Postoperative Rehabilitation Protocol Posterior Total Hip Replacement

Adam Barnard, PA-C

Owensboro Health Orthopedics

and Sports Medicine

acbarn215@gmail.com

270-417-7940

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone a Total Hip Replacement (also known as Total Hip Arthroplasty) through a posterior approach.  It is by no means intended to replace or substitute the clinical decision making process of the clinician assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol they should contact the treating surgeon or qualified team member.  

 

*This protocol applies to Primary Total Hip Replacement via posterior approach and is not applicable to Revision Hip Replacement procedures or scenarios in which surgical or post-operative complications have occurred.  If an anterior hip replacement was performed please use that specific protocol. 

 

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

 

*A word about “pain” and management of anticipated discomfort following Total Hip Replacement…

Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  

Phase 1-Early Post-surgical Phase (Days 0-5)

 

The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity, and maximize the patient’s mobility with a goal of functional independence. Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential. 

Goals: 

  1. Perform transfers with minimal assistance from others and advance to full weight bearing ability on the operative extremity
  2. Ambulate 25-100ft. continuously with ambulatory assistive device (walker). 
  3. Verbalize and demonstrate understanding and appropriate use of assistive devices (ie. walker, cane, wheelchair, bedside commode, etc)
  4. Establish patient understanding of dislocation precautions
  5. Implement use of nonpharmacologic modalities to control pain and swelling such as ice, manual massage, elevation of the extremity, etc
  6. Facilitate optimal wound healing environment-Dressing changes, counsel on nicotine avoidance and blood glucose control if diabetic
  7. Demonstrate ability to independently perform ADLs (bathing, dressing, toileting, stairs, bedding)

 

Assessment by Therapist:

  1. Assess surgical wound for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment AROM/PROM, efficiency/safety/necessity of ambulatory assistive devices
  5. Assess for signs of DVT (Homan’s sign, calf circumference, Well’s Criteria), PE (pulmonary embolism), Nerve palsy/dysfunction
  6. Assess gait mechanics, balance, weight transfer ability 

 

Therapeutic Exercises:

  1. Supine-Ankle pumps, quad sets, hamstring sets, gluteal sets, assisted heel slides, SAQ, hip abduction, gentle external and internal rotation to neutral
  2. Seated- Long arc quad and knee flexion 

 

Precautions:

  1. WBAT (Weight Bearing As Tolerated), initially with assistive device and wean use as patient demonstrates sufficient locomotor proficiency
  2. Avoid weights or resistance bands
  3. Avoid rotational torque and/or twisting of the hip while weight bearing
  4. Posterior hip precautions- No flexion > 90 degrees, no internal rotation past neutral, no ADDuction past midline.  Main restriction is combined maneuver of flexion + internal rotation 

 

*Patient may progress to Phase II when able to demonstrate sufficient quadriceps/hamstring activation, adequate pain control, ability to transfer independently, and ambulate greater than 100 ft with appropriate assistive devices.  



Phase II (Post-op Day 5 Through 6 Weeks)

Goals:

  1. Improve AROM with a goal of 0-110 degrees flexion
  2. Continue strengthening exercises of glutes, knee flexors/extensors.  May begin knee resistance exercises as tolerated when goals of Phase I are met
  3. Address any deficiencies or weaknesses of upper extremities, back/neck, or contralateral (non-operative) lower extremity
  4. Continue proprioceptive training and gait training (Encourage early discontinuation of assistive devices when appropriate, ie Trendelenburg gait resolved)
  5. Demonstrate ability to perform ADLs unassisted
  6. Decrease swelling/inflammation
  7. Return to work for primarily sedentary professions

 

Assessment by Therapist:

  1. Monitor wound for signs of infection, dehiscence, or complications of skin closure devices (Dermabond, Zip-line, sutures, staples)
  2. Monitor for signs/symptoms of DVT/PE
  3. Monitor for signs of dehydration (skin turgor, orthostasis, etc)
  4. Assess use of narcotic and non-narcotic analgesics
  5. Assess pre-treatment PROM/AAROM/AROM within hip precautions 

 

Therapeutic Exercises:

Week 1-4

  1. Manual therapy-soft tissue mobilization and lymph drainage as indicated, Stretching: passively including hip flexor to neutral (Thomas test position) or prone lie, quads, hamstrings, adductors and calf.
  2. Begin NuStep/stationary bike with minimal or no resistance and within precautions 
  3. Reinforce normal gait mechanics- equal step length, equal stance, time, heel to toe gait pattern, etc
  4. Continue Phase 1 exercises 

Week 4-6

  1. Continue week 1-4 exercises
  2. NMES of quads based on necessity (lack of appropriate activation).  May progress NMES from isometric to isotonic and functional activity
  3. Decrease sit-to-stand time 
  4. Consider aqua therapy if wound healed and available access to safe entry/exit pool 
  5. Supine- quad/gluteal/hamstring/adductor sets, ankle pumps, assisted to active heel slides, short arc quad, bridging, hip
    abduction as indicated 
  6. Sitting- Resisted LAQ and hamstring curl
  7. Sidelying- hip ABDuction and clam exercises
  8. Standing-mini squats, marching, heel raises, calf raises, single limb stance, step-ups, lateral stepping, 3-way hip exercises
    (ABDuction, extension, flexion)

 

Precautions

  1. Wean assistive devices only when the patient is supervised by a therapist and the patient is able to demonstrate minimal compensatory gait. There is no mandatory time frame for use of assistive devices and duration of time before weaning is based on multiple factors including patient apprehension/concern, fall risk, gait pattern kinematics, pre-operative need for such devices, and muscle activation/performance
  2. Monitor for increase in edema/swelling with increased activity levels, consider graduated compression stockings if accepted/indicated
  3. Continue posterior hip precautions

 

*Patient may progress to Phase III after achieving flexion AROM 0-110 degrees, adequate quadriceps activation, and able to ambulate > 500 ft uninterrupted without assistive device or significant gait disturbance.  Must also demonstrate adequate hip abductor strength of at least 3+/5



Phase III (Week 6-12)

Goals:

  1. Increase ambulation distance without assistive devices 
  2. Stair progressions without reciprocal pattern  
  3. Advance strengthening with precaution range 

Therapeutic Exercises

  1. Continue Phase I and II exercises and progress resistance, strengthening, and repetitions 
  2. Begin resistance bands/weights
  3. Begin closed chain exercises.  50% depth forward lunge and squats 
  4. Initiate static and dynamic balance and proprioceptive exercises, progress as tolerated and appropriate
  5. leg press, leg extension, hamstring curl, mutli-hip machine within precautions
  6. +/- NMES 

Precautions:

  1. Discontinue ROM precautions after 12 weeks after follow-up exam with physician 

 

*Patient may progress to Phase IV when able to complete Phase III without pain and sufficient locomotor stamina/strength 



Phase IV (Week 12-20)

Goals:

  1. Return to work unrestricted most professions (heavy labor professions may require indefinite restrictions/limitations) 
  2. Return to recreational sports/activities as indicated/desired (golf, cycling, pickleball, doubles tennis, outdoor hiking, etc)
  3. Pain free gait, including stairs/elliptical/bike  
  4. Transition from formal physical therapy to Home/Gym Exercise Program
  5. Normalized gait pattern without compensation flat and uneven surfaces 
  6. High impact activity such as running, singles tennis, skiing, etc are not advised and should NOT be goals.  Patient must discuss with surgeon risks and potential complications as a result of performing such activities