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Aug
05

Total Hip Replacement Updates: Anterior vs Posterior. Part 2 of 2.

Matt Miraglia, DPT

Guest Author: Matt Miraglia, DPT

Matthew Miraglia – received a Doctor of Physical Therapy degree from Temple University in May of 2019 and interned at Mackarey Physical Therapy. He grew up in Plains, PA and graduated from Coughlin High School in Wilkes-Barre. Prior to PT school, he received a bachelor of science in kinesiology from Temple University. Matthew plans to graduate with his doctoral degree in May and work in an outpatient physical therapy clinic in the Wilkes-Barre/Scranton Area.

As discussed last week in Hip Replacement Updates – Part 1, there are a wide variety of reasons for why a total hip arthroplasty (THA), or replacement, may be needed, as well as steps that lead to requiring a total hip replacement. Those that do eventually require a THA should be well prepared for their rehab journey going forward, both before and after the surgical procedure. This article will discuss potential precautions after surgery, as well as a few exercises that will serve as a foundation for the rehabilitation process going forward.

Your surgeon should have discussed with you the type of approach that he/she will be performing, and post-operative precautions that you should be aware of. Depending on the procedure approach, it is critical that recommended precautions are followed in order to protect the integrity of the joint replacement, and allow for proper healing.

  • These positions put the healing joint replacement in its most vulnerable position. Your surgeon may recommend additional precautions that are specific to you and your replacement. It is important that these precautions are followed as prescribed by your surgeon and that you feel comfortable and capable following all precautions.
  • Anterior approach – Patients receiving the anterior (front) approach have less post operative precautions. In fact, depending on surgeon preference, often there are no precautions after surgery. The lack of precautions and restrictions is due to the relatively small amount of soft tissue and musculature that must be cut during the procedure. Sparing of the tissue helps keep the replacement much more stable, and decreases risk for dislocation. The most common precaution for anterior approaches is to avoid hip extension, or moving your thigh backwards. Hip extension is most often seen while walking, and when propping oneself up on elbows while lying on stomach.
  • Posterior approach – Patients receiving the posterior (back) approach must follow more precautions and restrictions compared to the anterior approach. This is due to the fact that a much larger amount of soft tissue is cut during the procedure. With more soft tissue involved, the stabilizers of the hip are disrupted, requiring increased caution to protect the replacement for the first 6 weeks following the procedure.
    • The most common posterior precautions are: (See photos)
  1.  No bending hip past 90 degrees – i.e. bending over to pick up objects off the floor, and sitting in a low chair or toilet; (Photo A – Correct Sitting with knee below hip and Photo B-Incorrect sitting with hip below knee and Photo C 1- Incorrect bending at hips to pick up object from floor)
  2. No crossing legs (Photo C2 – Do Not Cross Legs)
  3.  No rolling leg or knees inward – i.e. toes should not be pointing inward when standing or laying down. (Photo D – Do Not Turn Hip or Knee In)

By following these precautions, your hip will be allowed to heal without putting additional strain on the replacement

  • Modifications to daily movements and positions to help you follow these rules include:
    • To Avoid Bending Hip Past 90 degrees– Utilize a grabbing device to pick objects up off floor, and kick affected leg out straight to prevent putting hip past 90 degrees when sitting
    • To Avoid Crossing Legs – put a pillow between your legs when sitting or lying
    • To Avoid Rolling or Turning Legs In – Lay or sleep with 1-2 pillows between your legs to prevent inward rotation of your hip

In addition to precautions, your surgeon should also discuss your ability to bear weight on the affected limb. Most patients are weight bearing as tolerated after surgery, meaning they can put as much weight as they are able to through the leg, but depending age, body type, and if there were any potential surgical complications, weight bearing status may be different. Often a walker is need for a short time after surgery and then advanced to a cane.

Prior to surgery and immediately after surgery there are a few simple exercises that will either maintain (prior to) or help restore (afterwards) hip strength and mobility regardless of the surgical approach utilized. These exercises include: (See Photos)

  • Ankle pumps – (move ankle up and down as if working a gas pedal) – assist with blood return and swelling
  • Quad sets (squeezing muscles in the front of your thigh) – assist with strengthening (Photo E – Quad Set)
  • Glute sets (squeezing muscles of the buttocks) – assist with strengthening
  • Front straight leg raise – (while lying on your back, lift leg up with knee straight) – assist with strengthening (may be performed in a protect range of movement) (Photo F – Straight Leg Raise)
  • Heel slides – (while lying on your back, slide your heel up and down) –  assist with regaining mobility of the hip and knee
  • Hip abduction and adduction (squeezing knees together against a pillow and pushing knees out against a resistance band) – assist with strengthening
  • Short/long arc quads (while sitting in a chair, kick knee out straight) – assist with strengthening. (Photo G – Long Arc Quads)

These exercises will serve as a base for strength and mobility of the hip until pain levels begin to decrease and you are able to tolerate and participate in exercises that require greater mobility in order to complete. Eventually, after a strong base has been formed with strength and mobility of the hip, functional activities will be reintroduced in order to make daily activities easier and more comfortable (walking, climbing stairs, sitting to standing, etc.)

Often, it is recommended that a patient see a doctor of physical therapy before surgery to review the procedure, prepare the home environment for safety and to begin a pre operative exercise program.

In summary, hip replacements have been shown to be one of the most stable of all joint replacements with good outcomes. This article highlights surgical precautions and gives a brief overview of the initial rehabilitation process after surgery. If you have further questions about your specific condition and your surgical treatment plan, you should consult your orthopedic surgeon or physical therapist to help guide you through the process.

For more information visit: American Academy of Orthopedic Surgeons at www.aaos.com

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine (formerly The Commonwealth Medical College).