Learn how to effectively work with clients who have had an anterior hip replacement.
By Elizabeth McIntyre, MAS, BSN, RN, LMT, December 5, 2014
Do you recognize any of your clients in the following symptoms?:
Faced with this scenario, many massage therapists rightly encourage the client to see their primary care physician to assess the problem. Many times what these clients will find out is that they have a pathological hip condition.
Hip problems typically originate from four potential causes, the most common of which is osteoarthritis, a degenerative disease that entails the loss of cartilage, gradual deterioration of the femur head and/or acetabulum, as well as the loss of joint space, leading to a painful bone on bone symptom. The American College of Rheumatology states that approximately 1 in 4 Americans can expect to develop osteoarthritis of the hip during their lifetime. Osteoarthritis may be due to excessive weight bearing, sports, overuse of the joint, and the general aging process.
Additionally, problems may be caused by a traumatic injury, avascular necrosis (loss of blood supply to the hip structures), or a bone tumor.
Some patients suffering with this condition will choose to treat the symptoms with non-steroidal antiinflammatory drugs, cortisone injections into the hip socket, glucosamine/chondroitin, non-weight bearing exercise such as swimming, or through the use of assistive devices, like canes, rollators and walkers. In many cases, however, this condition will eventually require hip replacement surgery.
If you haven’t already seen a client with a hip problem, statistics suggest you someday will, probably in the not-too-distant future. The Centers for Disease Control and Prevention (CDC) stated that more than 330,000 hip replacements were done in 2010, a 37 percent increase from 2000. This increase was due to several significant factors, including technological advances in prosthesis development, advances in surgical technique and an aging population.
With the development of the ceramic prosthesis, the lifespan of artificial joints has increased to at least 20 to 30-plus years—with minimal side effects. So, the “typical” demographic of hip replacement patient has changed from someone who may be 65–70, sometimes 90 years old, to patients in their 30s, 40s and 50s.
The second factor is the increasing use of the anterior surgical approach. This approach was developed in France in the 1950s, but was not utilized in the United States until the late 1990s. With this approach, muscles between the intramuscular and intranervous planes aren’t cut when the hip joint is replaced, making surgery and recovery easier for the patient. Patients also don’t have to be intubated during surgery, lying in a supine position instead of side-lying. The incision is small—four to five inches—and there are very few, if any, movement restrictions during recovery. Hospital stays and recovery times are also shorter, with patients returning to work within three to six weeks instead of the usual eight to 16 weeks. Additionally, postoperative pain is minimal.
This approach requires the patient be intubated in a side-lying position in the operating room. The posterior incision is approximately eight to 10 inches long, and the gluteus maximus—plus five other muscles—are cut for the procedure. Suturing and stapling of the skin is necessary, and the posterior aspect of the joint capsule is cut, which is believed to increase the chance of postoperative joint instability.
Some disadvantages to this approach are that the x-ray to confirm the exactness of joint placement/fitting cannot be done until after the procedure is completed. Because muscles are cut, postoperative pain and the need for pain medication are increased, specific movements are restricted (e.g., no flexion of the hip beyond 90 degrees, cannot bring the operative leg across the body’s midline and no internal rotation of the operative leg), and postoperative physical therapy is usually required. Patients are often unable to return to work for eight weeks.
Patients are not intubated and are lying in a supine position with this surgical approach. Here, the adipose and fascia are resected and the muscles are retracted (rectus femoris and tensor lata fascia) to reveal the hip capsule. Once the hip prosthesis is in place, the muscles are released and the adipose and fascia are sewed back together. Subcutaneous sutures are used for the skin approximation, and surgical glue is placed over the incision site. The incision is smaller than with the posterior approach, only four to five inches in length as compared to eight to 10.
Immediate radiological measurements of the patient’s hips are done bilaterally during the procedure so that surgeons can perfect the fit of the prosthesis in the acetabulum and femur, and equal leg lengths can be confirmed bilaterally.
