Protocol for physio post Total Hip Replacement (THR)

Protocol for physio post Total Hip Replacement (THR)

Hi, I had a Right THR, uncemented, lateral approach on the 13th March. At 3 days post-op I was discharged from hospital AND from physio. Yes I was given 3 physio exercises to continue myself at home... but no further input and the Othopaedic Surgeons (OS) follow-up appointment not until 9 weeks post-op.

Why? From surfing relevant forums it seem most patient's have ongoing physio input and exercises are assessed and altered to better suit the patient. I can't get to speak to my OS either (his PA is way to good at side-stepping any questions).

• I feel like I've been abandoned ! I'm having problems with:
• leg length discrepency,
• unlevel pelvis,
• back-pain,
• tightness behind my knee and in my groin.

I feel I need assessment and help but GP says wait for OS appointment in 4 weeks time (I'm nearly 5 weeks post-op now).

Is my experience normal or unusual? Is there anything I can do to help myself?

Thanks, Lesley

Hi lesley,
at the hospital that i work at it is routine procedure to have a home physio regime of exercises and usually out-patient physio is not required. however you are obviously still having problems and some of the could be benefitted from further physio input. Because you had an uncemented prosthesis i will assume that you are relatively young and were therefore probably quite active before surgery.if i were in your shoes i would probably ring your hospital switchboard and ask them to bleep the lead orthopaedic physio for you. if you explain to them the on-going problems then they may well be able to refer you for further physio input in out-pts. Hope this helps. Let me know.
Cheers,

john

Thanks John.... nothings ever quite that simple is it? 3 weeks after I spoke to my OS's secretary I got a phone call from him today. He said he'd just this week discussed me with OS, and gave me the direct dial number to contact OP physio myself. Guess what they asked? Have I been referred? They took my details and will check for a referral card and ring me back. Waited in all afternoon but phone didn't ring.... not suprising eh? OS says self-refer, physio says OS refer, where does that leave me? Struggling. Still off work too. (I work for NHS darn-it, I need to get back!) At 6 week post-op now I'm to learn to walk without crutches.... without help. It's creasing my back! I'm lopsided... my THR leg won't extend behind me so I can't take a decent size step with good leg... and my my pelvis on THR side is stiff and tilts up making my rump stick out backwards. So awkward and uncomfortable. So Frustrating!!!!

Have a look over the information as an attached file.

More information on hip relacement is as follows.

To prevent the joint dislocation or subluxation when the joint is unstable in the early postoperative days and weeks, the patient must avoid full ROM of operated hip.

If a posterolateral incision is made, excessive hip flexion and adduction beyond neutral must be avoided. During the first post operative days, avoid hip flexion past 45 degree and adduction past neutral during range of motion and ADLs. By two to three week postoperatively the patient is usually allowed to flex the hip to 90 degree. However, many surgeons agree to achieve the hip flexion up to 90 degree during the first two to three weeks.

If procedure involved an anterolateral approach, the patient should avoid hyperextension of hip as well as adduction past neutral.

Excessive hip Rotation must also be limited while tissue heals. If posterolateral approach is used, avoid internal rotation of hip. If anterolateral incision is used, avoid external rotation of hip.

Patients with cemented joint replacements can bear weight as tolerated unless the operative procedure involved a soft tissue repair or internal fixation of bone. Usually with cemented approach full weight bearing is started on the second post operative day while re-educating gait usually with walker or elbow crutches. However, with uncemented approach gait pattern is non weight bearing for 6 weeks, then partial weight bearing for 6 weeks. Walking aid must be used for 3 months.

Activities of daily living should be adapted as follows:

Have the patient transfer to the sound side.
Have the patient avoid sitting in low soft chair.
Suggest the patient to use raised toilet seat.
Do not allow the patient to excessively bend trunk over the operated hip when rising from a chair or to pick up an object from the floor.
Do not allow the patient to cross his legs.
Suggest to the patient that he or she sleep with an abduction pillow and to avoid sleeping on the side for atleast 8 to 12 weeks.
Do not turn your legs inwards.
An assistive such as walker, elbow crutch or stick is necessary to perform activities of daily livings.
Driving is not allowed for 6 weeks because there is loss of proprioceptive input to the hip joint.

That's a good lot of info thank you!

One further question: If using a treadmill for daily walking... is it best to do one long session a day... or several small sessions a day.... And should it be hands-free walking after 6 weeks on uncemeted THR... or holding lightly just to assist balance... or using handhold for partial weightbearing?

