Total Hip Replacement Management - Physiotherapy

By Jonathan Blood Smyth

Human populations are ageing across the world, particularly in developed countries such as the USA, Europe and Japan, with some developing countries such as China set to follow them over the next decades. This will place a large burden on physiotherapy and medical services as countries struggle to cope with steadily increasing levels of osteoarthritis (OA), an age-related degenerative condition. OA is responsible for significant levels of medical expenditure, disability, pain and work loss and provision of services such as joint replacement will be a challenge. Quality of life improvements after medical interventions vary but for joint replacement are some of the highest of all medical procedures.

Of all medical interventions, joint replacement has one of the highest increases in quality of life, transforming a person's mobility, outlook and independence. Developed in the 1960s to a level where mass treatment was feasible, total hip replacement has matured into a predictable and successful treatment for OA with very good results stretching to 15 years and beyond. Conservative treatments are the mainstay of management of OA but once it becomes severe hip replacement is the only option.

It is used to manage a variety of complex hip conditions with excellent outcomes at fifteen years and beyond.

Post-operative physiotherapy consists of reviewing the operation note and the medical observations, assessing the patient and instructing them in breathing and leg exercises. The physio assesses the sensibility and muscle power in the legs to exclude problems such as nerve injury, although an epidural can cause temporary loss of feeling and power in the lower body and delay mobilisation. The next physio job is to get the patient up out of the bed with an assistant, stand and walk them as appropriate with elbow crutches or a frame, taking account of the necessary precautions to avoid dislocation.

Toes, ankles, quadriceps, hip flexion and buttock exercises continue to restore normal muscle activity to the legs and maintain the circulation. Routine painkillers should be taken as this helps patients get up and about and once safe they can get up three times a day or more with a helper to walk, toilet and wash. Usual precautions are taken and when sat out the chair must be the correct height and normally patients do not put their feet up whilst sitting.

After hip replacement patients require instruction and correction to achieve a normal walking pattern, develop muscular power and improved function. Physiotherapists teach the appropriate gait at the time, often starting with "step to" where the patient moves the walking aid, steps the operated leg forwards and steps up to it with the other leg, a stable and safe pattern. Progression is to 'step through" where the unaffected leg steps beyond the other in an approximation of a normal walking pattern. Patients often progress naturally then to a gait where they move both the crutches and the affected leg forward at the same time and start to walk in a fully natural pattern.

Six weeks or so after the operation the patient will have a good gait, have reasonable muscle power and be able to do most functional activities such as a walk, climb stairs and ride in a car. They may then move on to a stick if stability or balance is difficult or the person is very old. Patients can now return to normal activities but need to maintain the hip precautions:

* Avoid hip flexion over 90 degrees by not sitting down in low seating, not sitting down or standing up too quickly, not bending over to the floor quickly and not crouching.

* Standing on the operated leg and rotating the body is risky.

* Don't flex the hip suddenly or above 90 degrees, such as by sitting in a low chair, sitting down too fast, crouching or leaning forward quickly to the feet.

* If an infection develops, for example chest, teeth or bladder, then the doctor should be informed as infections can settle in an artificial joint. - 32188

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