When hip pain is no longer successfully managed with more conservative approaches or causes disability, a total hip replacement (THR) surgery may be recommended. For many people, hip replacement surgery greatly reduces pain associated with hip osteoarthritis and improves quality of life. The University of Washington states that 10-year success rates for hip replacement surgeries are greater than 90 percent following THR (Department of Orthopaedics and Sports Medicine; University of Washington; 2015; www.orthop.washington.edu).
It is important to recognize that if a participant is joining your class following a hip replacement surgery, he or she likely has been cleared for physical activity. Most physical precautions and movement contraindications that are provided to a patient are up to three months following surgery, but some can be as long as a year. The type of hip replacement surgery and overseeing physician will dictate the limitations that should be adhered to following the procedure. The participant has the responsibility of following his or her doctor’s directions and working within appropriate limits.
Total hip replacement (THR) is one of the most common surgical procedures performed in the United States. Other types of hip replacement surgeries are partial hip replacement and hip resurfacing.
A partial hip replacement involves only half of the joint and includes replacing the ball portion of the joint, but not the socket portion. This procedure is more commonly seen in patients that have had a hip fracture.
Hip resurfacing is more common in younger, more active patients. This procedure involves resurfacing or reshaping just the head portion of the femur with a shell or a cap and does not require a long metal stem or socket replacement like total hip replacement. Hip resurfacing often gives the patient more time before having to replace the entire joint.
In a total hip replacement, the diseased cartilage and bone of the hip joint is replaced with artificial materials. The procedure involves surgical removal of the diseased ball (femur head) and socket (acetabulum) and replacing them with a metal, ceramic, or plastic ball and stem inserted in the femur bone and a metal, plastic, or ceramic cup socket. The prosthesis is inserted into the central core of the femur and fixed with either bony “cement” or a “cement-less” prosthesis. The surgeon decides what to use based on his or her own preference as well as the patient’s medical history.
Total Hip Replacement Surgical Procedures
There are three main surgical procedures used for total hip replacement. While it is beyond the scope of practice for a group fitness instructor to design a specific exercise program for a class participant based on each procedure, having a working understanding can increase your awareness of the types of limitations that may have been provided by the participant’s doctor, allowing you to provide more appropriate exercise variations.
1) In the posterior lateral approach an incision is made in the hip external rotators, with an incision between the gluteus maximus and medius. Because this technique makes the hip more susceptible to posterior dislocation, surgeons generally recommend the following movements be avoided:
- Hip flexion greater than 90 degrees
- Hip adduction past the midline of the body
- Hip internal rotation past neutral
Instructor safety tip: Cue for a moderate degree of forward flexion in a seated position
2) In the anterior lateral approach, the incision cuts through the gluteus maximus, minimus, and tensor fasciae latae, primarily affecting the hip abductors. General movement restrictions for this approach are:
- Combined hip external rotation and flexion
- Hip adduction past the midline of the body
- Hip internal rotation beyond neutral
Instructor safety tip: Seated pigeon pose or figure four pose, with foot on top of opposite thigh, may be inappropriate for a class participant post-hip replacement surgery
3) The interior approach uses an anterior incision between the tensor fasciae latae and sartorius; therefore, it does not violate the hip external rotators and abductors. The two general movement contraindications following this procedure are:
- Hyperextension of the hip
- Extreme hip external rotation
These precautions differ from surgeon to surgeon. Some participants may be guided to follow the movement limitations up to a year following their surgery while others may be given no movement limitations and have clearance for activity within a few weeks of the surgery. The group fitness instructor should first guide participants to use common sense and follow all doctor’s recommendations, then provide safe options for each exercise.
Post-Surgery Recommendations
After a patient returns home, physical therapy is often recommended. This could be done either at home or at an outpatient location. Depending on the surgical approach used, therapy could begin immediately or up to six weeks following the surgery. While there are many factors that influence if and how much physical therapy is provided, physical therapy generally lasts for one month, two to three times a week. Patients are usually given a set of exercises that can be done between physical therapy sessions.
The goal of a total hip replacement surgery is to return the patient to a good level of function without hip pain. Those who choose to participate in SilverSneakers signature classes and approved FLEX classes will benefit from having options in the programmed exercises to help them build strength, improve balance, and restore function.