I would not recommend the use of treadmill for gait training following uncemented approach as you know it is non weight bearing for first 6 weeks and partial weight bearing after 12 weeks. Moreover, gait training require a lot of support from walking aids and required level surfaces for gaining good balance and in treadmill due to slopped and sliding nature, it is difficult to achieve that. The use of treadmill for many times a days depend upon the particular regime for what it is being used, like stroke, cardiac rehabiliatation, etc. Adding suspension therapy by suspending an individual from the shoulders by supports by suspension therapy apparatus while using treadmill is a good idea but you have to be sure of the safety of your patient and his weight bearing status and also the capability of the patient to cooperate during the exercise regime. As Suspension therapy along with treadmill is used for gait training following the spinal cord injuries.

not always nwb for 6 weeks and usually you can go straight to FWB after 6 weeks anyway. i would say that you can use the traedmill as long as you feel safe. start slowly say 2.5 km/hr and increase as able. if you feel safe without holding on then you can do it. i find that a treadmill can be useful in getting out of habitual gait patterns.

Hmmm, I thought the UK was a 1st world country... Your experience sounds kinda of barbaric.

Why don't you just shell out for private physio? The way it is now, it sounds pretty painful and you can't get back to work. A few good sessions with a good physio should do wonders

I also think that using treadmill in gait training of patients with THR is a barbaric approach regarding the patient safety point of view. Infact, a lot of precautions have to be followed in gait training of patients with THR as in the Maximum protection phase (0-6 weeeks post operatively) and moderate & minimum protection phase (6-12 weeks post operatively). Soft tissue healing takes time and pain also resolves. Moreover, new bone takes times to form around the implant and joint position sense also develops with the passage of time. So be careful and follow the joint safety instructions to protect and use the new joint.

sorry sdkashif but you are talking nonsense. what is so "barbaric" about a treadmill.alophysio wasnt saying that a treadmill was barbaric he wasa stating that the patients experience was barbaric.

Actually After reviewing some good references, I have not found any recommendations for the use of treadmill in gait training in THR postoperatively. The following sources were reviewed to assess whether or not there is any justification of Treadmill use postoperatively following THR.

Therapeutic Exercises, Foundation and Techniques, 4th Edition, By Kisner & Colby

Tidy's Physiotherapy, 13th edition, By Stuart Porter

Cash's Texbook of Orthopaedic and Rheumatology for Physiotherapists, 2nd Edition by Marian E.Tidswell.

Patient following THR requires a lot of safety precautions as soft tissue healing around hip takes 6 weeks and is called a period of Maximum protection while new bone growth takes several months. Joint position sense also develop over several months following THR.

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not always nwb for 6 weeks and usually you can go straight to FWB after 6 weeks anyway

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Moreover, in uncemented approach FWB is not recommended straight. If the surgeon has used a cementless implantation then the patient is non weight bearing (toe touch with elbow crutches - hopping is not safe) for 6 weeks, then partial weight bearing for atleast another 6 weeks. This allows for the growth of fibroblasts into the hydroxyapatite coating.

weight bearing status is dependant on the surgeons protocol and the surgical procedure. i think we are going way of track here. the patient simply wanted advice. something tells me that you are a theorist sdkashif. i think more practically and functionally. i dont think that the patient intended to sprint on the treadmill only walking pace so where is the safety risk in that.

Personally as a physio I would not like to follow any unauthentic protocols for management of THR. And I don't think that any good surgeon have any good belief in full weight bearing status in initial 6 weeks postoperatively following THR in case of Cementless implantation. I wonder if some sugeon have such advice. Please, mention some good references for that. Kindly provide some information, link or evidence based findings or any good reference for Treadmill use following THR. I would like to read if any.

most patients having an uncemented THR in the uk will be FWB from day 1. most do well without physio anyway and so i dont know what all the fuss is about.

If they are advising the full weight bearing for THR postoperatively, then it is most probably for the cemented implantation. I would not give further comments regarding that as I have already provided the detail information and some authentic references. You may have a look over that.

Hi jwilso,

It has been years since i worked in a hospital or seen someone post-op hip joint replacement. It would seem to me that a little weightbearing would help the bone remodelling but too much may work the prothesis loose.

Having said that, i remember taking many patients for walks with support at 3 weeks post-op - i don't remember if they were cemented or not.

A quick look on Google showed that surgeons in the States say 6 weeks non-weight bearing.. Couldn't find anything with less than that

Do you have any references or a handout from a surgeon about this?

Thanks

Quote:

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Originally Posted by jwilso

most patients having an uncemented THR in the uk will be FWB from day 1. most do well without physio anyway and so i dont know what all the fuss is about.

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FWB in Uncemented THR from day 1 will definitely be hazardous for the patient, it will definitely break the prosthesis..i think u r confused with Cemented & Uncemented THR

no not confused.this is what happens at the hospital where i work.i hope that lesleyfx can let us know how quickly her weightbearing was progressed

hi
could u foreward some details about the same
Regards,
Ark.

LIFE WITH A NEW HIP JOINT

CONTENTS:

1.first 12 weeks / possible problems

2.pain in the replaced hip joint

3.noises in the new hip

4.do's and don'ts

5.stresses on your new total hip

6. weight bearing

7.walking aid devices


http://www.totaljoints.info/life_with_hip.htm

Here's a rehab protocol for THR .

