Total Hip Replacement: Difference between revisions

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'''Original Editors ''' - [[User:Annelies Beckers|Annelies Beckers]], [[User:Vincent Everaert|Vincent Everaert]]
'''Original Editors ''' - [[User:Annelies Beckers|Annelies Beckers]], [[User:Vincent Everaert|Vincent Everaert]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]].
 


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== Definition/Description <br>  ==
== Description     ==
 
[[File:Hip prosthesis components.jpeg|thumb|Hip prosthesis components|alt=Hip prosthesis components]]
[[Image:Hip replacement.jpg|border|right|200px|Hip Replacement]]<span style="line-height: 1.5em;">A total hip replacement is a '''surgical procedure''' to repair the&nbsp;</span>[[Hip|hip-joint]]<span style="line-height: 1.5em;"> by partly (Hemi arthroplasty) or fully (Bipolar-hemi arthroplasty) replacing the original hip joint with prosthetic substitutes. Care needs to be taken with this operation because of the invasive nature of this procedure </span><ref name="Gremeaux V."/><ref name="Jan M.">JAN, M., HUNG, J., LIN, J.C., WANG, S., LIU, T. TANG, P., Effects of a home program on strength, walking speed, and function after total hip replacement, http://www.archives-pmr.org/article/S0003-9993%2804%2900306-5/fulltext ( accessed: 2010-12-25)</ref><ref name="Stockton K.">STOCKTON, K.A., MENGERSEN, K.A., Effects of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2809%2900377-3/fulltext (accessed: 2010-12-25)</ref><ref name="Rahmann A.">RAHMANN, A.E, BRAUER, S.G., NITZ, J.C., A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2809%2900144-0/fulltext ( accessed: 2010-12-25)</ref><span style="line-height: 1.5em;">, it is cautiously deliberated if surgery is advised, to take account of age, medical problems, hip disease, activity status and possible fracture characteristics.</span><ref name="fractures of the hip">MEYERS, H. M., Fractures of the hip, Chicago: Year of the book medical publishers Inc.,1985</ref><ref name="Trudelle Jackson E">TRUDELLE-JACKSON, E., SMITH, S.S., Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial http://www.archives-pmr.org/article/S0003-9993%2804%2900156-X/fulltext (accessed 2010-12-25)</ref>
Total hip replacement (THR), or Total Hip Arthroplasty (THA), is a procedure that removes damaged bone and cartilage and replaces it with prosthetic components. THR is one of the most cost-effective and consistently successful surgeries performed in orthopaedics. 
 
* THR provides good outcomes for patients suffering from advanced degenerative [[Hip Osteoarthritis|hip osteoarthritis]], providing [[Pain Assessment|pain]] relief, functional restoration, and improved [[Quality of Life|quality of life.]]<ref name=":5">Varacallo M, Luo TD, Johanson NA. [https://www.statpearls.com/articlelibrary/viewarticle/22894/ Total Hip Arthroplasty Techniques.] InStatPearls [Internet] 2020 Jul 8. StatPearls Publishing.Available from: https://www.statpearls.com/articlelibrary/viewarticle/22894/ (accessed 14.2.2021)</ref><ref name=":3">Levine BR, Klein GR, Cesare PE. [https://www.researchgate.net/profile/Paul_Dicesare/publication/6296081_Surgical_approaches_in_total_hip_arthroplasty_A_review_of_the_mini-incision_and_MIS_literature/links/0f31752dc21c0f154c000000.pdf Surgical approaches in total hip arthroplasty: A review of the mini-incision and MIS literature.] Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):5-18.</ref>
<br>
 
<br>  


* During a THR, the head of the [[femur]] is replaced with a [[Prosthetics|prosthetic]] head on a shaft, and the joint surface of the [[Acetabulum fracture|acetabulum]] is lined with a bowl-shaped synthetic joint surface.
* A [[Partial Hip Replacement|partial hip replacement]] can also be done for neck of [[femur]] [[Fracture|fractures]] (mostly displaced)<ref name=":6">Iglesias SL, Gentile L, Mangupli MM, Pioli I, Nomides RE, Allende BL. [http://www.alliedacademies.org/articles/femoral-neck-fractures-in-the-elderly-from-risk-factors-to-pronostic-features-for-survival.pdf Femoral neck fractures in the elderly: from risk factors to pronostic features for survival.] Journal of Trauma and Critical Care. 2017;1(1).</ref> where only the femoral part is replaced.
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==
[[File:THR X-ray.jpg|thumb|313x313px|THR X-ray|alt=Total Hip Replacement  X-ray]]The hip is a ball and socket joint. This design allows the poly-axial movement seen at the [[Hip Anatomy|hip]].   


The [[Hip Anatomy|hip]]&nbsp;is a ‘ball and socket’ joint. This means that the caput of the femur fits in the acetabulum of the [[Pelvis|pelvis]]. The ‘ball’ is the femoral head which fits into the socket is the acetabulum of the pelvis. This ball and socket design is what allows the poly-axial movement seen at the hip. The hip is made up of the pelvis and the femur. The pelvis is formed by 3 bones; the ischium, ilium and pubis. The femur is the longest and strongest bone in the human body<ref name="Callaghan J.J.">CALLAGHAN, J.J., ROSENBERG, A.G., RUBASH, H.E., The adult hip, second edition, Philadelphia: Lippincott Williams Wilkins, 2007</ref>. The acetabulum is cup-shaped providing the articular surface for the head of femur to move within. 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.<ref name="Fractures of the hip">MEYERS, H. M., Fractures of the hip. Chicago: Year of the book medical publishers Inc., 1985</ref>;
The head of the femur and the inside of the acetabulum are covered with a layer of hyaline [[cartilage]].<ref name="Fractures of the hip">Meyers HM. Fractures of the hip. Chicago: Year of the book medical publishers Inc., 1985</ref> Once this cartilage is worn away or damaged (usually by [[arthritis]]), the underlying bone is exposed, resulting in pain, stiffness and possibly shortening of the affected leg. By replacing these surfaces the aim is to reduce pain and stiffness to restore an active and pain-free life.  
 
[[Image:Hip.jpg|center]]<br>
 
== Epidemiology /Etiology  ==
 
Total hip replacement is a frequently done procedure.<ref name="Gremeaux V."/><ref name="Jan M."/><ref name="Stockton K."/><ref name="Rahmann A."/>&nbsp;Hip replacements are used to repair hip fractures, caused by trauma’s such as a [[Falls|fall]]. [[Osteoporosis|Osteoporosis]]&nbsp;and&nbsp;osteomalacia are significant factors responsible for the high incidence of hip fractures within the elderly population. Arthritis is a common degenerative process occurring in joints within this elderly population, with [[Hip Osteoarthritis|osteoarthritis]]&nbsp;being&nbsp;the most common of the varieties. Due to the high degree of success at reinstating independence and mobility of osteoarthritis sufferers, total hip replacement procedures have become a well accepted treatment modality for hip degeneration secondary to osteoarthritis<ref name="Gremeaux V.">GREMEAUX, V., RENAULT, J., PARDON, L., DELEY, G., LEPERS, R., CASILLAS, J., Low frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2808%2901388-9/fulltext (accessed: 2010-12-25)</ref><ref name="Jan M."/><ref name="Stockton K."/><ref name="Crawford A."/><ref name="Rahmann A."/>.&nbsp;It is also a treatment for [[Juvenile Rheumatoid Arthritis|juvenile rheumatoid arthritis]] but only if all the other options have failed<ref name="Crawford A."/>.
 
