What are the steps for rehabilitation after total hip replacement?

Rehabilitation Steps After Total Hip Replacement

The rehabilitation process after total hip arthroplasty should include pre-operative exercise and education, followed by a structured postoperative pain management regimen, and a progressive rehabilitation program that can be effectively completed through self-directed home exercises in most patients. 1, 2

Pre-operative Phase

• Pre-operative exercise and education are strongly recommended (Grade A evidence) to reduce postoperative pain and improve functional outcomes 1, 2
• Education should include:
  • Movement restrictions to prevent dislocation
  • Proper use of assistive devices
  • Expected recovery timeline
  • Pain management strategies

Immediate Post-operative Pain Management

Basic Analgesic Regimen (Grade A evidence)

• Paracetamol (acetaminophen) started pre-operatively or intra-operatively and continued postoperatively 1, 2
• NSAIDs or COX-2 selective inhibitors started pre-operatively or intra-operatively and continued postoperatively 1, 2
• Single intra-operative dose of IV dexamethasone 8-10 mg for analgesic and anti-emetic effects 1, 2

Regional Anesthesia Options

• Single-shot fascia iliaca block or local infiltration analgesia is recommended 1, 2
• If spinal anesthesia was used for surgery, intrathecal morphine 0.1 mg could be considered 1
• Opioids should be reserved as rescue analgesics only for breakthrough pain 1, 2

Early Rehabilitation Phase (Days 1-14)

1. Day 1 Post-surgery:

   • Begin ankle pumps and gluteal sets
   • Assisted sitting at bedside
   • Weight-bearing as tolerated with walker/crutches (unless otherwise specified)
   • Begin basic bed mobility exercises

2. Days 2-3:

   • Progress to standing transfers
   • Begin short distance ambulation with assistive device
   • Start gentle hip range of motion exercises within precaution parameters
   • Continue pain management regimen

3. Days 4-14:

   • Progress ambulation distance
   • Begin stair training if applicable
   • Continue range of motion exercises
   • Begin gentle strengthening exercises

Mid-term Rehabilitation Phase (Weeks 2-6)

1. Weeks 2-4:

   • Progress from walker to crutches or cane as appropriate
   • Increase walking distance progressively
   • Add functional exercises (sit-to-stand, step-ups)
   • Begin light resistance exercises for hip muscles

2. Weeks 4-6:

   • Progress to single cane if not already
   • Increase resistance in strengthening exercises
   • Begin balance exercises
   • Focus on normalizing gait pattern

Advanced Rehabilitation Phase (Weeks 6-12)

1. Weeks 6-8:

   • Transition to walking without assistive devices as appropriate
   • Increase resistance in strengthening exercises
   • Begin more advanced balance activities
   • Start light endurance activities (stationary bike, swimming)

2. Weeks 8-12:

   • Progress to more functional strengthening
   • Increase endurance activities
   • Focus on return to specific activities of daily living
   • Address any remaining gait abnormalities

Important Considerations

• Self-directed home exercise is both safe and effective for most patients undergoing total hip arthroplasty, and formal physical therapy may not be required for all patients 3
• Research shows no significant difference in functional outcomes between patients receiving formal therapy and those participating in unsupervised home exercise 3
• Patients should be monitored for signs of severe postoperative pain, as studies show only about one-third of patients experience mild pain even with optimal analgesic regimens 4
• Resistance training alone is significantly less effective than total hip replacement for managing severe hip osteoarthritis 5

Precautions and Restrictions

• Avoid hip flexion beyond 90 degrees for 6-12 weeks (depending on surgical approach)
• Avoid crossing legs or internal rotation for 6-12 weeks
• Avoid low chairs and low toilet seats
• Use elevated toilet seats and chair cushions as needed
• Avoid twisting movements at the hip

Monitoring Progress

• Regular assessment of pain levels using validated instruments (VAS, numerical rating)
• Evaluation of functional outcomes using validated tools (Harris Hip Score, WOMAC, SF-36)
• Assessment of gait pattern and need for assistive devices
• Monitoring for complications (infection, dislocation, venous thromboembolism)

By following this structured rehabilitation protocol after total hip replacement, patients can achieve optimal functional outcomes while minimizing complications and pain.