Total hip joint replacement: physiotherapy treatment.
Author: Elkin, F.M.
Pub Date: 11/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2011 Source Volume: 39 Source Issue: 3
Accession Number: 288538000
Full Text: PRE-OPERATIVE TREATMENT

Patients are usually admitted two days before operations

(1) ELEVATION OF THE BED

The foot of the bed is elevated so that the patient is in the Trendelenburg position throughout his stay in hospital. This is done to aid venous return.

(2) STOCKINGS

The patient is measured for Tubigrip stockings and the importance of wearing them explained to him. The size of Tubigrip used depends upon the girth of the patient's leg, usually size G5. The stocking should extend from the web of the toes to the upper thigh, and allow for a 3 to 4 in. turnover at the top of the stocking which usually prevents it from rolling into a tight band.

Again, the purpose of the stocking is to assist venous return.

(3) MEASUREMENT OF THE LEGS

The circumferential measurements of both thighs and calves are recorded before operation, and daily after operation, as oedema is one for the first signs of deep vein thrombosis. The measurements must be taken in the same place each day. Usually the tibial tubercle is taken as the fixed bony point, and the circumference of the thigh measured 9 in. above this point, and the circumference of the calf approximately 3 in. below this point. (This is done over the stockings.)

(4) EXPLANATION OF THE SPLINT

The patient is shown the foam-rubber splint which will be applied immediately after operation; as the foam rubber does not move readily on the sheet, this immobilizes the hip joint, but the patient is still able to move his leg inside the splint.

(5) FOOT MOVEMENTS

Strong dorsi- and plantar-flexion of the ankle and flexion and extension of the toe are taught to the patient and special emphasis placed on "using the feet as pumps" so that it becomes almost an involuntary movement.

(6) STATIC QUADRICEPS AND GLUTEAL MUSCLE CONTRACTIONS

Again, the purpose of this and the foot movement is to aid venous return and prevent deep vein thrombosis.

(7) BREATHING EXERCISES

Deep breathing exercises, especially diaphragmatic breathing exercises, aid venous return and also help to prevent chest complications following an anaesthetic

(8) CRUTCHES

Metal elbow crutches are obtained and the patient shown how to use them.

This period is also used for assessing the patient's functional ability, gait, hip and spinal movements and "getting to know each other".

POST OPERATIVE TREATMENT

When the patient returns to the ward, he usually has a venous drip inserted and two Redivac drains, with the leg in the splint placed in slight abduction. The leg should never be allowed to adduct beyond the mid-line.

DAY OF OPERATION

(1) Foot movements--vigorously

(2) Gluteal and quadriceps contractions

(3) Breathing exercises

All these are to aid venous return and so lower the possibility of thrombo-embolism.

FIRST DAY

The splint is removed, the exercises already mentioned are performed, followed by

(4) Assisted hip and knee flexion and extension.

(5) Assisted abduction and adduction of the hip

These exercises are carried out twice during the day, but the patient is encouraged to perform the first three exercises almost continually throughout the day. The patient is also encouraged to lie flat for at least half-an-hour twice daily to assist extension of the hip joint.

SECOND DAY

The Redivac drains are removed if drainage has not been excessive, and the wound redressed. By this stage the drip is usually removed.

The same exercises are performed but the patient is encouraged to exercise independently by using: (a) Re-education board, a smooth-surfaced board. Care must be taken to ensure that the patient's heels are suitably protected to avoid pressure. (b) Slings, either by use of conventional axial suspension (Fig.1) or by using the "fishing rod" (Fig.2). This allows the patient to exercise beyond the time available for the physiotherapist to be in attendance, but it has to be ensured that the patient is doing something worthwhile. Pelvic tilt must be eliminated and no adduction allowed beyond the mid-line.

THIRD DAY

Resistance is now applied to the exercises by:

(1) Manual resistance

(2) Increasing the incline of the sliding board (Fig.3)

(3) Addition of springs to sling suspension Added to the exercise programme are:

(4) Prone lying--alternate knee flexion and extension

(5) Prone lying with the knees flexed to 90[degrees]. Rhythmic stabilizations to the internal and external rotators of the hip joint (Fig.4)

(6) Crook lying. Pelvic tilting to mobilize the lumbar spine

(7) Lying

(a) Flexion-adduction-external rotation pattern of movement

(b) Extension-abduction-internal rotation pattern of movement (Fig.5)

Walking and Sitting

If the systematic response is satisfactory (i.e. temperature settling) the patient sits on the side of the bed and does alternate leg swinging.