== Characteristics/Clinical Presentation  ==
 
'''Preoperative'''
 
*[http://www.physio-pedia.com/index.php5?title=Hip_Fracture hip fracture]:
 
Often unable to walk, complains of vague pain in the knee, thigh, groin, back or buttock and difficulty of weight bearing&nbsp;<ref name="Batra S.">BATRA, S., BATRA, M., McMURTRIE, A., SINHA. A.K, Rapidly destructive osteoarthritis of the hip joint: a case series, http://www.josr-online.com/content/3/1/3 ( accessed: 2010-12-25)</ref>&nbsp;&nbsp;&nbsp;
 
*[[Hip Osteoarthritis|osteoarthritis]]:
 
Crepitations are sensible or audible when the hip is moved, inability to assume the neutral anatomical position. <br>
 
*[[Rheumatoid Arthritis|rheumatoid arthritis]]:
 
Range of all hip movements is impaired, movement is painful, pain and stiffness when the activity is resumed after resting. <ref name="Crawford A."/>&nbsp;
 
'''Postoperative'''


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 consult a [[Physiotherapy / Physical Therapy|physiotherapist]]&nbsp;after&nbsp;surgery.<ref name="Gremeaux V." /> The result of the loss of strength is that the elderly are less independent.<ref name="Gremeaux V." /> Early postoperative [[Rehabilitation|rehabilitation]]&nbsp;after a total hip replacement focuses on resorting mobility, strength, flexibility and reducing pain.&nbsp;<ref name="Stockton K." />&nbsp;Patients with total hip replacement often present with a gradual decline in hip muscle strength two to three years after the operation.&nbsp;<ref name="Jan M." />&nbsp;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.<ref name="Jan M." /> A gait dysfunction may persist for many months after joint replacement. <ref name="Rahmann A."/><br>  
THR is mostly done electively.<ref name="Gremeaux V.">Gremeaux V, Renault J, Pardon L, Deley G, Lepers R, Casillas JM. [https://www.archives-pmr.org/article/S0003-9993(08)01388-9/fulltext Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial.] Archives of physical medicine and rehabilitation 2008;89(12):2265-73.</ref><ref name="Jan M.">Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. [https://www.archives-pmr.org/article/S0003-9993(04)00306-5/fulltext Effects of a home program on strength, walking speed, and function after total hip replacement.] Archives of physical medicine and rehabilitation 2004 ;85(12):1943-51.</ref><ref name="Stockton K.">Stockton KA, Mengersen KA. [https://www.archives-pmr.org/article/S0003-9993%2809%2900377-3/fulltext Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial.] Archives of physical medicine and rehabilitation 2009;90(10):1652-7.</ref><ref name="Rahmann A.">Rahmann AE, Brauer SG, Nitz JC. [https://www.archives-pmr.org/article/S0003-9993(09)00144-0/fulltext A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial.] Archives of physical medicine and rehabilitation 2009;90(5):745-55.</ref>
== Indications for Surgery  ==
The most common indication for THA hip OA. Other indications include:<ref name=":7">Affatato S. [https://books.google.co.za/books?hl=en&lr=&id=igujAgAAQBAJ&oi=fnd&pg=PP1&dq=+Perspectives+in+total+hip+arthroplasty:+Advances+in+biomaterials+and+their+tribological+interactions.+&ots=U9KaS5d_0r&sig=MNHZw0T712KtOThLEZBUZ6OnaSE#v=onepage&q=Perspectives%20i Perspectives in total hip arthroplasty: Advances in biomaterials and their tribological interactions.] London: Woodhead Publishing, 2014.
</ref>


== Indications for surgery  ==
* Trauma: can be considered in a case by case basis in [[Femoral Neck Fractures]] (displaced intracapsular) in active and healthy patients
* Osteonecrosis of the hip, commonly known as [[Avascular necrosis of the femoral head|avascular necrosis of the hip]]<ref>Hsu H, Nallamothu SV. Hip Osteonecrosis.Available:https://www.ncbi.nlm.nih.gov/books/NBK499954/ (accessed 9.12.2022)</ref>
* Developmental [[Hip Dysplasia|dysplasia of the hip]]
* Hardware failure after internal fixation of [[Femoral Neck Hip Fracture|hip fractures]]<ref name=":5" />


Pain and loss of mobility are the most common preoperative complaints&nbsp;of patients&nbsp;with a total hip arthroplasty.<ref name="Brunner L.">BRUNNER, L.C., ESHILIAN-OATES, L., KUO, T.Y., Hip fractures in adults, http://www.aafp.org/afp/2003/0201/p537.html (last checked: 2010-12-25)</ref>&nbsp;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.<ref name="Fractures of the hip"/>
== Complications ==
[[File:Leg length discrepancy after hip replacement.jpg|thumb|491x491px|Leg length discrepancy after THR|alt=Leg length discrepancy after Total Hip Replacement]]
Complications following THR can be loosely divided into systemic and procedure specific complications. Incidence of complications have improved over time, due to [[Surgery and General Anaesthetic|surgical]] and anaesthetic technique improvements, along with the better diagnosis and management of these complications.


Fractures of the neck of the femur caused by an underlying pathology for example [[Paget's Disease|Paget’s disease]] in older patients are generally treated with a total hip replacement.<ref name="Fractures of the hip"/><ref name="Kingma M.">KINGMA, M.J., KOEKENBERG, L.J.L., VAN LINGE, B., VAN RENS, TH.J.G., SIJBRANDIJ, S., Letsels van het steun en bewegingsapparaat, Utrecht/Antwerpen: Scheltema; Holkema BV,1983</ref>&nbsp;When a patient is suffering from a rapidly destructive hip disease<ref name="Brunner L." /> ,a rapid destruction of the femoral head or the pubic ramus is observed on the radiographs, therefore a total hip replacement should be the only option.<ref name="Crawford A."/>
The most common systemic complication is a [[Deep Vein Thrombosis|deep vein thrombosis]]. [[Infection Prevention and Control|Infection]] is the most dreaded complication. [[Leg Length Discrepancy|Leg length discrepancy]] is a common cause of patient dissatisfaction<ref>Park C, Merchant I. Complications of total hip replacement. InTotal Hip Replacement-An Overview 2018 Nov 5. IntechOpen. Available:https://www.intechopen.com/chapters/61241 (accessed 8.12.2022)</ref>. For more see [[Total Hip Replacement Complications]].


Important considerations before choosing for a total hip arthroplasty are age, activity status, the patients expectations and medical conditions based on radiological disorders. <ref name="Fractures of the hip"/><ref name="Trudelle Jackson E"/>&nbsp;Medics are cautious with performing a total hip replacement. It’s only used when all other options failed.<ref name="Crawford A."/><sup>&nbsp;</sup>In the end it’s the surgeon who decides if a total hip replacement is the best solution for the patient.<ref name="Fractures of the hip"/>&nbsp;<br>
== Contraindications for Surgery ==
THA is contraindicated in the following clinical scenarios:
* Local: [[Septic (Infectious) Arthritis]]
* Remote (i.e. extra-articular) active, ongoing infection or bacteraemia.
* Severe cases of  [[Peripheral Arterial Disease|Peripheral Vascular Disease]] <ref>Varacallo M, Luo TD, Johanson NA. [https://www.statpearls.com/articlelibrary/viewarticle/22894/ Total Hip Arthroplasty Techniques]. InStatPearls [Internet] 2020 Jul 8. StatPearls Publishing.Available from:https://www.statpearls.com/articlelibrary/viewarticle/22894/ (accessed 14.2.2021)</ref>
== Orthopaedic Assessment  ==


== Diagnostic Procedures ==
An assessment by an orthopaedic surgeon consists of several components:


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.<ref name="Crawford A.">CRAWFORD, A.J., HAMBLEN, D.L., Outline of Orthopaedics , thirteenth edition, London: Churchill Livingstone, 2001</ref>There are ways to see if the patient has the conditions in which a total hip replacement can be required for example an [[MRI Scans|MRI]]&nbsp;and&nbsp;a physical examination. It will be the decision of the treating doctor to do a hip replacement.  
* Medical history:  general health and questions about the extent of hip pain and how it affects ability to perform [[Activities of Daily Living|ADLs.]]
* [[Hip Examination]]
* [[X-Rays|X-rays]]. Assess the extent of damage or deformity in the hip.
* Other tests. Occasionally other tests, e.g., [[MRI Scans|MRI]] scan, may be needed to determine the condition of the bone and soft tissues of the hip.


There are specific ways to diagnose [[Osteoarthritis|osteoarthritis]], [[Rheumatoid Arthritis|rheumatoid arthritis]] and hip fracture but for those subjects see the links above.<br>  
The diagnosis of patients requiring THR is mostly symptom-based. Pain, loss of [[Range of Motion|range of motion]] and functional impairments are mostly considered.<ref name="Crawford A.">Crawford AJ, Hamblen DL. Outline of Orthopaedics , thirteenth edition, London: Churchill Livingstone, 2001</ref>
== Prosthesis    ==
[[File:Stainless steel and ultra high molecular weight polythene hip replacement (9672239334).jpeg|thumb|Stainless steel and ultra high molecular weight polythene THR|alt=Stainless steel and ultra high molecular weight polythene Total Hip Replacement]]
When performing a THR, the ball is removed, socket reshaped, and the artificial implant is positioned in the bone. The implant may be held in the bone by tightly wedging it in place, or cementing into position. Type of fixation used depends on the patient's bone health and the design of the implant. Contemporary THR techniques have evolved into press-fit femoral and acetabular components, and many variations exist.<ref>Very well health What Type of Hip Replacement Implant Is Best? Available:https://www.verywellhealth.com/what-type-of-hip-replacement-implant-is-best-2549558#citation-2 (accessed 8.12.2022)</ref> The basic components are:


