PHYSIOTHERAPY MANAGEMENT PROTOCOLPre and Post Operative Total Hip Replacement

Presenter – MD. Mozammal (BPT)PhysiotherapistOrthopedic Surgery Department (SSMCMH)

Pre operative Management

It contains

Examination and Evaluation Patient Education

Examination and Evaluation Pain ROM Muscle Strength Balance Ambulatory status and Gait Leg lengths Use of assistive devices General level of function Perceived level of disability

Patient Education Information for patient about joint disease and

operative procedure in non medical term. Postoperative precautions for hip dislocation. Rationale including positioning and weight bearing. Transfer instructions-

In and out of the bed.Chair (avoid deep chair) to minimize trunk flexion

Ambulation – Instruct on use of anticipated assistive device (walker).

Mentally prepare the patient for the painful active stage ahead.

Post Operative Management

It’s divided into four phases

Immobilization Phase Maximum Protection Phase Moderate Protection Phase Minimum Protection Phase and Resumption

of Full Activity

Immobilization Phase

o Position of the patient is supine in the bed and the operated limb may need to remain in a slight abduction and neutral rotation.

o Abduction pillow or wedge typically used to maintain this position

o To prevent a flexion contracture of the operated hip, avoid use of pillow under the knee.

Maximum Protection PhaseUsually the day or the day after surgery

Prevent vascular and pulmonary complicationAnkle pumping exercise to prevent venous stasis, thrombosis formation and potential for pulmonary embolismDeep Breathing exercise and bronchial hygiene to prevent postoperative atelectasis, pneumonia

Prevent post op dislocation or subluxation of operated hip

Diaphragmatic breathing exercise Costal breathing exercise

Achieve independent functional mobility prior to dischargeEmphasize proper trunk and lower extremity alignmentAmbulation with assisted device (initially a walker or two crutches)

Maintain a functional level of strength and muscular endurance in the upper extremities and non operative lower extremity

Prevent reflex inhibition and atrophy of musculature in the operated limbQuadriceps Hip extensors Hip abductor

Just enough to elicit contraction

Quad Set Inner Range Quad exercise

Early post op ROM precaution after THR Posterior/posterolateral approaches

Avoid hip flex >90 deg, add & int. rot beyond neutral.

Anterior/anterolateral & direct lateral approachesAvoid hip flex >90 deg & combined motion of hip flex, abduc & ext. rot.

Transgluteal/Trochanteric osteotomy approachNo active, antigravity hip abduction for at least 6-8 weeks or until approved by the surgeon

Do and Don’ts

Weight Bearing Considerations

It depends on Method of fixationSurgical approach

Other factors

o Cemented total hip: weight bearing to tolerance (WBTT) with walker immediately after surgery and carry on at least 3-6 weeks, then use a cane in the contralateral hand for 4-6 months.

o Cement less total hip: touch down weight bearing with walker for 6-8 weeks (some author recommended 12 weeks), then use a cane in the contra lateral hand for 4-6 months

o Traditional verses minimally invasive: More restriction after standard (Traditional) than minimally approach

o Trochanteric osteotomy: Restricted weight bearing at least 6-8 weeks or 12-16 weeks for bone healing

o Other factors include: use of bone graftPoor quality of patients bone

Criteria to progress Weak healed incision, no sign of wound

drainage or infection Independent level ground ambulation with

one crutch or cane Ability to bear full weight on the operated

site with full knee extension Muscle strength of operated hip at least 3/5

Moderate Protection PhasePhase of rehab begins at about 4 to 6 weeks

Goals and interventions Regain strength of hip abductors and

extensors

Improve cardiopulmonary endurance: Progressive stationary cycling, swimming, water aerobics

Restore ROM while adhering to precaution: Thomas test position in supine Passive stretch of hip flexor muscles Stretching anterior capsule while the

patient is in standing position. Improve postural stability, balance and gait

Thomas stretch: pt trying to stretch his right hip anterior capsule by pushing down hard in the bed with his right lower extremity

G Medius strengthening in side lying

Criteria to progress

Pain free ambulation with or without a cane and previous exercises

Functional ROM and strength of operated hip

Independence in ADL

Minimum Protection Phase and Resumption of Full Activity

Usually occurs around 12 weeks post op

Extended rehab & modification of activities Return to sport activities

Instruction for home

Continue previous exercises and ambulation activities

Continue to observe hip precautions Install elevated toilet seat in home Avoidance of trunk flexion Avoidance of driving for 6 weeks

Common Gait faults after THR

1. Trendelenburg gait (weak hip abductor)2. Flexion contracture of hip3. Avoidance extension of involved leg

Outcomes

Pain reliefPatient satisfaction

Quality of lifePhysical functioning