Hip Replacement Surgery and Physical Rehabilitation.
The information below will help understand how a normal hip works, the causes of hip pain and disease conditions, what to expect from hip replacement surgery, and what exercises and activities or physical rehabilitation or physical therapy will help restore your mobility and strength, and enable you to return to activities of daily living.
Hip joint replacement is surgery to replace all or part of the hip joint with a man-made joint. The artificial joint is called a prosthesis.
Hip replacement surgery is a procedure in which a doctor surgically removes a painful hip joint with arthritis and replaces it with an artificial joint often made from metal and plastic components. It usually is done when all other treatment options have failed to provide adequate pain relief. The procedure should relieve a painful hip joint, making walking easier.
Your hip joint is made up of 2 major parts. One or both parts may be replaced during surgery:
- The hip socket (a part of the pelvic bone called the acetabulum)
- The upper end of the thighbone (called the femoral head)
The new hip that replaces the old one is made up of these parts:
- A socket, which is usually made of strong metal.
- A liner, which fits inside the socket. It is usually plastic. Some surgeons are now trying other materials, like ceramic or metal. The liner allows the hip to move smoothly.
- A metal or ceramic ball that will replace the round head (top) of your thigh bone.
- A metal stem that is attached to the thigh bone to anchor the joint.
A total hip replacement is a surgical procedure to repair the hip-joint by partly (Hemi arthroplasty) or fully (Bipolar-hemi arthroplasty) replacing the original hip joint with prosthetic substitutes. Care needs to be taken with this operation because of the invasive nature of this procedure; it is cautiously deliberated if surgery is advised, to take account of age, medical problems, hip disease, activity status and possible fracture characteristics.
Total hip replacements and total knee replacements are among the most commonly performed surgical procedures in Ontario. Physiotherapy rehabilitation after first-time total hip or knee replacement surgery is accepted as the standard and essential treatment. The aim is to maximize a person’s functionality and independence and minimize complications such as hip dislocation (for hip replacements), wound infection, deep vein thrombosis, and pulmonary embolism.
Anatomy of the hip Joint
Hip joint is a strong and stable multiaxial synovial joint of ball and socket type. Femoral head is the ball and the acetabulum is the socket Next to the shoulder joint, it is the most movable of all joints. The round head of femur articulates with the cup like acetabulum of the hip joint.
Acetabulum The acetabular articular surface is an incomplete ring, the lunate surface. Acetabular depth is increased by a fibrocartilaginous acetabular labrum, which bridges the acetabular notch via the transverse acetabular ligament. Acetabular fossa contains fibro elastic fat covered by Synovial membrane.
Ligaments of hip joint
- Illio-femoral ligament
- Ischio-femoral ligament
- Pubo-femoral ligament
- Ligament of the head of the femur
Primary Epidemiology of Hip Joint
Primary osteoarthritis (OA) of the hip has a distinct etiology and epidemiology compared with other types of arthropathy in the hip joint. Arthritis of the hip can be secondary to conditions such as osteonecrosis, trauma, sepsis, or rheumatoid arthritis. Certain conditions, such as congenital hip disease and slipped capital femoral epiphysis, involve predisposing anatomic abnormalities; in such cases, the term “secondary OA” is used.
When either an anatomic abnormality cannot be determined or other specific causative entities are not identified, primary OA is the diagnosis of exclusion. The prevalence of hip OA is about 3% to 6% in the Caucasian population and has not changed in the past four decades. In contrast, studies in Asian, black, and East Indian populations indicate a very low prevalence of hip OA.
Statistics on patients who underwent total hip replacement for primary OA in San Francisco and Hawaii demonstrate a virtual absence of the condition in Asians and low rates in the black and Hispanic populations. Family studies from Sweden, Britain, and the United States show increased rates of hip OA in first-degree relatives of the index patient when compared with the normal population. Occupations requiring heavy lifting, farming, and elite sports activity are associated with increased rates of hip OA.
The low prevalence of hip OA in Asian and black populations in their native countries; the low incidence of total joint replacement for primary OA in Asian, black, and Hispanic populations in North America; and the familial association of hip OA in Caucasians all suggest that genetic factors may be involved in the occurrence of this disease.
