Hip Arthroplasty: Improving
Gait - An Update
John O'HalloranPT, DPT, OCS, ATC (retired), CSCS (retired), Cert
MDT, Certified SCTM-1
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Learning Objectives
• Compare and contrast hip arthroplasty procedures
performed in the past versus today
• Examine the statistical data surrounding hip arthroplasty
• Identify the type of approach, precautions, fixation methods,
and bearing surfaces in hip arthroplasty
• Identify and explain the advantages and disadvantages of
the various approaches and the current level of evidence
• Describe the phases of postoperative rehabilitation
• Consider how to manage leg length discrepancies depending
on the stage of the patient
• Describe the return-to-function process following hip
arthroplasty
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Chapter 1
Approaches to Hip Replacement
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Introduction
• 450,000 procedures a
year
• Second most commonly
replaced joint
• Leg length discrepancy
• Different approaches
• Precautions
• Rehabilitation
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Leg Length Discrepancy
• When should this issue be addressed?
• 5%–13% of total hip arthroplasties (THA) have a
measurable leg length discrepancy
• Weaker patients are usually given more length
• Lifts to correct new leg length (sometimes better
avoided and walking instead)
• Corrective stretching/manual therapies
• Hiking of hip results from adaptive shortening of other
muscles to compensate
– Stretch and strengthen to address this
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History of Hip Arthroplasty
• Originally developed in 1962
• Implant survivorship (most successful)
– 90% will last 20 years
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Let’s Discuss
• 450,000 performed in US annually at a cost of over
three billion dollars (primary only)
• Revisions: 137% between 2005 and 2030
• Research shows that patients get their information
from the therapist on surgery, rehabilitation, and what
not to do
• Excellent postoperative results: reported as high as
98%
• Cemented versus non-cemented has changed
• Type of approach
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Diseases Requiring THA
• Osteoarthritis: resulting from age, genetics, and now
more than ever, obesity
– Most common indication
• Inflammatory arthritis/rheumatoid arthritis
• Traumatic arthritis: resulting from fractures and/or
forms of avascular necrosis
– Causes femoral head to collapse
• Hip dysplasia, shallow cup, etc.
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Posterior Approach
• Oldest and most
common approach
• Provides greatest view
of surgical field
• Restrictions for 6–12
weeks postoperatively
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Minimally Invasive = Anterior Approach
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X-Ray Guidance
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Anterior Approach in the Past
However big the learning curve and small the scar, there is
the same amount of pain and bleeding, with two to three
times the number of complications.
– Femoral neck fractures
– Nerve palsies
– Dislocation
– Difficult to do on obese patients and/or patients with
malalignment, tight/big muscles, previous hardware,
revisions
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Anterior Approach Today
• Now surgeons can do these in everyone
– Including revisions, hardware removal, complications
• Drastically reducing postoperative recovery time
• Anterior versus posterior
– No difference after six weeks according to literature
– Anterior approach is still typically better for active people
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Anterior Approach Patient
• Holly had an anterior hip
replacement
• Yoga teacher and
athletic trainer
• Back to all activities and
motions eight weeks
after surgery
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Anterior Approach Patient (cont.)
The hip extension move here would make me nervous the
first six to eight weeks
– Hip capsule fibers need time to heal and seal up
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Comparable Function at Six Weeks
• Comparable function seen at six weeks with direct
anterior, posterior approach for THA
• Reference: Jacobs, C. Paper #17
– Presented at the American Association of Hip and Knee
Surgeons Annual Meeting
– November 7–9, 2014, Dallas
• JBJS September 2019: What’s New in Hip Replacement
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Comparable Function at Six Weeks (cont.)
“There does appear to be early benefits with direct anterior total
hip arthroplasty in terms of the functional milestones:” Cale
Jacobs, PhD, said during her presentation at the American
Association of Hip and Knee Surgeons Annual Meeting. “The
patients are leaving the hospital earlier, they are off the cane
earlier, and there has been greater pain relief reported, not only
in our study, but in other studies as well during the first 2–6
weeks after surgery. However, like the other available literature,
we saw that there does not seem to be a long-term benefit
demonstrated yet.”
• No difference after one year
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Bearing Surfaces
Two main types
1. Metal ball with polyethylene cup (left)
• Most traditional approach
2. Metal ball with metal cup (right)
• Larger head = greater stability = decreased dislocation
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Ceramic Head With Polyethylene Liner
Popular with young, active groups for durability
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Metal-on-Metal Debate
• In 2010, implants were
recalled due to a 14% revision
rate
– Normally only 1% revision
rate
• Abnormal amount of metal
accumulated in body due to
metal shavings from friction
of joint
– Chromium and cobalt found
in blood and urine
• No longer on the market
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Metal on Metal Debate (cont.)
What did the literature say?
– Metal ions shown in the blood and urine due to wear
debris
– No adverse reactions were documented
– No report of cancer or allergic reactions
Journal of Arthroplasty 2005
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Hip Resurfacing
• Advantages
– Preserves shaft of femur
– Head of femur is preserved
by shaving it down and
putting a cap on the femur
– Good for athletes
• Disadvantages
– Not good for people with
bone density issues or
avascular necrosis
– Usually not best option for
females
Randelli et al., Amstutz et al., De Smet et al. 2008
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Hip Resurfacing (cont.)
