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A total hip replacement (THR) is a surgical procedure whereby the diseased connective tissue (cartilage) and bone of the hip joint are surgically replaced with artificial materials. The hip joint is a ball and socket joint. The ball is the head of the thigh bone (femur). The socket (acetabulum) is a cup-shaped indentation in the pelvis.
During hip replacement surgery, the head of the femur is removed and replaced with a metal ball set on a stem. The stem is inserted into the canal of the femur. It may be fixed in place with cement, or the stem may be designed for placement without bone cement. The socket is sanded down to healthy bone, and a plastic cup or socket is held in place with screws and/or bone cement.
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Source: Medical Disability Advisor
| The most common reason for performing the total hip replacement procedure is progressively severe degeneration of the hip joint (arthritis) that causes pain. The most common type of arthritis leading to THR is degenerative arthritis (osteoarthritis) of the hip. Other conditions leading to THR include bony fractures of the hip joint caused by trauma (such as a fall), and death (necrosis) of the hip bone.
Hip joints are replaced when individuals have severe pain, significant loss of motion, and an inability to perform routine and recreational activities. THR is elective surgery; the decision to proceed is largely the individual's and is based primarily on pain. Even if the hip joint is damaged, hip replacement is generally not performed if the individual is not in pain.
The most common site individuals experience pain is in the hip joint where the ball and socket meet. Here, the joint surfaces may become damaged as the cartilage layer breaks down. The resulting friction during movement can create excruciating pain.
Hip replacement cannot be done if there is active infection in the joint or if the quality of the bone will not support the implants and increased weight bearing. |
Source: Medical Disability Advisor
| Hip replacement surgery normally is performed under regional or general anesthesia. During hip replacement surgery, the surgeon removes the diseased bone tissue and cartilage from the hip joint; the healthy parts of the hip are left intact. The surgeon then replaces the head of the femur and the acetabulum with new, artificial parts.
The surgeon may use a special glue or cement to bond the new parts of the hip joint to existing, healthy bone. This is referred to as a "cemented" procedure. In an "uncemented" procedure, the artificial parts are made of a porous material that allows the individual's own bone to grow in to the pores and hold the new parts in place. Sometimes a "hybrid" procedure replacement is performed, which consists of a cemented "stem" and an uncemented "socket." The new socket may be screwed to the hip bone. Hip replacement surgery usually lasts between 2 and 3 hours.
Some surgeons are beginning to employ a “minimally invasive” technique. An otherwise standard hip replacement, it uses from one or two smaller, less invasive incisions. The technique may reduce bleeding, as well as muscle and soft tissue trauma during surgery, and may in some cases allow earlier discharge to home or a slightly quicker return to full activity (Skerker). Some clinicians advocate using a direct anterior approach to further minimize soft tissue disruption and to possibly reduce some complications such as dislocation. (Lovell). Clinical research regarding these potential benefits, and any potential drawbacks, is ongoing but promising (Harkess; Swanson).
When the individual awakens, there will be an intravenous (IV) tube in place to administer fluids, pain medication, and antibiotics. There will be a small drainage tube called a "hemovac" collecting blood from the surgical site. A Foley catheter may be in place to drain the bladder until the individual is able to urinate independently. A removable brace or a firm pillow will be between the individual's legs to prevent rotating the hip or crossing the legs. Several measures are used to prevent blood clots, including wearing special stockings, the use of foot and calf pumps, oral, or subcutaneous injection of blood thinners. Hospitalization usually lasts for about 3 to 7 days. |
Source: Medical Disability Advisor
| The long-term prognosis remains good for most total hip replacement procedures. In general, total hip replacements currently last from 10 to 15 years (Skerker). |
Source: Medical Disability Advisor
| Note on research and authorship Ideally, rehabilitation begins before surgery by assessing the patient's medical and social condition in order to determine what the patient might require postoperatively for a successful outcome. The main goal of the rehabilitation after a total hip replacement is to restore function by controlling pain and normalizing gait.
Preoperative gait instruction might facilitate early post-operative ambulation. The main goal in the inpatient period is early ambulation and decrease of pain and swelling. As many patients experience an antalgic gait or limb weakness preoperatively, postoperative gait training and exercise may be beneficial (Roos).
Individuals who undergo total hip replacement require both physical and occupational therapy. Occupational therapy is needed after surgery for instruction in all transfer training, equipment needs and activities of daily living modifications. Individuals can be assessed and trained by the occupational therapist in the use of equipment such as an elevated commode, tub seat, reacher, long-handled shoe horn and long-handled sponges, as these facilitate independent activities of daily living in the postoperative period (Crowe).
