Our hips are classed as ‘ball and socket’ joints. They are designed for stability and weight-bearing. The bony surfaces of the hip joint are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily. When significant damage occurs to the hip joint, it is this cartilage that may not naturally repair and become painful. Over time, when conservative treatments such as physiotherapy and hydrotherapy are no longer able to manage your hip pain, the pain can become severely debilitating and affect your quality of life. At this stage, the hip joint itself may need to be replaced with a prosthetic hip joint, known as a hip replacement. As we did with last week’s article on knee replacement, today we’ll look at the ins and outs of hip replacements and how physiotherapy is crucial in your recovery.

What is a joint replacement?

A joint replacement (arthroplasty) is a surgical procedure to replace the weight-bearing surfaces of a joint. A total hip replacement (THR) is an operation which is done to relieve pain in the hip. There are many types of hip replacements, including cemented, uncemented, ceramic, plastic and metal. Your surgeon will explain the different types to you and will select the right hip replacement for you.

There are many surgical approaches for THR. These approaches determine the amount of soft tissue damage, location of the damage (anterior, lateral, posterior), and dictate the major precautions following total hip replacement surgery.

Most hip replacements will last between ten to fifteen years.

Note that your new hip may activate metal detectors required for security in airports and some buildings!

What conditions can lead to a hip replacement?

THRs are most commonly performed for osteoarthritis (OA), and also for other hip diseases such as rheumatoid arthritis, post-traumatic arthritis, avascular necrosis and childhood hip diseases like hip dysplasia, Perthes disease, slipped femoral capital epiphysis and septic arthritis.

Hip replacement ball joint

Image credit: PhysioWorks

Risks of hip replacement surgery include:

  • small risk of heart attack, stroke
  • chest infection
  • deep vein thrombosis (DVT) or pulmonary embolism (PE). This is a blood clot in the lungs which can come from a DVT or arise spontaneously in the lungs. This is managed with anticoagulant drugs
  • infection can be a complication of any surgery. Antibiotics are normally given before surgery starts and after your operation
  • dislocation – the rate of dislocation varies depending on surgery approach
  • leg length discrepancy. Whilst every effort is made to keep the leg lengths equal, sometimes this is not possible and you may need to use a shoe raise to balance any significant differences
  • prosthetic loosening and implant wear
  • difficulty returning to your previous level of activity
  • persistent hip pain
  • nerve damage

The good news is that more than 90% of patients have no complications post-surgery!

What are the signs and symptoms of hip arthritis?

  • limping, Trendelenberg swaying gait (walking pattern)
  • pain in your groin or thigh that can radiate to your buttocks or hip
  • stiffness in your hip joint that makes it difficult to walk or bend
  • leg length discrepancy
  • deformity may begin to appear
  • loss of hip range of movement
  • locking or sticking of the joint, and possible grinding noise when moving

How is hip arthritis diagnosed?

Your physiotherapist or doctor can assess your hip, looking for signs of limited hip movement causing pain and deformity. In most cases, an X-ray will be enough to show the degree of wear and tear, as seen in the image below.

Hip arthritis (pre-surgery)

Image credit: Hip and Knee

Can physiotherapy help?

The answer to that question is a loud and resounding YES! More research continues to come out suggesting physiotherapy should be your first line in arthritis management and is most effective in reducing mild or moderate arthritic pain. Massage, stretches, strengthening, Pilates and Hydrotherapy can all reduce your joint pain and slow its progression. Surgery should only be used as a last resort when all other treatments are no longer effective.

If surgery is planned and you haven’t previously seen a physio, you can still benefit from starting physio before your replacement. Studies show that the better your muscle strength and hip range of movement before surgery, then the better and quicker you recover! This might mean an earlier, pain-free return to the activities you love.

What does physio involve after surgery?

A joint replacement surgery is just that – the replacement of a joint through surgery. Your joint pain should disappear but unfortunately, the strength and stiffness of your hip won’t magically return post-surgery – it’s going to take some work!

