Rehabilitation After Hip Surgery
Robert E. Mayle Jr. and James I. Huddleston III.
Key Points
Introduction
Surgical treatment options for hip pathology include arthroplasty, resurfacing, arthroscopy, osteotomies, and fracture care. Rehabilitation after hip surgery is a crucial part of a patient’s recovery. In this chapter, we will focus on key components of rehabilitation of the patient following arthroplasty, arthroscopy, and osteotomy.
Rehabilitation is the field of medicine that focuses on return of function after illness or injury. Rehabilitation is coordinated by a team consisting of physical and occupational therapists, orthopedic surgeons, physical medicine and rehabilitation physicians, nurses, and ancillary staff. Successful rehabilitation addresses the physical and psychological challenges faced by the patient. Rehabilitation should not be limited to activities that occur postoperatively, as events and activities that occur preoperatively may influence outcomes. The goal of rehabilitation is to maximize functional outcomes and improve an individual’s ability to perform activities of daily living in a timely fashion after treatment has been rendered.
Hip Arthroplasty
Hip arthroplasty is one of the most successful and cost-effective operations performed, reliably leading to pain relief, increased function, and return to activity. Rehabilitation is directly related to the success of the procedure, as it allows a patient to gain maximal functional performance and improves his or her ability to perform activities of daily living. Common impairments that patients face following arthroplasty include pain, range-of-motion limitations, muscular weakness, and postoperative protective restrictions (positional and weight-bearing precautions). Maximal beneficial effects of rehabilitation are seen by 3 to 6 months following surgery, yet some patients are able to make continued improvement up to 2 years postoperatively.
Projected demands for total hip arthroplasty (THA) are expected to increase by 174% by the year 2030.1 Although the average length of stay in the acute hospital setting has decreased substantially over the past 15 years to average 4.2 days after hip arthroplasty,2 demands to discharge patients earlier are increasing.
Components of Rehabilitation Education
Preoperative education of patients undergoing THA is effective in preventing early dislocation, deep venous thrombosis, and pulmonary embolism, and in decreasing preoperative anxiety.3,4 However, as noted by a review conducted and published in 2004 by the Cochrane Database, although preoperative education led to a decrease in preoperative anxiety, no benefit was derived in terms of functional outcomes, postoperative pain, reduction in length of hospital stay, or change in postoperative anxiety level.3
Patients’ concerns and expectations vary widely.5 Anxiety prior to THA is common and can be reduced by making the unknown familiar.6 This can be accomplished by allowing patients to meet the staff that will care for them, introducing them to the hospital environment, and addressing the experiences that the patient will encounter postoperatively.6 This can also include a discussion of the surgeon’s approach to obstacles that may be encountered in the perioperative period.
The patient’s preoperative concerns may differ from those of the surgeon.5 Although a positive correlation of preoperative with postoperative functional outcomes may be lacking, patients’ expectations should not be underestimated, as they are linked to requests for elective, costly procedures and correlated with assessments of outcome.7
Preoperative Exercise
Osteoarthritic hips are painful and lead to reduced muscle strength, difficulty with performance of activities of daily living, and a decline in preoperative function.8 In a study conducted by Lavernia and associates, a correlation between preoperative function and postoperative function was noted in patients undergoing total hip or knee arthroplasty.9 Specifically, patients who had more extreme functional limitations preoperatively did not fare as well as those whose functional levels were better.
The goal of a preoperative exercise program is to enhance range of motion, muscle strength, and overall physical function.10 Despite this, the effectiveness of a preoperative physiotherapy program remains controversial. Grocen and associates,11 Wijman and coworkers,12 and Ferrara and colleagues13 published reports noting no significant difference in Harris Hip Scores, Barthel Index, SF-36 scores, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, hip abduction, pain, length of hospital stay, and time to stand/walk/climb a stair. To the contrary, Wang and associates14 and Rooks and colleagues15 reported significant differences in preoperative strength and functional status following a short preoperative exercise protocol. Additionally, significant postoperative differences were observed in gait velocity, stride length, and walking distance, along with a reduction in the odds for discharge to inpatient rehabilitation. As proposed by D’Lima and coworkers,16 this discrepancy may be due to three issues: (1) the duration of preoperative physical therapy may be insufficient for any substantial gains to be seen, (2) the dramatic improvement in symptoms following surgery may overshadow any small gains made preoperatively, and (3) the act of surgery deconditions the function of the extremity and erases any preoperative improvement. Additional studies are required to quantify the potential benefits of a preoperative exercise program.