Cheers!!!

Charlize29

Forgot to attach the file....:o

Here it is!!!:D

At last some evidence to back up what i have been saying......


"If you have an uncemented total hip, its fixation to the skeleton improves with time as new bone grows into its surface. The ingrowth of new bone is a process that takes time (4 -12 weeks), and the ingrowing bone should be protected from undue stresses during this period.

Originally, the surgeons believed that the patient must avoided loading of the cementless hip to achieve good ingrowth of the bone into the surface layer of the total joint prosthesis. Many surgeons do not adhere to this view longer. Here follow some reasons why:

Studies showed that in cementless total hip prostheses bone ingrowth fixation reliably occurs whether or not a partial or full weight-bearing postoperative protocol is followed. (Woolson 2002)

Moreover, studies demonstrated that even patients who were learned the "partial weight bearing" with crutches by their PT still put much more weight on their hips than learned, without knowing it. (Tveit 2001)"

Just a quick reply. My advice would be to take things steady, and pay out to see an independent Physiotherapist, which will only cost you around £70 for an hour, and £35 for half an hour. So for less than the cost of a new pair of shoes and a handbag you can have a couple of one to ones without rush.

You want to get better thoroughly not quickly. If someone is young to have a THR, then its doubly important to ensure a really good outcome, and speed of rehabilitation is frankly nonsensical.
NHS THR costs are based on cover for average treatment, and not necessarily extra Physiotherapy sessions, so these would be funded as extra, which is why you aren't getting them as routine, it's all a question of whose budget the consultations come from, and if the consultant doesn't consider it necessary he wont fund from Orthopaedic budget, and your GP might not want to spend his scant resources this way either. Sad but accurate, everthing is about funding.

Hi
thanx charlize & jwilso for the informn..

Hi Arkesh_physio,

No problem with that, but I have found this article which everyone was discussing about :

Quote:

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Treadmill training with partial body-weight support after total hip arthroplasty: a randomized controlled trial.
• Hesse S,
• Werner C,
• Seibel H,
• von Frankenberg S,
• Kappel EM,
• Kirker S,
• Kading M.
Department of Neurological Rehabilitation, Klinik Berlin, Kladower Damm 223, D-14089 Berlin, Germany. [email protected]
OBJECTIVE: To compare treadmill training with partial body-weight support (TT-BWS) and conventional physical therapy (PT) in ambulatory patients with hip arthroplasty. DESIGN: Randomized controlled trial. SETTING: Rehabilitation center. PARTICIPANTS: Eighty patients with a fully loadable implant who could walk independently with crutches after unilateral total hip arthroplasty were randomized to receive either TT-BWS (treatment group) or conventional PT (controls), for 10 working days. INTERVENTIONS: Each patient received 45 minutes of individualized PT, either treadmill training plus PT in the experimental or PT alone in the control group. MAIN OUTCOME MEASURES: The Harris score, recorded by blind assessors, served as the primary outcome measure. Secondary outcome measures were the hip extension deficit, gait velocity, gait symmetry, affected hip abductor power; hip abductor amplitude of electromyographic activation; and the interval from surgery to abandoning crutches. RESULTS: At the end of training, the treatment group's Harris score was 13.6 points higher (P<.0001) than the control group's score. Further, hip extension deficit was 6.8 degrees less (P<.0001), gait symmetry was 10% greater (P=.001), affected hip abductor was stronger (Medical Research Council grades 4.24 vs 3.73; P<.0001), and the amplitude of gluteus medius activity was 41.5% greater (P=.001) than those measures for controls. Gait velocity did not differ in the 2 groups. These significant differences in favor of the treatment group persisted at 3 and 12 months. The treatment group abandoned crutches sooner than the control group (3 vs 8wk). In the treatment group, 39 patients finished treatment, 35 appeared at 3, and 26 at 12 months for follow-up. In the control group, the corresponding numbers were 40, 35, and 24 patients, respectively. CONCLUSION: TT-BWS is more effective than conventional PT at restoring symmetrical independent walking after hip replacement.
PMID: 14669181 [PubMed - indexed for MEDLINE]

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:D

Well, it depends on you guys whether you want to incorporate treadmill training after THR. Goodluck!!!

Quote:

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Originally Posted by sdkashif

I also think that using treadmill in gait training of patients with THR is a barbaric approach regarding the patient safety point of view.

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As it was mentioned the poster did give reference to beginning slowly, perhaps more like walking pace and only if they feel safe. I have used treadmill training for years for patients after hip replacement. In fact because we have an unweighting system over the treadmill we can being this work when they are still partial weight bearing (PWB), expecially with cemented prostheses as these are their most strong really at day 1 after surgery. The beauty of this approach is you can perform sidewards and backwards walking in safety.