== Examination  ==
# '''Bearing surfaces''' are the surfaces which articulate in the prosthetic joint. The femoral head and the acetabular liner can be used in different combinations. These will give different appearance on radiograph depending on the configuration. Many options are available e.g., Metal-on-polyethylene, Ceramic-on-polyethylene, Ceramic-on-ceramic, Metal-on-metal.<ref name=":5" />
# '''Femoral component''' or stem: this refers to the prosthesis which is implanted into the femur. They can be described by length, taper, and presence of a collar. Attached to the femoral component is the neck and head which in most prostheses can be altered in size to create a stable joint<ref name=":0">Radiopedia [https://radiopaedia.org/articles/total-hip-arthroplasty THR] Available from:https://radiopaedia.org/articles/total-hip-arthroplasty (accessed 14.2.2021)</ref>.
# '''Prosthesis fixation:''' Femoral stem fixation can be either cemented or non-cemented (biological) fixation<ref name=":0" />. Prevalence of fixation technique: increasing trend towards cementless fixation; 93% of THA in United States in 2012 were cementless<ref name=":2">Ortho bullets [https://www.orthobullets.com/recon/5003/tha-implant-fixation THR] Available from:https://www.orthobullets.com/recon/5003/tha-implant-fixation (accessed 14.2.2021)</ref>


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.<ref name="Sohier">Raymond Sohier, Kinesitherapie de la hanche ; La Hestre : Sohier, 1974</ref>&nbsp;This gives an idea of the preoperative state of the patient.<br>The general physical and psychological state of the patient should also be taken care of. <br>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|crutches properly]] can also make the patient more self-confident when entering the postoperative stage of the therapy<ref name="Sohier" />.  
== Surgical Approaches ==
[[File:Posterior hip approach.jpg|thumb|Posterior hip approach|alt=Posterior hip approach illustration]]
Any number of approaches can be used for the THA procedure. The three most common approaches are:


== Medical Management <br> ==
# Posterior (PA): Most common surgical approach for THR. Major advantage of this approach is the avoidance of the [[Hip Abductors|hip abductors]]. Performed with a patient lying on their side and a surgical incision made along the outside of the hip.<ref name=":1">Varacallo M, Luo TD, Johanson NA. Total hip arthroplasty techniques. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK507864/ (accessed 8.12.2022)</ref>
# Direct Anterior (DA): This surgical procedure has been increasing over the past decade. This approach is performed with a patient lying on their back, and a surgical incision is made coming down the front of the thigh (between the [[Tensor Fascia Lata|tensor fascia lata]] and [[sartorius]] on the superficial end, and the [[Gluteus Medius|gluteus medius]] and [[Rectus Femoris|rectus femoris]] on the deep side). There are several potential advantages of the direct anterior approach. The two most prominent are a low dislocation risk and early postoperative recovery.<ref name=":1" />Perception is that DAA results in less tissue damage, however this lacks support in the literature.<ref>Mead PA, Bugbee WD[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8735710/ . Direct anterior approach to total hip arthroplasty improves the likelihood of return to previous recreational activities compared with posterior approach]. JAAOS Global Research & Reviews. 2022 Jan;6(1).Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8735710/ (accessed 8.1.2024)</ref>
# Direct lateral (Hardinge) or anterolateral: Often considered to be a balance between the AP and PA. Person positioned on their side, and the surgical incision is placed directly down the outside of the hip. The advantage: balance of having a versatile incision that can be used to correct deformities and insert specialised implants with lower dislocation rates following surgery than what is observed with posterior approaches.  Disadvantage: superior gluteal nerve dissection may result in nerve injury, leading to postoperative [[Trendelenburg Gait|Trendelenburg gait]], characterized by compensatory movements to address [[Hip Abductors|hip abductor]] weakness. <ref name=":1" />
[[File:THR with MAKOplasty procedure.jpeg|thumb|475x475px|MAKOplasty<sup>®</sup> THR is powered by Interactive Robotic Arm]]Additionally


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<ref name="Oldenrijk">Van Oldenrijk J. et al., Soft tissue damage after minimally invasive THA. Acta Orthopaedica 2010; 81 (6): 696-702</ref><ref name="Zhang">Zhang X. et al. Anterolateral muscle sparing approach total hip arthroplasty: an anatomic and clinical study. Chinese Medicine Journal 2008; 121 (15):1358-1363</ref>. Other studies have shown a better rehabilitation time and functional outcome<ref name="Röttinger">Röttinger H. Minimally invasive anterolateral approach for total hip replacement.,Operative Orthopädie und Traumatologie (4)</ref>. Because of the lowered risk of dislocation compared to a posterior approach<ref name="Sköldenberg">Sköldenberg O. et al. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing posterolateral to anterolateral approach. Acta Orthopaedica 2010; 81 (5): 583-587</ref>, early mobilizations as well as full weight bearing exercises according to tolerance are made possible in the first postoperative days<ref name="Röttinger" />.<br>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<ref>http://orthopedics.about.com/od/hipkneereplacement/a/implants.htm</ref>. Important components of prosthesis are friction-coefficient, survival, stability against dislocation and fixation in bone tissue<ref name="Bader">Bader R. et al. Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability of dislocation of total hip replacement. Journal of materials science: materials in medicine 2004; 15:711-718</ref><ref name="Garcia">Garcia-Rey E. et al. Alumina-on-alumina total hip arthroplasty in young patients. Clinical Orthopaedics and Related Research; 467 (9):2281-2289</ref>. In some cases there can be formation of [http://www.physio-pedia.com/index.php5?title=Avascular_Necrosis osteonecrosis] due to erosion of the two components rubbing against each other<ref name="Mahendra">Mahendra G. et al. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties. Acta Orthopaedica 2009; 80 (6): 653-659.</ref>.<br><br> {{#ev:youtube|0-O8IFzV8Nc}} <br>  
# Robotic Arm Assisted THR: Assists with THR surgery, helping in the accurate positioning of the implants which correlates with improved function and lifespan of the THR. Can be used in all current surgical approaches to the hip (AP, PA and lateral).
# Minimally invasive surgery is becoming popular all around the world, due to the quicker recovery rates and reduced postoperative pain. Long term follow-up and comparison studies are still needed in this field.<ref>Alecci V, Valente M, Crucil M, Minerva M, Pellegrino C, Sabbadini DD. [https://link.springer.com/article/10.1007/s10195-011-0144-0 Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings.] J Orthopaed Traumatol 2011;12:123-129.</ref>


== Physical Therapy Management <br>  ==
View this 3 minute video and learn about the different approaches to hip replacement surgery and the advantages of each method.


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.  
{{#ev:youtube|v=1cUu-vMcSkM|300}}<ref>John Hopkins Medical. Approaches to Hip Replacement Surgery | Dr. Savya Thakkar. Available from: https://www.youtube.com/watch?v=1cUu-vMcSkM [last accessed 8.12.2022]</ref>
== Physiotherapy Management ==
Plenty of questions remain concerning the most effective rehabilitation management of patients following a THA. This uncertainty exists as a comparison of the effectiveness and harms of interventions is difficult due to the diverse programs, frequently inadequate intervention description, and an extensive variety of outcomes reported across research. What is needed are well-conducted studies that address both effectiveness and harms of interventions using randomised controlled trials.<ref>Konnyu KJ, Pinto D, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Balk EM, Thoma LM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9464790/ Rehabilitation for Total Hip Arthroplasty: A Systematic Review.] Am J Phys Med Rehabil. 2023 Jan 1;102(1):11-18. doi: 10.1097/PHM.0000000000002007. Epub 2022 Mar 12. PMID: 35302955; PMCID: PMC9464790.Accessed 8.1.204 Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9464790/</ref>


<br>After a total hip replacement there are a set of essential and mandatory <u>'''precautions'''</u>&nbsp;patients should be taught and adhere to prevent dislocation. These precautions are '''hip flexion above 90 degrees''', '''endorotation''' and '''adduction across midline'''. For example, cycling with elevated saddle and low resistance keeps the articulation in a reasonable range of motion and induces bearable joint load<ref name="Kuster">Kuster M. Exercise recommendations after total joint replacement. Sports medicine 2002 ;32(7) : 433-445</ref>. For the anterior approach it is the combination of extension, extra-rotation and abduction although the probability of dislocation is less great than for the posterior approach.  
Discuss '''[[Hip Precautions|Hip precautions]]''' before surgery.
# PA avoid: flexion past 90 degrees; extreme internal rotation; adduction past body's midline
# Anterolateral approach avoid: extension; extreme external rotation; adduction past the body's midline
# AP avoid''':''' bridging; extension; extreme external rotation; adduction past body's midline<ref name=":2" />
Hip precautions have traditionally been used within the management of total hip arthroplasty to reduce the risk of dislocations <ref>Coole C, Edwards C, Brewin C, Drummond A. [https://journals.sagepub.com/doi/abs/10.4276/030802213X13729279114898 What do clinicians think about hip precautions following total hip replacement?] Br J Occup Ther. 2013;76:7:300-307.</ref>. This is particularly needed to provide safe boundaries for movement when patients are keen to “push” those boundaries soon after surgery or have other risk factors such as abductor deficiency with a history of previous dislocations, loose soft tissues, patients with neuromuscular and cognitive disorders<ref name=":8">Mandel RT, Bruce G, Moss R, Carrington RWJ, Gilbert AW. [https://www.tandfonline.com/doi/full/10.1080/09638288.2020.1845825?scroll=top&needAccess=true&role=tab Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning.] Disab Rehab. 2022;44:12:2842–2848</ref>. However, their use is increasingly controversial due to their association with a slower return to activities, an absence in the rise of dislocation rates when precautions are not used, and a lack of evidence to support their use <ref>Barnsley L, Leslie Barnsley L, Page R. [https://journals.sagepub.com/doi/pdf/10.1177/2151458515584640 Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review.] Geriatr Orthop Surg Rehabil. 2015;6:3:230-235</ref><ref name=":8" />.


