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How Physiotherapists Manage Total Hip Replacement

Populations across the world suffer from osteoarthritis (OA), the most common degenerative joint condition in world, causing large amounts of pain, disability and expense. Western developed populations are ageing and as the incidence of OA rises with each decade of life the impact of this condition will be felt ever more strongly. Less developed countries such as China will soon be joining the countries with ageing populations so the need for effective OA treatment will increase greatly. One of the approaches to managing OA is to perform joint replacement. Individuals may have been involved in a slip or a fall, for which they may receive accident compensation.

Quality of life improvements after medical interventions vary but for joint replacement are some of the highest of all medical procedures. Hip replacement has a long history but the 1960s saw its development into a reliable procedure, with modern developments making it a predictable and very successful treatment for hip osteoarthritis. It is used to manage a variety of complex hip conditions with excellent outcomes at fifteen years and beyond. Conservative treatment is always instituted initially but if the joint degeneration becomes severe then joint replacement is the remaining option. 

The surgeon removes the osteoarthritic joint surfaces and replaces them with new components which are made of steel alloy and ultra high density polyethylene. The ball of the hip is replaced by a metal ball and stem and inserted into pressurized cement in the femoral canal. The plastic socket is pushed into the cement in the prepared socket to complete replacement of the two surfaces. Using the two materials, very slippery plastic and highly polished metal, ensures very low joint friction and a long functional life under load. 

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.

The patient continues with buttock, hip flexion, quadriceps and foot exercises regularly to encourage normal limb muscle function and help circulation. They take regular analgesia to reduce pain and assist in their ability to mobilise.  Once safe they can mobilise independently at least three times a day to have a walk, go to the toilet and wash and dress. Sitting is encouraged as long as the chair is not low and they are not permitted to put their legs up when sitting.

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. 

Six weeks from discharge patients have usually developed a normal gait, good muscle power and have returned to many functional abilities including riding in a car, mounting stairs and normal walking. A stick can be used if the person is elderly or feels they have poor balance or stability. Sensible activities can now be performed as long as the precautions are observed:  Avoid having the legs crossed in sitting.  Standing on the operated leg and rotating the body is risky.  Bending the hip more than 90 degrees should be avoided in such activities as sitting down quickly, sitting in low seats, crouching down or leaning forwards to the floor quickly.  Inform a doctor if an infection develops in an area such as the teeth, bladder or chest, as these can track to a new joint.


The information contained within this article was written with the help of a London Physiotherapist

Author: Jonathan Blood-Smyth

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