Total hip arthroplasty has revolutionized the treatment of patients who have end-stage arthritis and has helped patients achieve marked improvements in pain and mobility often within 3 to 6 months after surgery (1). However, persistent gait impairment and functional limitations may result in disparity between standardized scoring systems such as the Harris hip score and patient-reported satisfaction rates (2,3). Furthermore, persistent limitations in patient activities may be present up to 2 years after the procedure and are usually secondary to decreased range-of-motion (ROM), loss of muscle strength, and postural imbalance following these procedures (4,5,6,7). With improved longevity of the modern-generation hip arthroplasty implants, younger and more athletic patients are now being offered this procedure. Moreover, recent advances in minimally invasive surgical techniques and improvement in the tribologic properties of newer bearings has led to increased demands for higher levels of activity and for the return to recreational sports such as single’s tennis, hiking, skiing, jogging, and running. However, most surgeons and rehabilitation specialists would allow less-impact activities such as doubles tennis, golf, light dancing, and gardening. Thus, clearly there remains a disparity between the clinicians’ and patients’ expectations of good functional outcomes after total hip arthroplasty (Table 31.1).

Marked muscle atrophy as evidenced by reduced cross-sectional area with selective type II muscle fiber loss and fatty infiltration (myoelastosis) is known to occur in the affected extremity in patients who have debilitating hip arthritis (7). In addition, there is selective atrophy of the gluteal muscles in patients who have hip joint arthritis, as well as variations in the patterns of atrophy based on the stage of the disease (8). In early osteoarthritis of the hip, it appears that the upper fibers (which originate from the posterior iliac crest) and lower fibers (which originate from the inferior sacrum and the upper lateral coccyx of the gluteus maximus) are not affected (8). However, more atrophy of the lower gluteus maximus occurs with advanced arthritis of the hip. The tensor fascia lata (TFL) is relatively unaffected in both early and advanced arthritis of the hip. However, gluteus medius muscle atrophy occurs in both early and advanced stages of osteoarthritis of the hip, while gluteus minimus and piriformis atrophy is only observed in advanced stages (8). Conventional nonresistance functional training without external loading following total hip arthroplasty usually leads to baseline return of muscle strength and function, but it may not prevent further muscle atrophy or recovery of muscle strength to pre-arthritic levels. This occurs because nonresistance training may lack the intensity needed to elicit muscle hypertrophy (9,10,11). Recent concepts of “fast track” physical therapy consisting of progressive resistance training (PRT) with sufficient intensity and dosage applied at an appropriate time can improve strength and lean muscle mass which can improve postoperative recovery following total hip arthroplasty. However, no clinical practice guidelines with detailed recommendations exist to help clinicians make informed decisions about the appropriate rehabilitation plans that may be beneficial for the patients. This emphasizes the necessity for further study but also suggests a carefully planned and targeted intensive rehabilitation protocol for patients undergoing total hip arthroplasty.

Overall, the rehabilitation protocol for total hip arthroplasty comprises four components with the ultimate goals of early ambulation, minimizing pain, maximizing ROM, and improving muscle strength. These include therapeutic exercises (ankle pumps, active hip flexion, quadriceps muscle, and gluteal muscle sets), gait training, transfer training (bed to standing and toilet transfer), and patient education about activities of daily living with instructions to prevent hip dislocation (12,13). There is a growing interest in conceptualizing this rehabilitation as a continuum, identifying individual health and psychosocial needs that are administered at various points before or after surgery, and this is commonly divided into the following phases (Table 31.2) (14).

More intense rehabilitation with the aim of increasing muscle strength, ambulation, independence in activities of daily living, returning to full functional activities, and returning to low-impact recreational sports is usually started 8 to 12 weeks after total hip arthroplasty.

The goals of the prerehabilitation phase would be to prepare patients for surgery with emphasis on (1) comprehensive education to prepare patients for the surgical and rehabilitation experience; (2) to address questions or concerns which the patients or their immediate family may have prior to the procedure and to reduce unrealistic expectations and improve satisfaction; (3) to organize the home environment and provide arrangements for social support; (4) to prescribe and train patients on the use of walking aids; (5) to address co-morbidities and optimize patients prior to surgery; and (6) put in place an individualized education program in-keeping with the level of de-conditioning secondary to pre-existing medical conditions and degenerative joint disease.

