Hip arthroplasty — posterior approach: rehabilitation protocol

Who is this for?

Adults following primary elective total hip arthroplasty through a posterior or posterolateral approach, 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 muscle or bone reconstruction.

The traditional protective programme

If this programme has been prescribed, during the early period avoid flexion beyond 90°, bringing the thigh across the midline and internal rotation of the operated leg.² Avoiding combinations of these movements³ and pivoting on a planted foot is particularly important. Change direction with small steps instead of turning the trunk over a weight-bearing leg.

The posters show precautions usually lasting for the first 6 weeks.^{2, 3} Individual instructions may specify a different period. The end of week six does not itself authorise stopping precautions; once they are lifted, increase movement gradually. An end-of-phase goal is not a requirement for the first session.

Not everyone needs the same restrictions

A randomised trial involving 1133 patients after primary posterior-approach arthroplasty with capsular repair found no significant difference in dislocation risk between groups with and without routine precautions. This does not mean there is no risk or that patients can stop following instructions themselves. A less restrictive programme must reflect the specific operation.⁴

Weight-bearing is a separate decision

The patient bears weight according to the discharge instructions. Where weight-bearing as tolerated is permitted, a walking frame or crutches are used and loading of the operated leg is increased while maintaining control.^{3, 13} If weight-bearing is restricted, the limit must not be exceeded simply because walking is painless. Permission to bear weight while walking does not mean permission for unrestricted movement or every strengthening exercise.

Information is needed about implant stability, tissue repair, intraoperative events and planned follow-up. Clarify missing details with the orthopaedic surgeon instead of drawing conclusions from the appearance of the scar alone.

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 recovery of limb control and tolerance of position changes.^{1, 9, 10}

Teach moving from lying to sitting, standing up, walking, turning and sitting down.^{1, 9} Choose a stable chair with armrests and a height that allows the prescribed flexion limit to be respected.² Introduce ankle pumps and gentle muscle contractions.⁵ Practise stairs before discharge if they will be needed at home.^{3, 9}

Goal: safe basic activities with appropriate assistance, understanding the instructions and preparing for return home. Dizziness, faintness or insufficient limb control are reasons to stop the attempt.¹⁰

Phase II — the first 2 weeks

Alternate several short walks and the exercises learned during the day with rest. Initially, safe walking without an increasing limp matters more than distance.⁶ Monitor the wound, pain, swelling and tolerance of daily activities.

The early exercise set may include ankle pumps, gluteal and quadriceps sets, and heel slides within the permitted range. The 3–5 short daily sessions shown on the poster do not mean that every exercise must be performed that frequently. The physiotherapist tailors the dose.

Goal: safe movement around the home with the necessary assistance and correct performance of the prescribed exercises. Do not try to exercise through wound deterioration or sudden pain.

Phase III — approximately weeks 2–6

Gradually increase walking distances, practise sitting down and standing up, and work on pelvic control. Perform gentle balance exercises with support. Continue to follow current movement and weight-bearing restrictions.¹³

Progression from two crutches to one depends on balance, strength and gait quality.⁶ A single crutch or stick is usually held on the side opposite the operated hip. Do not abandon walking aids at the cost of a pronounced limp; resume support if it returns.

Goal: greater independence and an improved gait pattern. Walking without crutches by a particular week is not a compulsory outcome for every patient.

Phase IV — approximately weeks 6–12

After assessing healing and updating instructions, increase exercise range and difficulty. Develop hip muscle strength, pelvic stability, balance and walking tolerance. The programme may include chair rises, supported mini-squats and low step-ups. A stationary bicycle requires clearance and a saddle height that respects the restrictions.^{6, 13}

After the protective period, cautiously reintroduce previously restricted flexion and rotation. Do not start with deep sitting combined with twisting or forceful end-range stretching. Do not pursue mobility at any cost.

Goal: better pelvic and limb control, longer walks and tolerance of selected strengthening exercises without a marked increase in pain or swelling.

Phase V — from approximately week 12

Develop the strength, endurance and function needed for work and recreation. Low-impact activities such as walking and cycling are preferred.⁷ 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.

Increase difficulty in stages. A date in the schedule does not automatically authorise full loading. Persistent limping, deteriorating pelvic control or pain require assessment and programme modification.