Wellness & Lifestyles Australia

TOTAL HIP REPLACEMENT (THR)

E-BOOK
prepared by
Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents

Page No.

IMPORTANT NOTICE .............................................................................................. 1

INTRODUCTION ................................................................................................... 2
HIP ANATOMY AND INDICATIONS FOR SURGERY ............................................................. 3
Anatomy ................................................................................................. 3
Indications for surgery ................................................................................. 3
PRE-OPERATIVE ADVICE AND PLANNING ...................................................................... 4
To prepare yourself .................................................................................... 4
To prepare your hip .................................................................................... 4
OPERATION PROCEDURE ......................................................................................... 7
Posterior approach ..................................................................................... 7
Lateral approach ....................................................................................... 7
ACUTE PHASE IN HOSPITAL (WEEK 1).......................................................................... 8
Goals...................................................................................................... 8
What to do ............................................................................................... 8
What NOT to do ......................................................................................... 8
What youll notice ...................................................................................... 9
Exercises ............................................................................................... 10
ACUTE PHASE AT HOME........................................................................................ 12
Sitting .................................................................................................. 12
Standing ................................................................................................ 12
Walking ................................................................................................. 12
Steps and stairs ....................................................................................... 12
Personal care .......................................................................................... 13
Sleeping ................................................................................................ 13
EARLY OUTPATIENT PHASE (WEEKS 2 to 6) ................................................................. 14
Goals.................................................................................................... 14
What to do ............................................................................................. 14
Exercises ............................................................................................... 14
HYDROTHERAPY PROGRAM .................................................................................... 18
LATE OUTPATIENT PHASE (WEEKS 6 to 12) ................................................................. 22
Goals.................................................................................................... 22
Exercises ............................................................................................... 22
RETURN TO NORMAL ACTIVITIES ............................................................................. 25
SUMMARY ........................................................................................................ 26
CONTACT US .................................................................................................... 27

MANUAL LAST MODIFIED 22/6/2010

IMPORTANT NOTICE
The information provided in this document can only assist you in the most general way. This document
does not replace any statutory requirements under relevant State and Territory legislation.
Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the
material contained in this document, which is provided on the basis that the Office of W&L is not thereby
engaged in rendering professional advice. Before relying on the material, users should carefully make
their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and
should obtain any appropriate professional advice relevant to their particular circumstances.
To the extent that the material in this document includes views or recommendations of third parties, such
views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its
commitment to a particular course of action.
Copyright Australia 2009
This work is copyright. You may download, display, print and reproduce this material in unaltered form
only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart
from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION
Welcome to the W&L series of eBooks. You have chosen the edition on total hip replacements.
This resource will be beneficial to anyone who:
is wondering what total hip replacement surgery involves
is participating in post total hip replacement rehabilitation program and wants a comprehensive guide
to their exercises
is running a rehabilitation program and wants up to date information with all the important details
This eBook will cover information about the anatomy of the hip, why someone would be eligible for hip
replacement surgery and an explanation of the procedure. It also will accompany you from the days
leading up to surgery until the last stages of your rehabilitation program with advice, answers and
exercises.
The information provided is up to date and follows industry standard. W&L recommend that you continue
to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to
your specific requirements.

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HIP ANATOMY AND INDICATIONS FOR SURGERY

Anatomy
The hip joint is classified as a ball and socket joint which is incredibly stable. The muscles at the back of
the hip (the buttocks) are large and strong muscles which help to kick your leg backwards, turn your leg
outwards and lift your leg out to the side, all very important movements for walking. At the front of your
hip there are muscles which bend your hip up and the muscles in your inner thigh bring your leg across
your midline, for example when crossing your legs. As well as these strong muscles which surround the
hip, there are several strong ligaments which help to hold the hip joint in place.
When these muscles contract, the hip moves by the ball rolling inside the socket. With joint degeneration
(arthritis) the joint surfaces can wear away, making the joint surfaces uneven and painful to move as they
rub against each other. With falls, it is common for hip fractures to occur, once again making it difficult
and painful to move the hip joint.

