REHABILITATION AFTER SURGERY
Mont MA, Tankersley WS, Hungerford
DS: In: Rehabilitation Secrets. Young MA, O'Yang
B, Steins SA, (eds). Hanley
and Belfus, Philadelphia, pp.
What is a hip arthroplasty?
hip arthroplasty is a replacement of damaged or arthritic
surfaces of the hip joint with materials to restore the
integrity of the joint. Most often materials are made of
metals and plastics.
How do total arthroplasty and hemiarthroplasty differ?
total hip replacement resurfaces both the femoral head and
acetabulum. A hemiarthroplasty only resurfaces the femoral
head. It is often used for displaced femoral neck fractures.
What are the indications for these procedures?
main indications are to relieve pain caused by arthritis,
correct deformity, and restore range of motion (ROM) and
function. More specifically, candidates for hip replacements
have severe degenerative changes on their hip x-rays and
the failure of nonoperative treatment to relieve their pain.
Nonoperative methods include anti-inflammatory medications,
the use of a cane, These methods should be used for 3-6
months before considering a hip arthroplasty.
after certain types of hip fractures, the procedure of choice
may be hip replacement. This option is chosen when the fracture
cannot be repaired or repair has little chance for clinical
success, such as in an 80-year-old with a severely displaced
femoral neck fracture.
What are the causes of osteoarthritis in the hip that progresses
to a total hip replacement?
primary osteoarthritis (approximately 70%)
capital femoral epiphysis
of trauma leading to joint incongruity
dysplasia of the hip
is no proof that other factors such as obesity, occupational
hazards, or a long history of jogging are risk factors for
to a hip replacement.
How many hip arthroplasty procedures are performed in the
United States annually?
How successful are these operations?
1 year, approximately 95% of patients can expect a good
to excellent clinical result, with minimal to no pain, the
ability to walk >1 mile, increased ROM, as well as patient
satisfaction with the procedure. These results are generally
maintained at 6 to 10 years after the procedure. There is
about a 1% failure rate per year, yielding about a 90% success
rate at 10 years.
Can patients develop allergies to the materials used to
construct hip replacement components?
reactions to these metal and plastic components are essentially
How are the components fixed to bone?
components can be cemented with polymethylmethacrylate or
affixed with noncemented methods such as press-fit and biological
ingrowth prostheses. For a press-fit prosthesis, the component
is placed in direct contact with bone, and the bone is finely
machined to ensure an exact fit. In biologic ingrowth prostheses,
components have a porous or meshed surface that allows bone
to grow into the interstices, achieving true biologic fixation.
Does the mode of fixation affect rehabilitation?
patients after hip surgery are kept on partial weight-bearing
for 6 weeks. In theory, patients with cemented prostheses
are capable of bearing full weight immediately after surgery.
The cement has reached 90% of its strength some 10-15 minutes
mixing. Patients who have a porous ingrowth prosthesis should
be on protected weight-bearing for up to 12 weeks, as this
allows time for the bone to grow into the pores of the component.
Should the physiatrist be aware of the surgical approach
used in a hip arthroplasty?
and Yes. The lateral approach involves splitting
the abductors with repair back to the greater trochanter
or trochanteric osteotomy with repair of the osteotomy.
In either case, the repair needs 6-8 weeks to heal. The
abductors (gluteus medius and minimis) are most commonly
weakened and should be a target of strengthening.
posterior approach involves splitting the gluteus
maximus and releasing the short external rotators which
are repaired. The hip extenders and the short external rotators
are affected and should be targeted. Concentric strengthening
can be started earlier. The rehabilitation specialist should
be wary of the higher incidence of posterior dislocation
with this approach. In addition, the hip flexors, quadriceps,
and hamstrings should all be strengthened after hip replacement.
How long will patients have significant pain after hip surgery?
patients recognize within 1-2 days after surgery that their
pain is markedly different than preoperatively. The arthritis
pain is typically eliminated immediately. The surgical pain
can last for 2-3 weeks but progressively gets better after
the first 1-2 days.
pain, especially after activities and ambulation, can persist
for several months or more depending on various factors,
such as the preoperative deformity or degree of muscle atrophy.
It may take many months to rebuild the required muscle mass
and strength to reduce this activity-related pain.
