Page 6 P H Y S I O T H E R A P Y March, 1969 Physiotherapy Following Total Hip Replacement THE M cK E E -F A R R A R PR O ST H ESIS By JO A N W A L K E R , M .N .Z .S .P ., D ip .T .P ., Lecturer Sub-D epartm ent o f Physiotherapy, U niversity o f the Witwatersrand, in co-operation with M iss M. von B R IT Z K E , Phyiotherapist, Colin G ord on H ospital, Johannesburg This article is an account o f the routine as fo llo w e d a t the Colin Gordon H ospital, advocated b y M r. S. Sacks, F .R .C .S ., O rthopaedic Surgeon. Purpose of Operation; T o correct deformity, relieve pain and to improve function. Pre-Operative Condition o f the Patient This varies with the condition present on which the decision to perform the operation was made. This is covered in the article in this issue by Mr. S. Sacks. This procedure is com m on ly carried ou t in osteoarthritis where a consider­ able pain factor is present. In these cases Mr. Sacks con ­ siders the presence o f pain to negate the value o f pre- operative physiotherapy to strengthen the m uscles round the hip, even if the exercises are given statically. For this reason the majority o f patients who have, up to date, received this operation at the C olin G ordon have not received pre­ operative physiotherapy, either as an out-patient, or as an in-patient. In conditions, where pain is not a main sym ptom , routine pre-operative exercises are given, to strengthen the hip abductors and extensors, to acquaint the patient with the post-operative routine and what will be expected o f him, to teach correct use o f canes. General Post-Operative Routine The patient returns to the ward with the legs tied together to prevent the risk o f dislocation. The legs are untied when the patient is conscious and co-operative. The patients are encouraged to sleep as flat as possible and from the second post-operative day to spend gradually longer periods in prone at least twice a day. Sitting over the side o f the bed, or in a ward arm chair is permitted from the third to fourth post-operative day provided the prosthesis is stable, but sitting is not en ­ couraged until the 10th post-operative day. X-rays are taken o n the 3rd or 4th post-operative day to confirm the p osition o f the prosthesis and if satisfactory gait training is com m enced from this time. T w o canes are used, how ever a walking frame m ay be used for the first couple o f days if the patient is elderly and very nervous, to gain m ore confidence. Crutches are not used. It is con ­ sidered that the use o f crutches has a p oor psychological effect o n the patient’s attitude to his condition. The stitches are rem oved usually on the 12th post-opera­ tive day and the patient com m on ly discharged on the 14th post-operative day. Stair training is com m enced on the 10th post-operative day, at first using on e rail one cane, but quickly progressed to tw o canes. Patients should be able to ascend and descend stairs by the day o f discharge. In certain patients a slower rate o f progress m ay be seen. Because this procedure is a m uscle split, m uscles are not divided unless, for instance a hip flexion contracture is corrected, the am ount o f physiotherapy necessary in the majority o f patients is m inim al and therefore out-patient physiotherapy is not given routinely. Certain patients, with poor pre-operative condition, continued gait problems m ay how ever require further physiotherapy as an out­ patient. D E T A IL O F T H E P H Y S IO T H E R A P Y P R O G R A M M E Pre-Operative Routine A s stated previously this is n o t routinely given, an addi­ tional factor being that the majority o f patients to date have been adm itted o n Saturday and operated on, on M onday. W hen the patient is adm itted for several days prior to surgery the follow in g routine is given. 1. D eep breathing, stressing lateral costal and diaphrag­ matic is taught and an efficient cough established. 2. Strong full range dorsi— and plantar-flexion o f the ankle is taught and stressed. 3. The post-operative gait pattern, using tw o canes is dem onstrated and taught where possible. 4. Static contractions taught for the quadriceps, hip extensors and abductors. A full assessm ent has been com pleted previously in the! hip clinic, see Chart, however the therapist w ill assess each patient, enabling her to have a guide to the improvement gained by the operation. This assessm ent will include functional ability; use, type and number o f walking aids; distance capable o f walking; type o f gait pattern; lumbar spine, hip, knee and ankle joint range, m uscle strength abou t the hip and knee. In particular she will exam ine for the presence o f a G luteus M edius limp and flexion con ­ tracture (which will be corrected routinely during the opera­ tion if present). Post-O perative Routine H ip flexion is not stressed, nor lateral rotation. (Surgeons w ho use an anterior approach tend to stress hip flexion, particularly a high stepping gait.) D a y 1: 1. deep breathing, diaphragmatic and lateral costal, with coughing 2. strong ankle dorsi- and plantarflexion 3. static contractions are given to the quadriceps, hip extensors and hip abductors. This is repeated during the day as m any times as the patient’s condition demands. D a y 2: as above plus 4. prone lying: assisted hip extension 5. side lying: assisted hip abduction in as much extension as possible and avoiding inner range o f adduction 6. lying: assisted hip abduction with medial rotation j 7. lying: with 1-2 pillow s under the knee: K n e e l extension. Assistance is given by the therapist how ever su s­ pension or a re-education board m ay be used. D a y 3: as above, decreasing the assistance to hip m ove­ m ents and increasing periods m orning and after­ n oon when the patient lies in prone. X -rays are taken and if the position is satisfactory, the patient m ay com m ence weight-bearing. D a y 4: continue exercises 4 to 7, decreasing assistance, adding m anual resistance. 8. U se o f diagonal patterns m ay be com m enced, em phasizing Ext. A bd. M ed. R o t., pattern. 9. Standing, with support and with the use o f a lon g mirror for posture retraining: standing balance, weight transference, resisted forward pelvic thrust (to encourage hip extension) and raising up on to toes (to establish c a lf m uscle action for normal heel-toe gait pattern are practised. 10. Standing on on e leg (with support): lateral pelvic tilt to the weight-bearing side practised, to elim inate a gluteus m edius limp. 