Page 4 P H Y S I O T H E R A P Y December, 1966 Post-operative Management of Hips By J . A. C. P R IN S L O O , B.Sc.(Physio)(Rand) G EN ERA L T R EA TM EN T 1. W herever possible, it is o f prim e im portance to treat patients pre-operatively. T each the specific exercises for the hip, as well as general m aintenance exercises. M ake sure the patient know s exactly how and why the exercises are to be done. 2. Especially in patients in the older age group (and the greater m ajority fall in this group) or th a t suffer from chronic chest com plaints, teach localised an d deep breathing exercises a n d m ake sure th a t coughing is efficient. D eep breathing exercises will also aid venous retu rn , which is o f im portance im mediately after th e operation. 3. Explain to the patient the im portance o f regular and purposeful exercise in the early post-operative stage, as tim e and recovery lost during this stage can never be made up at a later stage. 4. T each pro p er relaxation and rest after exercises as the muscles will tire an d overtire easily in th e early stages and this can give rise to several o f the complications. 5. Em phasise th e im portance o f doing the exercises at regular intervals during th e day in order to m aintain and even increase mobility an d to build up strength and en d u r­ ance in the muscles. Muscle function and strength recover quickly, but endurance slower. T hus progressive, purposeful exercises done regularly w ithin reasonable limits o f pain and com fort will give th e best results. T he recovery o f o ther soft tissues involved in th e operation, e.g. skin, bloodvessels, fascia, etc., will parallel the recovery o f muscle in o rder to comply w ith th e progressively increased physiological dem ands m ade by increased function and activity. Delay in recovery may be due t o : 1. Sitting, standing or lying to o long in one position. 2. A n inconsistent and irregular rehabilitation program m e. 3. Overactivity w ith resultant excessive fatigue, e.g. to com pensate fo r earlier negligence. 4. W rong use o f crutches, especially “ sw ing-through” gait instead o f “ walking” to sim ulate norm al gait. 5. A buse o f th e operated h ip by w eightbearing to o soon, i.e. pain an d limping on w eightbearing are indications th a t th e hip m ust still be protected by the use o f crutches. 6. L im itation o f m ovem ent due to pain which can in turn be due to : (a) congestion an d oedema. (b) haem atom a. (c) infection. (d ) ossification. O P E R A T IO N S O F T H E H IP T he following are the m ost com m on hip operations per­ form ed in m ost orthopaedic units. T h e Sm ith-Petersen cup arthroplasty an d the subsequent physiotherapy treatm ent will be described in detail, whilst variations from this in the o th er operations will be m entioned, b o th in technique and physiotherapy treatm ent. A . A R T H O PL A S T Y 1. Smith-Petersen Cup: In this operation a m etal cup is interposed between the acetabulum an d fem oral head after resection o f bony and soft tissue overgrow th an d tight an d contracted muscles have been cut a n d /o r re-attached, in o rder to re-establish sm ooth m ovem ent o f the hip. {a) Incision: T he anterior approach is used. T he skin incision starts 2 \ in. above the anterior superior iliac spine, along the iliac crest to the antero-lateral aspect o f the thigh, 2 in. below the level o f the pubis to an interval between sartorius and tensor fasciae latae. I t is extended poster­ iorly and distally to the iliotibial band when a trochan­ teric transplant is necessary. (6) Muscles Cut: 1. Origin o f sartorius. 2. T he iliotibial band when it is very tight. 3. I f no greater trochanteric transplant is necessary, gluteus minim us is cut at its insertion and retracted. 4. I f there is a m arked flexion contracture, iliopsoas is cut from its insertion for later re-attachm ent. This is done once the capsule has been cut. 5. In the case o f a n abduction contracture, an osteotom y o f the greater trochanter is done in line w ith the superior surface o f the fem oral neck. 6 . T h e sh o rt external ro ta to rs are cut from their insertion into the trochanteric fossa if there is diffi­ culty w ith the dislocation o f th e hip. (c) Dislocation of the Hip: 1. U sually a circumferential incision o f th e capsule is done, although it is sometimes necessary, and even custom ary these days, to do a com plete capsulotom y. I t has been found on post-operative follow-up that rem nants o f th e capsule tend to ossify an d limit m ovem ent, thus it is believed th a t the m ore radical the capsulotom y, the better the result. 2. T he anterior portion o f th e acetabulum is osteo- tom ised o r an osteotom y done along the old joint line in the case o f bony ankylosis. 3. T he hip is gently dislocated by means o f adducation, external ro tatio n and extension. 