Note: this post was written several years ago but still holds true. Just be aware that surgeries and protocols are changing with time and each surgeon will have their own specifics they want followed. I worked at a facility where the surgeons preferred a 2-incision "mini" replacement that carried no precautions, and several who debate whether to use an anterior or posterior approach. Just be up to date on what is preferred by your medical team.
Often, if the hip breaks near the joint's socket, the orthopedic surgeon will perform a total hip replacement (THR). This is also a common elective procedure for individuals w/ degenerative joint disease (DJD). There have been several advances in the operation, and there are new techniques that are less invasive and don't carry hip precautions. If for some strange reason you were pushed into a room with a patient you had no information on, and wanted to know whether this patient had a THR w/ precautions or an ORIF/pinning w/o precautions, the presence of a brace that extends from ankle to groin or a giant triangular pillow attached between the legs is the flashing sign that says "YES, I HAVE PRECAUTIONS." Don't count on the pt. to remember, as you may not have done a full cognitive eval yet, and it may have slipped even a very intact person's mind after the anesthesia.
For the sake of this example, we'll assume that our subject "M" has a THR w/ the standard precautions (no hip flexion past 90*, no crossing midline w/ operated leg, no internal hip rotation) and the fourth (no active abduction) which is used depending on the location of the fracture and the surgeon. There will also be a note about weight bearing status. Often, a person electing to have this surgery at a younger age will be allowed to weight bear as tolerated (WBAT). If there is more concern over the stability of the joint or bones, the surgeon will want less weight on that leg. We'll assume that "M" is partial weight bearing, which means that only 50% of her weight on the operated leg. (This saves us from having to explain toe-touch WB with the uncomfortable metaphor of not crushing an egg under your foot; and from non-WB which means that you have to hop. I have done the hopping w/ several... most recently an 89 y.o. female, and progress was slow)
We'll assume that in the OT evaluation, the therapist developed an occupational profile of "M", highlighting her concerns and priorities. We won't go into that in-depth in this post, as I actually want to finish it at some point. But, from my 'chart review,' I see that "M" is an educated woman who was respected at her job and has family support. The report states that she lives in a high-rise, which is good because it probably has elevators, but could be bad if they have rules about adaptations to apartments for safety. She also has vision difficulties, which could complicate ADL retraining.
ADL retraining, or relearning how to do the basic activities of bathing, dressing, toileting, transferring, etc, will be a large part of an OT's treatment for "M." Learning and understanding hip precautions is also a major task- non-medical personnel are not likely to instantly understand hip flexion, adduction, abduction, so this is a key for the therapist to rephrase, review, and demonstrate precautions so that the patient does not forget them and does not pop their hip out. Standard hip precautions often have to be followed for 3 months, so it needs to become second nature. (I once had a gentleman w/ dementia in his 80's that could not remember and understand these. He liked to draw, so I taped paper up on the wall and had him stand and draw cartoons of people obeying hip precautions) Here's some quick ways to simplify the precautions while covering some of the contingency situations:
- No hip flexion beyond 90*: Don't bend over! Don't try to get anything off the floor without a reacher! Don't lean forward when standing up from a chair. Use the adaptive equipment for dressing. (As a therapist, you can also help by modifying the hospital bed so that the legs don't raise. Often a little button on the foot of the bed or on the outside of a rail)
- No crossing over midline: Don't cross your legs! Use the wedge or pillows between your legs in bed. Avoid sleeping on your side.
- No hip internal rotation: Keep your toes pointed up in bed, don't let them turn toward each other. Don't pivot on the operated leg.
Transfers are often looked upon as "PT territory," but an OT can't expect to work without being comfortable helping people relearning safe transfers. This includes bed to chair, as well as into the tub or shower and to the toilet. Though the "comfort height" toilets are gaining ground, most people (and much of my hospital) has the standard 15" commode. This will not be workable for most individuals w/THR. There are risers for toilet seats, but I have always wondered about their sturdiness. I recommend getting a bedside commode / 3 in 1 toilet, throwing out the catcher/hat/pot, and putting it directly over the commode. In the tub or shower, I always recommend grab bars, and then experiment with different seats to see what works best for the patient. School-based OTs work to get their kids in the least-restrictive environment, I look for the least expansive tub chair that offers the patient the level of safety they need. I have had 1 person w/ THR demonstrate a safe step-in transfer to a tub, but most people will need some sort of seat to swivel into the tub. This is not natural to people, and takes practice.
As "M" progresses through the continuum of care from acute hospital, to skilled nursing, to home health (more likely than outpatient in her case), she will continue to work on more advanced skills that she had previously engaged in, such as cooking, car transfers, showering, etc, which OTs call IADLs. Hopefully someone will be able to visit her home as she gets near to discharge so that they can advise on home recommendations. That includes placement of grab bars, moving furniture, adaptations for low vision- anything to make "M" safer and more independent.