How should ambulation be performed after an uncemented left total hip replacement, including timing, weight‑bearing status, precautions, and pain management?

Ambulation Protocol After Left-Sided Uncemented Total Hip Replacement

Begin full weight-bearing ambulation on the day of surgery or within 24 hours using multimodal analgesia, progressing from wheelchair to walker as tolerated, without mandatory formal physical therapy if mobility is adequate and home support is present. 1

Immediate Mobilization (Day of Surgery to 24 Hours)

Weight-Bearing Status:

• Full weight-bearing as tolerated immediately after uncemented total hip arthroplasty – cementless fixation does not require protected weight-bearing and causes no additional pain compared to restricted protocols 1
• Mobilize on the operative day itself when possible, or within the first 24 hours at minimum to prevent joint stiffness, reduce pain, and avoid extension deficits 2
• Early ambulation (first walk within 24-48 hours) accelerates functional recovery and increases likelihood of direct home discharge rather than requiring high-level care 3

Initial Ambulation Sequence:

• Start with wheelchair mobilization within 24 hours, progressing to walker or crutch ambulation by 48-72 hours 4
• Patients who ambulate at least 5 feet within 72 hours have 9 times the odds of independent ambulation at 3 months compared to those who do not 5
• Use this 5-foot distance within 72 hours as a clear therapeutic goal to guide rehabilitation 5

Pain Management to Facilitate Ambulation

Multimodal Analgesia (Non-Opioid Foundation):

• Paracetamol (acetaminophen) plus NSAIDs or COX-2 inhibitors form the foundation – continue these scheduled medications throughout the early postoperative period 1
• Add intravenous dexamethasone 8-10 mg perioperatively for enhanced pain control 1
• Consider fascia iliaca block or local infiltration analgesia for additional pain relief without motor weakness 1

Opioid Use:

• Reserve opioids strictly for rescue analgesia only – scheduled opioid dosing provides no additional pain relief and markedly increases side effects that delay mobilization 1
• Unrelieved pain is directly associated with delayed ambulation, so aggressive multimodal pain management is essential 6
• Non-narcotic oral protocols result in lower pain scores in the first 24 hours, fewer adverse effects, and high patient satisfaction compared to traditional patient-controlled analgesia 7

Avoid These Analgesic Techniques:

• Do not use femoral nerve blocks, lumbar plexus blocks, or epidural analgesia – these cause limb weakness, bladder dysfunction, and delayed mobilization that outweigh analgesic benefits 8, 1
• Intrathecal morphine, while effective for pain, causes nausea, vomiting, pruritus, delayed ambulation, and is incompatible with early rehabilitation protocols 8

Hip Precautions and Movement Restrictions

For Uncemented Posterior Approach (Most Common):

• Avoid hip flexion beyond 90 degrees, internal rotation, and adduction across midline for 6-12 weeks to prevent dislocation
• Use elevated toilet seat, avoid low chairs, and keep knees below hip level when sitting
• Sleep with abduction pillow between legs for first 6 weeks

For Anterior Approach:

• Avoid hip extension, external rotation, and adduction
• Precautions are typically less restrictive and shorter duration (4-6 weeks)

Note: Confirm specific precautions with your surgical team as these vary by surgical approach and surgeon preference

Progressive Ambulation Timeline

First Week:

• Begin isometric quadriceps exercises (static holds, straight-leg raises) within the first week if pain-free 2
• Apply cryotherapy throughout the first week to reduce pain and swelling 2
• Progress from wheelchair to walker/crutches by days 2-3, advancing distance daily 4
• Full weight-bearing as tolerated throughout, tailored to individual pain and stability 2

Weeks 2-4:

• Transition from isometric to dynamic quadriceps exercises once muscle is reactivated and no joint effusion present 2
• Begin closed kinetic-chain exercises (leg press, squats, step-ups) from week 2 to build strength while minimizing hip stress 2
• Prioritize closed kinetic-chain over open kinetic-chain movements during the first month 2
• Consider neuromuscular electrical stimulation for 6-8 weeks as adjunct to boost quadriceps strength 2

Weeks 4-8:

• Increase exercise intensity while maintaining pain-free motion 2
• Cautiously introduce open kinetic-chain exercises from week 4 in restricted range (90°-45°), expanding progressively 2
• Incorporate eccentric training for greater strength gains 2
• Combine strength work with neuromuscular and motor-control exercises for dynamic stability 2

Physical Therapy Supervision

Discharge Planning:

• Formal supervised physical therapy and unsupervised home exercise achieve equivalent outcomes – individualize based on patient factors 1
• Prioritize formal physical therapy for patients with:
  • Limited social support or inadequate home assistance 1
  • Significant comorbidities 1
  • Insufficient progress with home exercise 1

Home-Based Rehabilitation:

• Appropriate for motivated patients with adequate social support and uncomplicated recovery 2, 1
• Ensure patients have adequate home support for at least the first postoperative week 1

Critical Pitfalls to Avoid

• Delaying mobilization beyond 24-48 hours leads to stiffness, extension deficits, prolonged recovery, and increased risk of complications 2, 3
• Using scheduled opioids instead of multimodal analgesia increases side effects and delays ambulation without improving pain control 1, 7
• Employing femoral or epidural blocks causes motor weakness that prevents early weight-bearing 8, 1
• Inadequate pain control directly delays ambulation – if pain prevents mobilization despite multimodal analgesia, reassess for complications such as infection or DVT 6
• Ignoring quadriceps strength deficits adversely affects long-term function – continue rehabilitation for 9-12 months for optimal recovery 2
• Advancing resistance exercises too aggressively before adequate muscle reactivation causes pain, effusion, and setbacks 2

Red Flags Requiring Immediate Evaluation

• Sudden increase in pain and swelling (especially around postoperative day 5) – evaluate immediately for DVT and periprosthetic infection 9
• Tachycardia, hypotension, or fever – suspect infection and obtain orthopedic consultation immediately 9
• Worsening pain despite adequate analgesia – mandates reevaluation for complications rather than attributing to normal postoperative pain 9