Surgical Exposure
In recent years, an increase has been seen in patient and market demand for the least invasive form of THA.17 Procedures performed using a certain technique or with a skin incision <10 cm are often defined as less invasive.10 Advocates of less invasive procedures purport that a patient’s rehabilitation is expedited, along with a reduction in soft tissue trauma, shorter intraoperative time, less perioperative blood loss, less postoperative pain, improved cosmetic appearance, and earlier discharge from the hospital.18 Despite this, there is a paucity of studies that support expedited rehabilitation. In a review performed by Sharma and associates,10 five studies were identified that pertained to the effects of a less invasive approach to THA on rehabilitation. Dorr and colleagues18 and Pagnano and coworkers19 noted that patients who underwent a less invasive approach had better pain control, earlier discharge home, earlier discontinuation and less usage of assistive devices, and faster return to activities of daily living. In contrast, Ogonda and associates20 identified no significant difference in early walking ability, length of hospital stay, and functional outcome. Pour and colleagues21 performed a randomized study of 100 patients undergoing the anterolateral approach for THA and evaluated the effects of an accelerated rehabilitation protocol and the length of the incision. Functional improvement at time of discharge, patient satisfaction, and walking ability at the time of discharge were better in patients who received the accelerated rehabilitation protocol, regardless of the size of the incision.
Perioperative Pain Management
Pain management directly correlates with patient satisfaction following THA.22 Effective perioperative management of pain is critical to the recovery of a patient following hip surgery. Consequences of uncontrolled postoperative pain include prolonged hospital stay, increased incidence of readmission, decreased range of motion, arthrofibrosis, potential for medicolegal action, and increased opioid use with possible side effects of nausea and vomiting.23 Currently, no gold standard exists for perioperative management of pain following THA. In recent years, the development of a multimodal approach to pain management has gained much attention. Maheshwari and associates defined multimodal analgesia as a multidisciplinary approach to pain management with goals to maximize analgesic effects and minimize potential side effects of medications.23 Analgesic methods for perioperative pain control include general or regional anesthesia, neuraxial analgesia, intraoperative periarticular injection, intravenous and oral narcotics, and preemptive analgesia. Preemptive analgesia effectively limits the sensitization of the nervous system to noxious stimuli by producing dense blockade of the transmission of a noxious afferent stimulus from the peripheral to the central nervous system for the appropriate duration.24 Effective multimodal perioperative analgesia has been demonstrated by Peters and colleagues25 to cause a significant reduction in rest pain scores, total narcotic consumption, and hospital length of stay, along with improvements in distance ambulated and time to achieve therapy goals.
Functional Activities
Dislocation
Dislocation following primary THA is a common complication and an important problem, occurring in 0.2% to 7% of patients. Instability is also an important mode of THA failure, with 10% to 25% of patients undergoing revision THA for this complication.26,27 Fifty percent of dislocations following primary THA occur within 3 months of the index procedure, and 75% may occur within 1 year.28 Surgical factors affecting the potential for dislocation include approach, implant selection and position, soft tissue tension, and experience of the surgeon. Patient factors include neuromuscular disorders, alcoholism, cognitive disorders, noncompliance, and history of previous hip surgery.
In the rehabilitation phase preceding and following THA, education and instruction regarding hip precautions can help to reduce the risk of dislocation. A surgical approach to the hip dictates these precautions. The surgical approach is classified on the basis of its location relative to the anatomy of the hip. Most THAs are performed from a posterolateral approach. This approach leads to minimal trauma to the abductor complex. Implantation of larger femoral heads and repair of posterior soft tissue structures are believed to reduce the risk of dislocation.29–32 Patients in whom the posterolateral approach was used must be instructed not to internally rotate, adduct, or flex their hips more than 70 to 90 degrees. The most common scenarios in which dislocations occur after a posterolateral approach to the hip include bending down from a seated position to tie shoes, getting off a low toilet or chair with the hip adducted and internally rotated, and twisting the trunk toward the operative side with the feet planted in sitting and standing positions.33 A direct lateral approach to the hip requires partial takedown of the glutei musculature. This has been associated with prolonged postoperative weakness of the abductor complex. A transtrochanteric osteotomy approach through the greater trochanter will require that patients avoid active abduction of the hip while the osteotomy heals. Patients who undergo an anterior or anterolateral approach to the hip, in which the anterior capsule is violated, should be instructed to avoid hyperextension, adduction, and external rotation to prevent dislocation.
