Hip arthroplasty — anterior approach: rehabilitation protocol

Who is this for?

Adults following primary elective total hip arthroplasty through the direct anterior approach (DAA), with a typical postoperative course. The programme does not automatically apply to revision surgery, hemiarthroplasty, treatment of an acute fracture, an intraoperative fracture or additional bone or muscle reconstruction. Nor is it a protocol for every variant of the anterolateral approach.

Protection after the anterior approach

Early on, avoid forced hip extension, especially combined with external rotation. This includes taking the operated leg far backwards, deep lunges and suddenly opening the hip backwards. Do not force a long stride or stretch the front of the hip. Turn with small steps instead of twisting the trunk over a planted foot.²

The posters show precautions during the first 6 weeks. This is not an identical set of restrictions for all patients. If the orthopaedic surgeon has prescribed a different scope or duration of protection, the individual plan applies. The end of week six does not itself authorise unrestricted movement; increase the range gradually once restrictions have ended.²

Do not automatically apply posterior-approach restrictions. The anterior approach alone does not justify imposing a 90° flexion limit on every patient. Tailor flexion to the instructions and tolerance, without forcing through groin pain.

Weight-bearing is a separate decision

Weight-bearing follows the discharge instructions. If weight-bearing as tolerated is permitted, the patient can gradually transfer weight onto the operated leg using a frame or crutches. Where a limit is prescribed, it also applies when walking is painless. Permission to bear weight while walking does not mean permission for every movement or any strengthening exercise.

Information is needed about implant stability, tissue condition, any additional repairs, intraoperative events and planned follow-up. Clarify missing details with the surgeon.

Phase I — day of surgery to discharge

Mobilisation starts on the day of surgery if the clinical condition allows, generally within the first 24 hours. First standing and walking are supervised after assessing limb control and tolerance of position changes.¹

Teach moving from lying to sitting, standing up, walking, turning and sitting down. Use a stable chair and calm movements, without suddenly moving the operated leg backwards. Introduce ankle pumps and gentle gluteal and quadriceps sets. Practise stairs before discharge if they will be needed at home.²

Goal: safe basic activities with appropriate assistance, understanding the instructions and preparing to return home. Dizziness, faintness or insufficient limb control are reasons to stop the attempt.

Phase II — the first 2 weeks

Alternate short walks around the home and the exercises learned with rest. Monitor the wound, pain, swelling and tolerance of daily activities. Initially, steady walking without an increasing limp matters more than distance.²

The early exercise set may include ankle pumps, gluteal and quadriceps sets, and heel slides with hip flexion within the permitted, comfortable range. The 3–5 short daily sessions illustrated do not mean that every exercise must be performed that frequently. The dose follows the physiotherapist’s individual instructions.

Goal: increasing independence in basic activities and correct performance of selected exercises. Do not try to exercise through wound deterioration or sudden pain.

Phase III — approximately weeks 2–6

Gradually increase walking distances, improve pelvic control and practise balance with support. Continue avoiding excessive extension and sudden opening of the hip. Do not add resistance to a movement that increases groin or anterior thigh pain.²

Progression from two crutches to one depends on gait quality, balance and permitted weight-bearing. A single crutch or stick is usually held opposite the operated hip. Do not abandon walking aids at the cost of a pronounced limp; resume support if it returns.³

Goal: greater independence and an improved gait pattern. The timing of stopping crutches is not the same for every patient.

Phase IV — approximately weeks 6–12

After assessing healing and updating instructions, gradually increase exercise range and difficulty. Develop gluteal strength, pelvic control, balance and walking endurance. Examples include chair rises, supported mini-squats, low step-ups and movement against light resistance. Introduce a stationary bicycle once permitted, with appropriate adjustment and without painfully forcing the hip.²

Increase extension through a small, controlled range without arching the lower back. Do not start with deep lunges or aggressive stretching. Persistent groin pain or deteriorating movement control call for load adjustment and assessment, rather than extra repetitions.

Goal: greater independence, more efficient walking, better limb control and tolerance of selected strengthening exercises. Achieve phase goals gradually, rather than at any cost.

Phase V — from approximately week 12

Move the programme towards activities needed for work and recreation. Develop strength, endurance, balance and tolerance of longer walks. Low-impact activities such as walking and cycling are preferred. Swimming and water exercises may begin once the wound is fully healed and the activity is permitted. Contact sports, running and jumping require an individual decision.⁴

Increase exercise intensity gradually. Starting this phase does not authorise unrestricted loading. Readiness also depends on gait quality, pelvic control, exercise tolerance and the type of activity planned.