The risk of dislocation after replacement is great because of the trauma to the stabilizers of the hip such as the capsule, ligaments and muscles but also due to the size difference of the prosthesis to the bones. The average diameter of the head of femur in a human is 46mm and the prosthetic head of femur can range between 32mm-38mm and therefore this reduced size makes it easier to dislocate until the stabilizing tissues have healed and adapted to this smaller size<ref>Mirza S, Dunlop D G, Panesar S, Syed G N, Shafat G, Saif S. Basic Science Considerations in Primary Total Hip Replacement Arthroplasty. The Open Orthopaedics Journal. 2010;4,169-180</ref>. This generally takes up to 6 weeks to occur.
==== Pre-operative ====
One on one preoperative physical therapy session protocol is effective at reducing the number of postoperative PT visits and time for readiness to discharge from PT. It plays an important role towards improving preoperative quality of life (people can wait many months for surgery and experience further deterioration in health-related quality of life during long waits).<ref>Soeters R, White PB, Murray-Weir M, Koltsov JC, Alexiades MM, Ranawat AS. Preoperative physical therapy education reduces time to meet functional milestones after total joint arthroplasty. Clinical orthopaedics and related research. 2018 Jan;476(1):40.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5919221/ (accessed 89.12.2022)</ref>See also [[Physical Activity Pre and Post Surgery]]


<br>The treatment after a total hip arthroplasty (without other complications) includes the non-exhaustive set of items listed below<ref name="Sohier" /><ref name="Suetta">Suetta C. et al. Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse 2004; 97: 1954-1961</ref>. 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.
Pre-operative assessment and treatment session   
* Helps to develop a patient-specific rehabilitation programme to follow post-operative, taking assessment findings into consideration e.g., Does the patient desires to re uptake golf.
* Benefits: decreased length of stay<ref>Crowe J,Henderson J. [http://journals.sagepub.com/doi/abs/10.1177/000841740307000204 Pre-arthroplasty rehabilitation is effective in reducing length of hospital stay]. Canadian Journal of Occupational Therapy 2003;70:88-96.</ref>; decreased anxiety levels<ref name=":4">Barnes RY, Bodenstein, K, Human N. Raubenheimer J, Dawkins J, Seesink C, Jacobs J, van der Linde J, Venter R. [https://journals.co.za/content/journal/10520/EJC-ee9fbc7e5 Preoperative education in hip and knee arthroplasty patients in Bloemfontein.] South African Journal of Physiotherapy 2018;74(1).</ref>; improved self-confidence<ref name="Sohier">Raymond Sohier, Kinesitherapie de la hanche ; La Hestre : Sohier, 1974</ref>; establish a relationship of trust between the physiotherapist and patient.
* A combination of verbal explanation and written pamphlets is the best method for health education.<ref name=":4" /> Important to incorporate this into the pre-operative physiotherapy management of patients prior to total hip replacements (linked to better post-operative adherence).<ref name=":4" />
'''Pre op Assessment'''
* Subjective history 
* Range of motion 
* Muscle power 
* Circulation 
* Mobility and function<ref name="Sohier" /> 
'''Pre op Treatment'''
* Education and advice: Patient information booklet; Precautions and contraindications; Rehabilitation process; Goals & expectations; Functional/ADL adaptions; Safety principles
* Encourage to [[Smoking Cessation and Brief Intervention|stop smoking]] if applicable
* [[Discharge Planning|Discharge planning]]
* Teach: Bed exercises; Transfers in and out of bed (within precautions)
* [[Gait]] re-education with mobility [[Assistive Devices|assistive device]] ([[crutches]] vs [[walkers]])
* Stair climbing 


<br>  
==== Post-operative ====
Start the day of surgery as leads to decreased length of stay, reduces pain and improves function.
* Aim of post-operative rehabilitation: address the functional needs of the patient (e.g. start mobilizing) and to improve mobility, strength, flexibility and reduce pain.<ref name="Stockton K." />&nbsp;. This starts off as an assisted process, but the aim is to get the patient as functional as possible prior to discharge.
* As a result of the underlying pre-operative pathology, patients may present with muscle atrophy and loss of strength, particularly in the gluteus medius and quadriceps muscles. The result of the loss of strength is that the elderly are less independent.<ref name="Gremeaux V." />
* Surgery will correct the joint problems but associated muscle weakness that was present before the surgery will remain and require post-operative rehabilitation (research has shown hip abductor weakness after surgery is a major risk associated with joint instability and prosthetic loosening).<ref name="Jan M." /> Patients can achieve significant improvements through a targeted strengthening programme following total hip replacement.<ref>Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. [https://www.archives-pmr.org/article/S0003-9993(08)00305-5/fulltext A targeted home-and center-based exercise program for people after total hip replacement: a randomized clinical trial.] Archives of physical medicine and rehabilitation 2008;89(8):1442-7.</ref> Motor Imagery training, has been found to be a useful adjunct therapy tool as it improves both specific and general adaptations that were related to patients’ physical capabilities when added in a corollary to routine physical therapy.<ref>Paravlic AH, Pisot R, Marusic U. Specific and general adaptations following motor imagery practice focused on muscle strength in total knee arthroplasty rehabilitation: A randomized controlled trial. PloS one. 2019;14(8).</ref>
* No specific general hip replacement protocol is currently in use, as small elements of the rehabilitation process are surgeon specific. For example, in some enhanced recovery after surgery protocols, patients are mobilised out of bed within the first 6 hours post-surgery. Other settings may only start mobilizing patients out of bed on day 1 or 2 post-surgery. Accelerated rehabilitation programmes and early mobilization have shown to give patients more confidence in their post-operative mobilization and activities of daily living, as well as being more comfortable with earlier discharge.<ref>Robertson NB, Warganich T, Ghazarossian J, Khatod M. [https://www.hindawi.com/journals/aos/2015/387197/ Implementation of an accelerated rehabilitation protocol for total joint arthroplasty in the managed care setting: the experience of one institution.] Advances in Orthopedic Surgery. 2015;387197.</ref>


*<u>First postoperative day:</u>
==== Evidence ====
Physiotherapy: can improve strength and gait speed after total hip replacement and help prevent complications such as subluxation and thromboembolic disease; increases the patient’s mobility and offers education about the exercises and precautions that are necessary during hospitalization and after discharge.<ref>Coulter CL, Scarvell JM, Neeman TM, Smith PN. [https://www.sciencedirect.com/science/article/pii/S183695531370198X Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review.] Journal of physiotherapy. 2013;59(4):219-26.</ref>; 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<ref name="Freburger">Freburger J. [https://academic.oup.com/ptj/article/80/5/448/2842484 An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty.] Physical therapy 2000;80(5):448-458.</ref>
* Bed exercise following a total hip replacement important for the effects on oedema, cardiac function and improving range of motion and muscle strength<ref name="Perhonen">Perhonen MA, Franco F, Lane LD, Buckey JC, Blomqvist CG, Zerwekh JE, Peshock RM, Weatherall PT, Levine BD. [https://www.physiology.org/doi/full/10.1152/jappl.2001.91.2.645 Cardiac atrophy after bed rest and spaceflight.] Journal of applied physiology 2001;91(2):645-53.</ref>.
* Early weight bearing and physical activity have benefits for the quality of bone tissue<ref name="Mahendra">Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. [https://www.tandfonline.com/doi/full/10.3109/17453670903473016 Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties: relation to implant failure and pseudotumor formation.] Acta orthopaedica 2009;80(6):653-9.</ref>, improving the fixation of the prosthesis and decreases the incidence of early loosening. The amount of activity is patient-specific, and clinical reasoning should be used to make adaptions where needed. Certain specific sport movements have a higher risk of injury for unskilled individuals, and should be incorporated later in the rehabilitation process under supervision of a physiotherapist.


