Osteoarthritis (OA), and especially osteoarthritis of the hip, is the commonest joint degeneration condition in the world, resulting in huge amounts of pain and suffering, work loss, expense and disability.
aging of western developed populations, soon to be followed by some developing countries such as China, will place an increasing burden on medical services as the occurrence of Osteoarthritis rises steadily with age. There will be an increasing need to provide medical and physiotherapy treatment for OA over the next 50 years and for many thousands of people this will involve joint replacement.
Medical interventions can be rated on a scale which calculates the improvement in quality of life which results and here hip replacement comes out top of all treatments. The 1960s saw its development into a standard treatment for hip arthritis but the 21st century has seen the technique evolve into a complex and predictable approach to many hip conditions, with excellent fifteen year plus results. Once conservative treatments have been exhausted due to a worsening joint then joint replacement becomes the standard choice.
In surgery the degenerative joint is excised and artificial components of alloy steel and plastic are substituted. The hip joint ball is removed and the socket cored out in preparation, the new ball and stem is inserted into pressurized cement in the femur and the new cup is pressed into cement in the socket. The two materials, steel alloy and ultra high density polyethylene, ensure very low friction in the joint similar to the original and contribute to low wear and long life of the joint.
Post-operative physiotherapy consists of reviewing the operation note and the medical observations, assessing the patient and instructing them in breathing and leg exercises. The physio assesses the sensibility and muscle power in the legs to exclude problems such as nerve injury, although an epidural can cause temporary loss of feeling and power in the lower body and delay mobilization. The next physio job is to get the patient up out of the bed with an assistant, stand and walk them as appropriate with elbow crutches or a frame, taking account of the necessary precautions to avoid dislocation.
Hip flexion, knee extension, buttock and calf exercises are practiced whilst in bed to reactivate the leg muscles and pump the blood around the limb. Routine analgesia is very useful as reduced pain allows easier exercising and mobilizing. Patients can now go to the toilet, wash and dress and walk about the ward with a helper if needed, at least three times a day to get their confidence. When sitting, correct height chairs are vital and patients should avoid having their feet up on a stool.
After hip replacement patients require instruction and correction to achieve a normal walking pattern, develop muscular power and improved function. Physiotherapists teach the appropriate gait at the time, often starting with "step to" where the patient moves the walking aid, steps the operated leg forwards and steps up to it with the other leg, a stable and safe pattern. Progression is to 'step through" where the unaffected leg steps beyond the other in an approximation of a normal walking pattern. Patients often progress naturally then to a gait where they move both the crutches and the affected leg forward at the same time and start to walk in a fully natural pattern.
Six weeks or so after the operation the patient will have a good gait, have reasonable muscle power and be able to do most functional activities such as a walk, climb stairs and ride in a car. They may then move on to a stick if stability or balance is difficult or the person is very old.
Patients can now return to normal activities but need to maintain the hip precautions:
Avoid crossing the legs in sitting.
Don't stand on the affected leg and rotate.
Don't flex the hip suddenly or above 90 degrees, such as by sitting in a low chair, sitting down too fast, crouching or leaning forward quickly to the feet.
If an infection develops, for example chest, teeth or bladder, then the doctor should be informed as infections can settle in an artificial joint.
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