Rehabilitation after Total hip replacement (THR)

[BSHC]

Heel Slides
This exercise helps strengthen the quadricep muscles at the hip and the hamstring muslces at the knee. Perform as follows:

• Sit with your legs straight out in front of you.
• Begin by sliding your heel toward your buttox by bending your knee. Keep your heel on the ground during this motion.
• Slowly straighten your knee and slide your leg back to the starting position.
• Relax and repeat 10 more times.

Straight Leg Raises
Straight leg raises help strengthen the hip joint. Perform as follows:

• Lay on your back on a flat surface.
• Bend the knee of your uninvolved leg (the one that wasn't operated on) to a 90-degree angle, and keep your foot flat on the surface. Keep your involved leg straight without the knee bent.
• Slowly lift the involved leg six inches off the floor (by contracting the front thigh muscles). Hold for five seconds.
• Slowly lower your leg to the floor.Relax and repeat 10 more times.

Gluteal Sets
Gluteal sets are easy exercises that help strengthen the gluteal muscles of the hip. Strong gluteal muscles help in hip extension as well as stabilization of the joint. Perform as follows:

• Lie on your back with your knees bent in a 10- to 15-degree angle.
• Squeeze your buttock muscles together.
• Hold for five seconds.
• Relax.
• Repeat 10 more times.
• Perform three sets of 10, three times a day.

Joint replacement surgery requires that you take an active role in your preoperative and postoperative care as well as rehabilitation. This booklet will provide useful and important information about your surgery and serve as a reminder and reference after surgery. If you have any questions, please feel free to ask your surgeon, nurse or therapist. 

Introduction

Total hip replacement (THR) is a common operation today. Approximately 200,000 replacements are performed each year. A wide variety of disorders result in hip disease. They all result in pain, limitation of motion and restriction of a person's ability to participate in the activities of daily living. The primary goal of hip replacement surgery is to relieve pain. This can be accomplished in more than 95% of patients. The results of THR can last approximately 15 years. In fact, one study found that more than 80% of THRs lasted a minimum of 20 years. 

 Total hip replacements are very successful at relieving the pain and limitations resulting from hip disease. However, you must actively participate in the care of your hip replacement after surgery. Some activities will need to be modified and some may not be appropriate after hip replacement.

 The hip joint is composed of a socket (the acetabulum, a part of the pelvis) and a ball (femoral head, the upper end of the thigh bone). In total hip replacement, both the socket and the ball are replaced with metal and plastic parts. The socket is replaced by a metal shell. The ball is replaced by a metal ball attached to a stem that goes inside the canal of the femur.

Before Surgery

Several important steps need to be taken before joint replacement surgery.

First, we are committed to providing you with the highest quality of care. In order to do that, we need information about you, your health and how pain and imobility has affected your daily life. You will receive several questionnaires in the mail. Please take time to complete and return them. All information is strictly confidential and will be used to track your progress throughout each stage of recovery and rehabilitation.

In addition, blood and urine tests will be taken as well as an EKG and, possibley, a chest x-ray.

These will be reviewed by your primary care physician to ensure that you are in good medical condition and can tolerate anesthesia safely. If you have had any recent dental surgery or infections, you should inform your surgeon before admission. Any planned dental work should be carried out before joint replacement surgery.  Stop taking aspirin or aspirin-like products ten days before the day of surgery.

 Most patients will be asked to donate two units of their own blood before surgery. This blood will then be available for use during or after surgery. One unit of blood is donated at a time. The second unit will be donated one week after the first. Then two weeks are allowed for your blood to rebuild before proceeding with surgery. Some patients may not be able to donate their own blood or may require more units than they donate. This blood will come from the Blood Bank. All of the blood in the Blood Bank, including the units you donate, is screened for Hepatitis C and HIV (the virus that causes AIDS) according to Red Cross guidelines. However, there is still a small risk of disease transmission by transfusion.

 If you have any questions, please ask your physician for a further explanation. 

Physical and occupational therapists will meet with you before the surgery. They will introduce themselves and begin instruction on the precautions you should follow after the surgery to prevent dislocation of the hip replacement.

