Total hip replacement: how long can we do the contraindicated things ?

[pkkenchan]

Dear all ,

we all have a knowledge that THR patient was not allowed to peform excessive hip flexion (namely pass 90 degree), adduction (past neutral) , internal rotation (for posteriolateral approaches).

But for how long that this kind of contraindication can be weaved and we can tell patient that you can treat your op hip as the normal one, rather than taking extra care on it ? and we as physiotherapist need to train those mm in order to maintain mm balance of both LL.

would any one please give advice on this one ?

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[Josephine]

Speaking as a nurse who's had a lifetime in joint replacement surgery and now does joint replacement counselling, it all depends upon the surgeons! Some like the restrictions, others don't. Those that apply them usually cite between 6 and 12 weeks before those movements can be used generally. The risk, of course, is dislocation.

The risk is on a sliding scale meaning the first week or two it's high then gradually reduces as the time since surgery grows. The key is the healing of the muscles and recovery of tone, of course.

Short story long, first ascertain what instructions the patient's surgeon has given them. Once that period is over, they should be able to return to normal activities amost immedately or as soon as they feel able. For patients who have had no restrictions, they can do it sooner, as they feel able.

Hope this helps some. It's rather one of those 'how long is a piece of string' questions!

[Ontogenese]

Dear all ,

we all have a knowledge that THR patient was not allowed to peform excessive hip flexion (namely pass 90 degree), adduction (past neutral) , internal rotation (for posteriolateral approaches).

But for how long that this kind of contraindication can be weaved and we can tell patient that you can treat your op hip as the normal one, rather than taking extra care on it ? and we as physiotherapist need to train those mm in order to maintain mm balance of both LL.

would any one please give advice on this one ?

Six weeks are needed for the tissue recovery. During this period the hip has the greatest risk of dislocation. People should be well aware of the restrictions of this new hip. After these first six weeks, the chances of dislocation are significantly reduced, however, still present.

Oh, by the way, Lübbeke et al (2009) recently found that preoperative instruction may reduce postoperative dislocation.

Regards, Thomas

[Josephine]

Just as a matter of interest, I have a friend who has 5 joint replacements! (2 hip, 2 knees and a shoulder) His hips were put in in 2001. He has returned to running his two businesses which are a small trucking company (he drives a truck himself!) and a ranch.

A couple of weeks ago he had to dismount to examing a situation out on the ranch. Usually he uses a mounting block but since he was out on the ranch somewhere, he had to do his best. His horse is a big beast as well! Needless to say, it was a bit of a struggle for him to get his foot in the stirrup, nor that he ended up putting his hip out! Fortunately he had his cell-phone with him and was able to ring home but even so, it took over 40 minutes for him to be found.

He had the hip reduced and 24hrs later was back driving his truck! Surprisingly, he's been fine since though he's sticking to using his mounting block for the time being!

This is just a cautionary and unusual tale and not to be recommended!

[smshaffe]

my understanding is that it varies by surgeon. however, this is misleading. it doesn't just vary by surgeon it varies by patient and method of surgery. and, everyone heals differently and has different underlying tissue extensibility. i've head stories of surgeons (but can't verify the truth of said stories) that say they specifically move the hip as far as they can before it feels like it will pop out while the pt is still on the table; solid hips get less time on precautions and loose ones more. i've seen pts that dislocated and have precautions for the rest of their lives. if you feel confident you can assess passive accessory movement and see what it feels like but most PTs i know would never want to do that.

Some literature references:
A review (which I have not read) in 2009 states, "Available studies justify no hip restrictions following an anterolateral approach but none have examined the question for a posterior approach."
Sharma V et al. Clin Orthop Relat Res. 2009 Jun;467(6):1400-11.

"Total hip arthroplasty through an anterolateral approach is likely to be associated with a low dislocation rate. Removal of several restrictions did not increase the prevalence of dislocation following primary hip arthroplasty at our institution. However, it did promote substantially lower costs and was associated with a higher level of patient satisfaction as patients achieved a faster return to daily functions in the early postoperative period."
Peak EL et al. J Bone Joint Surg Am. 2005 Feb;87(2):247-53.

[Josephine]

Oh indeed the anterior has much less dislocation factor! Since way back when, (before hip replacements - yes I am old enough to have experience of then! LOL) hemi-arthroplasties carried out for #NOF were most often done via a posterior incision and dislocation rate always seemed to be a common occurence.

Your apocryphal tale of surgeons testing the hip before the patient is transfered off the table is quite true. It's generally a routine part of the procedure as is checking the leg length by approximating the medial malleoli. Not the most accurate, granted, but they do it anyway.

[smshaffe]

then i guess this is the same as with most other situations. 10+ variables means there is no easy answer.

[leahweah]

Generally three months. To allow healing of the capsule.