Post hip replacement x-ray

Image credit: Students 4 Best Evidence

Post-surgery, you will normally experience some pain and swelling. This can take time to settle. Your hospital physiotherapist will normally show you exercises to do post-surgery. These exercises will help increase circulation to your legs and feet, which is important for preventing blood clots. They will also help strengthen your muscles and improve hip movement.

You can begin your exercises in the recovery room shortly after surgery. You may feel uncomfortable at first, but these exercises will help speed up your recovery and actually diminish your postoperative pain.

If you aren’t up and moving after your surgery, your hip will continue to weaken and stiffen up. Hence most recovery protocols will have you up out of bed usually on day 1 post surgery. Your hospital physio will assist you in using your crutches for walking, teach you the rules for climbing stairs, sitting and sleeping, and show you exercises to get you back on your feet, normally the next day! By the time you are ready to go home, you should be able to:

  • get in and out of bed, perform transfers with the least amount of help possible, using your gait aid
  • walk at least 5-10 metres and go up and down stairs using crutches
  • have a full understanding of your restrictions
  • perform your home exercises without assistance

Most patients are in hospital for 3-5 days (those with more complex care needs may need to spend a week or two in rehab prior to discharge home). Once you are cleared to go home by your surgeon, the hard work begins!

Will I need more physio once I am back home?

For most people the answer is definitely “yes”. The whole rehabilitation period for a hip replacement can take between 3-6 months, but in some cases, it may last longer depending on your progress.

Post-operative physiotherapy will help advise, monitor and educate you on the necessary precautions and restrictions of your surgery, and help you restore hip motion, strength and day to day function. Therapies include:

  • massage
  • ice packs
  • hydrotherapy
  • Clinical Pilates
  • home exercises

Your physio treatment goals include:

  • reducing hip pain and inflammation
  • reducing scar tissue
  • restoring hip joint range of motion
  • strengthening your hip muscles, whilst adhering to your restrictions
  • strengthening your lower limb and core muscles
  • improving your proprioception, agility and balance
  • improving your technique and function e.g. walking, stair climbing, squatting and bending

What restrictions should I expect post-surgery?

Your risk of hip dislocation is greatest in the first few months after surgery while the tissues are healing. To decrease the risk of dislocation the following is advised:

  • do not sit in low chairs
  • keep your knees level with or below your hips
  • sit with your knees apart
  • do not squat down to do up your shoes, etc.
  • do not bend from your hips to pick up anything
  • do not cross your legs
  • do not lie on your operated side
  • when lying on your non-operated side, always have two pillows between your knees

Post hip replacement rules

Image credit: Aurora Healthcare

What items can help me when I return home?

Several modifications to your home can help protect your hip in the early stages following your surgery and support your recovery. The following items may help with daily activities:

  • a stable chair for your early recovery with a firm seat cushion, a firm back, and two arms
  • a raised toilet seat
  • a stable shower bench or chair for bathing
  • a long-handled sponge and shower hose
  • a dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip
  • a ‘pick-up stick’ that will allow you to grab objects without excessive bending of your hips
  • firm pillows for your chairs, sofas and car, that allow you to sit with your knees lower than your hips
  • removal of all loose carpets and electrical cords from the areas where you walk in your home

When can I return to my leisure activities?

Most patients achieve pain-free walking, hiking, bending, stair and ladder climbing, kneeling, crawling and return to low-impact sports such as golf, swimming, cycling, tennis, and most gym exercises. Some activities that require extreme flexibility (such as some yoga positions) may not be possible at all – it’s best to avoid extreme positions to prevent dislocation of the hip.

Many younger patients can jog (at least a short distance) although this is generally not advised, as it is an activity that involves impact loads to the joint. Sexual activity can be resumed when comfortable but is not recommended in the first six weeks post-surgery.

You may feel some numbness in the skin around your incision, and some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.

At Revive Physio, we have years of experience working with patients suffering arthritic hip pain or those recovering after hip replacement surgery. Feel free to call us on 9391 2600 to discuss your issues or to make an appointment with one of our Physiotherapists today.