The physical therapist will review some exercises which will be helpful postoperatively, such as "foot pumps", tightening the thighs and buttocks which, will help you maintain muscle tone and good blood circulation in your legs. The occupational therapist will show you how to do some of the basic activities of daily living after THR.

Your surgeon will provide an estimate of your expected length of stay in the hospital and your functional level at the time of discharge. This will provide a basis for you to plan for your home care. You may wish to have someone stay with you for several weeks after surgery until you are independent in your daily activities. 

 Before you come to the hospital, you should prepare several things. It will be very helpful for you to provide a list of all the medications you take, including the dose and number of times you take them per day and a list of any allergies you have to medications, foods, tape or latex products. You should bring in a knee-length bathrobe, a pair of shorts or sweat pants and a pair of sturdy shoes with non-skid soles (tennis shoes or sneakers are ideal) to use for therapy and for walking in the hall post-operatively. The night before surgery do not eat or drink anything after midnight. Prepare your home by removing loose rugs and making sure your carpeting is secure. You might want to set up a room on one level of your home where you stay comfortably for a majority of the day.

On the day of surgery, you will meet one of the orthopaedic surgery residents who will perform a history and physical examination and review your medications, allergies and your laboratory studies. The anesthesiologist will also meet with you to discuss your anesthesia and answer any questions you have about it. The anesthesiologist will start an intravenous line and may begin the anesthesia before you enter the operating room if you have decided to have an epidural or spinal anesthesia. 

You will then be taken to the operating room, where you will be sedated or anesthetized and positioned for the surgery. After the surgery, you will be transported to the recovery room in your hospital bed. You will be in an "abduction pillow" that will help keep your legs apart to prevent dislocation. Your incision will be covered with a bulky dressing, and you will have a drainage tube from the dressing to prevent blood from accumulating at the site. 

In the recovery room the nurses will frequently check your blood pressure, temperature and heart rate. The circulation to your feet will also be monitored. If you have an epidural or spinal anesthesia you may not be able to move your toes or legs for several hours after surgery. This is normal and the function will return after the anesthesia wears off. If appropriate, you may receive a patient-controlled analgesia (PCA) device that will allow you to control your own pain medication. Limits are set in the device to prevent you from overmedicating yourself. The amount of medication you receive can also be adjusted to maintain your comfort. 

After you have recovered from the anesthesia, you will be taken to your room on the orthopaedic surgery floor located on the sixth floor of the Main hospital building. A nurse will continue to monitor your vital signs, circulation and pain. You should try to cough, take deep breaths and pump your feet. These activities will help to improve your breathing and maintain the circulation in your legs while in bed.

After Surgery

You will remain in bed until that evening or the first day after surgery. While you are in the hospital bed, you should continue deep breathing and coughing to prevent congestion in your lungs. These exercises should be performed every hour while you are awake. 

After surgery, we do several things to reduce the risk of blood clots forming in the veins of your legs. If they do form, this can lead to increased swelling in your legs. If the clots break loose they may travel to your lungs and interfere with breathing. To avoid such complications, before the surgery, we will apply elastic stockings to help prevent blood from pooling in your legs. We may place you on either aspirin or Coumadin to thin your blood to reduce the risk of clot formation. In addition, you should continue the exercises in bed to maintain the blood flow in your legs and to keep your heart and muscles strong.  Pump your feet up and down 20 times each hour while awake.  Also, perform the tightening exercises of the thighs and buttocks.

Your bed will have an overhead trapeze bar for you to use to reposition yourself. You may use this to lift your buttocks off the bed and shift your position. The nurses will also assist by turning you from side to side and placing pillows behind you for support. You may move in bed within the limits of your comfort and the restrictions of the abduction pillow between your legs. This activity will help to prevent your skin from becoming irritated and improve your comfort. If an area of your skin feels hot or sore and cannot be relieved by shifting, notify your nurse.

After you have recovered from anesthesia, you will be able to drink and eat. However, because of the medication you have received for pain control and anesthesia, your stomach will not be able to tolerate more than a small amount. Initially, you should start with small amounts of fluids and then slowly progress to solid food over the first 24 to 36 hours after surgery.

 Pain Medication

After surgery the operative site will be significantly painful for the first one or two days.  You will be able to control your pain with the PCA. More traditional methods of pain management, such as intermittent injections of medication, can be provided instead of a PCA.

