What is the recommended rehabilitation approach for an older adult with potential comorbidities after undergoing hemiarthroplasty (partial joint replacement surgery)?

Rehabilitation After Hemiarthroplasty in Older Adults

Early Mobilization Protocol

Older adults undergoing hemiarthroplasty should begin physical therapy on postoperative day one with weight-bearing as tolerated, as this approach reduces DVT risk, improves functional recovery, and decreases overall complications. 1, 2

Immediate Postoperative Phase (Days 1-7)

• Initiate mobilization within 24 hours of surgery if the patient is medically stable, focusing on transfer training, gait training with assistive devices, and basic activities of daily living 1
• Implement weight-bearing as tolerated immediately—there is no need for protected weight-bearing with modern cemented hemiarthroplasty 1, 2
• Begin therapeutic exercises focusing on hip range of motion within pain-free limits, avoiding excessive hip flexion beyond 90 degrees and internal rotation if a posterior approach was used 1

Structured Rehabilitation Setting (Weeks 1-12)

Patients benefit most from intensive inpatient rehabilitation programs rather than home-based therapy alone, particularly those with cognitive dysfunction or multiple comorbidities. 3

• Intensive short-term inpatient rehabilitation (typically 2-3 weeks) produces superior functional outcomes compared to extended slow-stream rehabilitation or home programs alone, with patients 2.3 times more likely to return to prefracture mobility 3
• For cognitively intact patients under age 71 without significant comorbidities who do not live alone, home-based physiotherapy with therapist supervision is an acceptable alternative to inpatient rehabilitation 4
• Patients with cognitive dysfunction require structured geriatric rehabilitation programs—lack of formal rehabilitation correlates with significantly poorer walking ability and higher rates of wheelchair dependence at one year despite well-functioning hip prostheses 5

Exercise Prescription Components

Progressive resistance training and functional exercises should be the cornerstone of rehabilitation, not just range of motion exercises. 6

Functional Training (Daily)

• Sitting-to-standing transfers, stair climbing practice, and progressive ambulation distance 6
• Start with short bouts (10 minutes) of walking, adding 5 minutes per session until 30 minutes is reached 6
• Use weight-bearing exercises (walking) or non-weight-bearing options (cycling, hydrotherapy) based on patient tolerance 6

Strength Training (2-3 days per week)

• Begin progressive resistance training using the patient's pain threshold as a guide, starting with as few as 2-3 repetitions and progressing to 10-12 repetitions 6
• Focus on hip abductors, extensors, and quadriceps strength using resistance bands or light weights 6
• Target intensity at Borg RPE scale 12-15 (moderate exertion) 6

Flexibility and Balance (Daily)

• Stretch hip flexors, hamstrings, and gastrocnemius for 5 minutes each morning and 10 minutes each evening 6
• Incorporate balance training to reduce fall risk, which is critical given the underlying osteoporosis in this population 6

Critical Rehabilitation Considerations

Interdisciplinary Care Model

Utilize interdisciplinary care programs involving orthopedics, geriatrics, physical therapy, and nursing—this approach decreases complications and improves functional outcomes. 1, 2

• Coordinate with geriatric medicine for management of comorbidities including diabetes, hypertension, chronic kidney disease, and atrial fibrillation 6
• Monitor cognitive function regularly, as postoperative delirium affects rehabilitation participation 5
• Assess nutritional status and pressure sore risk throughout the rehabilitation period 1

Pain Management During Rehabilitation

• Continue multimodal analgesia with regular acetaminophen (paracetamol) throughout the perioperative period to optimize pain control without impairing cognition 1, 2
• Use opioids cautiously, especially in patients with renal dysfunction, as they increase risk of postoperative cognitive dysfunction and constipation 1
• Avoid NSAIDs in patients with renal impairment 1

Contraindications and Red Flags

• Discontinue exercise if unusual or persistent fatigue, increased weakness, decreased range of motion, or joint pain lasting more than one hour after exercise occurs 6
• Avoid vigorous, repetitive exercises that stress the hip prosthesis excessively 6
• Monitor for signs of prosthetic dislocation (sudden pain, leg length discrepancy, inability to bear weight) particularly in patients with cognitive or neurological impairment who received a posterior approach 1

Long-Term Management (Beyond 3 Months)

• Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment to prevent subsequent fractures 1, 2
• Transition to community-based exercise programs such as senior center circuit training classes (50 minutes, twice weekly) combining cardiovascular and strength training 6
• Continue home exercise program indefinitely to maintain functional gains 6

Common Pitfall to Avoid

Do not assume that elderly patients with cognitive dysfunction cannot benefit from rehabilitation—they absolutely can, but they require more structured, supervised programs rather than self-directed home exercises. 5 The lack of formal rehabilitation, not the surgery itself, predicts poor functional outcomes in this vulnerable population.