If a patient had a uni-lateral THJR a "three-and-one" gait is taught, and if they have had or are to have a bi-lateral THJR a "four-point" gait is taught.

It is important from the beginning to make the patient conscious of his posture and how to correct it, now that he is able to do so.

If the patient sits out of bed in a chair, a "sitting-standing" regime is instituted; ie every ten minutes he stands up, and every ten minutes he goes for a walk. This can only be done if the physiotherapist is sure that the patient is able to get out of the chair by himself, and is confident enough to go for a walk; otherwise, it is considered better for him to remain in bed in the elevated position.

THIRD TO TENTH DAY

Throughout this period, emphasis is placed on walking reeducation. "Old habits" have to be broken; the feet have to be used as they are meant to be, by putting the heel down first and using the "push-up" off the toes (even strides should be encouraged) lifting forward of the thigh and use of the hip extensors.

About the seventh day the patient is able to manage stairs and though he has been taking himself to the toilet for days, he may need a raised toilet seat or a rail.

TENTH DAY

The sutures are removed and the patient is now allowed to shower and dress himself and increase his activity by going to the Occupational Therapy Department, where activities for daily living are discussed and exercise tolerance increased by use of adapted looms and bicycle fretsaws.

By establishing a timetable between the Physiotherapy and Occupational Therapy Department the patient is given a variety of work during the day.

Patients who have had a unilateral THJR are usually discharged between the second and third weeks and those who have had a bilateral THJP between the fifth and sixth weeks. There is seldom any need for further out-patient physiotherapy. The patient is told to go home and use his "new" hip.

Commentary

How times have changed!

Comparing the physiotherapy treatment protocols for total hip joint replacements (THJR) from 1971 until now has been an interesting experience. THJR are now seen as a routine surgery where the emphasis is on early mobilisation and an average stay of 2-5 days, depending on a number of factors (Oldmeadow et al 2004, Pearse et al 2007).

Patients will normally arrive the morning of surgery having previously attended a pre-op education day regarding strengthening and range of motion exercises of the hip. They will have also received education on what to expect from the multi-disciplinary team during their stay and how to prepare their homes and themselves for discharge.

Our physiotherapy team encourages our patients to mobilise as far as is reasonable on the first day post-op (if medically stable), with standing an absolute minimum. Research now suggests early mobilisation results in a 30-fold reduction in post-operative deep vein thrombosis as well as a reduced length of stay in hospital. Time is spent firstly mobilising with a frame until independence is gained before progressing onto elbow crutches. This is normally how patients will mobilise when they return home and may do so for up to 6 weeks post-op. Gait education is also provided during mobilisation to ensure an even step-through-gait is achieved.

The exercises given seem to be similar in that we start with bed exercises of ankle plantar-flexion/dorsi-flexion to help reduce deep vein thrombosis as well as static quadriceps/gluteal muscle exercises, and active-assisted hip flexion and hip abduction exercises, with the emphasis on patients doing as much as they can for themselves. What has changed however has been the progression to standing hip exercises using gravity as resistance instead of a prolonged series of resisted exercises in bed. We also encourage patients to become involved in the daily hip and knee class on the ward to promote independence.

Discharge planning begins from day 1 post-op with the needs assessment and occupational therapy team assessing the patient for home supports and equipment. From a physiotherapy point of view, patients are provided assistance as required early post-surgery but we aim that a patient should be as independent as possible prior to discharge in terms of transfers and mobility. The need for further outpatient physiotherapy is not indicated in the majority of THJR patients and it is therefore not offered unless we feel it is needed, as seen back in 1971.

Overall, the change in physiotherapy treatment protocols from 1971 until now is significant. THJR have become normal routine surgery. The emphasis on early mobilisation is the biggest change as patients are up day 1-2 compared to the longer periods of bed resting and splinting as seen in the 1971 paper. It will be interesting to see what physiotherapy treatments will be provided for patients post-THJR in the next 40 years.

Carolyn Davies

Orthopaedic Physiotherapist

North Shore Hospital

REFERENCES

Pearse EO, Caldwell BF, Lockwood RJ, Hollard J (2007): Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. Journal of Bone and Joint Surgery--British volume 89-B (3): 316-322.

Oldmeadow LB, McBurney H, Robertson VJ, Kimmel L, Elliott B (2004): Targeted postoperative care improves discharge outcome after hip or knee artrhoplasty. Archives of Physical Medicine and Rehabilitation 85: 14241427.

F M Elkin, MCSP, NZRP
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