Hip Resurfacing Post-Op Rehabilitation Protocol (Hip Groin Approach)

Pathophysiology

Hip resurfacing is a bone-conserving alternative to total hip arthroplasty (THA), primarily indicated for younger, active patients with osteoarthritis, avascular necrosis (AVN), or other hip joint pathologies. In hip resurfacing, the femoral head is trimmed and capped with a metal prosthesis, while a metal cup is implanted into the acetabulum. This procedure preserves more of the patient's own bone stock and allows for a greater range of motion compared to THA. The hip groin approach, also known as the anterior approach, involves an incision in the front of the hip, between muscles, which typically results in less muscle damage and potentially faster recovery. However, specific muscle damage (even minimal) related to surgical retraction during the hip groin approach will affect early therapy.

This rehabilitation protocol is designed to guide physical therapy intervention following hip resurfacing via the hip groin (anterior) approach. It outlines a progressive, criterion-based program to optimize functional recovery, minimize complications, and facilitate a safe return to activity. The patient’s individual progress, pain levels, surgeon’s recommendations, and overall health status will influence the progression through the phases.

Phase I: Protection (Weeks 0-4)

Goals:

• Protect the surgical site and healing tissues.
• Minimize pain and edema.
• Initiate gentle range of motion (ROM) exercises.
• Maintain core and upper extremity strength.
• Promote early weight-bearing as tolerated (WBAT) with assistive device.

Precautions:

• Adhere to weight-bearing restrictions as prescribed by the surgeon (typically WBAT initially).
• Avoid excessive hip flexion (beyond 90 degrees), adduction past midline, and external rotation, especially in combination.
• Avoid pivoting on the operated leg.
• Monitor for signs of infection (increased pain, redness, swelling, drainage, fever).

Interventions:

• Education: Hip precautions, weight-bearing status, wound care, pain management techniques.
• Pain and Edema Management: Ice packs (20 minutes, several times a day), elevation, gentle compression.
• Ankle Pumps and Calf Stretches: To prevent deep vein thrombosis (DVT).
• Isometric Exercises: Gluteal sets, quad sets, hamstring sets, adductor sets (avoiding excessive adduction past midline). Focus on proper muscle activation without pain.
• Assisted Range of Motion (AROM): Heel slides, gentle hip flexion/extension, abduction/adduction within pain-free range.
• Gait Training: WBAT with crutches or walker, focusing on proper gait mechanics and minimizing limping. Progress to one crutch as tolerated.
• Core Strengthening: Gentle core activation exercises (e.g., pelvic tilts) avoiding excessive abdominal strain.
• Upper Extremity Strengthening: Bicep curls, triceps extensions, shoulder abduction/flexion (using light weights or resistance bands).

Phase II: Loading (Weeks 4-8)

Goals:

• Increase hip ROM and flexibility.
• Improve strength and endurance of hip and surrounding musculature.
• Progress weight-bearing to full weight-bearing (FWB) as tolerated and prescribed by the surgeon.
• Improve balance and proprioception.
• Normalize gait pattern.

Precautions:

• Continue to monitor for pain and signs of instability.
• Avoid overexertion and activities that exacerbate pain.
• Gradually increase activity levels to avoid setbacks.

Interventions:

• Range of Motion Exercises: Progress to active range of motion (AROM) exercises, incorporating gentle stretching of hip flexors, extensors, abductors, and adductors.
• Strengthening Exercises:
  • Standing hip abduction, adduction, flexion, and extension with resistance bands.
  • Bridging exercises.
  • Mini squats (within pain-free range, avoiding excessive hip flexion).
  • Heel raises.
  • Leg press (light resistance).
• Balance and Proprioception Exercises:
  • Single leg stance (progressing to increased duration).
  • Weight shifting exercises.
  • Balance board or foam pad exercises.
• Gait Training: Progress to FWB without assistive device as tolerated, focusing on proper gait mechanics, stride length, and cadence. Address any gait deviations.
• Cardiovascular Exercise: Stationary bike (with proper seat height to avoid excessive hip flexion), elliptical trainer (low resistance).

Phase III: Return to Function (Weeks 8+)

Goals:

• Achieve full ROM and strength in the hip.
• Return to pre-operative activity level.
• Improve cardiovascular fitness and endurance.
• Maintain proper body mechanics to prevent re-injury.

Precautions:

• Avoid high-impact activities initially.
• Listen to your body and avoid overdoing it.
• Continue to maintain proper body mechanics.

Interventions:

• Advanced Strengthening Exercises:
  • Progressive resistance training with weights or resistance bands.
  • Lunges (forward and lateral).
  • Step-ups.
  • Plyometric exercises (low impact, as appropriate).
• Sport-Specific Training: Gradually return to sports or recreational activities, starting with low-impact activities and progressing to more demanding activities as tolerated.
• Cardiovascular Exercise: Increase intensity and duration of cardiovascular activities, such as jogging, swimming, or cycling.
• Maintenance Program: Establish a home exercise program to maintain strength, flexibility, and cardiovascular fitness.
• Patient Education: Reinforce proper body mechanics, injury prevention strategies, and activity modification techniques.

Common Special Tests

These tests are often used to assess hip joint pathology and surrounding structures. The therapist will use these tests to determine the status of the hip and influence the plan of care. Note that these tests are typically performed during the initial evaluation and periodically throughout the rehabilitation process to monitor progress.

• Thomas Test: Assess hip flexor tightness.
• Ober's Test: Assess iliotibial (IT) band tightness.
• Trendelenburg Test: Assess gluteus medius strength.
• FABER (Patrick's) Test: Assess hip joint pathology (e.g., osteoarthritis, labral tear).
• Scour Test: Assesses for intra-articular hip pathology.
• Log Roll Test: Assesses for intra-articular hip pathology and capsular tightness.
• FADDIR (Flexion, Adduction, Internal Rotation) Test: Assess for femoroacetabular impingement (FAI) or labral tear.

Disclaimer: This rehabilitation protocol is a general guideline and should be modified based on the individual patient’s needs, surgeon’s recommendations, and clinical judgment. It is essential to communicate regularly with the surgeon and other members of the healthcare team to ensure optimal patient outcomes.