Postoperative physical therapy is necessary for gait training on level and uneven surfaces, such as stairs. Weight bearing status is determined by the physician, and patients may use assistive devices as needed. Knee and ankle range of motion exercises are indicated to prevent the development of postoperative circulatory complications, and to maintain strength and range of motion in these joints during this period of limited patient mobility. Some postoperative protocols dictate the use of hip exercise while others do not. When indicated, isometric exercises of the lower limb and the hip abductors help to regain muscle recruitment and strength. Applying local cold packs, being careful to protect the surgical wound, can decrease pain and swelling. After discharge from the hospital, physical therapy may continue with the goal of normalizing gait, range of motion, and muscle strengthening of the involved lower extremity, according to the limitations of the surgeon. Instruction in hip exercises is based on the surgeon's protocol and should be incorporated only if prescribed.
An important goal of therapy is to teach precautionary measures to the individual and should be reinforced by both the physical and occupational therapists (Grissom). Care must be taken to protect the integrity of the prosthesis and the surrounding soft tissue during all activities and while at rest. All weight bearing and exercise should be continued under the direct guidance of the surgeon and within the movement limitations necessary to protect the integrity of the hip prosthesis. Restrictions of the range of motion and weight bearing depend on the surgical approach.
The final goal of physical therapy is increasing functional abilities. The functional abilities include not only walking, but also abilities required for vocational and recreational activities. |
| FREQUENCY OF REHABILITATION VISITS | | Surgical ‡ | |
| Occupational Therapist | | Daily | | | | | | | | Physical Therapist | | Up to 12 visits in 6 weeks | |
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| ‡ Note on Surgical Guidelines: Amount of outpatient rehab is very variable as per the physician's protocol. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| As with all major surgical procedures, complications can occur. The most common complications following hip replacement surgery are deep vein blood clots (thrombophlebitis, deep vein thrombosis), infection, dislocation, and loosening of the prosthesis.
Thrombophlebitis can occur after any operation but is more likely after surgery on the hip, pelvis, or knee. Deep vein thrombosis occurs when blood clots form within the large veins of the leg. Pulmonary embolus occurs when the clot breaks off and goes to the lungs. Pressure stockings to keep blood circulating and medications to thin the blood can be used for prevention.
Longer-term complications may include decreased muscle strength, limited range of motion and flexibility, and gait abnormalities. These functional limitations have persisted as long as a year following surgery; some cases of hip joint weakness have persisted as long as 2 years. In light of these potential complications, extending therapeutic exercises and their potential benefits past the initial recovery period of 12 weeks when appropriate is considered reasonable (Skerker). |
Source: Medical Disability Advisor
| Work restrictions or accommodations should include no prolonged standing, limited stair climbing, frequent rest periods, and use of a walker or cane during early recovery stages. Stooping, squatting, and excessive forward bending should be avoided for 6 weeks. Riding in a car is permitted, but frequent stops (hourly) must be made to get out and walk and stretch.
A higher chair or firm cushions added to a low chair will be necessary to assist in standing. A chair with armrests to assist in standing may be needed.
In some cases, therapeutic exercise will continue past the initial 12-week recovery period.
With proper physical therapy, the individual should be able to return to an active lifestyle. |
Source: Medical Disability Advisor
| Crockarell, John R., and . "Arthroplasty of the Hip." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beatty. 11th ed. Philadelphia: Mosby Elsevier, 2008.Crowe, J., and J. Henderson. "Pre-Arthroplasty Rehabilitation is Effective in Reducing Hospital Stay." Canadian Journal of Occupational Therapy 70 2 (2003): 88-96. National Center for Biotechnology Information. National Library of Medicine. 5 Dec. 2008 <PMID: 12704972>. Grissom, S. P., and L. Dunagan. "Improved Satisfaction During Inpatient Rehabilitation after Hip and Knee Arthroplasty: A Retrospective Analysis." American Journal of Physical Medicine and Rehabilitation 80 11 (2001): 798-803. National Center for Biotechnology Information. National Library of Medicine. 5 Dec. 2008 <PMID: 11805449>. Lovell, T. P. "Single Incision Direct Anterior Approach for Total Hip Arthroplasty Using a Standard Operating Table." Journal of Arthroplasty 23 7 Supp (20087): 64-68. National Center for Biotechnology Information. National Library of Medicine. 13 Feb. 2009 <PMID: 18922376>. Roos, E. M. "Effectiveness and Practice Variation of Rehabilitation after Joint Replacement." Current Opinion in Rheumatology 15 2 (2003): 160-162. National Center for Biotechnology Information. National Library of Medicine. 5 Dec. 2008 <PMID: 12598806>. Skerker, Robert S., and Gregory J. Mulford. "Total Hip Replacement." Frontera: Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, et al. 2nd ed. Philadelphia: Saunders, Elsevier, 2008. Swanson, T. V. "Posterior Single-incision Appraoch to Minimally Invasive Total Hip Arthroplasty." International Orthopaedics National Center for Biotechnology Information. National Library of Medicine. 13 Feb. 2009 <PMID: 17653544>. |
Source: Medical Disability Advisor
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