Preoperative and postoperative education regarding hip precautions is crucial for patients’ understanding and compliance. The duration of hip precautions varies and depends on both the surgeon and the patient. Uncomplicated patients should adhere to precautions for 6 weeks; more complicated patients who are at higher risk for dislocation should observe precautions for 12 weeks.34
In an attempt to prevent patients’ operative extremities from moving into a position that would make them vulnerable to dislocation, many physicians advocate functional restrictions, in addition to hip range-of-motion precautions. Functional restrictions include placing an abduction wedge or pillows between the legs when in bed, using a knee immobilizer placed on the operative extremity,35 as well as higher chairs and toilet seats, and avoiding getting into and out of an automobile with low seats. Few studies, however, have evaluated the efficacy of the use of aids in helping to prevent dislocation. A recently published randomized prospective study, conducted to assess the efficacy of functional restrictions in preventing dislocation following THA from an anterolateral approach, revealed no increased benefit of functional restrictions.23 In addition, patients reported a higher level of satisfaction when functional restrictions were not placed.
Weight Bearing
Historically, full weight bearing on the operative extremity was permitted in patients who underwent THA with a cemented femoral component, while patients receiving cementless femoral components were restricted to partial weight bearing for 6 weeks. Restricted weight bearing in cementless femoral component fixation was thought to decrease micromotion of the stem, which may interfere with osseointegration. Early investigations examining immediate weight bearing following bilateral THAs with cementless femoral components, however, revealed that bone ingrowth can occur despite initial subsidence of the femoral stem.35,36 Woolson and associates reported their results following implantation of cementless, fully porous-coated collared femoral components, noting excellent bone ingrowth in patients allowed to bear weight immediately following THA.37 In this series, no patients exhibited evidence of radiographic subsidence of the femoral component at last follow-up (minimum of 2 years). In addition, at final follow-up, patients who were allowed to immediately bear full weight had a higher Harris Hip Score compared with patients who had restricted weight bearing immediately following surgery. Similar results were demonstrated in a recent study by Klein and coworkers with a minimum of 5-year follow-up using the Fiber Metal Taper Stem (Zimmer Inc., Warsaw, Ind), a cementless, collarless, proximally coated, distally tapered femoral implant.38 Duration of hospital stay and postoperative rehabilitation were significantly decreased when patients were allowed to bear weight immediately after surgery.39 Partial weight bearing for a 6-week period is not a benign limitation and may slow and prolong a patient’s rehabilitation.36 Partial weight-bearing status leads to muscle atrophy of the operative limb and increased stresses placed on the upper extremities and the contralateral lower extremity.
Restriction of weight-bearing status may be unavoidable in instances where a fracture in the greater trochanter, femoral calcar, or shaft is observed intraoperatively, or when a trochanteric osteotomy is performed. In these instances, weight bearing should be restricted until the fracture or osteotomy site has healed. Patients should be allowed toe-touch weight-bearing status during this period. Non–weight bearing should be avoided, as this action requires the patient to hold the affected limb off the ground. This may place as much, if not more, force across the implants, as does full body weight.40
Assistive Devices
Restoration of balance and gait is a primary goal of any postoperative rehabilitation program following THA. Sensory input and functional changes that contribute to instability of the hip following surgery include excision of the capsule with damage to proprioceptors, abductor weakness, altered abductor lever arms, restricted range of motion, and potential changes in leg length.41 Assistive devices are a routine component of a patient’s postoperative rehabilitation, as they provide stability and promote restoration of gait. Canes, crutches, and walkers are examples of ambulatory assistive devices. They provide stability, augment muscle action, and allow for joint and soft tissue unloading. Assistive devices have a direct effect on a patient’s physical and psychological well-being. Improvement in confidence and safety allows for enhanced levels of activity and independence. Increased activity leads to prevention of cardiorespiratory deconditioning, enhanced circulation, and improved renal function.42 Selection of an assistive device should be based on evaluation of the patient’s balance, coordination, mental status, strength, age, weight-bearing status, other joint impairments, and purpose for use.