The anterior approach also uses the Hana table, which enables orthopedic surgeons to perform the anterior hip replacement surgery with less difficulty because hip and leg positions, tensions and range of motion are easily performed. Additionally, a C-arm x-ray machine can take immediate images and provides the surgeon instant visualization of the prosthesis and anatomical structures, and a patient’s range of motion can be easily evaluated with the prosthesis in place, as well.
A massage therapist’s therapeutic goals for this client include decreasing or eliminating pain that may be due to muscular spasm, decreasing muscular tightness in the quadricep area, and assisting with hip stretches as tolerated by the patient.
Some surgeons, for example, will request that people who do weight lifting stop a couple of weeks preoperatively so that the quadriceps are not so tight.
Despite frequent appointments, the massage therapists I saw had great difficulty in loosening the quadriceps, as well as performing internal and external leg rotations when I was in a prone position. My muscles were simply too tight, and my range of motion and joint space was so limited. I never experienced pain, only muscle spasms.
During this time, the therapeutic goals of massage therapy are to decrease swelling in the more proximal anterior aspect of the upper leg and to decrease/ eliminate any pain that may be due to muscular edema from the surgical procedure.
By using broad strokes bilaterally on the leg from just a few inches below the joint area up to the joint, then to move further distal and then back up to the joint, and then either further distal back to the joint, the massage therapist can soften the tissue and help relieve any excess fluid in the interstitial space that can be common post-op. By working the most proximal area first, massage therapists can further decrease edema and promote more distal work to get similar effects.
Some surgeons will allow massage therapists to work on patients within the hospital setting, while others will support the work to be done once the patient is home. There are no surgical staples at the incision site—only subcutaneous sutures and surgical glue on the surface—so massage therapists would need to avoid working directly over the incision site. Typically, the incision site is very well approximated (the edges are next to each other) and there is no swelling.
Many patients will note a decreased sensation of swelling in the upper leg after treatment, and the massage therapist may notice a decrease in the circumference of the upper thigh.
Because patients who have undergone anterior hip replacement surgery are very mobile postoperatively, some may require that the muscles that have shortened preoperativley be stretched as tolerated.
For example, I had an external rotation of my lower extremity preoperative, but postoperatively, my alignment was corrected due to the surgical procedure. So, my lower lateral muscles needed to be stretched and readjusted to the new position. Each patient will have different needs, so working with clients both preoperatively and postoperatively can be a real asset.
It is a wonderful experience to see a patient who has had such difficulty for a period of time come to a massage therapist postoperatively with the major aspect of their problem resolved.
Massage therapy is proving itself helpful in a large number of ways relating to health care, and preoperative and postoperative care is one. As the population starts to age, you might find yourself seeing more clients who are undergoing joint replacement therapy, including of the hip. Knowing what the surgery entails, as well as ways massage therapy is beneficial, can better help you reach those clients who may not understand the role you can play in helping them maintain their health and well-being.
After seeing three orthopedic surgeons for my osteoarthritic hip, I discovered that some surgeons don’t perform the anterior approach simply because they don’t want to stop their current practice and learn a new approach. One surgeon I saw suggeseted I have bariatric surgery first due to my obesity.
Other health care practices might not have the equipment that is needed to perform anterior hip replacement surgery, such as the Hana table, which is necessary in order for instant radiographic information during surgery to be available.
Despite some of this reluctance, however, health care practices that offer the anterior approach are seeing a tremendous upswing in the number of anterior hip replacement surgeries being done. For example, a case study done at St. Marks Hospital in Salt Lake City, Utah, indicated that from 2006, the year the hospital began using the anterior approach, to 2009, hip replacement surgeries increased by 72 percent, in part because of the efficiency of the anterior approach over the traditional, posterior approach.
Within these same years, hip replacement surgeries using the anterior approach increased by 1008 percent, going from 2.4 surgeries utilizing the approach in 2006 to 28.2 in 2009. Conversely, the number of traditional, posterior hip surgeries being done plunged by 91 percent,with 14.8 being performed in 2006 and only 1.3 in 2009.
So, although patients may have to spend some time looking for a health care provider that is a good fit for their needs (some may even have to travel to a health care practice that performs anterior hip replacement surgery), this approach is gaining ground and proving itself advantageous to a wide variety of patients who are looking for relief from hip problems.
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