Indications for surgery

There are several reasons to have hip replacement surgery, the most common are:
Osteoarthritis or rheumatoid arthritis
Hip fracture
Compromised circulation of the joint (Avascular Necrosis of the femoral head)
Tumours
Revision total hip replacement

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PRE-OPERATIVE ADVICE AND PLANNING

To prepare yourself
Talk to your surgeon about what type of surgery it will be (see Operation procedure for the different
types) and ask what complications can be associated with each type. Ask what sort of equipment you may
require after the surgery. It is common for people to use walking sticks or frames initially after the
operation and some may need some special equipment in the house, for example, not all chairs are
suitable to sit in initially following a hip replacement.

To prepare your hip

Before the operation it is best to do some strengthening exercises to maximise your recovery after
surgery. Practicing these exercises beforehand will also make it easier to do them after the surgery.
Repeat this exercise session twice a day:

Hip abduction (lying)

Hip and knee flexion

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Hip extension (standing)

Sit to stand

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Bridging with arms

Knee extension

Ankle pumps

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OPERATION PROCEDURE
There are two main procedures used for total hip replacements and each surgeon has their own
preference.

Posterior approach
A posterior approach means that the hip joint is being accessed from the back. There is an incision
through the gluteus maximus muscle in your buttocks. The hip joint is dislocated with the leg bent up,
rotated inward and brought across the midline.

This approach has a higher re-dislocation rate after surgery than the lateral approach but this risk can be
limited by avoiding the position which the hip was originally dislocated in (for example, crossing your
legs).

Lateral approach
A posterior approach means that the hip joint is being accessed from the side over the bony area you can
feel at the side of your hips. The three muscles gluteus medius, gluteus minimus and vastus lateralis are
detached. The hip is dislocated with the leg brought back behind, rotated outwards and brought across
the midline.

This approach is more likely to result in buttock muscle weakness and poor pelvic control after surgery but
this risk can be limited by strengthening the buttock muscles and doing pelvic control exercises.

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ACUTE PHASE IN HOSPITAL (WEEK 1)

Goals
The main goals for this first week are to be able to:
Control your pain.
Walk and transfer from your bed and chairs (with the use of walking aids).

What to do

Do as much exercise as tolerated in bed to prepare your body for when it is time to walk.
Have supervision and assistance when trying activities for the first time (such as steps or sitting) to
ensure that you have a safe technique.
Lay to rest when feeling sore or overworked.
Use cold packs or massaging to help relieve pain.

What NOT to do

Allow your operated hip to be bent more than 90 (be particularly aware of this when sitting up).

Allow your operated leg to cross your midline (be particularly aware of this when getting out of bed on
your operated side, try to get out on the un-operated side where possible).

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Allow your operated leg to turn inwards (be particularly aware of this when you are turning whilst
walking, try to always turn away from your operated leg, for example clockwise if youve had a left
total hip replacement).

Lift your leg unsupported when lying on your back.

What youll notice

There will probably be a triangular pillow in between your legs called a Charnley pillow. This is to
ensure that your operated leg doesnt move across your midline.
Youll be given special stockings (TED stockings) which are used to prevent blood clotting in your legs
from less movement.

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Exercises
These can be started straight after the operation in bed.

Ankle pumping: do 10 hourly

The following exercises should be done 10 times, twice daily.

Static quadriceps: Push the back of your knee into the bed and hold for 3 seconds

Gluteal squeezes: Clench your buttocks together for 3 seconds

Hip and knee flexion

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Bridging with arms

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ACUTE PHASE AT HOME

At home youll be able to do most activities you are used to but it is important to allow some extra time
for each activity as well as rest time if you are feeling tired. As general principles, dont let your operated
hip bend more than 90, twist inwards or cross your midline to reduce risk of dislocation. Keep the
following activity modifications in mind for you own safety and recovery.

Sitting

Choose tall chairs with arm rests which can be used to assist getting in and out.
Make sure that your feet and knees are parallel and pointing forwards (avoid crossing legs or feet).
To get into a car seat, sit on your bottom first and then lift in your legs ensuring that the operated leg
does not cross your midline.
Do not sit for longer than 1 hour before having a stretch and small walk to prevent stiffness.

Standing

It is usually safe to put all of your weight through your hip after it has been operated straight away
but check this with your surgeon or physiotherapist and only do what you feel comfortable with.
Aim for a symmetrical posture with even weight bearing through your legs.
Keep feet and knees parallel and facing forwards.
Contract your buttock and stomach muscles to keep your trunk tall and straight.