The cane is the most commonly used assistive device. A cane is lightweight and versatile and can be used to improve balance, transmit sensory input from the floor/ground surface, decrease joint reaction force on an arthritic hip, and reduce force on the prosthetic hip and incised abductor muscles.43,44 Use of a cane requires good upper body strength; a cane can support only 15% to 20% of body weight. A cane is most beneficial when there is unilateral lower extremity involvement or when physical impairment is mild. Correct use of a cane requires that it be held by the contralateral upper extremity. This can reduce the hip contact force by 60%.45 Ajemian and associates noted a decrease in the abduction moment by 26% and 28% on operative and nonoperative sides, respectively, when a cane was used on the contralateral side. In addition, they noted a decrease in the duration of contraction of the hip abductor musculature during gait.44 Proper fit of a cane requires that it come up to the ulnar styloid with the shoulder and elbow in a neutral position. Once held, the elbow should be flexed 15 to 20 degrees.43
Axillary crutches are versatile, allow for easy maneuvering of stairs, are associated with increased gait velocity, and can support full body weight. Disadvantages include balance instability leading to a fall and the potential for neurologic palsy if direct pressure is applied to the brachial plexus. Their use is often better tolerated in younger patients, who are more agile and are better able to control/maneuver the operative extremity. Proper sizing of axillary crutches should allow 2 inches between the armpit and the top of the crutch. This places the elbow in approximately 15 degrees of flexion.
Walkers are commonly used in the immediate period following hip arthroplasty. They provide a wide base to enhance stability with ambulation. Walkers are commonly used for patients with bilateral lower extremity weakness, balance disorders, or when greater body weight support is needed than can be provided by a cane alone. Walkers may come with two, four, or no wheels. Walkers without wheels provide the greatest support; however, they require more energy to use. The two-wheeled walker is the most commonly used model. The sizing of a walker is analogous to that of a cane.
In the early postoperative period, gait training should be provided with the use of a walker under the direction of a physical therapist. As strength, balance, and mobility improve, patients should be transitioned from a walker to crutches or a cane. Patients may expect to use a walker for 2 to 4 weeks or longer if needed. Delay in progression is often attributed to advanced age, multiple medical comorbidities, lack of work with physical therapy, lack of support at home, or the inability to control the operative extremity with less supportive assistive devices. Additional assistive devices that should be considered for a patient who has undergone THA include raised seats for a chair, a toilet, and the shower.43
Brace Wear
Dislocation after revision THA has a reported incidence of 10% to 25%.27 In an effort to mobilize patients immediately and safely following revision THA, a hip abduction orthosis may be prescribed. Efficacy of brace wear and prevention of dislocation continue to be controversial.
Hip abduction orthoses (Fig. 29-1) are customized for each patient, with consideration given to height, weight, waist size, widest part of the hip, and circumference of the affected thigh. Settings for patients at risk for posterior dislocation include a hip abduction angle of 15 degrees and allowance of 70 degrees for forward flexion of the hip. Patients at risk for anterior dislocation should be allowed hip flexion from 40 to 70 degrees. A knee-ankle-foot orthosis may be added to control and prevent rotation of the extremity.27
Figure 29-1 A through D, Hip abduction orthosis.
Hip abduction orthoses should be worn for 6 to 12 weeks, whenever a patient is out of bed. Comfort level, familiarity, and ease of application will directly influence a patient’s compliance with brace wear.
Postoperative Exercise
The postoperative rehabilitation of a patient after THA begins immediately in the acute hospital setting. However, the intensity and setting of rehabilitation will vary between patients. The nursing staff, physical therapists, and occupational therapists should begin to work with patients immediately postoperatively. Initial assessments should be performed once patients are medically stable. If a patient undergoes surgery in the morning, physical therapists may begin to mobilize the patient as early as the afternoon on the day of surgery. The nursing staff should encourage patients to get out of bed and sit in a chair at least two times per day for 30 minutes at a time. Occupational therapists may begin to work with patients to instruct and advise on proper maneuvers to perform activities of daily living.