• Static contraction of the M. Quadriceps in order to have a muscular and circulatory effect.<br>• Flexion/extension/rotation of feet and toes to prevent edema<br>• Education of muscular relaxation<br>• Upper limb exercises to stimulate the cardiac function<br>• 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.  
'''Suggested protocol in the absence of complications:''' Surgeon preference should be taken into account, as well as any other factors that might hinder the following of the protocol. Adaptions should be made to make it more patient specific.<ref name="Sohier" /><ref name="Suetta">Suetta C, Aagaard P, Rosted A, Jakobsen AK, Duus B, Kjaer M, Magnusson SP. [https://www.physiology.org/doi/pdf/10.1152/japplphysiol.01307.2003 Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse.] Journal of Applied Physiology 2004;97(5):1954-61.</ref>


Bed exercise following total hip replacement does not seem to have an effect on the quality of life<ref name="Smith">Smith T. et al. Bed exercises following total hip replacement : a randomized controlled trial. Physiotherapy 2008; 94: 286-291</ref> but remains none of the less important (edema, cardiac function, etc.)<ref name="Perhonen">Perhonen M. et al. Cardiac atrophy after bed rest and spaceflight. Journal of Applied Physiology 2001; 91: 645-653</ref>. It also allows an assessment of the physical and psychological condition of the patient right after surgery.
==== Day 1 Post-Surgery ====
* Education and advice


<br>
* Education of muscular relaxation
* Revision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).
* Bed exercises:
** Circulation drills
** 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 mobilisation on the operated hip
** Isometric quadriceps (progressing to concentric VMO) and gluteal contractions
** Active-assisted (progressing to active) heel slides, hip abduction/adduction
* Bed mobilisation using unilateral bridging on the unaffected leg
* Getting in and out of bed (see [https://www.allinahealth.org/health-conditions-and-treatments/health-library/patient-education/total-hip-replacement/preparing-for-surgery/mobility-and-activity-techniques-for-daily-living here])
* Getting on and off a chair with arms (see [https://www.allinahealth.org/health-conditions-and-treatments/health-library/patient-education/total-hip-replacement/preparing-for-surgery/mobility-and-activity-techniques-for-daily-living here])
* Sit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)
* Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)
* Sitting out in chair for maximum 1 hour
* Positioning when transferred back to bed


*<u>First postoperative week:</u>
==== Day 2 Post-Surgery ====
* Bed exercises as described above, progressing repetitions and decreasing assistance given to patient
* Progression of distance mobilised and/or mobility assistive device
* Incorporate balance exercises if needed
* Sitting in chair


• Active/passive mobilizations to gain ROM<br>• Progressive resistance exercises<br>• Progressive weight bearing exercises according to tolerance<br>• Equilibrium exercises including walking with crutches/2 canes/1 cane.  
==== Day 3 Post-Surgery ====
[[File:Straight leg raise.png|thumb|single leg bridge|alt=single leg bridge illustration]]
Bed exercises as described above, progressing repetitions and decreasing assistance given to patient
* Progression of distance mobilised and/or mobility assistive device
* Stair climbing (at least 3, or as per home requirements)
* Sitting in chair
* Revision of precautions, contraindications and functional adaptions
* Give 6 week progressive resistive strengthening [[Adherence to Home Exercise Programs|home exercise]] to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)
After 3 days clients are usually discharged home if they meet the discharge criteria. The physiotherapist and nurse help to transfer to a car whilst maintaining hip precautions. As majority of patients lack understanding about the activities they can do following THR surgery, discharge education about pre-discharge pain management, movement, ADL, and support requirements should be provided to the clients. A recent RCT showed that video-assisted discharge program and education booklets given to the patient and their relatives after THR on activities of daily living, functionality, and patient satisfaction found that video-assisted discharge program along with physiotherapy reduced pain perception and kinesiophobia, improve hip function, and increase patient satisfaction. Further research is needed to assess the long-term outcomes of video-assisted discharge education in THR patients.<ref>Cetinkaya Eren O, Buker N, Tonak HA, Urguden M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8866490/ The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study]. Scientific Reports. 2022 Feb 23;12(1):1-9.</ref> 


Early exercises including full weight bearing exercises have shown different positive effects on the recovery of patients after THA (faster recovery<ref name="Ström">Ström H. et al. Unrestricted weight bearing and intensive physiotherapy after uncemented total hip arthroplasty. Scandinavian Journal of Surgery 2006; 95: 55-60</ref>, gain in walking ability<ref name="Kishida">Kishida Y. et al. Full weight-bearing after cementless total hip arthroplasty. International Orthopaedics 2001; 25: 25-28</ref>). Physical activity is also good for quality of bone tissue<ref name="Mahendra" />. 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.
===== '''Discharge Home Criteria:''' =====
* independent ambulation with assistive device
* independent transfers
* independent ADLs
* stairs with supervision
* appropriate home assistance (spouse, family, visiting nurses)<ref name=":2" />


<br>  
==== Home Planning ====
[[File:Crutches Walking.png|alt=crutch gait swing phase illustration|400x400px|thumb|crutch gait swing phase ]]
Several modifications to make home easier to navigate. The following items help with daily activities:
* Securely fastened safety bars or handrails in shower or bath
* Secure handrails along all stairways
* A stable chair for your early recovery with a firm seat cushion (allows knees to remain lower than hips), a firm back, and two arms
* A raised toilet seat
* A stable shower bench or chair for bathing
* A long-handled sponge and shower hose
* A dressing stick, a sock aid, and a long-handled shoehorn
* A reacher allowing grasping of objects without excessive bending of your hips
* Firm pillows for chairs, sofas, and car enabling client to sit with knees lower than hips
* Removal of all loose carpets and electrical cords from the areas walked in home<ref name=":2" />
This 7 minute video presents post-operative exercises after a total hip replacement for weeks 1-4.{{#ev:youtube|v=9eU8G038zFo|300}}<ref>HeartlandOrthospecial. Post-Operative Exercises Weeks 1-4 for Total Hip Replacement. Available from: https://www.youtube.com/watch?v=9eU8G038zFo[last accessed 24.3.2023]</ref>


*<u>1-12 postoperative month:</u>
==== 6 Weeks Post Surgery ====
* Patients are normally followed up by orthopaedic surgeon
* Surgeon determines if the patient is allowed the following:  
** Full range of motion at the hip
** Full weight bearing without mobility assistive device
** Driving 


• Gain of initial ROM, muscular force (stabilization), and control (proprioception).<br>• Endurance<br>• Flexibility<br>• Equilibrium on one foot<br>• Speed, precision, neurological coordination<br>• Functional exercises  
==== After 6 Weeks ====
* Gain of initial ROM, stabilization, and proprioception
* Endurance
* Flexibility
* Balance
* 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<ref name="Freburger">Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Physical therapy 2000; 80 (5): 448-458</ref>.<br>
==== Return to sport ====
Low-impact exercises are preferred
* golf: handicap shows minimal change after THA; handicap shows increase after TKA
* high-impact exercises increase revision rates in patients less than 55 years-old


== Outcome Measures  ==
== Outcome Measures  ==
* [[Harris Hip Score]]
* Oxford Hip Score ([http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html/ OHS])
* [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walking Test]]
* [[Timed Up and Go Test (TUG)|Timed Get Up & Go Test]]
* Western Ontario and McMaster universities osteoarthritis index ([http://www.womac.org/ WOMAC])
* [http://www.sf-36.org/ SF-36]
* [[Fear Avoidance Belief Questionnaire|Fear Avoidance Belief Score]] 
* Hip Disability & Osteoarthritis Outcome Score ([http://www.orthopaedicscore.com/scorepages/hip_disability_osteoarthritis_outcome_score_hoos.html/ HOOS]) 
* [[International Hip Outcome Tool (iHOT)|International Hip Outcome Tool]] 
* [[Ibadan Knee/Hip Osteoarthritis Outcome Measure (IKHOAM)|Ibadan Knee/Hip Osteoarthritis Outcome Measure]] 


[http://www.womac.org/ WOMAC]<br>
== Team Work ==
 
Total hip arthroplasty (THA) is one of the most reliable, reproducible, successful, and cost-effective procedures in all of orthopedics. The procedure requires coordination of care across various healthcare provider groups, including nurses, physical therapists, advanced practitioners and physician extenders, medical physicians, and orthopedic surgeons.
[http://www.sf-36.org/ SF-36]
 
[http://www.orthopaedicscore.com/scorepages/hip_disability_osteoarthritis_outcome_score_hoos.html/ HOOS]
 
[http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html/ OHS]
 
== 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)<br>
 
== Clinical Bottom Line  ==
 
Proper preoperative examination and early postoperative rehabilitation is crucial for successful outcome.  
 
