Indications for Surgery
The following are possible indications for prosthetic replacement of the proximal femur.
• Acute, displaced intracapsular (subcapital, transcervical) fractures of the proximal femur in an elderly patient with poor bone stock and an anticipated low-demand level of activity after surgery
• Failed internal fixation of intracapsular fractures associated with osteonecrosis of the head of the […]

Despite the number of sources in the literature that emphasize the importance of rehabilitation programs or, more specifically, a postoperative exercise and ambulation program after THA, the impact of these postoperative interventions has not been clearly established. The NIH reported that there is currently insufficient evidence to determine what constitutes an appropriate level of physical […]

Two to three decades of studies indicate that both cemented and cementless THA have yielded equally positive postoperative outcomes in all areas of assessment, with the most consistent being reduction of pain. Despite the success of both cemented and uncemented THA, debate continues as to the benefits and limitations of both types of fixation. What […]

Improvements in ROM, postural stability, strength, and functional mobility are significant but occur gradually after THA. Patients typically achieve 90% of their expected level of overall functional improvement by the end of the first year. During the next 1 to 2 years, patients have self-reported additional gains in strength, with improvement in function reaching a […]

Patient satisfaction after THA as well as the assessment of pain and perceived level of function and quality of life as judged by the patient and/or the surgeon generally reflect a marked decrease in pain and improvement in function. Historically, patient-related outcomes were assessed by the surgeon rather than the patient. During the past decade […]

For carefully selected patients who have undergone minimally invasive primary THA, an accelerated rehabilitation program may be feasible to achieve optimal outcomes as rapidly as possible. However, few guidelines have been published to date.
Berger and colleagues developed and implemented a program specifically designed for patients undergoing primary cementless THA with a two-incision approach. Patients eligible […]

After traditional THA the intermediate and late phases of rehabilitation begin about 4 to 6 weeks postoperatively. The degree of protection of the operated hip required varies substantially from patient to patient. Some degree of moderate protection may be necessary for 12 weeks postoperatively. However, full healing of soft tissue and bone continues for up […]

Common impairments exhibited by patients during the acute and subacute stages of soft tissue healing and the initial phase of postoperative rehabilitation after THA are pain secondary to the surgical procedure, decreased ROM, muscle guarding and weakness, impaired postural stability and balance, and diminished functional mobility (transfers and ambulation activities). Depending on the type of […]

Posterior/Posterolateral Approaches
ROM
• Avoid hip flexion > 80 to 90 and adduction and internal rotation beyond neutral.
ADL
• Transfer to the sound side from bed to chair or chair to bed.
• Do not cross the legs.
• Keep the knees slightly lower than the hips when sitting.
• Avoid sitting in low, soft chairs.
• If the bed at home […]

The use of therapeutic exercise interventions for patients after THA has been reported in the literature for several decades. Although the time frame for and extent of patient-therapist contact have decreased substantially since these early descriptive reports were published, the ultimate goal of rehabilitation remains the same: to optimize a patient’s postoperative level of function. […]

In two recent randomized, controlled investigations, the effects of immediate weight bearing as tolerated during ambulation and other functional activities after cementless or hybrid arthroplasty were compared with the effects of restricted weight bearing. No short-term or long-term adverse effects of immediate weight bearing were identified in either study. It is important to note that […]

Method of Fixation
• Cemented.
Immediate postoperative weight bearing as tolerated.
• Cementless and hybrid.
Recommendations vary from partial weight bearing (toe-touch or touch-down) for at least 6 weeks to weight bearing as tolerated (no restrictions) immediately after surgery.
Surgical Approach

• Standard versus minimally invasive.
Weight-bearing usually more restricted after standard (traditional) approach because of more extensive surgical disturbance and repair […]

• Length of incison: ≤ 10 cm, depending on the location of the approach and the size of the patient.
• Most if not all muscles and tendons left intact
• Single-incision or two-incision approach
• Single incision: usually posterior or anterior, or occasionally lateral.
• Two-incision: approach: two 4- to 5-cm incisions, one anterior for insertion of acetabular […]

The operative approaches used to gain access to the involved joint and to implant the prosthetic components during THA can be divided into two broad categories: standard and minimally invasive approaches. For decades hip arthroplasty procedures have involved the use of rather long surgical incisions (15 to 25 cm) to expose the joint. Although long-term […]

• Examination and evaluation of pain, ROM, muscle strength, balance, ambulatory status, leg lengths, gait characteristics, use of assistive devices, general level of function, perceived level of disability
• Information for patients and their families about joint disease and the operative procedure in nonmedical terms
• Postoperative precautions and their rationale including positioning and weight bearing
• Functional […]