Can patients return to playing sports after hip replacement
patients can return to playing low-impact sports, such as
golf, doubles tennis, and bowling, walking, and using such
exercise machines such as stationary cycles and cross-country
ski simulators. High impact exercises such as running, singles
tennis, basketball, volleyball, and football should be avoided,
as this may lead to excessive wear of the prosthesis (unless
you are Bo Jackson).
How long will a total hip last?
this will vary from patient to patient, many large series
show continued good to excellent results of >90% of patients
at 10 years. Hopefully future hip replacements will last
What is the most common cause for failure in a patient with
total hip arthroplasty?
The young, very active, and obese people are at high risk.
Evidence of loosening can be detected radiographically in
5-30% of cases at 10 years.
When will the patient receive full benefit after hip arthroplasty?
by 3 months, the patients have regained most of their strength
across the joint as well as ROM. They continue to improve
throughout the first year after surgery. Usually, by 1 year,
the patient has achieved full benefit from the operation.
Describe a general management approach in a patient with
total hip arthroplasty.
breathing exercises, incentive spirometry
ankle ROM exercises
muscle isometrics depending on surgical approach
hips in abduction
assisted and knee flexion exercises as tolerated
ambulation with a walker or crutches; initiate progressive
total hip replacement
ingrowth total hip replacement
weight-bearing for 6 wks.
advance to weight-bearing as tolerated
secure reattachment, start weight-bearing as tolerated;
if tenuous, partial weight-bearing Instruct hip
energy conservation and work simplification techniques
assisted exercise, progress to active ROM motion and
adaptive ADLs without violating hip precautions
day 7-3 mos
strengthening and ranging of the trunk, hip, and knee
kinetic chain exercises
endurance and gait pattern
the use of assistive devices
therapy, bicycling, long-distance walking, progressive
stair climbing, and isotonic exercises with weights
on level and location of pain, daily walking distance,
sitting or standing duration, use of assistive
devices, method of stair climbing, use of analgesics,
and community reintegration
How long should a patient maintain total hip precaution?
12 weeks after the procedure. This allows for a pseudocapsule
to reform. The incidence of dislocation is reduced by >
95% after 12 weeks.
How should a patient ambulate stairs after hip surgery?
with the good and down with the bad." When going up
stairs, the patient leads with the nonoperative extremity
and then follows with the crutches and operative extremity,
taking one step at a time. When descending, the patient
leads with crutches and the operative extremity and then
follows with the nonoperative extremity.
What are the most common cause of falls after hip surgery?
falls are caused by decreased visual acuity and a decrease
in balance sensation that occurs in the elderly population.
With this in mind, accident prevention tips should be stressed
while the patient is on a rehabilitation service, and in-home
visit for safety should be considered. Fall prevention should
include measures such as ensuring that are well lit in the
patients home; avoiding throw rugs on floors; and
avoiding thick carpets, which may cause stumbling Finally,
the patient should have a well-lit and easy path from the
bed to the bathroom, as many falls occur when patients get
up at night to visit the bathroom.
Do patients need prophylaxis for deep venous thrombosis
after hip replacement?
incidence of deep venous thrombosis measured by Doppler
studies or venograms after hip surgery is > 50% in most
reported series. It is therefore considered the standard
of care to give some form of prophylaxis for deep venous
thrombosis after hip surgery. This prophylaxis can include
mechanical adjuncts, such as support hose and pneumatic
compression devices, which should be continued throughout
the course of the hospitalization. In addition, many surgeons
give some form of pharmacologic prophylaxis, such as warfarin.
weight supported through the affected limb is measured by
placing the limb on a weight scale and applying force on
of body weight
Up to 20% of body weight
20-50% of body
50-100% of body weight
100% of body weight
When can patients bear full weight after hip surgery?
are typically kept on partial weight-bearing for 6-12 weeks.
Most patients will walk with crutches or a walker with foot-flat
weight-bearing on the operative side for the first 6 weeks.
Foot-flat weight-bearing allows 50-60 lbs to be placed across
the hip joint during this time. Patients are rapidly progressed
from a walker or crutch ambulation to cane ambulation for
an additional 4-6 weeks and then to weight-bearing without
an ambulatory assistive device usually after 3 months.
period of partial weight-bearing is necessary to accomplish
allows the soft tissues to heal adequately.
allows for the muscles to reattach firmly to bone or
for the trochanteric osteotomy to heal.
allows more adequate time for bone ingrowth to be achieved
if the patient received bone-ingrowth prosthesis.