Walking

You will probably use a frame, crutches or a walking stick to help you walk initially and your
physiotherapist will teach the appropriate technique for you.
Try to take even steps and contract your buttock muscles when your foot makes contact with the
ground.
When turning around, turn away from the operated side to make sure that the operated leg doesnt
turn in.

Steps and stairs

A saying often used in physiotherapy to remember the order of steps when walking up or down stairs is
good leg to heaven, bad leg to hell. In practice this translates to:
Walking frame going up:
Frame
Good leg
Bad leg
Walking frame going down:
Frame
Bad leg
Good leg
Crutches or walking stick going up:
Good leg
Bad leg and crutches/walking stick together
Crutches or walking stick going down:
Crutches/walking stick
Bad leg
Good leg

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Personal care

When showering you can sit in a tall plastic chair for extra support if you feel unsteady.
When toileting you may need to use a seat raise so that you hip doesnt bend more than 90. Use
sitting principles when going to the toilet.
When dressing put the clothing on the operated leg first.
Ask for assistance or use shoe horns to put on socks and shoes where possible.

Sleeping

It is important to sleep on your back and use a pillow to divide your legs (similar to the Charnley
pillow used in hospital).
Additional pillows can be placed around your operated leg to prevent it turning inwards or outwards
while you sleep.
Enter or exit the bed on either side as long as your leg doesnt cross the midline. This is easier to
achieve by entering or exiting on the opposite side to your operated leg.

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EARLY OUTPATIENT PHASE (WEEKS 2 to 6)

Goals

Increase confidence in walking with less reliance on your frame, crutches or walking stick.
Be able to bend your hip to 90
Be able to move your leg to the side and backward while keeping your trunk and pelvis fixed and
controlled.

What to do

Continue to wear the TED stockings until then end of the 6 week period.
Continue to lie on your back while sleeping.
Make sure that your leg doesnt turn in or cross your midline. This means not crossing your legs and
keeping feet and knees pointing forwards when sitting, standing or bending over.

Exercises
These exercises are a progression of the ones done in the first week. Do this session twice daily.

Hip and knee flexion: Slide your heel towards your bottom until you begin to feel pain. Hold for 10
seconds and repeat 10 times. Ensure that your knee doesnt tilt inwards or outwards.

Hip abduction: Laying on your back, rest your hands on your hips. Tighten your stomach and buttock
muscles and slide your leg out to the side, making sure that that you keep your trunk and pelvis still.
Slide your leg back to the centre but do not cross the midline. Repeat 10 times.

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Bridging without arms: Lying on your back with your knees slightly bent up, have your arms rest on
your chest. Work your buttocks to lift your hips off of the bed and hold for 3 seconds. Repeat 5 times.

Quadriceps stretch in side lie: Lay on your good side with a pillow in between your legs. Have your
operated leg straight and bend you knee back with a strap tied around your ankle. Hold the stretch for
30 seconds and repeat 3 times.

Hip extension on your stomach with knee flexion: Have a pillow under your stomach and contract
your stomach and buttocks to hold your trunk still. With your knee slightly bent, contract your thigh to
slightly lift it off of the bed. Hold for 2 seconds and repeat 5 times.

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Hip extension (standing): While holding onto a surface (such as a kitchen bench) contract your
stomach and buttock muscles. Move your operated leg diagonally backwards so that it is behind you
and slightly out to the side. Make sure that your trunk and pelvis are controlled and still. Hold for 3
seconds and repeat 10 times.

Calf stretch over step: While holding onto a surface (such as a kitchen bench) have the balls of your
feet on a step or phonebook. Drop your heels down and tuck in your bottom so that you feel a stretch
in your calves. Hold this for 30 seconds and repeat 3 times.

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Weight transfer in lunge: Stand with your operated leg in front and knee slightly bent, put most of
your weight through your operated leg. Check that your hips and shoulders arent twisted or tilted and
that your belly button is directly in line with your big toe. Hold this position for 5 seconds and then
step forward with your good leg. Repeat this step 5 times.