Clinical Presentation of the pathology of the hip Joint
The hip joint is becoming increasingly recognized as a source of groin pain and, in the authors’ experience, buttock and low back pain.
In a prospective study of 25 consecutive hip arthroscopies to determine the range of pathologic diagnoses, clinical presentation, and the correlation between magnetic resonance arthrographic, ultrasonographic, and arthroscopic findings done by Mitchell B, McCrory P, Brukner P, O’Donnell J, Colson E, Howells R., they found out that all of the hips arthroscoped had pathology. Back pain and hip pain were the 2 most common presentations. The only consistently positive clinical test result was a restricted and painful hip quadrant compared with the contralateral hip. Of the 17 patients whose flexion, abduction, external rotation (FABER) tests results were reported at the time of examination, 15 (88%) were positive, and 2 (12%) negative. Plain radiographs were normal in all patients. All but 1 patient underwent magnetic resonance arthrography. Although specificity of 100% was achieved in our study, the sensitivity was significantly lower, with a relatively high number of false negatives. Hip arthroscopy proved the definitive diagnostic procedure for intraarticular pathology.
Hip pathology, particularly labral pathology, may be more common than has been previously recognized. In those patients with chronic groin and low back pain, a high index of suspicion should be maintained. Clinical signs of a painful, restricted hip quadrant and a positive FABER test result should suggest magnetic resonance arthrography in the first instance, but a negative magnetic resonance image should not preclude hip arthroscopy if there is high clinical suspicion of hip joint pathology.
Indications for Total Hip Replacement Surgery
Patients eligible for this surgery have moderate to severe arthritis in the hip, including osteoarthritis, rheumatoid arthritis or post-traumatic arthritis that causes pain and/or interferes with daily living. For example:
- Walking, going up stairs, and bending to get in and out of chairs is difficult
- Pain is moderate to severe even while resting, and may affect sleep
- Joint degeneration has caused stiffness that affects the patient’s range of motion during normal activities; the patient may also have a limp
- Symptoms are not adequately alleviated by non-surgical treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, steroid injections, or the use of a cane or walker
About 90% of patients who undergo hip replacement have hip osteoarthritis. In addition to arthritis, some patients have hip replacement surgery to correct problems related to fractures (i.e. a “broken hip”) or other medical conditions, such as osteonecrosis (bone death caused by inadequate blood supply).
Diagnostic Procedures for Hip Replacement Pathology
It is important to begin the hip examination process as comprehensively as possible (including all potential diagnoses)
The patient will go through subjective history, physical examination, and radiographic examination each
Age of the patient will assist in differential diagnosis of hip pain. Pediatric and adolescent pathologies are clinically different in presentations.
Differential diagnosis with regard to the lumbar spine, pelvis and hip is often difficult due to the inter‐dependent relationship between these three regions. The presence of a limp, groin pain, or limited internal rotation (IR) of the hip significantly predicted diagnosis of a disorder originating primarily from hip opposed to from the spine.
Groin pain is a common location for multiple hip pathologies (as well as lumbar spine and pelvic girdle pathologies).
Observation of the athlete presenting with hip pain should include general postural assessment (both statically and dynamically), gait, transfers, and potential limitations in strength and mobility with daily tasks from both the anterior‐posterior view as well as laterally.
Range‐of‐motion (ROM) of the hip can also be observed without formal assessment. Limitations in hip ROM can also be assessed with daily activities. Gait on level surfaces requires only 30 to 44° of hip flexion, while ascending and descending stairs requires 45 to 66° of hip flexion. Sitting in a chair of an average seat height requires 112° of hip flexion. Putting on socks requires 120° flexion, 20° abduction and 20° of external rotation.
Difficulty performing such daily tasks can alert the clinician as to which particular motions to more closely examine during the motion assessment.
Several hip muscles are active during gait, especially the gluteal muscles. Dysfunction of these muscles (primarily the gluteus medius and minimus) is depicted in an excessive drop of the contralateral (or non‐weight‐bearing “swinging”) side of the pelvis, or Trendelenburg gait pattern. Athletes with hip osteoarthritis and slipped capital femoral epiphysis have demonstrated this type of gait dysfunction. Patients with hip dysfunction involving the strength deficits of the gluteus maximus are likely to present with functional deficits during stair climbing, step‐ups, and sit to stand maneuvers since these muscles generate torque in order to propel the upper body of a person upward and forward from a position of hip flexion.