What are the dangerous positions to move the hip after hip
are four basic positions to be avoided after hip arthroplasty,
particularly for the first 3 months.
flexion of the hip past 90° with respect to the
axis of the body
adduction of the leg past the midline of the body
combined extension of the hip joint with external rotation
of the lower extremity
flexion with internal rotation
Why should abduction pillows be utilized? For how long?
of the abduction pillow prevents the patient from getting
into positions that could cause dislocation of the hip prosthesis
(adduction, internal rotation). The pillows should be used
after all total hip arthroplasties while the patient is
sleeping or resting in bed.
pillows are typically worn for 6-12 weeks. At the end of
that time, a pseudo-capsule has formed around the hip joint,
and the musculature is usually sufficiently strengthened
to allow proprioceptive control and stability of the joint
itself. Patients who have had previous hip surgery are at
higher risk for dislocation and frequently require abduction
What ranges of motion of the hip are allowed after hip arthroplasty?
patients are allowed to flex the leg to 80 - 90° and
to extend it fully. They are allowed gentle (20 30°)
internal and external rotation of the lower extremity. They
are also allowed passive abduction as tolerated. Active
abduction should be avoided for the first 6 weeks in patients
who have undergone a lateral approach.
What is are the sequence of ambulatory aids usually given
to patients after total hip replacement?
the first day or two, the patient usually works in physical
therapy on the parallel bars. He or she is then progressed
to crutches or a walker for the first 6 weeks. The patient
is then advanced to one crutch or cane, which is continued
for an additional 6 weeks. Greater than 70% of patients
are ambulatory without an assistive device at the end of
Give four goals of occupational therapy after total hip
reestablish basic activities of daily living (ADL) with
modifications that keep the patient's ROM within restricted
teach joint protection
review fall risks
provide equipment with training.
What special devices are used to achieve modified independence
toilet seats, shower seats, shoe horns, elastic shoe laces,
reachers that allow socks to be pulled on, and other devices.
Are resisted concentric exercises important after hip or
exercises against resistance should be avoided for the first
6-8 weeks. During that time, the patient can perform isometrics
and active ROM exercises against gravity. After the first
6-8 weeks, resisted open kinetic chain strengthening can
start in the place of joint motion with 1-10 lbs. Exercises
performed with heavy weights against resistance cause undue
wear on the prosthetic components.
What about sex after joint replacement?
Many people express a concern about a dislocation or damage
to the prosthesis while having intercourse after a hip replacement.
After 10-12 weeks the pseudocapsule has reformed around
the hip joint, and the muscles typically have been rehabilitated
so that the risk of a dislocation or damage to the prosthesis
is negligible. Certainly, for patients who have had to cease
coitus because of pain or a loss of ROM prior to hip surgery,
the return of sexual activity should be one goal postoperatively.
Where are the most frequent sites of hip fracture in the
neck and the intertrochanteric and subtrochanteric areas.
What are the surgical indications and rehabilitations for
the various hip fracture types?
fracture (Garden III and IV)
and impacted fractures (Garden I and II)
on the stability of surgical fixation
displaced two-part fractures, or unstable three-part
operatively with multiple pins or screws and side-plate
on degree of fracture stabilization, bone stock, patients
frailty, and risks of immobility
fragmented, or comminuted
with a blade plate and screws or an intramedullary
until fracture demonstrates evidence of healing
= open reduction and internal fixation.
Are there negative predictors of ambulation after hip fracture?
of social support
Age >85 years
Poor prefracture functional status
What factors are associated with institutionalization after
to transfer or ambulate, incontinence, dementia, fewer hours
of physical therapy and lack of family involvement.
Name two major risk factors for hip fracture.
How can osteoporosis be prevented?
than 50% of hip fractures are thought to occur without a
precipitating trauma or fall and are presumbly secondary
to osteoporosis. Proper calcium intake, weight-bearing exercise,
and hormonal replacement at menopause are beneficial in
preventing osteoporosis. Reducing the risk factors for osteoporosis,
such as smoking, alcohol use, and caffeine intake, are also
helpful. For more progressive osteoporosis, one might consider
calcitonin, calcitriol, and/or biphosphonates therapy. (See
also the chapter on osteoporosis).
