What is the normal aftercare following hip replacement surgery?

Normal Aftercare Following Hip Replacement Surgery

Comprehensive aftercare following hip replacement should include immediate mobilization within 24 hours, multimodal analgesia with paracetamol as baseline therapy, thromboprophylaxis for up to 5 weeks, early removal of urinary catheters, nutritional support, and structured rehabilitation continuing for at least 3 months postoperatively. 1

Immediate Postoperative Care (First 24-48 Hours)

Pain Management

• Continue regular paracetamol (acetaminophen) as baseline analgesia for all patients, supplemented by NSAIDs and opioids as needed using a step-down approach. 1
• Peripheral nerve blocks provide effective analgesia but typically only through the first postoperative night. 1
• Pain should be assessed as part of routine nursing observations to enable timely mobilization and prevent complications. 1

Respiratory Support

• Administer supplemental oxygen for at least 24 hours postoperatively, as older patients are at significant risk of hypoxia. 1
• Oxygenation and respiratory function improve with mobilization. 1

Fluid Management and Catheter Removal

• Remove urinary catheters as soon as possible (ideally within 24 hours) to reduce urinary tract infection risk, which is a common complication. 1
• Encourage early oral fluid intake rather than routine intravenous fluids, as hypovolemia is common but oral intake is preferred. 1

Early Mobilization

• Begin weight-bearing mobilization as soon as medically appropriate, typically within the first 24 hours, to prevent deep vein thrombosis and optimize functional recovery. 1, 2
• Modern protocols using modified precautions (avoiding only combined hip flexion, adduction, and internal rotation) allow more patient movement and faster functional recovery. 2

Thromboprophylaxis

Low molecular weight heparin (LMWH) is the preferred method of VTE prophylaxis after hip replacement, as it is more effective than warfarin in preventing asymptomatic thromboembolism. 1

• Continue thromboprophylaxis for approximately 5 weeks after total hip replacement, as the risk of DVT persists for up to 2 months following surgery. 1
• The risk of DVT without prophylaxis ranges from 12-37% in the extended postoperative period. 1
• Adjusted-dose warfarin (INR target 2.5, range 2.0-3.0) is an alternative if LMWH is contraindicated, though it may have higher bleeding risk at the surgical site. 1

Cognitive and Medical Monitoring

Postoperative Cognitive Dysfunction

• Screen for acute confusional states, which occur in approximately 25% of hip fracture patients (though less common in elective arthroplasty). 1
• Treatment requires multimodal optimization including adequate analgesia, nutrition, hydration, electrolyte balance, appropriate medication review, and early mobilization. 1
• Identify and treat complications such as chest infection, silent myocardial ischemia, and urinary tract infection that can precipitate delirium. 1
• Use haloperidol or lorazepam only for short-term symptom control; avoid cyclizine due to antimuscarinic side effects in older patients. 1

Nutritional Support

• Assess nutritional status early, as up to 60% of hip fracture patients are malnourished on admission (less common in elective cases but still relevant). 1
• Provide nutritional supplementation when indicated, as this may reduce mortality and length of stay. 1

Structured Rehabilitation Program

Early Phase (0-4 Weeks)

• Begin immediate weight-bearing as tolerated with correct gait pattern, monitoring for pain, effusion, or increased temperature. 3
• Start isometric quadriceps exercises in the first week when they provoke no pain to reactivate muscles. 3
• Incorporate gentle hip, trunk, and functional strengthening that avoids positions compromising the surgical site. 3
• Expected activity progression: approximately 1,098 steps daily at week 1, increasing to 2,491 steps at week 2,4,130 steps at week 3, and 4,850 steps at week 4. 2

Mid-Phase (4-8 Weeks)

• Progress to dynamic strengthening exercises for hip and trunk muscles, particularly gluteus medius. 3
• Incorporate balance and proprioceptive training to address deficits in dynamic balance and single-leg stability. 3
• Begin low-impact aerobic activities such as stationary cycling or aquatic exercises to improve cardiovascular fitness without excessive joint loading. 3
• Monitor quality of movement during exercises, focusing on proper alignment during functional tasks like sit-to-stand and gait. 3
• Expected activity: approximately 5,712 steps daily at week 5 and 6,069 steps at week 6. 2

Advanced Phase (8-12 Weeks and Beyond)

• Progress to functional strengthening exercises that mimic daily activities and desired recreational pursuits. 3
• Continue progressive resistance training for hip and lower extremity muscles to address persistent strength deficits. 3
• Incorporate more challenging balance activities and functional task training. 3
• Monitor response with validated outcome measures such as HAGOS or IHOT questionnaires. 3

Rehabilitation Setting and Duration

• Home-based physiotherapy is as effective as inpatient rehabilitation for appropriate patients and should be the preferred option for those under 71 years who do not live alone and lack significant comorbidities. 4
• High-quality evidence supports that home-based physiotherapy achieves equivalent functional outcomes to inpatient rehabilitation at 1 year after surgery. 4
• Continue structured rehabilitation for at least 3 months postoperatively, as longer duration programs show better outcomes; discontinuing exercise programs too early is a common pitfall. 3

Expected Recovery Timeline

Functional Recovery Milestones

• Patients typically recover to approximately 80% of healthy control levels for perceived physical functioning, functional capacity, and daily activity by 6-8 months postoperatively. 5
• Preoperatively, patients function at less than 50% for perceived functioning, 70% for functional capacity, and 80% for actual daily activity compared to healthy controls. 5
• 74% of patients return to work by week 4, and 76% of left hip replacement patients return to driving by week 4. 2

Hospital Discharge

• Mean length of acute inpatient stay ranges from 8-30 days for hip fracture patients (mean 16 days), though modern fast-track protocols achieve discharge within 24-26 hours for elective arthroplasty in appropriate patients. 1, 6
• Only 44% of hip fracture patients admitted from home are discharged back home within 30 days; 22% require residential or nursing home placement. 1
• For elective arthroplasty with fast-track protocols, all patients can be discharged the day after operation with appropriate support. 6

Activity Resumption

• Light gardening activities in raised beds: 4-6 weeks postoperatively. 7
• Full return to all gardening activities: 12 weeks postoperatively. 7
• Avoid gardening entirely during weeks 1-4 to allow adequate soft tissue healing. 7

Common Pitfalls to Avoid

• Delaying mobilization due to pain concerns increases thromboembolism risk more than it protects the surgical site. 1
• Leaving urinary catheters in place "just in case" significantly increases infection risk without benefit. 1
• Failing to address specific impairments such as hip muscle weakness, altered gait mechanics, or balance deficits leads to suboptimal outcomes. 3
• Discontinuing exercise programs before 3 months results in inferior functional outcomes. 3
• Not monitoring treatment response with appropriate outcome measures can lead to missed opportunities for intervention. 3
• Liberal use of anticholinergic medications worsens cognitive dysfunction in elderly patients. 1

Long-Term Management

• Encourage ongoing physical activity as part of long-term management to optimize quality of life. 3
• Continue periodic strengthening exercises to maintain hip and core muscle strength indefinitely. 3
• Consider secondary prevention of falls and osteoporosis in the early postoperative period, as subsequent fragility fractures carry particularly poor prognosis. 1
• Orthogeriatric co-management should coordinate rehabilitation aimed at returning patients to pre-fracture activity levels and residence status. 1

Monitoring for Complications

• Watch for signs of exercise intolerance including increased pain, joint effusion, or limping, and adjust intensity accordingly. 3
• Medical and surgical complications are common, particularly in older patients with comorbidities, but most can be managed in a ward setting with orthogeriatric input. 1
• Critical care facilities should be available but are not routinely required for most patients. 1
• The 30-day mortality rate is 8.4% for hip fracture patients, with up to 15-30% dying within one year, though elective arthroplasty carries much lower risk. 1