4. T he fem oral head is reshaped w ith a ream er to healthy bleeding bone. T h e acetabulum is then ream ed to the desired shape, i.e. until full range passive hip movem ents are possible w ith th e ream er still in place. (d) Closure: 1. T h e w ound is debrided, washed w ith physiologic saline an d bone an d soft tissue fragm ents removed by means o f suction. T he metal cup is carefully placed in position and th e fem oral head relocated. 2. Incorrect muscle pull is im proved as follows: (i) Iliopsoas is transplanted forw ard into the distal p a rt o f the hip jo in t capsule. T hus th e pull will be directly across th e hip w ith a resultant increase in stability and correction o f external ro tatio n deformity. (ii) I f th e fem oral neck is shortened, the greater trochanter an d the abductors attached to it are transplanted m ore distally on th e lateral aspect o f the fem ur. I t is wired w ith the hip in abduc­ tion as screws tend to pull out. 3. T ension on the w ound is avoided by means o f bony resection o f th e acetabular rim, where necessary. (e) Traction: 1. 5 to 7 lbs. are enough to overcome muscle spasm a n d it is put o n while the patient is still anaesthetised. 2. T h e hip is kept in slight flexion, m oderate abduction, neutral o r slight internal ro tatio n and the knee is slightly flexed. 3. T he patient is treated in traction fo r 3 to 4 weeks. T h e following are som e o f the other hip operations, variations in the approach to th e jo in t and thus muscles cut and th e subsequent post-operative rehabilitating. 1. Moore’s and Thompson’s Prostheses: These consist o f the rem oval o f the fem oral head which is then replaced by a prosthesis which is driven in to the shaft o f the fem ur. T h e postero-lateral approach, usually the G ibson m odification, is used. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pecember, 1966 P H Y S I O T H E R A P Y Page 5 ANTERIOR APPROACH LATERAL APPROACH POSTERO-LATERAL APPROACH R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 (а) Incision: . . . Patient is in the lateral position. Proxim ally the incision starts 2} in. to 3 in. anterior to the posterior superior iliac spine and ju st distal to the iliac crest, over the anterior border o f gluteus maximus and then distally to the anterior edge o f the greater trochanter and along the line o f the femur for 6 in. to 7 in. (б) Muscles Cut: 1. T he iliotibial band is incised in line w ith its fibres, from the distal end o f th e incision and proxim ally to the greater trochanter. T he thigh is abducted and the incision extended proxim ally along the sulcus at the anterior border o f gluteus maximus. 2. G luteus m edius an d —m inim us are nicked or even divided at their insertion, but enough tendon left for suture at the closure. (c) Dislocation: T he capsule is incised superiorly along the axis o f the fem oral neck, along the jo in t line anteriorly and along the anterior intertrochanteric line anteriorly and along the anterior intertrochanteric line laterally. T he hip is dis­ located by flexion o f the hip and knee, abduction and external ro tatio n o f the hip. (d) Closure: . T he muscles are re-attached by means o f interrupted sutures. Sometimes the greater trochanter with all itsattached muscles is osteotom ised and then re-attached by m eans o f tw o wire loops. (e) Physiotherapy: These patients are not treated in tractio n and are usually allowed partial w eightbearing after 10 to 14 days. M obilisa­ tio n o f the hip in side lying is started after 4 to 5 days and in prone after 7 to 8 days. One would avoid internal ro tatio n or adduction o f the hip in association with flexion fo r 3 to 6 weeks, depending on th e extent o f the muscles cut an d the speed o f recovery. Once m ore the criteria o f this as well as th e indications fo r full weightbearing am bulation, are full range and controlled painless movem ents o f the hip. 2. Total Replacement Prosthesis: T his is also know n as the McKee-Farror prosthesis and consists o f the replacem ent o f the fem oral head with a prosthesis, as well as a prosthetic cup fitted to the aceta­ bulum by m eans o f cement. F o r this the lateral approach o r so-called U -incision is used. (а) Incision: I t starts at th e anterior superior iliac spine, goes distally to the greater trochanter, then curves posteriorly across the fem ur. F rom there it curves posteriorly an d proxim ally to end halfway between the greater trochanter and the posterior superior iliac spine. (б) Muscles Cut: 1. A n osteotom y o f the greater tro ch an ter is done and it is reflected up w ith piriform is, gemelli and gluteal muscles still attached. 2. G luteus m aximus is separated along the posterior limb o f the skin incision and reflected. 