== Search Strategy  ==


For search use: [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed], [http://www.archives-pmr.org/ Archives of Physical Medicine and Rehabilitation], [http://www.pedro.org.au/ PEDro]
Clinicians including the surgeon, nurse practitioner, and physiotherapist should work together to provide the patient and family with education regarding the procedure, expected issues, and guidance for aftercare.<ref name=":5" />
== Virtual Clinic Visits ==
Virtual follow-up for hip and knee arthroplasty patients is an effective substitute to in-person clinic assessment, substantiated in a recent investigation including 1,749 patients seen in a virtual visit between January 2017 and December 2018.  


Keywords: total hip replacement, total hip arthroplasty, surgical approach for THR, rehabilitation/physiotherapy + THR.<br>  
# For the 1-year postoperative visit and routine scheduled follow-up visits, only 7.22% of the patients required a further in-person assessment.
# Is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.<ref>El Ashmawy AA, Dowson K, El-Bakoury A, Hosny HA, Yarlagadda R, Keenan J. Effectiveness, patient satisfaction, and cost reduction of virtual joint replacement clinic follow-up of hip and knee arthroplasty. The Journal of arthroplasty. 2021 Mar 1;36(3):816-22.Available:https://pubmed.ncbi.nlm.nih.gov/32893060/ (accessed 6.12.2022)</ref>  


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1VGbwYNWYlcvZ3D0zVFypUxsIPdtLHcgjA6s69QJzPYMwuFk_f</rss></div>
== References  ==
== References  ==


<references /><br>  
<references /><br>      


[[Category:Surgery]] [[Category:Joints]] [[Category:Hip]] [[Category:Procedures]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Orthopaedic Surgical Procedures]]
[[Category:Joints]]
[[Category:Hip]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Vrije Universiteit Brussel Project]]
[[Category:Acute Care]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Conditions]]
[[Category:Interventions]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Hip - Interventions]]
[[Category:Osteoarthritis]]
[[Category:Arthroplasty]]

Latest revision as of 13:42, 11 January 2024

Original Editors - Annelies Beckers, Vincent Everaert as part of the Vrije Universiteit Brussel's Evidence-based Practice project.


Top Contributors - Lucinda hampton, Annelies Beckers, Leana Louw, Jessie Tourwe, Didzis Rozenbergs, Kim Jackson, Vincent Everaert, Admin, Yana Motte, Scott Buxton, Vidya Acharya, Johnathan Fahrner, Rebecca Willis, Liesel Muyelle, Liese Bosman, Blessed Denzel Vhudzijena, George Prudden, Aminat Abolade, WikiSysop, Heleen.Mergan, Karen Wilson, 127.0.0.1, Kenny Bosmans, Laura Mertens, Uchechukwu Chukwuemeka, Shaimaa Eldib, Evan Thomas, Redisha Jakibanjar, Samuel Adedigba, Lauren Lopez and Daniele Barilla

Description[edit | edit source]

Hip prosthesis components
Hip prosthesis components

Total hip replacement (THR), or Total Hip Arthroplasty (THA), is a procedure that removes damaged bone and cartilage and replaces it with prosthetic components. THR is one of the most cost-effective and consistently successful surgeries performed in orthopaedics. 

Clinically Relevant Anatomy[edit | edit source]

Total Hip Replacement X-ray
THR X-ray

The hip is a ball and socket joint. This design allows the poly-axial movement seen at the hip.

The head of the femur and the inside of the acetabulum are covered with a layer of hyaline cartilage.[4] Once this cartilage is worn away or damaged (usually by arthritis), the underlying bone is exposed, resulting in pain, stiffness and possibly shortening of the affected leg. By replacing these surfaces the aim is to reduce pain and stiffness to restore an active and pain-free life.

THR is mostly done electively.[5][6][7][8]

Indications for Surgery[edit | edit source]

The most common indication for THA hip OA. Other indications include:[9]

Complications[edit | edit source]

Leg length discrepancy after Total Hip Replacement
Leg length discrepancy after THR

Complications following THR can be loosely divided into systemic and procedure specific complications. Incidence of complications have improved over time, due to surgical and anaesthetic technique improvements, along with the better diagnosis and management of these complications.

The most common systemic complication is a deep vein thrombosis. Infection is the most dreaded complication. Leg length discrepancy is a common cause of patient dissatisfaction[11]. For more see Total Hip Replacement Complications.

Contraindications for Surgery[edit | edit source]

THA is contraindicated in the following clinical scenarios:

Orthopaedic Assessment[edit | edit source]

An assessment by an orthopaedic surgeon consists of several components:

  • Medical history: general health and questions about the extent of hip pain and how it affects ability to perform ADLs.
  • Hip Examination
  • X-rays. Assess the extent of damage or deformity in the hip.
  • Other tests. Occasionally other tests, e.g., MRI scan, may be needed to determine the condition of the bone and soft tissues of the hip.

The diagnosis of patients requiring THR is mostly symptom-based. Pain, loss of range of motion and functional impairments are mostly considered.[13]

Prosthesis[edit | edit source]

Stainless steel and ultra high molecular weight polythene Total Hip Replacement
Stainless steel and ultra high molecular weight polythene THR

When performing a THR, the ball is removed, socket reshaped, and the artificial implant is positioned in the bone. The implant may be held in the bone by tightly wedging it in place, or cementing into position. Type of fixation used depends on the patient's bone health and the design of the implant. Contemporary THR techniques have evolved into press-fit femoral and acetabular components, and many variations exist.[14] The basic components are:

  1. Bearing surfaces are the surfaces which articulate in the prosthetic joint. The femoral head and the acetabular liner can be used in different combinations. These will give different appearance on radiograph depending on the configuration. Many options are available e.g., Metal-on-polyethylene, Ceramic-on-polyethylene, Ceramic-on-ceramic, Metal-on-metal.[1]
  2. Femoral component or stem: this refers to the prosthesis which is implanted into the femur. They can be described by length, taper, and presence of a collar. Attached to the femoral component is the neck and head which in most prostheses can be altered in size to create a stable joint[15].
  3. Prosthesis fixation: Femoral stem fixation can be either cemented or non-cemented (biological) fixation[15]. Prevalence of fixation technique: increasing trend towards cementless fixation; 93% of THA in United States in 2012 were cementless[16]

Surgical Approaches[edit | edit source]

Posterior hip approach illustration
Posterior hip approach

Any number of approaches can be used for the THA procedure. The three most common approaches are:

  1. Posterior (PA): Most common surgical approach for THR. Major advantage of this approach is the avoidance of the hip abductors. Performed with a patient lying on their side and a surgical incision made along the outside of the hip.[17]
  2. Direct Anterior (DA): This surgical procedure has been increasing over the past decade. This approach is performed with a patient lying on their back, and a surgical incision is made coming down the front of the thigh (between the tensor fascia lata and sartorius on the superficial end, and the gluteus medius and rectus femoris on the deep side). There are several potential advantages of the direct anterior approach. The two most prominent are a low dislocation risk and early postoperative recovery.[17]Perception is that DAA results in less tissue damage, however this lacks support in the literature.[18]
  3. Direct lateral (Hardinge) or anterolateral: Often considered to be a balance between the AP and PA. Person positioned on their side, and the surgical incision is placed directly down the outside of the hip. The advantage: balance of having a versatile incision that can be used to correct deformities and insert specialised implants with lower dislocation rates following surgery than what is observed with posterior approaches. Disadvantage: superior gluteal nerve dissection may result in nerve injury, leading to postoperative Trendelenburg gait, characterized by compensatory movements to address hip abductor weakness. [17]
MAKOplasty® THR is powered by Interactive Robotic Arm

Additionally

  1. Robotic Arm Assisted THR: Assists with THR surgery, helping in the accurate positioning of the implants which correlates with improved function and lifespan of the THR. Can be used in all current surgical approaches to the hip (AP, PA and lateral).
  2. Minimally invasive surgery is becoming popular all around the world, due to the quicker recovery rates and reduced postoperative pain. Long term follow-up and comparison studies are still needed in this field.[19]

View this 3 minute video and learn about the different approaches to hip replacement surgery and the advantages of each method.

[20]

Physiotherapy Management[edit | edit source]

Plenty of questions remain concerning the most effective rehabilitation management of patients following a THA. This uncertainty exists as a comparison of the effectiveness and harms of interventions is difficult due to the diverse programs, frequently inadequate intervention description, and an extensive variety of outcomes reported across research. What is needed are well-conducted studies that address both effectiveness and harms of interventions using randomised controlled trials.[21]

Discuss Hip precautions before surgery.

