Friday Q&A: Helping a Student with a Hip Replacement

Hip Joint from Behind

Q: I am a relatively new yoga instructor that teaches Gentle Hatha to (mostly) seniors.  Recently, a gentleman came in with bilat hip replacements from 10 and 12 years previous. He rides his bike and is in pretty good shape for a gent in his 60's. His hips were replaced by a posterior approach. How cautious do I need to be with this man? Do we modify mostly in the early days after the operation? Of course, I've modified the asanas to his ability and told him to not push it to the extreme. So is it fresh post op that we worry mostly about or for decades following? Thanks!

A: This is a great question and I am glad you asked it. In most cases, the hip replacement should outlast an individual’s lifespan. The literature states that total hip replacements typically last from 15-to-20 years after the initial surgery, but in some instances they can last over 30 years. But this is neither a guarantee nor assurance, for the simple reason that life is unpredictable.  Many factors affect the future of a hip replacement, such as accidents, fractures, late infections, and deterioration in overall health. Also, how well you take care of yourself down the road is something the surgeon cannot control. The longevity of a hip replacement thus depends on many factors, including the following:

• Surgeon skill in implanting the components
• Known history or track record of the implants
• How well you take care of yourself and your health
• Understanding and respecting the limitations of a prosthetic lifestyle
• Your activity level and body weight
• Avoiding high impact or extreme sports

Medical literature states that the most common reasons for individuals needing subsequent hip replacement surgery include:

• Loosening of the implant. 
• Dislocation of the implant
• Infection, such as staph infections either around the time of surgery or later through the introduction of the bacteria into the blood stream.

It is believed that the most common reason why hip replacements fail is because the weight-bearing surface wears out and the prosthesis begins to loosen. So, what is hip replacement loosening? When a hip replacement is placed into the body, it is either press-fit into the bone or cemented into position. Either way, it is fit tightly into the bone of the thigh (femur) and pelvis so that the implant cannot move. Hip replacement loosening occurs over time, and can cause problems with the normal function of the hip replacement prosthesis. When implants loosen, the hip replacement can begin to move small amounts. This can be caused by the shaft of the prosthesis becoming loose in the hollow of the thighbone or due to thinning of the bone around the implant.

Loosening of the joint can occur at any time, but it normally occurs 10-15 years after the original surgery was performed. Signs that the joint has become loose include pain and feeling that the joint is unstable and that there is increased loss of hip mobility. Another operation (revision surgery) may be necessary, although this cannot be performed on all patients.

Both physicians and patients are very concerned about the problem of hip replacement loosening because a hip replacement revision surgery (replacement of a joint replacement) is a much more difficult operation and hip replacement revisions are often not as successful as the first operation. After revision operations, patients tend to recover less overall motion of the joint. Also, the longevity of the implant decreases with each revision. Therefore, physicians tend to avoid joint replacement surgery until absolutely necessary, and try to get as much mileage out of each replacement as possible.

In about 1 in 20 cases, the hip joint can come out of its socket. This is most likely to occur in the first few months after surgery when the hip is still healing. But, unfortunately some people’s hips will dislocate very distant to the original hip replacement. My advice here is that a hip doesn’t typically dislocate without warning signs. Pain that increases as an activity is continued is the most prevalent symptom.

So how cautious should you be with your student? The surgical hips will have a certain degree of motion that is limited by their soft tissue, hip capsule, how the prosthesis sits in the acetabulum, and so on. Start by checking your student’s range of motion while he is lying in a supine position. Test all the movements of the hip (hip up toward chest with knee bent, same knee position but bring it out to side for abduction, and turn the hip out in abduction for external rotation by bringing the bent knee up toward the armpit. Then look at his hip mobility while standing: hip flexion, abduction, external rotation and extension. You should also see if he tolerates adduction by having him sit on a chair and cross one leg over the other. If he can't do this, then any pose that has internal rotation must be modified significantly. You should have your student do this for both hips to get a sense of how it feels to his hip and see if there is any pinching or grabbing. Then you can modify the asanas accordingly.

If you ask a surgeon if his patient has any precautions after three months post op, he will generally say no, but he will modify his statement telling the patient to “use your own judgment.” So do we continue with precautions forever? Well, that is an area of disagreement. I err on the side of moderation saying, “If it makes you anxious or causes pain, discomfort, pulling, or pinching, please stop.” A student can have the potential of dislocation forever if they are not mindful on how they move and move repeatedly into discomfort. And remember the combined positions of flexion, abduction and internal rotation are the holy triad. If your student can tolerate the movements separately then you can find his limits and slowly challenge his hips, but both you and he must be aware of how the hip feels. NO PAIN should be elicited from asana and that means soreness after class or the next day. Learning how to ask how a movement feels is tricky because not everyone will say something hurts, so this includes learning which words your student uses to describe sensation changes.

So for your student, keep making sure that he observes his body’s limits and doesn’t push beyond his current activity. And congratulate him for coming to your class and investing in his continued health!

—Shari

Total Hip Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s post Arthritis of the Hip Joint about what the next step might be when your own self care management techniques are not as effective and your quality of life is severely impacted. I thought I would give some background about the elective procedure of total hip replacement and why people might elect to have it done. I see a lot of total hip replacements in my work as a home health physical therapist, and I also do have yoga students who come to my class either after the procedure or before hand as they are preparing themselves for the surgery.