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. ) March, 1969 P H Y S I O T H E R A P Y Page 7 11. G ait training is com m enced, com m only with tw o canes, possibly with a walking frame, p a y 5 -1 0 : Exercises 4-11 continued, adding resistance, springs m ay be used. A straight leg raise should be accom plished on the 5th day. The patient is walked, on an average, 4 times a day, progressing the distance (this varies with individual age and physical condition). The patient should be lying in prone, for at least 20 m inutes, m orning and afternoon. G eneral m aintenance exercises for back extensors, abdom inals m ay be added to the programme. D ay 10: Stair training is com m enced, as described previously, on the 10th day, and practise given in turning, toilet and slopes if available. The patient practises changing from sitting to standing to exercise extensor m uscle groups, flexion is still not stressed. H O M E P R O G R A M M E A simple list o f exercises is given, depending on the patient’s mental ability. 1. prone lying: hip extension (with straight and flexed knee) 2. „ „ hip extension with abduction and medial rotation 3. side lying: hip abduction with m edial rotation, under leg well flexed and hip kept in as much exten sion as possible. 4. standing: raising pelvis laterally and balancing o n the operative side, without trunk sway 5. „ raising body weight up on toes, lowering slow ly. Instructions are given to: sleep flat o n a firm mattress, practise walking daily, avoiding turning the fo o t out or sw aying the trunk and TO U S E BO TH C A N E S for further SIX W EEK S. Excessive exercise, or any jarring m ovem ents should be avoided, sw im m ing can be encouraged. Average L evel o f Function at Discharge: The hip m uscles can be graded Grade 3 and the patient com m on ly has a hip flexion o f 90 per cent which allow s him to sit in a chair but not to do up his sh oe laces or attend to his foot toilet. H e walks o n the level with two canes, use o f which will be continued for six weeks, can ascend and descend stairs with a variable degree o f confidence, can manage the toilet but requires assistance in getting on to the high hospital beds. X-rays are taken before discharge, com m only 14th day, and repeated in on e year’s time provided no com plications have arisen. The patient attends the hip clinic six weeks after discharge, then at six weeks after that, then at three-monthly intervals for one year, and follow in g that at six-m onthly intervals. Later Functional Ability: M ost patients are able to do up their shoe laces and attend to their foot toilet. At 15 m onths the majority o f patients have discontinued use o f any walking aids. Prior to this use o f one cane when walking outside, on rough ground, in crowds is encouraged, more as a restraint to overactive use o f the new joint. In conclusion, the majority o f patients w ho have received the M cKee-Farrar prosthesis achieve a g ood functional result with the above in-patient physiotherapy and in con ­ tinuing, at hom e, a certain number o f exercises, so that further out-patient physiotherapy is considered not neces­ sary, or indicated. The patient m ust gradually “wear in” his new hip, in the sam e manner a car is “ run in” . A C K N O W L E D G E M E N T S The author w ould like to thank Mr. S. Sacks for his willing assistance in the preparation o f this article. R E F E R E N C E S M cK ee, G . K. and W atson Farrar, J. (1966). Replacem ent o f Arthritic H ips by the M cKee-Farrar Prosthesis. J. Bone Jt. Surg., 48B, 245. M cK ee, G . K . (1967). R eplacem ent Hip Surgery, Nursing Times, 63, 984. M cK ee, G . K. (1967). Total Prosthetic R eplacem ent o f the H ip, Physiotherapy, 53, 412. Graveling, B. M. (1967). Physiotherapy for R eplacem ent o f Arthritic H ips by the M cK ee-Farrar Prosthesis, P h ysio­ therapy, 53, 416. HIP A S SE SSM E N T F O R M JO H A N N E S B U R G G E N E R A L H O SPITA L With the kind perm ission o f M r . S . S acks, O rthorpaedic Surgeon. D ate: N am e: E tiology: N um ber: Unilateral or B ilateral: A g e : 1. P A IN : G rading (a) N o n e or negligible. (b) N oticeab le but insufficient to limit activities. (c) Sufficient to limit work and activities. Requires regular analgesics. (d ) Crippling pain, preventing work and activities. Pain at rest in bed. 2. F U N C T IO N A L A C TIVITY: A c tiv ity (a) Limp Y es ............................................... N o ............................................... (b) Trendelenburg test Positive ...................................... N egative ...................................... (c) W alking outside Unaided ...................................... One stick ...................................... Tw o s t i c k s ...................................... Crutches ...................................... (d) D istance walked One m ile + ...................................... i m i l e ............................................... 100 yards ...................................... N o t at all ...................................... (e) Com pletely bedridden .................... ( / ) Putting on sh oe and sock Yes .................................. With difficulty ............................. N o ............................................... (g ) Climbing stairs Yes ............................................... With difficulty ............................. N o ............................................... (h) Sitting A n y chair ...................................... High c h a i r ...................................... Special chair only .................... (/) Capacity for work Fit for norm al em ploym ent Fit for light work .................... Totally unfit for work M O B IL IT Y : R ight Left F lexion deformity ...................................... Further f l e x i o n ............................................... E xtension ........................................................ A b d u c t i o n ........................................................ A d d u c t i o n ........................................................ Internal R otation ...................................... External R otation ............................. . N ote: (Leg Length, Other D iseases, Previous Treatment, R ecom m ended Treatment, C om plications on the reverse side o f this sheet.) 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. )