After two days, the PCA or injections should no longer be necessary and oral medications will provide satisfactory pain relief. The oral pain medication can cause nausea, constipation and a light-headed sensation. If these occur, inform your surgeon or nurse and the medication can be changed. You will be given a prescription for pain medication when you are discharged from the hospital. This is helpful as some people are more active at home than in the hospital before discharge.

 Dressings & Sutures

The postoperative dressing will remain in place for two or three days unless it becomes soiled. After the initial dressing is removed, it will be replaced with a dry gauze dressing daily until all drainage stops (approximately three to six days after). The staples will be removed approximately 10 to 20 days after the surgery. This may require you to return to the surgeon's office for staple removal after discharge from the hospital.

Hip Precautions

The positioning of your hip is very important after hip replacement surgery. Avoid excessive flexion, adduction and internal rotation of the hip. You should not sit straight up in bed or bring the operative leg up toward your chest.  Use the pillow between your legs to help maintain the proper position and to keep your legs apart. Do not rotate your operative leg inward. These precautions are necessary to prevent dislocation of the operative hip. Your routine activities will be modified to maintain the operative hip in a good position, and these changes will be addressed by your therapist. Continue your hip precautions for the first six weeks after surgery.

Swelling

Swelling in the operative leg is normal after hip replacement. Normal swelling is reduced in the morning when awakening, and gradually accumulates throughout the day as you are active and on your feet. This can be reduced by elevating your legs or lying down for 30 to 60 minutes during the day. Any activity that leaves your feet on the floor, such as sitting in a chair or walking can lead to swelling. If the swelling is severe in the morning when you first arise, contact your surgeon.

Physical Therapy

The primary objective of hip replacement is to eliminate your hip pain in order to allow you improved mobility. Physical and occupational therapy will begin on the first day after surgery. The therapist will review the exercises and instructions on hip positioning you received before surgery. It is important to follow the instructions carefully while you are in the hospital and after you are discharged.

Specific instructions and safe positions for your hip will vary depending on the surgeon and the surgical approach used. In general, you should not bend your hip beyond 90 degrees, a right angle (flexion), and you should not bring your legs or knees together (adduction, internal rotation). The amount of weight you will be able to bear on your new hip will vary depending on the type of hip replacement device used and the surgeon's preference. Your surgeon will provide this information to you.

Getting out of Bed

Getting out of bed begins the evening of or the day after surgery.  First, you will dangle your legs over the edge of the bed and transfer to a chair. If you tolerate this well, you will take a brief walk in the room with a walker and the help of a nurse or therapist.

When you first get up, you may become dizzy.  Please inform the therapist or nurse if this happens. This is normal and usually passes as you become more accustomed to getting up. The therapist will instruct you on the correct way to get into and out of bed. It is important to keep your leg straight and out to the side.

Transferring to a Chair

Take care to not lean forward when getting in or out of the chair. Keep your legs and knees apart and avoid excessive flexion at the hip joint. At home, use chairs with arms to help you get in and out of the chair.

Walking & Stairs

You may bear as much of your weight on the operative leg as tolerated.You will begin walking with a walker. You will be given a pair of crutches to assist your walking. The therapist will teach you how to safely use the walker or crutches. Stair climbing will also be part of your instruction while in the hospital. Your therapist will review and practice these techniques with you.

Occupational Therapy

The occupational therapist will review important information about how to safely perform your activities of daily living. The therapist will discuss how to safely bathe, dress, prepare food and function independently at home after surgery.

The Bath and Toilet

An elevated toilet seat will be required both in the hospital and at home for the first six to eight weeks after discharge. This will make it safer and easier to use the toilet.  Your occupational therapist will help you obtain an elevated toilet seat during your hospital stay. Plan to use a shower or sponge bath at home after surgery. A walk-in stall shower with a support rail is ideal. A shower seat may also be useful if applicable to your bathroom. If you cannot safely get in and out of the shower, you may sponge bathe at a sink. You will not be able to take a bath for eight weeks after surgery.  Traction strips for the shower are helpful to prevent slipping. You will wash your feet with a long-handled sponge and dry them with a long beach towel to avoid stressing your hip.    