  1. PA avoid: flexion past 90 degrees; extreme internal rotation; adduction past body's midline
  2. Anterolateral approach avoid: extension; extreme external rotation; adduction past the body's midline
  3. AP avoid: bridging; extension; extreme external rotation; adduction past body's midline[16]

Hip precautions have traditionally been used within the management of total hip arthroplasty to reduce the risk of dislocations [22]. This is particularly needed to provide safe boundaries for movement when patients are keen to “push” those boundaries soon after surgery or have other risk factors such as abductor deficiency with a history of previous dislocations, loose soft tissues, patients with neuromuscular and cognitive disorders[23]. However, their use is increasingly controversial due to their association with a slower return to activities, an absence in the rise of dislocation rates when precautions are not used, and a lack of evidence to support their use [24][23].

Pre-operative[edit | edit source]

One on one preoperative physical therapy session protocol is effective at reducing the number of postoperative PT visits and time for readiness to discharge from PT. It plays an important role towards improving preoperative quality of life (people can wait many months for surgery and experience further deterioration in health-related quality of life during long waits).[25]See also Physical Activity Pre and Post Surgery

Pre-operative assessment and treatment session

  • Helps to develop a patient-specific rehabilitation programme to follow post-operative, taking assessment findings into consideration e.g., Does the patient desires to re uptake golf.
  • Benefits: decreased length of stay[26]; decreased anxiety levels[27]; improved self-confidence[28]; establish a relationship of trust between the physiotherapist and patient.
  • A combination of verbal explanation and written pamphlets is the best method for health education.[27] Important to incorporate this into the pre-operative physiotherapy management of patients prior to total hip replacements (linked to better post-operative adherence).[27]

Pre op Assessment

  • Subjective history
  • Range of motion
  • Muscle power
  • Circulation
  • Mobility and function[28]

Pre op Treatment

  • Education and advice: Patient information booklet; Precautions and contraindications; Rehabilitation process; Goals & expectations; Functional/ADL adaptions; Safety principles
  • Encourage to stop smoking if applicable
  • Discharge planning
  • Teach: Bed exercises; Transfers in and out of bed (within precautions)
  • Gait re-education with mobility assistive device (crutches vs walkers)
  • Stair climbing

Post-operative[edit | edit source]

Start the day of surgery as leads to decreased length of stay, reduces pain and improves function.

  • Aim of post-operative rehabilitation: address the functional needs of the patient (e.g. start mobilizing) and to improve mobility, strength, flexibility and reduce pain.[7] . This starts off as an assisted process, but the aim is to get the patient as functional as possible prior to discharge.
  • As a result of the underlying pre-operative pathology, patients may present with muscle atrophy and loss of strength, particularly in the gluteus medius and quadriceps muscles. The result of the loss of strength is that the elderly are less independent.[5]
  • Surgery will correct the joint problems but associated muscle weakness that was present before the surgery will remain and require post-operative rehabilitation (research has shown hip abductor weakness after surgery is a major risk associated with joint instability and prosthetic loosening).[6] Patients can achieve significant improvements through a targeted strengthening programme following total hip replacement.[29] Motor Imagery training, has been found to be a useful adjunct therapy tool as it improves both specific and general adaptations that were related to patients’ physical capabilities when added in a corollary to routine physical therapy.[30]
  • No specific general hip replacement protocol is currently in use, as small elements of the rehabilitation process are surgeon specific. For example, in some enhanced recovery after surgery protocols, patients are mobilised out of bed within the first 6 hours post-surgery. Other settings may only start mobilizing patients out of bed on day 1 or 2 post-surgery. Accelerated rehabilitation programmes and early mobilization have shown to give patients more confidence in their post-operative mobilization and activities of daily living, as well as being more comfortable with earlier discharge.[31]

Evidence[edit | edit source]

Physiotherapy: can improve strength and gait speed after total hip replacement and help prevent complications such as subluxation and thromboembolic disease; increases the patient’s mobility and offers education about the exercises and precautions that are necessary during hospitalization and after discharge.[32]; 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[33]

  • Bed exercise following a total hip replacement important for the effects on oedema, cardiac function and improving range of motion and muscle strength[34].
  • Early weight bearing and physical activity have benefits for the quality of bone tissue[35], improving the fixation of the prosthesis and decreases the incidence of early loosening. The amount of activity is patient-specific, and clinical reasoning should be used to make adaptions where needed. Certain specific sport movements have a higher risk of injury for unskilled individuals, and should be incorporated later in the rehabilitation process under supervision of a physiotherapist.

Suggested protocol in the absence of complications: Surgeon preference should be taken into account, as well as any other factors that might hinder the following of the protocol. Adaptions should be made to make it more patient specific.[28][36]

Day 1 Post-Surgery[edit | edit source]

  • Education and advice
  • Education of muscular relaxation
  • Revision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).
  • Bed exercises:
    • Circulation drills
    • 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 mobilisation on the operated hip
    • Isometric quadriceps (progressing to concentric VMO) and gluteal contractions
    • Active-assisted (progressing to active) heel slides, hip abduction/adduction
  • Bed mobilisation using unilateral bridging on the unaffected leg
  • Getting in and out of bed (see here)
  • Getting on and off a chair with arms (see here)
  • Sit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)
  • Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)
  • Sitting out in chair for maximum 1 hour
  • Positioning when transferred back to bed

Day 2 Post-Surgery[edit | edit source]

  • Bed exercises as described above, progressing repetitions and decreasing assistance given to patient
  • Progression of distance mobilised and/or mobility assistive device
  • Incorporate balance exercises if needed
  • Sitting in chair

Day 3 Post-Surgery[edit | edit source]

single leg bridge illustration
single leg bridge

Bed exercises as described above, progressing repetitions and decreasing assistance given to patient

  • Progression of distance mobilised and/or mobility assistive device
  • Stair climbing (at least 3, or as per home requirements)
  • Sitting in chair
  • Revision of precautions, contraindications and functional adaptions
  • Give 6 week progressive resistive strengthening home exercise to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)

After 3 days clients are usually discharged home if they meet the discharge criteria. The physiotherapist and nurse help to transfer to a car whilst maintaining hip precautions. As majority of patients lack understanding about the activities they can do following THR surgery, discharge education about pre-discharge pain management, movement, ADL, and support requirements should be provided to the clients. A recent RCT showed that video-assisted discharge program and education booklets given to the patient and their relatives after THR on activities of daily living, functionality, and patient satisfaction found that video-assisted discharge program along with physiotherapy reduced pain perception and kinesiophobia, improve hip function, and increase patient satisfaction. Further research is needed to assess the long-term outcomes of video-assisted discharge education in THR patients.[37]

Discharge Home Criteria:[edit | edit source]
  • independent ambulation with assistive device
  • independent transfers
  • independent ADLs
  • stairs with supervision
  • appropriate home assistance (spouse, family, visiting nurses)[16]

Home Planning[edit | edit source]

crutch gait swing phase illustration
crutch gait swing phase

Several modifications to make home easier to navigate. The following items help with daily activities:

  • Securely fastened safety bars or handrails in shower or bath
  • Secure handrails along all stairways
  • A stable chair for your early recovery with a firm seat cushion (allows knees to remain lower than hips), a firm back, and two arms
  • A raised toilet seat
  • A stable shower bench or chair for bathing
  • A long-handled sponge and shower hose
  • A dressing stick, a sock aid, and a long-handled shoehorn
  • A reacher allowing grasping of objects without excessive bending of your hips
  • Firm pillows for chairs, sofas, and car enabling client to sit with knees lower than hips
  • Removal of all loose carpets and electrical cords from the areas walked in home[16]

This 7 minute video presents post-operative exercises after a total hip replacement for weeks 1-4.

[38]

6 Weeks Post Surgery[edit | edit source]

  • Patients are normally followed up by orthopaedic surgeon
  • Surgeon determines if the patient is allowed the following:
    • Full range of motion at the hip
    • Full weight bearing without mobility assistive device
    • Driving

After 6 Weeks[edit | edit source]

  • Gain of initial ROM, stabilization, and proprioception
  • Endurance
  • Flexibility
  • Balance
  • Speed, precision, neurological coordination
  • Functional exercises

Return to sport[edit | edit source]

Low-impact exercises are preferred

  • golf: handicap shows minimal change after THA; handicap shows increase after TKA
  • high-impact exercises increase revision rates in patients less than 55 years-old

Outcome Measures[edit | edit source]

Team Work[edit | edit source]

Total hip arthroplasty (THA) is one of the most reliable, reproducible, successful, and cost-effective procedures in all of orthopedics. The procedure requires coordination of care across various healthcare provider groups, including nurses, physical therapists, advanced practitioners and physician extenders, medical physicians, and orthopedic surgeons.

