Rehabilitation After Hip Surgery

Key Points

The goal of rehabilitation is to maximize functional outcomes and improve an individual's ability to perform activities of daily living in a timely fashion after treatment has been rendered.
Surgical treatment options for hip pathology include total hip arthroplasty (THA), resurfacing arthroplasty, arthroscopy, osteotomies, and fracture care.
To be discharged home after hip surgery, a patient must be able to ambulate approximately 50 to 100 feet with an assistive device, use a toilet, perform transfers, perform activities of daily living, demonstrate understanding of and compliance with hip precautions, independently perform home exercises, and be medically stable. It may be beneficial to have additional help at home in the perioperative period.
Following THA, functional improvement, patient satisfaction, and walking ability at the time of discharge were better in patients who received the accelerated rehabilitation protocol regardless of the size of the incision.
The postoperative rehabilitation program following hip arthroscopy will be based on the patient's diagnosis, the procedure performed, and patient characteristics. Typically, 10 to 12 weeks of supervised therapy is to be expected. Hip range of motion (ROM) is permitted in the perioperative period to prevent labral-capsular adhesions. Patients who undergo cheilectomy are usually advised to be partial weight-bearing for 4 to 6 weeks postoperatively.
Following acetabular reorientation and proximal femoral osteotomy procedures, a period of restricted weight bearing is required. Focus should be placed on mobilization, gait training, and isolated exercises with strict observance of weight-bearing restrictions. Once allowed, patients should work with their therapists on gait training, ROM, and strengthening exercises.

Surgical treatment options for hip pathology include arthroplasty, resurfacing, arthroscopy, osteotomies, and fracture care. Rehabilitation after hip surgery is a crucial part of a patient's recovery. In this chapter, we will focus on key components of rehabilitation of the patient following arthroplasty, arthroscopy, and osteotomy.

Rehabilitation is the field of medicine that focuses on return of function after illness or injury. Rehabilitation is coordinated by a team consisting of physical and occupational therapists, orthopedic surgeons, physical medicine and rehabilitation physicians, nurses, and ancillary staff. Successful rehabilitation addresses the physical and psychological challenges faced by the patient. Rehabilitation should not be limited to activities that occur postoperatively, as events and activities that occur preoperatively may influence outcomes. The goal of rehabilitation is to maximize functional outcomes and improve an individual's ability to perform activities of daily living in a timely fashion after treatment has been rendered.

Hip Arthroplasty

Hip arthroplasty is one of the most successful and cost-effective operations performed, reliably leading to pain relief, increased function, and return to activity. Rehabilitation is directly related to the success of the procedure, as it allows a patient to gain maximal functional performance and improves the patient's ability to perform activities of daily living. Common impairments that patients face following arthroplasty include pain, range-of-motion (ROM) limitations, muscular weakness, and postoperative protective restrictions (positional and weight-bearing precautions). Maximal beneficial effects of rehabilitation are seen by 3 to 6 months following surgery, yet some patients are able to make continued improvement up to 2 years postoperatively.

Projected demands for total hip arthroplasty (THA) are expected to increase by 174% by the year 2030. Although the average length of stay in the acute hospital setting has decreased substantially over the past 15 years to average 4.2 days after hip arthroplasty, demands to discharge patients earlier are increasing.

Components of Rehabilitation Education

Preoperative education of patients undergoing THA is effective in preventing early dislocation, deep venous thrombosis, and pulmonary embolism, and in decreasing preoperative anxiety. However, as noted by a review conducted and published in 2004 by the Cochrane Database, although preoperative education led to a decrease in preoperative anxiety, no benefit was derived in terms of functional outcomes, postoperative pain, reduction in length of hospital stay, or change in postoperative anxiety level.

Patients’ concerns and expectations vary widely. Anxiety prior to THA is common and can be reduced by making the unknown familiar. This can be accomplished by allowing patients to meet the staff that will care for them, introducing them to the hospital environment, and addressing the experiences that the patient will encounter postoperatively. This can also include a discussion of the surgeon's approach to obstacles that may be encountered in the perioperative period.

The patient's preoperative concerns may differ from those of the surgeon. Although a positive correlation of preoperative with postoperative functional outcomes may be lacking, patients’ expectations should not be underestimated, as they are linked to requests for elective, costly procedures and correlated with assessments of outcome.

Preoperative Exercise

Osteoarthritic hips are painful and lead to reduced muscle strength, difficulty with performance of activities of daily living, and a decline in preoperative function. In a study conducted by Lavernia and associates, a correlation between preoperative function and postoperative function was noted in patients undergoing total hip or knee arthroplasty. Specifically, patients who had more extreme functional limitations preoperatively did not fare as well as those whose functional levels were better.

The goal of a preoperative exercise program is to enhance ROM, muscle strength, and overall physical function. Despite this, the effectiveness of a preoperative physiotherapy program remains controversial. Gocen and associates, Wijgman and coworkers, and Ferrara and colleagues published reports noting no significant difference in Harris Hip Scores, Barthel Index, SF-36 scores, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, hip abduction, pain, length of hospital stay, and time to stand/walk/climb a stair. To the contrary, Wang and associates and Rooks and colleagues reported significant differences in preoperative strength and functional status following a short preoperative exercise protocol. Additionally, significant postoperative differences were observed in gait velocity, stride length, and walking distance, along with a reduction in the odds for discharge to inpatient rehabilitation. As proposed by D'Lima and coworkers, this discrepancy may be due to three issues: (1) the duration of preoperative physical therapy may be insufficient for any substantial gains to be seen, (2) the dramatic improvement in symptoms following surgery may overshadow any small gains made preoperatively, and (3) the act of surgery deconditions the function of the extremity and erases any preoperative improvement. Additional studies are required to quantify the potential benefits of a preoperative exercise program.

Surgical Exposure

In recent years, an increase has been seen in patient and market demand for the least invasive form of THA. Procedures performed using a certain technique or with a skin incision less than 10 cm are often defined as less invasive. Advocates of less invasive procedures purport that a patient's rehabilitation is expedited, along with a reduction in soft tissue trauma, shorter intraoperative time, less perioperative blood loss, less postoperative pain, improved cosmetic appearance, and earlier discharge from the hospital. Despite this, there is a paucity of studies that support expedited rehabilitation. In a review performed by Sharma and associates, five studies were identified that pertained to the effects of a less invasive approach to THA on rehabilitation. Dorr and colleagues and Pagnano and coworkers noted that patients who underwent a less invasive approach had better pain control, earlier discharge home, earlier discontinuation and less usage of assistive devices, and faster return to activities of daily living. In contrast, Ogonda and associates identified no significant difference in early walking ability, length of hospital stay, and functional outcome. Pour and colleagues performed a randomized study of 100 patients undergoing the anterolateral approach for THA and evaluated the effects of an accelerated rehabilitation protocol and the length of the incision. Functional improvement at time of discharge, patient satisfaction, and walking ability at the time of discharge were better in patients who received the accelerated rehabilitation protocol regardless of the size of the incision.

Perioperative Pain Management

Pain management directly correlates with patient satisfaction following THA. Effective perioperative management of pain is critical to the recovery of a patient following hip surgery. Consequences of uncontrolled postoperative pain include prolonged hospital stay, increased incidence of readmission, decreased ROM, arthrofibrosis, potential for medicolegal action, and increased opioid use with possible side effects of nausea and vomiting. Currently, no gold standard exists for perioperative management of pain following THA. In recent years, the development of a multimodal approach to pain management has gained much attention. Maheshwari and associates defined multimodal analgesia as a multidisciplinary approach to pain management with goals to maximize analgesic effects and minimize potential side effects of medications. Analgesic methods for perioperative pain control include general or regional anesthesia, neuraxial analgesia, intraoperative periarticular injection, intravenous and oral narcotics, and preemptive analgesia. Preemptive analgesia effectively limits the sensitization of the nervous system to noxious stimuli by producing dense blockade of the transmission of a noxious afferent stimulus from the peripheral to the central nervous system for the appropriate duration. Effective multimodal perioperative analgesia has been demonstrated by Peters and colleagues to cause a significant reduction in rest pain scores, total narcotic consumption, and hospital length of stay, along with improvements in distance ambulated and time to achieve therapy goals.

Functional Activities

Dislocation

Dislocation following primary THA is a common complication and an important problem, occurring in 0.2% to 7% of patients. Instability is also an important mode of THA failure, with 10% to 25% of patients undergoing revision THA for this complication. Fifty percent of dislocations following primary THA occur within 3 months of the index procedure, and 75% may occur within 1 year. Surgical factors affecting the potential for dislocation include approach, implant selection and position, soft tissue tension, and experience of the surgeon. Patient factors include neuromuscular disorders, alcoholism, cognitive disorders, noncompliance, and history of previous hip surgery.

In the rehabilitation phase preceding and following THA, education and instruction regarding hip precautions can help reduce the risk of dislocation. A surgical approach to the hip dictates these precautions. The surgical approach is classified on the basis of its location relative to the anatomy of the hip. Most THAs are performed from a posterolateral approach. This approach leads to minimal trauma to the abductor complex. Implantation of larger femoral heads and repair of posterior soft tissue structures are believed to reduce the risk of dislocation. Patients in whom the posterolateral approach was used must be instructed not to internally rotate, adduct, or flex their hips more than 70 to 90 degrees. The most common scenarios in which dislocations occur after a posterolateral approach to the hip include bending down from a seated position to tie shoes, getting off a low toilet or chair with the hip adducted and internally rotated, and twisting the trunk toward the operative side with the feet planted in sitting and standing positions. A direct lateral approach to the hip requires partial takedown of the glutei musculature. This has been associated with prolonged postoperative weakness of the abductor complex. A transtrochanteric osteotomy approach through the greater trochanter will require that patients avoid active abduction of the hip while the osteotomy heals. Patients who undergo an anterior or anterolateral approach to the hip, in which the anterior capsule is violated, should be instructed to avoid hyperextension, adduction, and external rotation to prevent dislocation.

Preoperative and postoperative education regarding hip precautions is crucial for patients’ understanding and compliance. The duration of hip precautions varies and depends on both the surgeon and the patient. Uncomplicated patients should adhere to precautions for 6 weeks; more complicated patients who are at higher risk for dislocation should observe precautions for 12 weeks.

In an attempt to prevent patients’ operative extremities from moving into a position that would make them vulnerable to dislocation, many physicians advocate functional restrictions in addition to hip ROM precautions. Functional restrictions include placing an abduction wedge or pillows between the legs when in bed, using a knee immobilizer placed on the operative extremity, as well as higher chairs and toilet seats and avoiding getting into and out of an automobile with low seats. Few studies, however, have evaluated the efficacy of the use of aids in helping prevent dislocation. A recently published randomized prospective study, conducted to assess the efficacy of functional restrictions in preventing dislocation following THA from an anterolateral approach, revealed no increased benefit of functional restrictions. In addition, patients reported a higher level of satisfaction when functional restrictions were not placed.

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