What is an appropriate postoperative physical therapy and rehabilitation protocol for a medically stable 56‑year‑old woman after primary total hip arthroplasty?

Post-Total Hip Replacement Physical Therapy and Rehabilitation Protocol for a 56-Year-Old Female

Begin mobilization on the day of surgery with full weight-bearing as tolerated, supported by multimodal analgesia, and discharge home without mandatory formal physical therapy if the patient demonstrates adequate mobility and has appropriate social support. 1, 2, 3

Immediate Postoperative Phase (Day of Surgery - Day 1)

Early Mobilization Strategy

• Mobilize the patient on the day of surgery rather than waiting until postoperative day 1, as this approach reduces length of stay from 3.38 days to 2.06 days and decreases 30-day readmission rates from 4.72% to 0.52%. 3
• Full weight-bearing is recommended immediately after cementless total hip arthroplasty, as there are no clinical differences in pain outcomes between partial and full weight-bearing protocols. 1
• Aim for discharge home rather than to a rehabilitation facility—96% of patients with accelerated rehabilitation can be discharged directly home versus only 62% with traditional protocols. 3

Pain Management Foundation

• Continue paracetamol 1g every 6 hours (maximum 4g daily) started preoperatively, as this forms the cornerstone of multimodal analgesia. 2, 4
• Administer NSAIDs or COX-2 inhibitors on a scheduled basis (not as-needed) for optimal anti-inflammatory effect throughout the postoperative period. 2, 4
• Reserve opioids strictly for rescue analgesia only—never use scheduled opioid dosing, as adding modified-release morphine to a multimodal regimen provides no benefit but significantly increases opioid-related side effects. 1, 2, 4

Hip Precautions Controversy

Hip precautions (movement restrictions) are not mandatory for primary total hip arthroplasty in standard-risk patients, as evidence supporting their effectiveness in preventing dislocation is limited and they may negatively impact patient recovery. 5

• Many centers have discontinued routine hip precautions without experiencing a rise in dislocation rates. 5
• Consider individualized restrictions only for patients with specific risk factors predisposing them to dislocation (severe ligamentous instability, neuropathic joints, or revision surgery). 5
• The controversy stems from surgical advances that have reduced dislocation risk, making blanket restrictions potentially unnecessary. 5

Physical Therapy Approach

Formal PT vs. Home Exercise

Either formal physical therapy or unsupervised home exercise is equally supported after total hip arthroplasty—the choice depends on patient factors rather than a universal requirement. 1, 2

• For younger, motivated patients (like this 56-year-old) with adequate social support, home exercise programs are clinically noninferior to formal physical therapy with home health services. 6
• Electronic patient rehabilitation applications (EPRAs) can effectively replace traditional home health services in appropriate candidates, demonstrating equivalent patient-reported outcomes at 12 weeks while being substantially less costly. 6
• Formal physical therapy should be reserved for patients with limited social support, significant comorbidities, or those who fail to progress with home exercise. 1

Preoperative Optimization (Retrospective Consideration)

While this patient has already undergone surgery, note that preoperative exercise and education significantly reduce postoperative pain and improve functional outcomes (Grade A recommendation). 2, 4

Social Determinants and Discharge Planning

• Assess social support before surgery, as limited social resources negatively affect length of stay, total cost of care, and mortality after THA. 1
• For this 56-year-old female, ensure she has adequate support at home for at least the first week postoperatively. 1
• Plan the surgical date to align with caregiver availability when social support is limited. 1

Common Pitfalls to Avoid

• Do not delay mobilization to postoperative day 1—same-day mobilization is safe and beneficial. 3
• Do not prescribe scheduled opioids—this increases side effects without improving pain control when multimodal analgesia is optimized. 1, 4
• Do not assume all patients require formal physical therapy—this 56-year-old is likely an excellent candidate for home exercise alone. 1, 6
• Do not use NSAIDs as-needed dosing—scheduled administration is required for optimal anti-inflammatory effect. 4
• Do not routinely impose hip precautions unless specific risk factors for dislocation are present. 5

Expected Timeline

• Day of surgery: Mobilization with walker or crutches, full weight-bearing as tolerated. 3
• Discharge: Typically 2 days for accelerated protocols versus 3+ days for traditional approaches. 3
• 12 weeks: Expected achievement of functional recovery milestones with either formal PT or home exercise. 6