Hips

Orthopedic Framework for Hip Recovery

• The approach to hip rehabilitation is categorized by the "Three P's": Pain, Positioning, and Performance.

• Pain strategies involve the early use of cold interventions while respecting the client's pain levels to simultaneously encourage active and functional movement.

• Positioning focuses on ensuring healing through specific movement precautions, distinguishing between Open Reduction Internal Fixation (ORIF) and hip replacements.

• Performance prioritizes the functional side of recovery, specifically concentrating on Activities of Daily Living (ADLs) and independence rather than just biomechanical exercise.

• While orthopedic recovery improves through exercise (Therex), functional performance remains the primary priority for occupational therapy.

Surgical Interventions for Hip Fractures

• Hip fractures are typically addressed through surgery because the femur is responsible for carrying a significant portion of the body's weight, making it a high-stress zone.

• Unlike shoulder fractures, which can sometimes heal through rest, a hip fracture requires surgery because bed rest (necessary for conservative healing) would cause strength loss and other secondary complications.

• There are two primary surgical approaches for hip fractures:

  • Open Reduction Internal Fixation (ORIF): This involves putting screws and hardware into the bone to hold it together. It is the least invasive surgical option that provides enough stability for recovery. It is chosen when the fracture location and severity allow the bone to heal if held in place.

  • Total Hip Arthroplasty (THA): Also known as a hip replacement. This is required when an ORIF is insufficient for the severity or location of the injury. The procedure involves cutting off the head of the femur and replacing it with an artificial ball and an artificial cup (socket) in the pelvis to create a fully artificial hip joint.

Weight-Bearing Status and Progression

• Weight-bearing (WB) refers to the amount of pressure or weight a person is permitted to put through the surgical bone to prevent re-fracturing.

• The physician or surgeon determines weight-bearing status; occupational therapists must follow and enforce these precautions during ADLs and mobility.

• The levels of weight-bearing include:

  • Non-Weight Bearing (NWB): No weight at all on the lower extremity. The foot should not touch the ground.

  • Toe Touch Weight Bearing (TTWB): The client can touch their toes to the ground for balance and proprioceptive security, but they cannot put their full heel down or use the leg to support their weight. This is estimated at roughly $5\% \times 10\%$ of total body weight.

  • Partial Weight Bearing (PWB): The client can put $50\%$ of their body weight through the extremity. This allows a client to stand still on two legs without a device, but they must use a device for ambulation because stepping shifts $100\%$ of the weight to one leg. In these cases, the other $50\%$ of the weight must be supported by the arms through a device.

  • Weight Bearing As Tolerated (WBAT): The client is trusted to let pain be their guide. The surgeon has few concerns about the integrity of the bone. Mobility depends on the client's pain tolerance, ranging from toe-touch levels to near-full functionality.

  • Full Weight Bearing (FWB): No restrictions on weight; the client can put as much weight on the leg as they desire.

• While a walking device is technically optional for WBAT and FWB, it is almost always utilized for balance and safety shortly after surgery.

Hip Precautions and Soft Tissue Mechanics

• Hip precautions are distinct from weight-bearing precautions. While weight-bearing concerns the bone/hardware, hip precautions protect the soft tissue (labrum, tendons, and ligaments).

• The connective tissue surrounding the hip acts as the "rotator cuff of the hip," forming a tight pocket that keeps the ball in the socket. Surgery requires cutting this tissue, making the joint looser and susceptible to dislocation while healing.

• Precautions are determined by the surgical approach:

  • Anterior Approach (Anterolateral): The incision is on the front side of the hip. Avoid movements that put pressure on the anterior side of the labrum.

  • Posterior Approach (Posterolateral): The incision is on the back side of the hip. Avoid movements that put pressure on the posterior side of the labrum.

• The Mnemonic/Hand Exercise for Hip Precautions:

  • Use the right hand to represent the right femur and pelvis. The fist is the femur head, and the other hand is the pelvis socket.

  • Hip Flexion (fist moving forward/up): Puts pressure on the posterior side. Avoid in posterior approach.

  • Hip Extension (fist moving back): Puts pressure on the anterior side. Avoid in anterior approach.

  • External Rotation (toes pointing away/pigeon feet): Puts pressure on the anterior side. Avoid in anterior approach.

  • Internal Rotation (toes pointing inward): Puts pressure on the posterior side. Avoid in posterior approach.

  • Adduction: Bringing the knees close together or crossing them. This is avoided in both approaches because the labrum is loose and the hip could dislocate.

Specific Movement Restrictions and Adaptive Solutions

• Posterior Precautions Specifics:

  • No Flexion past $90^{\circ}$: Sitting normally is roughly $90^{\circ}$. Bending forward or raising the knee higher while sitting is prohibited.

  • Internal Rotation: Avoided to prevent posterior dislocation.

  • Solutions: Use a reclining wheelchair to allow for an angle greater than $90^{\circ}$. Use a raised toilet seat to prevent deep hip flexion.

• Anterior Precautions Specifics:

  • Extension and External Rotation: Avoided to prevent anterior dislocation.

• Adduction Solutions: Use an abduction wedge or pillows between the legs while sleeping to prevent the knees from touching and the hip from adducting/dislocating.

Functional Performance and Fall Prevention

• OTs prioritize function through education and adaptation. This includes:

  • Fall Prevention: Turning lights on before walking at night, removing clutter and tripping hazards, and home modifications.

  • Mobility Transfers: For the posterior approach, the client should kick their surgical leg out so the foot is $6 \times 12\,\text{inches}$ in front of the other leg before sitting or standing. This maintains a hip angle wider than $90^{\circ}$.

  • ADLs and Adaptive Equipment:

    • Lower Body Dressing: Because bending over or bringing the foot up is restricted, clients use a reacher, shoehorn, sock aid, and dressing stick.

    • Bathing: Long-handled sponges and tub transfer benches are used. A tub transfer bench is essential for those who cannot step over a tub wall due to weight-bearing or flexion restrictions.

    • Toileting: Raised toilet seats and grab bars.

Questions & Discussion

• Practice Question: OT is planning to review kitchen activities with a client who underwent a total hip replacement and plans to return home tomorrow. The chart says that the client is toe touch weight bearing. How will the weight-bearing restriction impact participation in kitchen-related activities?

• Options and Analysis:

  • A: The client should perform kitchen activities from a sitting position due to not being able to place any weight on the affected leg. (Incorrect: This describes Non-Weight Bearing).

  • B: Standing kitchen activities can be performed by placing about $50\%$ of the person's body weight on each leg. (Incorrect: This describes Partial Weight Bearing).

  • C: Kitchen activities will be performed in standing by placing $90\%$ of weight on the non-operated leg and upper extremities. (Correct: This describes Toe Touch Weight Bearing, where only about $10\%$ of weight goes through the toes).