Total Hip Replacement Management – Physiotherapy

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.

Medical interventions can be rated on a scale which calculates the improvement in quality of life which results and here hip replacement comes out top of all treatments. The 1960s saw its development into a standard treatment for hip arthritis but the 21st century has seen the technique evolve into a complex and predictable approach to many hip conditions, with excellent fifteen year plus results. Once conservative treatments have been exhausted due to a worsening joint then joint replacement becomes the standard choice.

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

On return from operation the physiotherapist will check the patient\’s operative record, medical observations and assess the patient. Initial physio treatment consists of checking respiratory status and the muscle power and feeling in the legs to exclude nerve injury. Exercises are given to restore normal movement although an epidural can cause loss of movement in the legs and delay progress. The physiotherapist will then mobilise the patient with an assistant, taking care of the hip precautions, stand them up and walk them a short distance with elbow crutches or a frame.

Assessment of leg muscle function and sensory ability is important to exclude nerve injury and the physio will give leg exercises to get the limb moving, although an epidural can slow this process by reducing power and feeling for a while. The patient will be mobilised up into walking by the physiotherapist and an assistant, using a frame or elbow crutches and observing hip safety precautions to avoid dislocation. Hip flexion, knee extension, buttock and calf exercises are practiced whilst in bed to reactivate the leg muscles and pump the blood around the limb. Routine analgesia is very useful as reduced pain allows easier exercising and mobilising. Patients can now go to the toilet, wash and dress and walk about the ward with a helper if needed, at least three times a day to get their confidence. When sitting, correct height chairs are vital and patients should avoid having their feet up on a stool.

A good gait pattern is important in restoring normal walking function, ranges of movement and muscle power and balance. Initial gait taught by physiotherapists is typically the \”step to gait\”, the walking aids moving forward first followed by the operated leg and then the unaffected leg steps up to the other. This is a slow but stable gait pattern and good for the initial stages. Patients progress quickly to the \”step through gait\” where the unaffected leg moves past the operated one, and eventually to an advanced gait where the crutches are moved forward at the same time as the operated leg. This pattern is very close to normal walking with a pair of crutches attached.

Once they return for their follow up appointment at six weeks after operation patients have often achieved a good gait, reasonable hip strength and returned to some activities of daily living. The physio may advise a stick if they are unsteady, slow or older, and they can gradually regain their previous abilities provided they observe the precautions to prevent hip dislocation:

* 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.

* Get medical advice if an infection develops e.g. in the bladder, chest or teeth, as this can transfer to an artificial joint.

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

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Winchester physiotherapy visit his website.

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