.

Transfer Guidances

  • Bed to Chair- Avoid leaning forward to get out of chair or off bed. Slide hips forward to the edge of the chair first, then come to standing. Do not cross legs when pivoting from supine to bedside position. Therapist or nurse assists until able to perform safe, secure transfers.
  • Bathroom- Use elevated toilet seat with assistance. Continue assistance until able to perform safe, secure transfers.

Transfer to Home

  • Instruct patient to travel in the back seat of four door sedan, sitting or reclining lengthwise across the seat, leaning on one or two pillows under the head and shoulders to avoid sitting in a deep seat.
  • Avoid sitting with hip flexed more than 90 degrees to prevent posterior dislocation.
  • Urge those without a four-door sedan to sit on two pillows with the seat reclined.
  • May begin driving 6 weeks postoperative, when agreed by the surgeon.

Stair training in Hip Replacement Rehabilitation

  • Going up stairs- Step up first with the uninvolved leg, keeping crutches on the step below until both feets are on the step above, then bring both crutches up on the step. If available hold the handrail.
  • Going down stairs- Place crutches on the step below, then step down with the involved leg, and then with the uninvolved leg. If possible, hold the rail.

Exercise Progression in Hip Replacement Rehabilitation

  • At 5-6 week, begin standing hip abduction exercises with pulleys, sports cords or weights. Also may perform side stepping with a sports cord around the hips, as well as lateral step ups with a low step, if clinically safe. Progress hip abduction exercises until the patient exhibits a normal gait with good abductor strength.
  • Perform prone lying extension exercises of the hip to strengthen the gluteus maximus. These may be performed with the knee flexed (to isolate the hamstrings and gluteus maximus) and with the knee extended to strengthen the hamstrings and gluteus maximus.
  • Initiate general strengthening exercises, develop endurance and perform cardiovascular exercises.

Instructions for Home in Hip Replacement Rehabilitation

  • Continue with the previous exercises and ambulation activities. Continue to observe precautions.
  • Install elevated toilet seat at home.
  • Supply walker for home.
  • Review rehab specific for home situation, like- steps, stairways, narrow doorways.
  • Ensure home physical therapy has been arranged.
  • Avoid driving for minimum 6 weeks.
  • Patient should have prescription of prophylactic antibiotics that may be needed eventually for dental or urologic procedures.

Managing Problems After Total Hip Replacement

1-Trendelenburg Gait (weak hip abductors)

  • Concentrate on hip abduction exercises to strengthen abductors.
  • Evaluate leg-length discrepancy.
  • Make the patient stand on involved leg with flexed opposite knee. If opposite hip drops, have patient try to lift and hold in an effort to reeducate and work gluteus medius muscle.

2- Flexion Contracture of the Hip

  • Avoid placing pillow under the knee after surgery.
  • Walking backward helps stretch flexion contracture. Perform Thomas Stretch 30 times a days.

The above mention Hip Replacement Rehabilitation Protocol should be tailored to individual patients need and performed in guidance of a physical therapist.

Precautions After Total Hip Replacement

Following points must be explained clearly during Hip Replacement Rehabilitation. AVOID

  • Crossing your legs or bringing them together(adduction).
  • Bringing the knee too close to your chest- extreme hip flexion ( you can bend until your hand gets to your knee).
  • Turning the foot in toward the other leg (internal rotation).

Research Articles

  • Hip Replacement- Physical Therapy Reference Summary [PubMed]
  • Bitzer EM, Dörning H, Schwartz FW. Effects of rehabilitation after hip replacement surgery on postoperative complaints regarding the disease and limitation of function. Rehabilitation (Stuttg). 2001 Feb;40(1):43-9.
  • Di Monaco M, Vallero F, Tappero R, Cavanna A. Rehabilitation after total hip arthroplasty: a systematic review of controlled trials on physical exercise programs. Eur J Phys Rehabil Med. 2009 Sep;45(3):303-17. Epub 2009 Feb 23.

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