3. Sometim es vastus lateralis is cut at its origin from the greater troch anter and along the linea aspera. (c) Dislocation: T he capsule is cut longitudinally along the superior surface o f the fem oral neck both anteriorly and posteriorly. T he hip is dislocated by m eans o f flexion o f hip and knee, adduction and internal ro tatio n o f the hip. (d ) Closure: T he greater trochanter is re-attached by means o f two wire loops. (e) Physiotherapy: T he general outline o f rehabilitation is the same as fo r the M oore’s prosthesis. These patients can usually do partial weightbearing after tw o weeks and full weightbearing after five weeks. I t is advisable to avoid any flexion strain on the hip for the first few weeks in these cases. \ B. C O M P R E S S IO N O S T E O T O M Y : Once m ore the approach is usually lateral as described above. Thus vastus lateralis is cut partially, iliopsoas where there is a flexion contracture an d gluteus medius rarely, usually in cases with a difficult approach. A wedge osteotomy is usually done between the level o f the tw o trochanters and a compression plate inserted. These patients do partial weightbearing after ten days and weightbearing to nearly full with the aid of a walking stick after about six weeks. C. P S E U D O -A R T H R O S IS : This is the G irdlestone operation o r variations o f it. This consists mainly o f excision o f the fem oral head at the neck and a valgus osteotom y below th e greater trochanter. This gives rise to a m ore direct line o f weightbearing and a rela­ tively painfree pseudo-arthrosis. Once more th e approach is lateral as above. Usually iliop­ soas is detached from th e lesser trochanter an d re-attached to th e greater trochanter. These patients are treated in traction for 4 to 5 weeks. Physiotherapy: W hilst in traction, it w ould be along th e same lines as for the cup arthroplasty. In the first three weeks after the operation one w ould avoid ro tatio n and extension in ex­ trem es o f range because o f th e transplantation o f iliopsoas. Emphasise mobility, especially o f abduction and internal ro tatio n . Resisted exercises on th e affected hip are usually started after 4 to 6 weeks, depending on the age and con­ dition o f the patient. Full weightbearing is n o t allowed for a t least six m onths. R EH A B ILITA T IO N PR O G R A M M E T he following is a suggested program m e o f exercise and rehabilitation fo r Cup A rthroplasty which can be modified to suit other hip operations. I t has been found th at manually controlled exercises are th e safest and give th e best results in th e early post-operative stages. This way the physiothera­ pist can gauge an d control passive range o f movem ent as well as the am ount o f assistance necessary, or resistance th at can be tolerated, in the case o f isotonic contractions. One w ould start with isolated movem ents especially o f the hip, i.e. pure flexion, extension etc. and progress to P.N .F. patterns after a week to te n days, o n th e affected sid e.' P .N .F . can be given to the uninvolved leg and arm s. Sling suspension is useful to build up endurance and m aintain mobility once th e patient has enough muscle pow er to control the hip joint. Pre-operative training for 2 to 3 days if possible. 1. Breathing exercises and coughing. 2. F o o t exercises for “ pum ping” action. 3. Static quadriceps contractions. 4. Teach full range hip movements, as well as static con­ tractions o f muscles expected to be cut. 5. G eneral tru n k and arm exercises. Post-operative: Day 1: Patients are nursed flat for 24 hours, but encouraged to change position often. 1. Breathing exercises and coughing. 2. F o o t movements, m ainly to aid circulation. 3. Static quadriceps contractions. Day 2: 1. A ll the above. T raction weights can be rem oved during th e exercise periods to enable th e biggest range of movement possible. 2. Active rotation, w ithin the limit o f pain and avoiding extremes o f range. 3. A bduction and adduction, first passively by th e physio­ therapist and then actively by the patient with assistance if necessary. A gain this is within the limits o f pain and adduction beyond the midline is avoided. In a rth ro ­ plasty, especially, it is o f prim e im portance to obtain as great a range as possible, first passively and then December, 1966P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) allowing the patient to control it voluntarily, in the early post-operative stage. “ Limit o f pain” has to be judged carefully by the physiotherapist, i.e. there will be a certain am ount o f pain on movem ent im mediately after the operation, so one has to obtain the greatest range possible w ithout causing dam age by excessive force and still take the patient’s pain tolerance into consideration. 4 C o n tra c tio n o f gluteus m ax im u s for h y p e rex ten sio n , i.e. static w o rk w here th e re is tra c tio n but in side lying in o th e r cases. 5 . Use o f arm s for lifting, moving around in bed, etc., and even start simple arm exercises. In the case o f the stronger and more agile patient one can attach springs to the bed for resistive exercises for the arm s an d uninvolved leg. Day 3: 1. All the above, increasing the range and the power, the latter by decreasing assistance or increasing resistance, as the case may be. 2 . Add simple trunk exercises like attem pted o r active “sit-ups” , side flexion and bridging with th e affected leg in extension. Always avoid the com bination o f flexion, adduction and internal ro tatio n as this is the most com m on cause o f dislocation in unstable hips or where muscle pow er is not yet sufficient to control unnatural strains. 