A variety of materials in form of print, audio–visual, and interactive sessions are recommended for use by health care professionals for providing preoperative education to patients undergoing total hip arthroplasty. Gill and McBurney (15), in a recent systematic review, reported improvement in pain and physical function in patients waiting for hip arthroplasty with preoperative exercise–based interventions. McDonalds et al., in a Cochrane review on the effect of preoperative education on outcomes, reported a reduction in the preoperative anxiety and a moderate beneficial effect on postoperative anxiety; but the effect was noted to be small and was not supported by some studies. Nevertheless, the beneficial effect of preoperative education was found to be higher when intervention was targeted to patients most in need of support, such as those who were disabled or in need of social support. However, the impact of preoperative education on pain, functional outcomes, length of stay, and postoperative outcomes was inconclusive (16). Wallis and Taylor in a systematic review of low-to-moderate level evidence studies reported that preoperative education programs combined with land-based exercise regimens resulted in short-term improvement in function and activity at 3 weeks postoperatively in patients undergoing total hip arthroplasty. However, they reported no beneficial effect regarding health care utilization as evidenced by the length of stay or discharge destination (17).

Researchers have found that patients who had a timed up and go test (TUG test) of greater than 10 seconds preoperatively usually have poorer outcomes and ambulation scores after total hip arthroplasty (18). In these patients, it becomes critical to identify factors affecting the TUG such as muscle-strength, balance and/or coordination, and to address some of these issues preoperatively to achieve better postoperative functional outcomes. Thus, identifying patients using a variety of functional tests (e.g., stair ascent time test, time taken for repeated chair rise, single limb stance time, 6-minute walking distance) and categorizing them so that targeted rehabilitation can be performed postoperatively may be beneficial. These functional tests also help clinicians identify and stratify patients into different
rehabilitation groups so that they then can have an individualized prerehabilitation program customized to their needs.

This phase usually lasts for the first 3 to 4 days after surgery prior to discharge from the hospital. The increasing interest among patients and third-party payers to decrease the length of hospital stay has led to the multidisciplinary “team approach” involving surgeons, anesthetists, nurses, physical therapists, occupational therapists, and discharge planners to develop rapid rehabilitation or “fast-track” clinical pathways (19,20). Most physical therapy services for inpatients are offered 6 days a week, with a select group of high-risk patients having surgery on Thursday or Friday requiring rehabilitative care on Sunday as well.

Although physical therapy protocols are mostly similar, the goal of any acute care rehabilitation program involves early mobilization, muscle activation, gait training, as well as improving active, and active-assisted ROM. This is usually started on the day after surgery. For patients undergoing surgery before noon, it may be beneficial to have the first physical therapy consultation on the day of surgery without increasing the risk of complications (21). Muscle strength is known to decline by 4% per day during the first week of immobilization after major surgery, which exemplifies the need to start rehabilitation as soon as possible after surgery (22). Munin et al. (21) in a prospective randomized trial (n = 71), reported that patients who received earlier inpatient rehabilitation care (postoperative day 3) had shorter length of stays, achieved more rapid attainment of short-term functional milestones, and independence as compared to patients who started rehabilitation later (postoperative day 6).

During the inpatient phase, emphasis should be placed on multi-modal pain management, thromboprophylaxis, and preventing any perioperative complications such as postoperative nausea and vomiting, delirium, and anemia. Moreover, bowel and bladder training, independence in self-care, transfer training, and postdischarge care plans are started during this rehabilitative phase (23). Daily physical therapy is recommended, with “at-risk” patients (diabetes mellitus, preoperative stiffness, other co-morbidities) benefitting from twice-daily visits by the physical therapists. The treatment program involves supine-to-sit, sit-to-stand, bed-to-chair transfer, and stair climbing. A variety of exercises including deep breathing, and isometric sets of gluteal, quadriceps, and ankle pumps are recommended during this phase. During days 2 to 4 of the in-hospital stay, instructions regarding hip precautions, supervised ambulation with assistive devices, and training with respect to appropriate weight-bearing are provided to all patients. Other factors taken into account when prescribing walking aids include balance, active ROM, and pain. Ambulation is started with rolling walkers and gradually progressed to bilateral crutches. These assistive devices improve biomechanical stabilization and somatosensory feedback by transferring stabilization forces to the hands (24

Stay updated, free articles. Join our Telegram channel

Join