Clinicians including the surgeon, nurse practitioner, and physiotherapist should work together to provide the patient and family with education regarding the procedure, expected issues, and guidance for aftercare.[1]

Virtual Clinic Visits[edit | edit source]

Virtual follow-up for hip and knee arthroplasty patients is an effective substitute to in-person clinic assessment, substantiated in a recent investigation including 1,749 patients seen in a virtual visit between January 2017 and December 2018.

  1. For the 1-year postoperative visit and routine scheduled follow-up visits, only 7.22% of the patients required a further in-person assessment.
  2. Is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.[39]  

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Varacallo M, Luo TD, Johanson NA. Total Hip Arthroplasty Techniques. InStatPearls [Internet] 2020 Jul 8. StatPearls Publishing.Available from: https://www.statpearls.com/articlelibrary/viewarticle/22894/ (accessed 14.2.2021)
  2. ↑ Levine BR, Klein GR, Cesare PE. Surgical approaches in total hip arthroplasty: A review of the mini-incision and MIS literature. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):5-18.
  3. ↑ Iglesias SL, Gentile L, Mangupli MM, Pioli I, Nomides RE, Allende BL. Femoral neck fractures in the elderly: from risk factors to pronostic features for survival. Journal of Trauma and Critical Care. 2017;1(1).
  4. ↑ Meyers HM. Fractures of the hip. Chicago: Year of the book medical publishers Inc., 1985
  5. ↑ 5.0 5.1 Gremeaux V, Renault J, Pardon L, Deley G, Lepers R, Casillas JM. Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial. Archives of physical medicine and rehabilitation 2008;89(12):2265-73.
  6. ↑ 6.0 6.1 Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. Effects of a home program on strength, walking speed, and function after total hip replacement. Archives of physical medicine and rehabilitation 2004 ;85(12):1943-51.
  7. ↑ 7.0 7.1 Stockton KA, Mengersen KA. Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(10):1652-7.
  8. ↑ Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(5):745-55.
  9. ↑ Affatato S. Perspectives in total hip arthroplasty: Advances in biomaterials and their tribological interactions. London: Woodhead Publishing, 2014.
  10. ↑ Hsu H, Nallamothu SV. Hip Osteonecrosis.Available:https://www.ncbi.nlm.nih.gov/books/NBK499954/ (accessed 9.12.2022)
  11. ↑ Park C, Merchant I. Complications of total hip replacement. InTotal Hip Replacement-An Overview 2018 Nov 5. IntechOpen. Available:https://www.intechopen.com/chapters/61241 (accessed 8.12.2022)
  12. ↑ Varacallo M, Luo TD, Johanson NA. Total Hip Arthroplasty Techniques. InStatPearls [Internet] 2020 Jul 8. StatPearls Publishing.Available from:https://www.statpearls.com/articlelibrary/viewarticle/22894/ (accessed 14.2.2021)
  13. ↑ Crawford AJ, Hamblen DL. Outline of Orthopaedics , thirteenth edition, London: Churchill Livingstone, 2001
  14. ↑ Very well health What Type of Hip Replacement Implant Is Best? Available:https://www.verywellhealth.com/what-type-of-hip-replacement-implant-is-best-2549558#citation-2 (accessed 8.12.2022)
  15. ↑ 15.0 15.1 Radiopedia THR Available from:https://radiopaedia.org/articles/total-hip-arthroplasty (accessed 14.2.2021)
  16. ↑ 16.0 16.1 16.2 16.3 Ortho bullets THR Available from:https://www.orthobullets.com/recon/5003/tha-implant-fixation (accessed 14.2.2021)
  17. ↑ 17.0 17.1 17.2 Varacallo M, Luo TD, Johanson NA. Total hip arthroplasty techniques. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK507864/ (accessed 8.12.2022)
  18. ↑ Mead PA, Bugbee WD. Direct anterior approach to total hip arthroplasty improves the likelihood of return to previous recreational activities compared with posterior approach. JAAOS Global Research & Reviews. 2022 Jan;6(1).Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8735710/ (accessed 8.1.2024)
  19. ↑ Alecci V, Valente M, Crucil M, Minerva M, Pellegrino C, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthopaed Traumatol 2011;12:123-129.
  20. ↑ John Hopkins Medical. Approaches to Hip Replacement Surgery | Dr. Savya Thakkar. Available from: https://www.youtube.com/watch?v=1cUu-vMcSkM [last accessed 8.12.2022]
  21. ↑ Konnyu KJ, Pinto D, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Balk EM, Thoma LM. Rehabilitation for Total Hip Arthroplasty: A Systematic Review. Am J Phys Med Rehabil. 2023 Jan 1;102(1):11-18. doi: 10.1097/PHM.0000000000002007. Epub 2022 Mar 12. PMID: 35302955; PMCID: PMC9464790.Accessed 8.1.204 Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9464790/
  22. ↑ Coole C, Edwards C, Brewin C, Drummond A. What do clinicians think about hip precautions following total hip replacement? Br J Occup Ther. 2013;76:7:300-307.
  23. ↑ 23.0 23.1 Mandel RT, Bruce G, Moss R, Carrington RWJ, Gilbert AW. Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning. Disab Rehab. 2022;44:12:2842–2848
  24. ↑ Barnsley L, Leslie Barnsley L, Page R. Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review. Geriatr Orthop Surg Rehabil. 2015;6:3:230-235
  25. ↑ Soeters R, White PB, Murray-Weir M, Koltsov JC, Alexiades MM, Ranawat AS. Preoperative physical therapy education reduces time to meet functional milestones after total joint arthroplasty. Clinical orthopaedics and related research. 2018 Jan;476(1):40.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5919221/ (accessed 89.12.2022)
  26. ↑ Crowe J,Henderson J. Pre-arthroplasty rehabilitation is effective in reducing length of hospital stay. Canadian Journal of Occupational Therapy 2003;70:88-96.
  27. ↑ 27.0 27.1 27.2 Barnes RY, Bodenstein, K, Human N. Raubenheimer J, Dawkins J, Seesink C, Jacobs J, van der Linde J, Venter R. Preoperative education in hip and knee arthroplasty patients in Bloemfontein. South African Journal of Physiotherapy 2018;74(1).
  28. ↑ 28.0 28.1 28.2 Raymond Sohier, Kinesitherapie de la hanche ; La Hestre : Sohier, 1974
  29. ↑ Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. A targeted home-and center-based exercise program for people after total hip replacement: a randomized clinical trial. Archives of physical medicine and rehabilitation 2008;89(8):1442-7.
  30. ↑ Paravlic AH, Pisot R, Marusic U. Specific and general adaptations following motor imagery practice focused on muscle strength in total knee arthroplasty rehabilitation: A randomized controlled trial. PloS one. 2019;14(8).
  31. ↑ Robertson NB, Warganich T, Ghazarossian J, Khatod M. Implementation of an accelerated rehabilitation protocol for total joint arthroplasty in the managed care setting: the experience of one institution. Advances in Orthopedic Surgery. 2015;387197.
  32. ↑ Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. Journal of physiotherapy. 2013;59(4):219-26.
  33. ↑ Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Physical therapy 2000;80(5):448-458.
  34. ↑ Perhonen MA, Franco F, Lane LD, Buckey JC, Blomqvist CG, Zerwekh JE, Peshock RM, Weatherall PT, Levine BD. Cardiac atrophy after bed rest and spaceflight. Journal of applied physiology 2001;91(2):645-53.
  35. ↑ Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties: relation to implant failure and pseudotumor formation. Acta orthopaedica 2009;80(6):653-9.
  36. ↑ Suetta C, Aagaard P, Rosted A, Jakobsen AK, Duus B, Kjaer M, Magnusson SP. Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse. Journal of Applied Physiology 2004;97(5):1954-61.
  37. ↑ Cetinkaya Eren O, Buker N, Tonak HA, Urguden M. The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study. Scientific Reports. 2022 Feb 23;12(1):1-9.
  38. ↑ HeartlandOrthospecial. Post-Operative Exercises Weeks 1-4 for Total Hip Replacement. Available from: https://www.youtube.com/watch?v=9eU8G038zFo[last accessed 24.3.2023]
  39. ↑ El Ashmawy AA, Dowson K, El-Bakoury A, Hosny HA, Yarlagadda R, Keenan J. Effectiveness, patient satisfaction, and cost reduction of virtual joint replacement clinic follow-up of hip and knee arthroplasty. The Journal of arthroplasty. 2021 Mar 1;36(3):816-22.Available:https://pubmed.ncbi.nlm.nih.gov/32893060/ (accessed 6.12.2022)


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