• Need to wait a year for the bone density to build up
again around the peg
• Posterior approach
Cook et al.
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Positioning of Joint Head
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Dislocations
• 2%–4% of primary TSA, up to 20% of revisions
• Causes
– Small femoral head
– Improper version
– Short neck
– Infection
– Behavior (violated precautions/restrictions)
• Restrictions are typically 6–12 weeks
– Can be up to one year or even for life in some cases
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Dislocations (cont.)
• Traditional THA are inherently unstable due to design
• Normal hip dislocates from trauma, such as a high-
velocity car accident
• THA dislocate because the ball is a lot smaller than the
socket
– In order to provide a plastic bearing surface and a socket
that is thick enough, the head had to be smaller to have
longevity
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Femoral Head Size Today
• Natural hip head is 33% larger than that used in a THA
– 44–56 mm (natural) versus 28 mm (prosthetic)
• Femoral heads are getting larger
– Resulting in fewer dislocations
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Precautions
• Posterior approach
– No hip flexion over 90 degrees
– No hip adduction beyond neutral
– No hip internal rotation beyond neutral
• Anterior approach
– No hip extension beyond neutral
– No hip external rotation beyond neutral
– No prone lying
– No bridging
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Chapter 1 Summary
• We described the different surgical approaches for hip
replacement
• We described the precautions following hip
replacement
• We described the metal-on-metal hip replacement
recall
• We described the current concepts of hip replacement
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Chapter 2
Rehabilitation of the Hip
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Hip Rehabilitation
• Trendelenburg is caused by a tight psoas 46% of time
and a weak gluteus medius 36%1
• Total body movements versus isolation for hip rehab2
• Earlier conditioning causes patients to rate satisfaction
higher3
• Quadriceps function, trunk function, tight psoas, etc.4
1. O’Halloran Data, non-published
2. Arch Phys Med Rehab 2012
3. Liebs et al. 2010
4. Gait and Posture 2012
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Chapter 2 Summary
• We described the traditional early-stage rehabilitation
• We compared and contrasted a more functional
approach to bed exercises
• We demonstrated weight-bearing exercises for the first
21 days
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Chapter 3
Therapeutic Tips
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Precautions
• Balance is critical to improve gait and stability
– Often overlooked
• Core awareness
• Eccentric weight shifting for femoral internal rotation
control
• Small proximal deficit results in a large distal deficiency
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Trendelenburg Gait
• 47% of
Trendelenburg gait
caused by tight
psoas
• 36% caused by weak
gluteus medius
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Early-Phase Outpatient Rehab
• Classic case of leg length discrepancy due to adaptive
muscles
• First, stretch out shortened muscles
• Stretch out short and tight muscles
• Doorway exercises to release hip flexor and facilitate
the abductors and rotators
• Reach to elongate lateral trunk and hip flexor
– Reach across
• Step up to facilitate gluteus muscles
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Late-Phase Outpatient Rehab
• Assess
– Balance
– Hip flexor mobility
– Muscles that control femoral internal rotation
eccentrically
– Trunk and core control
• Incorporate a sequence of therapeutics that will
facilitate objectives
• Become impairment-based
JOSPT April 2011
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Assessments
• Assessments give objective information for patient,
payer, and physician
• Diagonal exercises, such as chops and lifts
– Good for people doing sports
– Need proximal stability to get distal mobility
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Recommendations Following THA, 2011, 2018
• Survey sent to members of the Hip Society and
American Association of Hip and Knee Surgeons (2007
and 2011)
• 549 respondents (72%)
• 30 groups of activities; 37 specific sports
– “Allowed”
– “Allowed with experience”
– “Not allowed”
– “Undecided”
Klein et al.
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“Allowed Activities” Following THA
• Golf • Dancing (ballroom, jazz,
• Swimming square)
• Doubles tennis • Weight machines
• Walking • Stair-climber
• Speed walking • Treadmill
• Hiking • Elliptical
• Stationary skiing • Downhill skiing
• Bowling • Cross-country skiing
• Road cycling • Weightlifting
• Stationary bicycling • Ice skating/rollerblading
• Low-impact aerobics • Pilates
Klein et al.
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“Activities Not Allowed” Following THA
• Racquetball/squash
• Jogging
• Contact sports
– Football, basketball, soccer
• High-impact aerobics
• Baseball/softball
• Snowboarding
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Research
Why did snowboarding get a “not allowed” grade while
other sports like skiing and in-line skating were upgraded
to “allowed with experience”?
– Less familiar activity
– Biomechanically, surgeons are concerned with the torque
created around the hip when feet are fixed to the board
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Previously in the “Not Allowed” Category
Recently been upgraded to the “activities allowed with
experience” category per the AAHKS
– Downhill skiing
– Weightlifting
– Ice skating/rollerblading
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“Undecided” Activities Following THA
• Martial arts
• Singles tennis
Kelin et al.
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Summary
• We learned surgical techniques for various hip
replacements
• We learned rehabilitation methods for postoperative
phases
• We learned return-to-activity guidelines
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Hip Arthroplasty: Improving Gait - An Update
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MedBridge
Hip Arthroplasty: Improving Gait - An Update
John O'Halloran, PT, DPT, OCS, ATC (retired), CSCS (retired), Cert MDT, Certified SCTM-1
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