X-Ray of Hip Replacement from Wikimedia

As background, here is what the Mayo clinic says about hip replacement surgery:

"Hip replacement surgery, also called total hip arthroplasty, involves removing a diseased hip joint and replacing it with an artificial joint, called a prosthesis. Hip prostheses consist of a ball component, made of metal or ceramic, and a socket, which has an insert or liner made of plastic, ceramic or metal. The implants used in hip replacement are biocompatible — meaning they're designed to be accepted by your body — and they're made to resist corrosion, degradation and wear.

The goal of hip replacement surgery is to relieve pain and increase the mobility and function of a damaged hip joint. If a stiff, painful hip joint has forced you to cut back on everyday activities, successful surgery may allow you to resume them. Conditions that can damage the hip joint, sometimes necessitating hip replacement surgery, include:

• Osteoarthritis
• Rheumatoid arthritis
• Broken hip
• Bone tumor
• Osteonecrosis, which occurs when there is inadequate blood supply to the ball portion of the hip joint

To perform a hip replacement, your surgeon:

• Makes an incision over the front or side of your hip, through the layers of tissue
• Removes diseased and damaged bone and cartilage, leaving healthy bone intact
• Implants the prosthetic socket into your pelvic bone, to replace the damaged socket
• Replaces the round top of your femur with the prosthetic ball, which is attached to a stem that fits into your thighbone

Your new, artificial joint is designed to mimic the natural, gliding motion of a healthy hip joint. "

Artificial Joint from Wikimedia

Techniques for hip replacement are evolving. As surgeons continue to develop less invasive surgical techniques, the hope is that these techniques might reduce recovery time and pain compared with standard hip replacements. However, studies comparing the outcomes of standard hip replacement with those of minimally invasive hip replacement have had mixed results.

Choosing an orthopedist to perform your surgery is a very personal decision and we all research our concerns in different manners. Please, though, when you have found a surgeon that you want to work with, make sure you discuss the different types of hip replacement surgeries that they may perform so you understand clearly the advantages and disadvantages that each surgical procedure presents. Be particular that the surgeon understands your own particular yoga practice and what it entails. Bring pictures of poses that you currently do (or have done) and make sure the doctor understands the stresses you place on your hip joint. Telling a physician who doesn’t do yoga “I do yoga” isn’t enough, so show him or her the positions your hip needs to be able to move through.
The surgical options that exist are very different in what the post operative limitations are and the longer standing limitations that the post replacement hip might present you with.

The basic categories of total hip replacement are either:

• posterior lateral approach
• anterior lateral approach
• anterior approach
• minimally invasive anterior approach or minimally invasive posterior approaches

These are all different, but as far as hip precautions go there are no hip precautions for the anterior approaches.

Now this important for the practice of yoga. Which approach is recommended for your particular situation is going to affect your asana practice. Please ask your surgeon what your post-operative physical limitations are and for how long. Make sure you learn how to safely get up and down from the floor so as to not dislocate your new hip and that you learn the specific precautions associated with your category of hip replacements. The key is that you learn to identify what position is your hip in when you do your poses and you need to think of both legs when you do each side (don’t just focus on the surgical side).

In the more traditional posterior or posterior lateral approach there are limitations on hip flexion, adduction and internal rotation. That means that if you combine these three positions you are more apt to dislocate your prosthetic hip because the muscle support is weakened by the surgical procedure. That is definitely going to affect your asana practice. Poses you might want to not do for approximately six months would be: Standing Forward Bend (Uttanasana), Eagle pose (Garudasana), Cow-Face pose (Gomukhasana), and Child’s pose (Balasana). Gentle backbends generally are okay for posterior/posterior lateral hips.

For anterior lateral hips the precautions will be very different. Typically hip extension and hip abduction will be affected and you don’t want to be aggressive in these combined movements. So start thinking about your backbends and standing poses. Remember that the position of the front and the back legs are very different in the standing poses. The front hip may be placed into positions of flexion and external rotation and abduction but the back hip may be in extension with external rotation.

For anterior hip replacement surgeries the doctor will typically tell you that you have no restrictions but that doesn’t mean you are going to jump back into your asana practice. The hip is going to be sore and painful because of the surgical trauma (though it is less in this procedure than some of the other ones I talked about because there is no actual muscle cutting in this procedure but the muscles are certainly stretched as they are moved for the surgery).

So now armed with your knowledge of what type of hip surgery you have had, and what your physical restrictions are and for how long, consider the critical importance of studying with a teacher who can assist you in practicing safely. Knowing what props to use and when are important, and so is knowing how deep to go into a pose. In addition, different surgeries have different time frames for returning to asana practice but the rule of thumb to return to any activity post operatively is how you feel. You can get time estimates on when to resume an activity but the bottom line is your own healing process and energy level. As always respecting your energy level and not be overly aggressive as you return to your asana practice is crucial.

In my clinical experience I have never had a client tell me that he or she is sorry to have undergone this surgery. In all medical procedures, knowledge, mental and emotional preparation and conviction in your choice of action go a long way towards healing. That certainly sounds like an engaged yoga practice off of the mat!