Total hip replacement rehabilitation (THR)

Rehabilitation following total hip replacement (THR) is a multifaceted process aimed at restoring patients' mobility and quality of life. Post-operative rehabilitation is crucial as patients often exhibit abnormal gait patterns that do not naturally revert to normal, which can increase the risk of osteoarthrosis in adjacent joints. Effective rehabilitation involves imprinting correct gait patterns in long-term memory, and visual feedback has been shown to significantly improve mental representation of gait, enhancing recovery outcomes . Additionally, walking rehabilitation is highly recommended, but patients must control the weight load on their limbs, which can be challenging. A proposed monitoring system embedded in customized shoes, which includes pressure sensors and a smartphone application, helps patients manage weight load and gait, providing real-time feedback and alerts to prevent excessive weight bearing and falls . The development of rehabilitation guidelines, often based on consensus processes due to limited scientific evidence, assists healthcare teams in making informed decisions about post-operative care, ensuring consistency and safety in practice . Rehabilitation aims to enable patients to use their residual abilities effectively, promoting personal autonomy and a fulfilling life. This process involves not only physical recovery but also cognitive, social, and psychological support, aligning with the World Health Organization's comprehensive definition of rehabilitation . Innovative devices like the Therapeutic Hand Robot (THR), which uses electromechanical-assisted exercises and voice-activated commands, exemplify advancements in rehabilitation technology, offering home-based tele-rehabilitation options that reduce healthcare costs and waiting lists . Overall, the integration of advanced technologies, evidence-based guidelines, and holistic rehabilitation approaches is essential for optimizing recovery and enhancing the quality of life for THR patients.

1. Total hip replacement rehabilitation Dr Joe Antony Physical Medicine and Rehabilitation King George Medical University 1

2. Prehabilitation

3. Prehabilitation Patient Education Disease process Procedure, expectations, and complications of THA Expected functional recovery Expected return to sports Expected rehab protocol Healthy lifestyle guidelines Physical activity Weight management Smoking and alcohol cessation 3

4. Hip specific preparation Achieving maximum ROM possible Hip musculature and trunk strengthening Balance training Training to use mobility aids 4

5. Peri-operative rehabilitation

6. Peri-operative rehabilitation Goals Prevent hazards of bed rest (DVT,PE, Pressure ulcer) Assist patient with adequate and functional ROM Strengthen hip musculature and trunk Assist patient in achieving functional independence Achieve independent ambulation with an assistive device 6

7. Concerns with surgical approach Lateral or anterolateral Posterolateral approach Anterior Approach Minimally invasive Abductors incised and repaired Abductors preserved Technically demanding No evidence to suggest better outcome Weakness of hip abductors Higher rate of dislocation Require fracture table and intra operative fluoroscopy Higher risk of femoral fractures, wound healing problems, component malposition Poor repair can cause prolonged Trendelenburg gair Dislocation can be prevented by using larger heads 7

8. Hip Precautions Precautions to prevent dislocation- especially in posterolateral approach Dislocation happen when hip is adducted past midline Abduction pillow - between knee while in bed Between thighs while sitting In revisions or non compliant patients Knee immobilizers and Abduction Braces For 6 to 12 weeks post operatively After anterolateral Approach Extreme external rotation, adduction, and extention 8

9. Weight bearing Non-weight bearing- Not recommended- muscle forces acting to maintain level pelvis is greater than TTWB Toe Touch Weight Bearing (TTWB)- More than 10% of body weight. Preferred initial weight-bearing method Partial weight bearing (PWB)- more than 30% body weight Full Weight-bearing 9

10. Assistive devices Walkers – first choice- wide base, better stability Reduce the freedom of both hands- self care activites more challengning Occasionally wont fit through door ways Rolling walker- Better patient selected speeds, poorer stability compared to standard walker Axillary crutches or forearm crutches- better suited for younger patients, less stability Canes- used on contralateral side- offload 10-20% weight Only used in fully weight bearing 10

11. Post op Protocol 11

12. Home Discharge criteria Independent ambulation more than 150feet Adherence to hip precautions Achieving Basic functional activities of daily living 12

13. Out Patient Protocol Achieving full, allowed active ROM at the hip by the end of the sixth postoperative week. For example: hip flexion 90 degrees, hip abduction 40 degrees for the patient who has had a posterior approach surgery Additional ROM may be restored through stretching exercises once the physician’s postoperative precautions have been lifted. Progress functional strengthening; including closed kinetic chain and balance exercises. Independent ambulation by week 12 (and without the use of an assistive device for those who did not require their utilization preoperatively). Patient able to drive by the end of the sixth postoperative week. Patient able to assume side-lying on operative hip by the end of the sixth postoperative week. Return to most recreational/sports pursuits by the end of the twelfth week postoperative 13

14. Return to sports 14

15. Common problems 15

16. Trendelenburg Gait Concentrate on hip abduction exercises to strengthen abductors. • Evaluate leg-length discrepancy. • Have patient stand on involved leg while flexing opposite (uninvolved) knee 30 degrees. If opposite hip drops, have patient try to lift and hold in an effort to re-educate and work gluteus medius muscle (hip abductor). • Walk stance weight shifts: In a walk stance position patient should shift weight forward over the involved hip until unable to control hip/pelvic drop and then shift back, progressing to full weight shift and weightbearing on involved limb over time as the hip abductor strength improves. • Manual or pulley resistance at the pelvis with lateral walking. 16

17. Flexion contracture of hip AVOID placing pillows under the knee after surgery. Walking backward helps stretch flexion contracture. Perform a Thomas stretch of 30 stretchesa day (five stretches six times per day). Pull the uninvolved knee to the chest while supine. Push the involved (postoperative) leg into extension against the bed. This stretches the anterior capsule and hip flexors of the involved leg. 17

18. Gait deviations and management 18

19. M ost gait faults either are caused by or contribute to flexion deformities at the hip. These faults generally are attributable to the patient’s attempts to avoid extension of the involved hip because such extension causes an uncomfortable stretching sensation in the groin. 19

20. Asymmetric steps Large step with involved side – to avoid extension on involved side Auditory cues while gait training to have symmetric steps 20

21. Early heel off and knee flexion in late stance To avoid hip extention Auditory cues during gait training to keep heel on ground during late stance 21

22. Trunk flexion in late stance To correct this, teach the patient to thrust the pelvis forward and the shoulders backward during mid and late stance phase of gait 22

23. Thank you References Orthopedic rehabilitation, 4 th edition, Brotzman IAPMR textbook of PMR