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Total hip replacement rehabilitation (THR)
- 1. 1 TOTAL HIP REPLACEMENT REHABILITATION DrJoe Antony Physical Medicine and Rehabilitation King George Medical University
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- 3. 3 Prehabilitation • Patient Education •Disease process • Procedure, expectations, and complications of THA • Expected functional recovery • Expected return to sports • Expected rehab protocol • Healthy lifestyle guidelines • Physical activity • Weight management • Smoking and alcohol cessation
- 4. 4 HIP SPECIFIC PREPARATION • Achieving maximumROM possible • Hip musculature and trunk strengthening • Balance training • Training to use mobility aids
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- 6. 6 PERI-OPERATIVE REHABILITATION Goals • Prevent hazardsof bed rest (DVT,PE, Pressure ulcer) • Assist patient with adequate and functional ROM • Strengthen hip musculature and trunk • Assist patient in achieving functional independence • Achieve independent ambulation with an assistive device
- 7. 7 Concerns with surgical approach Lateral or anterolateral Posterolatera lapproach Anterior Approach Minimally invasive Abductors incised and repaired Abductors preserved Technically demanding No evidence to suggest better outcome Weakness of hip abductors Higher rate of dislocation Require fracture table and intra operative fluoroscopy Higher risk of femoral fractures, wound healing problems, component malposition Poor repair can cause prolonged Dislocation can be prevented by
- 8. 8 Hip Precautions ◦ Precautionsto prevent dislocation- especially in posterolateral approach ◦ Dislocation happen when hip is adducted past midline ◦ Abduction pillow- between knee while in bed ◦ Between thighs while sitting ◦ In revisions or non compliant patients ◦ Knee immobilizers and Abduction Braces ◦ For 6 to 12 weeks post operatively ◦ After anterolateral Approach ◦ Extreme external rotation, adduction, and extention
- 9. 9 Weight bearing ◦ Non-weightbearing- Not recommended- muscle forces acting to maintain level pelvis is greater than TTWB ◦ Toe Touch Weight Bearing (TTWB)- More than 10% of body weight. Preferred initial weight-bearing method ◦ Partial weight bearing (PWB)- more than 30% body weight ◦ Full Weight-bearing
- 10. 10 Assistive devices ◦ Walkers– first choice- wide base, better stability ◦ Reduce the freedom of both hands- self care activites more challengning ◦ Occasionally wont fit through door ways ◦ Rolling walker- Better patient selected speeds, poorer stability compared to standard walker ◦ Axillary crutches or forearm crutches- better suited for younger patients, less stability ◦ Canes- used on contralateral side- offload 10-20% weight ◦ Only used in fully weight bearing
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- 12. 12 Home Discharge criteria ◦Independentambulation more than 150feet ◦Adherence to hip precautions ◦Achieving Basic functional activities of daily living
- 13. 13 Out Patient Protocol ◦Achieving full, allowed active ROM at the hip by the end of the sixth postoperative week. ◦ For example: hip flexion 90 degrees, hip abduction 40 degrees for the patient who has had a posterior approach surgery ◦ Additional ROM may be restored through stretching exercises once the physician’s postoperative precautions have been lifted. ◦ Progress functional strengthening; including closed kinetic chain and balance exercises. ◦ Independent ambulation by week 12 (and without the use of an assistive device for those who did not require their utilization preoperatively). ◦ Patient able to drive by the end of the sixth postoperative week. ◦ Patient able to assume side-lying on operative hip by the end of the sixth postoperative week. ◦ Return to most recreational/sports pursuits by the end of the twelfth week postoperative
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- 16. 16 Trendelenburg Gait ◦ Concentrateon hip abduction exercises to strengthen abductors. • Evaluate leg-length discrepancy. • Have patient stand on involved leg while flexing opposite (uninvolved) knee 30 degrees. If opposite hip drops, have patient try to lift and hold in an effort to re-educate and work gluteus medius muscle (hip abductor). • Walk stance weight shifts: In a walk stance position patient should shift weight forward over the involved hip until unable to control hip/pelvic drop and then shift back, progressing to full weight shift and weightbearing on involved limb over time as the hip abductor strength improves. • Manual or pulley resistance at the pelvis with lateral walking.
- 17. 17 Flexion contracture ofhip ◦ AVOID placing pillows under the knee aftersurgery. ◦ Walking backward helps stretch flexion contracture. ◦ Perform a Thomas stretch of 30 stretchesa day (five stretches six times per day). Pull the uninvolved knee to the chest while supine. Push the involved (postoperative) leg into extension against the bed. This stretches the anterior capsule and hip flexors of the involved leg.
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- 19. 19 ◦ Most gaitfaults either are caused by or contribute to flexion deformities at the hip. ◦ These faults generally are attributable to the patient’s attempts to avoid extension of the involved hip because such extension causes an uncomfortable stretching sensation in the groin.
- 20. 20 Asymmetric steps ◦ Largestep with involved side – to avoid extension on involved side ◦ Auditory cues while gait training to have symmetric steps
- 21. 21 Early heel offand knee flexion in late stance ◦To avoid hip extention ◦Auditory cues during gait training to keep heel on ground during late stance
- 22. 22 Trunk flexion inlate stance ◦ To correct this, teach the patient to thrust the pelvis forward and the shoulders backward during mid and late stance phase of gait
- 23. Thank you References 1. Orthopedicrehabilitation, 4th edition, Brotzman 2. IAPMR textbook of PMR