Sit to stand: Shuffle your bottom to the front of your chair and tuck your feet under. Lean forward
and use your buttock muscles to lift yourself off of the chair (use your hands to help push if necessary
at first). To sit down again, focus on lowering slowly with control and symmetry.

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HYDROTHERAPY PROGRAM
Hydrotherapy is an excellent option for strengthening muscles. It is particularly useful soon after the
operation as weight through the leg can be controlled and there is a low fall risk. A hydrotherapy program
is usually started about 3 weeks after surgery. See your physiotherapist to check how much exercise is
appropriate for you.
Warm up:
Walking forwards, sideways and backwards, 2 laps each.
By the edge of the pool to hold on:
Marching on the spot, 20 steps.

Bringing your heel to your bottom, 20 times.

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Forward and backward pendular swings (floating your leg up in front of you and then swinging it in a
backward direction as far as you can manage) 20 times.

Sideward leg swings (lift your leg out to the side trying to keep your trunk still) 20 times.

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Squats, 10 times.

By the steps:
Step up leading with operated leg and step down leading with non operated leg (this is the opposite to
the stepping order on land), 20 steps.

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With a floating cuff:

Attach the floating cuff to your operated foot to assist with these stretches.
Quadriceps stretch: stand tall and bend the knee of your operated leg behind you until you feel a
stretch in the front of your thigh. Hold for 30 seconds and repeat twice more.

Hamstring stretch: stand tall and raise your operated leg straight in front of you while keeping your
trunk straight. Feel the stretch at the back of your thigh or in your knee and hold for 30 seconds and
repeat twice more.

Cool down:
Walking forwards, sideways and backwards, 2 laps each.

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LATE OUTPATIENT PHASE (WEEKS 6 to 12)

Goals

Be able to walk confidently without using a walking aid

Be able to bend your hip more than 90
Have the same strength in hip muscles as pre-surgery

Exercises
The previous exercises should be continued but may be progressed as suggested below. Perform the
session twice daily.

Bridging without arms: Lying on your back with your knees slightly bent up, have your arms rest on
your chest. Work your buttocks to lift your bottom off of the bed and also lift your toes up. To
progress one step further, lift your bottom and raise your good leg and hold for 3 seconds. Repeat 5
times.

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Hip extension (standing): While holding onto a surface (such as a kitchen bench) contract your
stomach and buttock muscles. Move your operated leg straight backwards with your foot slightly
turned in. Make sure that your trunk and pelvis are controlled and still. Hold for 3 seconds and repeat
10 times.

Hip abduction in side lie: Lay on your good side with a pillow between your legs. Straighten your
operated leg and lift it slightly off of the pillow without letting your leg turn in or out. Hold for 2
seconds and repeat 10 times.

Hip rotation in side lie: Lay on your good side with a pillow between your legs and your knees bent
approximately 60. Keep your ankles touching and lift your knee like a clam shell but keep your trunk
still. Repeat 5 times.

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Balancing on one leg: Standing while holding onto supports (for example, chairs either side) shift your
weight over to your operated leg and lift your good leg up. When you feel confident, lift your hands
one at a time and count how long you can hold it. Continue daily until you can hold your balance for
more than 20 seconds.

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RETURN TO NORMAL ACTIVITIES

It is expected that it would take at least 3 months to have a complete recovery following a total hip
replacement.
When you have fully recovered you can expect to be able to do everything you did before the operation
and possibly even more without the limitations of arthritic pain.

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SUMMARY
In summary, total hip replacements are a common surgery which has very good outcomes for arthritic hips
and hips injured in falls. There are two main reconstruction techniques and each surgeon has their own
preference.
Early rehabilitation will gently increase hip strength and range of motion but there is a need avoid
positions which may dislocate the hip. There are several activity modifications to facilitate the smooth
recovery of your hip. Rehabilitation progresses to make the hip and trunk have control in more challenging
activities and works towards returning to normal activities independently.
Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist.
All the best for a speedy recovery,
W&L team

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CONTACT US
Wellness & Lifestyles Australia
2/59 Fullarton Road, Kent Town SA 5067
P: +61 08 8331 3000
F: +61 08 8331 3002
E: contact@wellnesslifestyles.com.au
W: www.wellnesslifestyles.com.au www.wleducation.com.au
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