3. The patient can sit up in bed if there are no complications and even in a chair, with the d o cto r’s perm ission, where there is no traction. M ake sure the p atient understands the im portance o f avoiding an adduction, internal ro ta ­ tion strain on the hip in the sitting position. 4. Resisted exercises to the uninvolved leg an d the arm s. Day 5: 1. The above, once more increasing the active range and power. 2. Active hip and knee flexion with the traction tem porarily relieved, is started. This can be assisted m anually a t first but aim at free full range movem ent controlled volun­ tarily by the patient as soon as possible. Week 2-4: (simple arthroplasty) Week 2-6: (reconstruction with trochanteric transplant) The patient will be kept in traction for the above length of time, depending on the type o f operation he had. 1. The above exercises are continued, aim ing at the maxi­ mum range an d steadily increasing pow er and endurance in all the muscles by increasing resistance and exercise time to suit the p atient’s tolerance. To encourage and measure progress, patients can be given charts to fill in exercises done, num ber o f times per day, increase in range, etc. Exercises have to be done regularly and purposefully, but with adequate rest in between and relaxation after sessions. 2. The arm s an d unaffected leg m ust be exercised strongly by means o f springs, m anual resistance, etc. 3. Carefully graded resistance can be given to movements o f the operated hip tow ards the end o f th e period o f traction, provided the patient has painfree movement w ith sufficient muscle pow er and especially endurance. After 4-6 weeks: The patient is weaned from traction an d the affected hip exercised in as full a range as possible in preparation for am bulation. 1- G luteus maximus is o f prim e im portance, thus hyper­ extension o f the hip in prone lying is graduated to fully resisted work. 2. H ip adduction and abduction is graduated to side lying with increasing resistance. 3. Static quadriceps and iliopsoas contractions are gradu­ ated to full straight leg raising. 4. Increasing resistance is given to hip and knee flextion. 5. T runk flexion from supine with hands behind head. 6 . T runk hyperextension, lifting head, shoulders and both feet in prone. December, 1966 Page 7 These are the m ost im portant exercises for am bulation as the patient needs good control o f hip extension and abduction, as well as a stable knee and tru n k for successful and functional am bulation. Ambulation: Once the patient can do all the above exercises w ith ease, as well as move from the bed to chair and back w ithout any assistance, am bulation training is started. A n ordinary walking gait is taught, using crutches with the affected leg to ensure partial w eightbearing at first. G radually increase to full weightbearing, then managing stairs. A lim p or unrelieved pain in the hip are always signs o f too early or to o much weightbearing and such a hip should be supported by crutches until the surrounding m usculature is sufficiently strengthened to ensure painless and sm ooth am bulation. Discharge and Follow-up: Once th e patient has sufficient endurance and control of am bulation, he can be discharged with the following instruc­ tions. The patient will be seen by the surgeon at regular intervals and may sometimes come in fo r an additional period o f physiotherapy treatm ent as an out-patient, as the merits o f the case w arrant. 1. Patients have to avoid sitting for periods longer th an an ho u r at first. It is sufficient ju st to stand o r stretch where long periods o f sitting are unavoidable. 2. A n exercise program m e, com patible w ith hom e life is given, once m ore stressing the most im portant muscle groups and keeping it simple. Ideally the patient should have frequent, short sessions with adequate rest in between. 3. Stress th a t exercises should be done to the point o f discom fort only an d that overactivity should be avoided. ACKNOWLEDGEMENT The a u th o r wishes to th an k D r. I. S. de W et o f the O rth o ­ paedic D epartm ent, P retoria for th e help and encouragem ent in the preparation o f this article. A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS Manufacturers and Suppliers of: O R T H O P A E D IC A PPLIA N C E S, A R T IF IC IA L LIM BS, TRU SSE S, SU R G IC A L CORSETS, U R IN A L S , A R C H SU PPO R TS, C O LO STO M Y BELTS, E LA STIC ST O C K IN G S, A N K L E G U A R D S , W R IST G U A R D S , ELBOW G U A R D S , K N E E G U A R D S , L IG H T D U R A L C R U T C H E S F O R C H IL D R E N , W O O D E N C R U T C H E S, A N D M E T A L ELBOW C R U T C H E S. Phone 23-2496 P.O. Box 3412 312 Bree Street, Johannesburg P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )