Total Hip Replacement

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Original Editors - Annelies Beckers, Vincent Everaert

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Search Strategy

Database searched:

• Pubmed
• Web of Knowledge
• American Academy of Family Physicians
• Archives of Physical Medicine and Rehabilitation.

Keywords: total hip replacement physiotherapy, total hip arthroplasty, etiology hip replacement, surgical approach for THR, materials for hip prosthesis, complications after THR, rehabilitation after THR, effectiveness of physical therapy/physiotherapy after THR, exercises following THR, cardiac output after surgery.

Definition/Description

A total hip replacement is a surgical procedure to repair the hip-joint via surgery, by (partly) replacing the original hip joint with prosthetic substitutes. It is a widely performed invasive procedure^{[20,21,22,25]}. Because of its invasive nature it is cautiously deliberated if surgery is advised while taking account of age, associated medical problems, associated hip disease, activity status and possible fracture characteristics.^[17][28]

Because patients with a hip replacement have muscular atrophy and loss of muscle strength, particularly in the gluteus medius muscle and ipsilateral quadriceps, it may be good to see a physiotherapist after surgery. ^[20] Patients with total hip replacement often present with a gradual decline in hip muscle strength two to three years after the operation (literally copied from source number 21). It is important for patients with total hip replacement after hospital discharge to follow a physiotherapy program to strengthen the muscles of the hip to prevent the declining of strength and prevent complications. It is known that impairments and functional limitations remain a year after surgery.^[29]

Clinically Relevant Anatomy

The hip is a ‘ball and socket’ joint. This means that the caput of the femur fits in the acetabulum of the pelvis. The ‘ball’ is the femur head and the socket is the acetabulum of the pelvis. The pelvis is formed by 3 bones: the ischium, ilium and pubis. The femur is the longest and strongest bone in the human body (literally copied from the adult Hip [18]). The acetabulum is cup-shaped. The head of the femur is gripped by the acetabulum beyond its maximum diameter. The caput of the femur and the inside of the acetabulum are covered with a layer of hyaline cartilage. ^[17]

Epidemiology /Etiology

The first cases of one-stage bilateral total hip replacement were executed at the end of the 1960s ^[19]. Total hip replacement is a frequently done procedure. ^{[20,21,22,25]} Hip replacements are used to repair hip fractures. These fractures can be caused by a trauma such as a fall. Osteoporosis and osteomalacia are significant factors responsible for the high incidence of a fractured hip at the elderly. Among the people past middle age arthritis is a common degenerative process occurring in joints, with osteoarthritis as one of the most common varieties. Administering the positive developments of the post operational patients, total hip replacement procedures furthermore become a well accepted treatment modality for arthritis. ^{[20,21,22,24,25]} It is also a treatment for (juvenile) rheumatoid arthritis but only if all the other options have failed. ^[24]

Characteristics/Clinical Presentation

Preoperative

• hip fracture:

Often unable to walk, complains of vague pain in the knee, thigh, groin, back or buttock and difficulty of weight bearing ^[26] ( read more: http://www.physio-pedia.com/index.php5?title=Hip_Fracture)

• osteoarthritis:

Crepitations are sensible or audible when the hip is moved, inability to assume the neutral anatomical position. (read more http://www.physio-pedia.com/index.php5?title=Osteoarthritis)

• rheumatoid arthritis:

Range of all hip movements is impaired, movement is painful, pain and stiffness when the activity is resumed after resting. [24] (read more: http://www.physio-pedia.com/index.php5?title=Rheumatoid_Arthritis)

Postoperative

Early postoperative rehabilitation after total hip replacement focuses on resorting mobility, strength, flexibility and reducing pain. (literally copied from source number 22; read more below ‘Physical therapy management’). After a total hip replacement patients may have muscle atrophy and loss of strength of the hip muscles. The atrophy is marked in the gluteus medius and the ipsilateral quadriceps on the operated side. The result of the loss of strength is that the elderly are less independent. ^[20] Research has also shown that when the hip abductors are weak after surgery there is a major risk associated with joint instability and prosthetic loosening. ^[21] A gait dysfunction may persist for many months after joint replacement. ^[25]

Differential Diagnosis

It's not possible to give a differential diagnosis for a hip replacement, therefore ‘Indications for surgery’ are added.

Indications for surgery

Pain and loss of mobility are the most common preoperative complaints by patients who elect to have a total hip arthroplasty. ^[27] Preexisting hip disease is a valid indication for primary total hip replacement. When there are complications with the internal fixation of a fracture to the femoral neck, in particularly if articular cartilage in the acetabulum is lost or when endoprosthesis have failed in acute fractures, a total hip replacement is a good solution. ^[17]

Fractures of the neck of the femur caused by an underlying pathology for example Paget’s disease (read more http://www.physio-pedia.com/index.php5?title=Paget%27s_Disease) in older patients are generally treated with a total hip replacement. ^[17][23] When a rapid destruction of the femoral head or the pubic ramus is observed on the radiographs, a total hip replacement should be the only option to be considered. In this case the patient is suffering of rapidly destructive hip disease. ^[24]

Important considerations before choosing for a total hip arthroplasty are age, activity status, the patients expectations and medical conditions based on radiological disorders. ^[17][28] Medics are cautious with performing a total hip replacement. It’s only used when all other options failed.^[24] In the end it’s the surgeon who decides if a total hip replacement is the best solution for the patient. ^[17]

Diagnostic Procedures

There is no specific way to diagnose if a patient is in need of a total hip replacement. Mainly because there are multiple possible disorders where a total hip replacement is recommended. When a patient is complaining about hip pain this is notoriously misleading, for often it is referred from the spine or pelvis and so it has no connection to the hip joint itself. [24] There are ways to see if the patient has the conditions in which a total hip replacement can be required for example an MRI and a physical examination. It will be the decision of the treating doctor to do a hip replacement.

There are specific ways to diagnose osteoarthritis, rheumatoid arthritis and hip fracture but for those  subjects see the links: http://www.physio-pedia.com/index.php5?title=Osteoarthritis, http://www.physio-pedia.com/index.php5?title=Rheumatoid_Arthritis, http://www.physio-pedia.com/index.php5?title=Hip_Fracture

Outcome Measures

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Examination

The task of a physical therapist consists before the operation of investigating the muscular state (force, volume), ROM and the circulatory state of the injured as well as the healthy limb . This gives an idea of the preoperative state of the patient.
The general physical and psychological state of the patient should also be taken care of.
For example explaining the surgical technique and the therapeutic monitoring after surgery can help lowering the patient’s anxiety. Explaining how to use a rollator or walk on crutches properly can also make the patient more self-confident when entering the postoperative stage of the therapy.

Medical Management

Many surgical approaches for THR are described but we can resume them to anterior, lateral and posterior approach. These approaches determine the amount of soft tissue damaged. Many surgeons are changing from a posterior approach to a more anterior one. Cadaveric studies show that this type of approach is less invasive and damaging for muscles, capsules, ligaments and nerves. Other studies have shown a better rehabilitation time and functional outcome. Because of the lowered risk of dislocation compared to a posterior approach, early mobilizations as well as full weight bearing exercises according to tolerance are made possible in the first postoperative days.
The articulating couples (head and cup) used by surgeons are made of metal-on-polyethylene (PE), ceramic-on-PE, metal-on-metal and ceramic-on-ceramic. Important components of prosthesis are friction-coefficient, survival, stability against dislocation and fixation in bone tissue. In some cases there can be formation of osteonecrosis due to erosion of the two components rubbing against each other.

Physical Therapy Management

The main factors defining the therapy management are the surgical approach and the general state of the patient. Whether the patient desires to gain physical fitness or wishes to recover for recreational activity should also be taken into account when establishing the rehabilitation program.
The posterior approach implies that precautions should be taken against dislocation when exercises combining flexion, endorotation and adduction are given. For example, cycling with elevated saddle and low resistance keeps the articulation in a reasonable range of motion and induces bearable joint load. For the anterior approach it is the combination of extension, exorotation and abduction although the probability of dislocation is less great than for the posterior approachv.
The treatment after a total hip arthroplasty (without other complications) includes the non-exhaustive set of items listed below. The given order is not fixed but shows a progressive contribution of the patient in the therapy. It should start as soon as possible according to the patient’s tolerance and medical recommendations.

• First postoperative day:

• Static contraction of the M. Quadriceps in order to have a muscular and circulatory effect.
• Flexion/extension/rotation of feet and toes to prevent edema
• Education of muscular relaxation
• Upper limb exercises to stimulate the cardiac function
• Maintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilization on the operated hip.

Bed exercise following total hip replacement does not seem to have an effect on the quality of life but remains none of the less important (edema, cardiac function, etc.). It also allows an assessment of the physical and psychological condition of the patient right after surgery.

• First postoperative week:

• Active/passive mobilizations to gain ROM
• Progressive resistance exercises
• Progressive weight bearing exercises according to tolerance
• Equilibrium exercises including walking with crutches/2 canes/1 cane.

Early exercises including full weight bearing exercises have shown different positive effects on the recovery of patients after THA (faster recovery, gain in walking ability). Physical activity is also good for quality of bone tissue. It improves the fixation of the prosthesis and decreases the incidence of early loosening. Once again the amount of activity is linked to the general state of the patient. Certain specific sport movements have a higher risk of injury for unskilled individuals.

• 1-12 postoperative month:

• Gain of initial ROM, muscular force (stabilization), and control (proprioception).
• Endurance
• Flexibility
• Equilibrium on one foot
• Speed, precision, neurological coordination
• Functional exercises

Physical therapy quickly maximizes the patient’s function which is associated with a greater probability of earlier discharge, which is in turn associated with a lower total cost of care.

Key Research

• Minns Lowe C. J. et al. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskeletal Disorders 2009; 10 (98)
  

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