What factors are associated with an increased risk of falls?
of falls cannot be overemphasized in the elderly. Factors
that increase the incidence of falls include lower-limb
impairment such as weakness and ankle/foot problems, gait
abnormalities, use of multiple medications, balance disorders,
dementia, visual impairment, previous history of falls,
Parkinsons disease, and palmomental reflex.
How commonly does avascular necrosis occur?
hip disease annually afflicts about 5,000-10,000 young adults
under age 45 years old and causes bone in the femoral head
to die. Untreated, it leads to disabling hip arthritis and
accounts for approximately 10% of the hip replacements that
are performed in the United States each year.
What are the causes or associated factors for avascular
many cases in the population over age 60 years, femoral
neck fractures will impair the blood supply of the femoral
head and lead to avascular necrosis of the femoral head,
necessitating hip replacement. In other cases, there is
no recognized direct cause-and-effect relationship, but
the disease is associated with various factors. These factors
include steroid use and alcohol use, which account for about
90% of the known causes of avascular necrosis in the patient
population under age 45 years.
Conditions Associated with Avascular Necrosis
systemic lupus erythematosus
and other anemias
from Mont MA, Hungerford DS: Non-traumatic avascular necrosis
of the femoral head. J Bone Joint Surg 77A:459-474, 1995.
Describe a rehabilitation program for a patient with avascular
rehabilitation program includes exercise, pain control,
and joint protection techniques. Isotonic exercises, such
as straight-leg raising, that distribute the stress through
the hip joint must be avoided. Gravity-eliminated active
assistive exercise, such as pool therapy and isometric exercises,
can improve hip ROM and strength.
What is the prognosis for patients with avascular necrosis
treated with nonoperative modalities that restrict weight-bearing?
studies have reported >90% progression of collapse and
the need for total hip replacement within 4 years.
FA Jr, Wheeler HB: Natural history and epidemiology
of venous thromboembolism. Orthop Rev 23:5-9, 1994.
AJ Jr, Walker MW, Kilfoyle RM, et al: Experience with
bipolar prosthesis in hip arthroplasty: A clinical study.
Orthopedics 8:460-467, 1985.
VA, Hinderer SR, Alpiner N, Oh TH: Rehabilitation in
joint and connective tissue diseases: Limb disorders.
Arch Phys Med Rehabil 76 (Suppl 5):S-47-S-56.
DM, Grobbelaar CJ, Learmonth ID, Dall G: Charnley low-friction
arthroplasty of the hip: Long-term results in South
Africa. Clin Orthop 211:85-90, 1986.
CA, Bobyn JD, Glassman AH: Porous-coated hip replacement:
The factors governing bone ingrowth, stress shielding,
and clinical results. J Bone Joint Surg 69B:45-55, 1987.
JC: High-risk factors and diagnostic challenges associated
with venous thromboembolic disease. Orthop Rev 23:10-16,
W.H.: Factors controlling optimal bone ingrowth of total
hip replacement components. In AAOS Instructional Course
Lectures, vol 35. Park Ridge, IL, American Academy of
Orthopaedic Surgeons. 1986, pp 184-187.
BF, Ilstrup DM, Fitzgerald RH Jr: Revision total hip
arthroplasty. J Bone Joint Surg 67A:517-526, 1985.
KA, Mont MA, Maar DC: A new neck preserving total hip
arthroplasty for the young patient. Orthopaedics 17:253-259,
PF, Rosenstein BD: Long-term results of Harris total
hip replacement. J Arthroplasty 1:229-236, 1986.
GS, Vedel P, Nielsen PM: Fractures of the femoral neck
treated with a bipolar endoprosthesis. Clin Orthop 218:63-67,
RL, Capozzi J, Mont MA: Intertrochanteric hip fractures.
In Browner BD ed): Skeletal Trauma, Philadelphia, W.B.
MA, Hungerford DS: Non-traumatic avascular necrosis
of the femoral head. J Bone Joint Surg 77A:459-474,
Institutes of Health Consensus Conference: Prevention
of venous thrombosis and pulmonary embolism. JAMA 256:744-749,