When a hip replacement is needed
Hip replacement surgery is usually necessary when the hip joint is worn or damaged to the extent that your mobility is reduced and you experience pain even while resting.
The most common reason for hip replacement surgery is osteoarthritis. Other conditions that can cause hip joint damage include:
- rheumatoid arthritis
- a hip fracture
- septic arthritis
- ankylosing spondylitis
- disorders that cause unusual bone growth (bone dysplasia)
Who is offered hip replacement surgery?
A hip replacement is major surgery, so is normally only recommended if other treatments, such as drugs or steroid injections, haven’t helped reduce pain or improve mobility.
You may be offered hip replacement surgery if:
- you have severe pain, swelling and stiffness in your hip joint and your mobility is reduced
- your hip pain is so severe that it interferes with your quality of life and sleep
- everyday tasks, such as shopping or getting out of the bath, are difficult or impossible
- you’re feeling depressed because of the pain and lack of mobility
- you can’t work or have a normal social life
You’ll also need to be well enough to cope with both a major operation and the rehabilitation afterwards.
How hip replacement surgery is performed
A hip replacement can be carried out under general anesthetics (where you’re asleep during the procedure) or an epidural (where the lower body is numbed).
The surgeon makes an incision into the hip, removes the damaged hip joint and replaces it with an artificial joint made of a metal alloy or, in some cases, ceramic.
The surgery usually takes around 60-90 minutes to complete.
Recovering from hip replacement surgery
The rehabilitation process after surgery can be a demanding time and requires commitment.
For the first four to six weeks after the operation you’ll need a walking aid, such as crutches, to help support you.
You may also be enrolled on an exercise programme that’s designed to help you regain and then improve the use of your new hip joint.
Most people are able to resume normal activities within two to three months but it can take up to a year before you experience the full benefits of your new hip.
Physiotherapy rehabilitation after first-time total hip replacement surgery is accepted as the standard and essential treatment.
The physiotherapy rehabilitation routine has 4 components:
- Therapeutic exercise,
- Transfer training,
- Gait training, and
- Instructions in the activities of daily living.
Physiotherapy rehabilitation for people who have had total joint replacement surgery varies in where, how, and when it is delivered. After a patient is discharged from an acute care hospital, people who have had a primary total knee or hip replacement may receive inpatient or outpatient physiotherapy.
Inpatient physiotherapy is delivered in a rehabilitation hospital or specialized hospital unit. Outpatient physiotherapy is done either in an outpatient clinic (clinic-based) or in the person’s home (home-based). Home-based physiotherapy may include practicing an exercise program at home with or without supplemental support from a physiotherapist.
Finally, physiotherapy rehabilitation may be administered at several points after surgery, including immediately postoperatively (within the first 5 days) and in the early recovery period (within the first 3 months) after discharge. There is a growing interest in whether physiotherapy should start before surgery. A variety of practices exist, and evidence regarding the optimal pre- and post-acute course of rehabilitation to obtain the best outcomes is needed.
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- ↑ Jump up to:1.01 1.2 1.3 1.4 GREMEAUX, V., RENAULT, J., PARDON, L., DELEY, G., LEPERS, R., CASILLAS, J., Low frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2808%2901388-9/fulltext (accessed: 2010-12-25)
- ↑ Jump up to:2.01 2.2 2.3 2.4 JAN, M., HUNG, J., LIN, J.C., WANG, S., LIU, T. TANG, P., Effects of a home program on strength, walking speed, and function after total hip replacement, http://www.archives-pmr.org/article/S0003-9993%2804%2900306-5/fulltext ( accessed: 2010-12-25)
- ↑ Jump up to:3.01 3.2 3.3 STOCKTON, K.A., MENGERSEN, K.A., Effects of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2809%2900377-3/fulltext (accessed: 2010-12-25)
- ↑ Jump up to:4.01 4.2 4.3 RAHMANN, A.E, BRAUER, S.G., NITZ, J.C., A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial, http://www.archives-pmr.org/article/S0003-9993%2809%2900144-0/fulltext ( accessed: 2010-12-25)
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