Following hip surgery, physical activity and goals of therapy should consist of a graduated series of events (Table 29-1). In the immediate postoperative period, range of motion of the hip, knee, ankle, and foot of the operative extremity should be instituted (Figs. 29-2 and 29-3). Patients may begin with simple exercises such as foot/ankle pumps and ankle rotations. These can be followed by gluteal contractions, bed-supported knee bends, and abduction exercises. Once ready, patients should be encouraged to sit outside of the bed in a chair and/or to stand with assistance. Muscle strengthening of the operative extremity should focus on the hip abductors/extensors and the quadriceps, and can be performed in the supine or standing position. The goal of these exercises is to increase muscle strength and gain control of the limb. Gait training should focus on teaching patients to stand erect and walk comfortably. A walker should be used to aid in balance, support, and coordination. Assistive devices should be required until the patient is able to ambulate with a minimal Trendelenburg lurch and/or antalgic gait. Patients should be instructed on navigation of stairs. A side rail should be used with stair ascent and descent. Patients should always ascend stairs leading with their “good” or nonoperated leg and should descend stairs leading with their operative leg. Stairs higher than the standard height of 7 inches should be avoided.
Table 29-1
Exercises After Total Hip Arthroplasty*
| Exercise | Description | Frequency |
| Abduction | While supine, abduct hip and then return to neutral | 10 times, 3-4 times per day |
| Ankle pumps | Plantar/dorsiflexion of ankle | Ad lib |
| Ankle rotations | Internal/external rotation of ankle | 5 times each direction, 3-4 times per day |
| Bed-supported knee bends | Slide heel toward buttocks while lying in bed; avoid internal rotation of the knee | 10 times, 3-4 times per day |
| Buttock contractions | Tighten gluteal muscles and hold contraction for 5 seconds | 10 times, 3-4 times per day |
| Exercycling | While seated with no resistance, pedal backward; once a comfortable motion has been established, pedal forward; increase resistance once strength builds (4-6 weeks) | 10-15 minutes, 2 times per day; increase to 30-40 minutes 3-4 times per week |
| Quadriceps set | While supine, tighten quadriceps in attempts to straighten knee; hold for 5-10 seconds | 10 times, 3-4 times per day |
| Resistive hip flexion† | Stand with feet slightly apart, flex hip then return to neutral | 10 times, 3-4 times per day |
| Resistive hip abduction† | Abduct operative hip to one side, then return to neutral | 10 times, 3-4 times per day |
| Resistive hip extension† | Extend the operative hip, then return to neutral | 10 times, 3-4 times per day |
| Stair climbing/descending | Use a side rail for assistance; lead with nonoperated extremity going up the stairs; descend stairs with operated leg first | |
| Standing | Transition from supine to standing position | Ad lib |
| Standing hip abduction | With hip, knee, and foot pointing straight forward, abduct hip; slowly return to neutral | 10 times, 3-4 times per day |
| Standing hip extension | Keeping back straight, extend hip while keeping knee straight; hold for 2-5 seconds; slowly return to neutral | 10 times, 3-4 times per day |
| Standing knee raises | Flex hip and knee (avoid lifting knee higher than your waist); hold for 2-5 seconds; lower slowly | 10 times, 3-4 times per day |
| Straight-leg raise | While supine, tighten quadriceps, flex hip and keep knee straight while lifting extremity off bed; hold for 5-10 seconds; lower slowly | 10 times, 3-4 times per day |
| Walking† | Stand erect and comfortably, attempt to walk smoothly; cadence: heel-strike, foot flat, toe-off; aim to spend same amount of time on each lower extremity | 5-10 minutes, 3-4 times per day |
*Please adhere to postoperative restrictions imparted by your surgeon.
†Resistive exercises performed with an elastic tubing around the ankle of the operative extremity and attached to a stationary object; a chair should be used to help maintain balance.
†Please adhere to any weight-bearing restriction imparted by your surgeon.
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