Absolute
• Active joint infection
• Systemic infection or sepsis
• Chronic osteomyelitis
• Significant loss of bone after resection of a malignant tumor or inadequate bone stock that prevents sufficient implant fixation
• Neuropathic hip joint
• Severe paralysis of the muscles surrounding the joint

Relative
• Localized infection, such as bladder or skin
• Insufficient function of the gluteus medius muscle
• Progressive […]

One of the most widely performed surgical interventions for advanced arthritis of the hip joint is total hip arthroplasty . Osteoarthritis is the underlying pathology that accounts for most primary total hip procedures.
Indications for Surgery
The following are common indications for total hip arthroplasty (THA), also referred to as total hip replacement (THR).
• Severe hip pain […]

Many joint surgeries are available to treat early- and late-stage joint disease of the hip and some fractures that compromise the vascular supply to the head of the femur. As a result of advances in arthroscopy of the hip over the past decade, small to medium-size full-thickness lesions of the articular cartilage of the acetabulum […]

As healing progresses and symptoms subside, the emphasis of management includes the following goals and interventions.
Progressively Increase Joint Play and Soft Tissue Mobility
Joint mobilization techniques. Progress joint mobilization to stretch grades (grade III sustained or grade III and IV oscillation) using the glides that stretch restricting capsular tissue at the end of the available ROM. […]

In conjunction with medical management of the disease for inflammation and pain, correction of faulty mechanics is an integral part of decreasing pain in the hip. Faulty hip mechanics may be caused by conditions such as obesity, leg-length differences, muscle length and strength imbalances, sacroiliac dysfunction, poor posture, or injury to other joints in the […]

To make sound clinical decisions when treating patients with hip disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and identify presenting impairments, functional limitations, and possible disabilities. Conservative and postoperative management of these conditions is also described in this section.
Joint Hypomobility: Nonoperative Management

Osteoarthritis (Degenerative Joint Disease)
Osteoarthritis is the most […]

The hip is innervated primarily from the L3 spinal level; hip joint irritation is usually felt along the L3 dermatome reference from the groin, down the front of the thigh to the knee.
Major Nerves Subject to Injury or Entrapment
Sciatic nerve. Entrapment may occur when the sciatic nerve passes deep to the piriformis muscle (occasionally it […]

During the normal gait cycle, the hip goes through a ROM of 40° of flexion and extension (10° extension at terminal stance to 30° flexion at midswing and initial contact). There is also some lateral pelvic tilt and hip abduction/adduction of 15° (10° adduction at initial contact, 5° abduction at initial swing); and hip internal/external […]

Anterior Pelvic Tilt Posture
• Short TFL and IT band
• General limitation of hip external rotation
• Weak, stretched posterior portion of the gluteus medius and piriformis
• Excessive medial rotation of the femur during the first half of stance phase of gait with increased stresses on the medial structures of the knee
• Associated lower extremity compensations including […]

Muscles function through habit. Faulty mechanics from inadequate or excessive length and an imbalance in strength cause hip, knee, or back pain. Overuse syndromes, soft tissue stress, and joint pain develop in response to continued abnormal stresses.
Common muscle length-strength imbalances include the following.
• Shortened iliotibial (IT) band with shortened tensor fasciae latae (TFL) or […]

Abnormal structure or impaired function of the hip—such as a leg-length discrepancy, decreased flexibility, or muscle imbalances—can contribute to stress in the spine or other joints of the lower extremities.
Decreased Flexibility
Decreased flexibility in the structures around the hip joint cause weight-bearing forces and movement to be transmitted to the spine rather than absorbed in the […]

Pelvic Motions and Muscle Function
The pelvis is the connecting link between the spine and lower extremities. Movement of the pelvis causes motion at the hip joints and lumbar spine articulations. The hip musculature causes pelvic motion through reverse action. Hip flexors cause an anterior pelvic tilt; hip extensors, a posterior pelvic tilt; and abductors and […]

The joint capsule is richly supplied with mechanoreceptors that respond to variations in position, stress, and movement for control of posture, balance, and movement. Reflex muscle contractions of the entire kinematic chain, known as balance strategies, occur in a predictable sequence when standing balance is disturbed and regained. Joint pathologies, restricted motion, or muscle weakness […]

Characteristics
The hip is a ball-and-socket (spheroidal) triaxial joint made up of the head of the femur and acetabulum of the pelvis. It is supported by a strong articular capsule that is reinforced by the iliofemoral, pubofemoral, and ischiofemoral ligaments. The two hip joints are linked to each other through the bony pelvis and to the […]

The hip is often compared with the shoulder in that it is a triaxial joint, able to function in all three planes, and that it is also the proximal link to its extremity. In contrast to the shoulder, which is designed for mobility, the hip is a stable joint, constructed for weight bearing. However, to […]