Dressing

 Several devices can be helpful in dressing.  A sock donner is a device that will allow you to put on your own socks without stressing your hip. A long shoe-horn can be used to help you put on your own shoes. Donning your own shoes can also be facilitated by using elastic shoelaces or Velcro closures.

A reacher device and dressing stick can be very helpful. These will help you put on your pants and help you remove your socks and shoes. The reacher also allows you to pick up objects you have dropped without stressing your hip.  The occupational therapist will review these devices and methods of dressing to allow you to maximize your independence with self-care at home. 

Use of the Car

Getting in and out of a car can be challenging.  The back seat of a four-door sedan is usually easiest for keeping your legs extended. Open the car door and move the seat, if possible, all the way back. Then, move back through the open door, and slide into the seat. Bring your legs in while trying to keep them as straight as possible. If you will require handicapped parking permit during rehabilitation, please obtain the necessary forms from your state department of motor vehicles. Bring these forms to the office and we will complete the forms for you.

 If you drove on a regular basis without restrictions before surgery, you may be able to resume driving six weeks after surgery. Before venturing on the road, take time to practice in a secluded area. You may notice that your reaction time is longer, particularly if your right hip is replaced. You should discuss this with your doctor.

Additional Hints

A bag can be attached to your walker or crutches to help you carry items.

When sitting, always use a firm chair with a pillow and arms for the first six weeks.

Rearrange your cabinets and refrigerator, closets, etc., before admission to place frequently used items within easy reach.

Preparation for Discharge

 Physical Therapy and the orthopaedic team will assess your progress after your surgery and make recommendations as to whether you should go home or to a rehabilitation facility.  You may want to contact your insurance company and get a list of approved rehabilitation facilities and tour some before your hospitalization.  If rehabilitation is the recommendation, you will then have an idea of where you would like to go.  Our caseworkers will facilitate your placement and transfer to the facility.

Whether to home or a rehabilitation facility,  you will be provided with prescriptions for pain medication and enteric coated aspirin after the surgery. Continue the aspirin for six weeks after the date of surgery. This will help prevent blood clots in your veins. At home, keep your wound clean and dry until after the staples are removed. This will usually be done in your surgeon's office 10 to 20 days after the surgery.

For transportation home you may ride in a car. If this is not possible, we will make other appropriate arrangements.

Care of Your THR

Patients commonly have questions about which activities are acceptable after THR. It is safe and recommended that you walk as much as you can tolerate. In addition, you may engage in nonimpact activities, such as stationary bicycling, swimming, golf and bowling. However, impact activities, such as racquet sports, jogging and horseback riding are not advised because they may lead to excessive wear or loosening of the prosthetic components. As you resume activities with a non-cemented prosthesis, you may experience "thigh pain". It is a dull ache over the front of the mid-thigh. It is related to your bone adjusting to the metal implant. If this occurs, it should resolve in several months. If the pain persists or worsens, you should call the office.

Sexual Activity

As with other activities after THR, it is generally safe to resume sexual activity six to eight weeks after the surgery. After this period of time, the incision and the capsule surrounding the new hip are sufficiently healed. The major complication that might occur with sexual activity is dislocation. It is important to continue to observe hip precautions (avoid excessive flexion, adduction and internal rotation of the hip) when first resuming sexual activity.

Antibiotics

Before any dental, urological, gastrointestinal or surgical procedure you must notify your doctor that you have a joint replacement. You may need to take antibiotics to protect the joint replacement from infection. If you or your physician have any questions, you should contact your surgeon.

Follow-up

It will be necessary for you to return to your surgeon's office for regular eval‎!uations. This is particularly important in the weeks and months immediately following your surgery. Generally, these office visits take place two weeks from the day of surgery, then at four weeks, three months, six months, one year and then every other year. During these visits, several parameters will be assessed, including your incision, level of pain, range of motion, and x-rays. The surveys you completed before surgery will need to be filled-out at each postoperative visit.

This information should serve as a general guide for you in the care of your hip replacement. As this is general information, your own care after surgery may be modified by your surgeon based on the specific nature of your surgery and general condition. If your have any concerns or do not understand something, we hope you will call and ask questions