1. Assessment summary (POD 4)

• Wound and swelling (girth at the joint line and 10 cm above and below the patella)
• Quadriceps lag (extensor lag on straight leg raise)
• Calf tenderness and Homans' sign for DVT
• Skin temperature
• Sensation
• Other joints

2. Problem list

1. Severe postoperative pain (7.2/10)
2. Reduced knee flexion ROM (75°) and a risk of an extension deficit or flexion contracture
3. Postoperative swelling and effusion
4. Quadriceps inhibition and general lower limb weakness (MMT pending)
5. Reduced proprioception and balance
6. Risk of DVT/PE, wound infection and chest complications from reduced mobility
7. Fear of movement and anxiety, which may limit participation in therapy

3. Goals

• Pain at or below 3 to 4/10 at rest and below 5/10 with activity
• Knee flexion at least 90° and full passive extension (0°)
• Swelling reduced (girth within 1 to 2 cm of the pre-op or opposite side)
• Quadriceps lag absent or less than 5° (grade 3 or better)
• Independent bed mobility and transfers
• Independent walker gait on level ground with correct weight bearing
• Patient and family understand precautions and the home exercise programme (HEP)
• No complications (DVT, infection)

• Knee flexion 110 to 120° or more, extension 0°
• Quadriceps and hamstring strength at grade 4 to 5
• Independent walking without a device, with a normal gait pattern
• Independent on stairs (reciprocal pattern) and with sit-to-stand
• Independent in all ADLs, with return to work, household and community activities
• Good balance and a low fall risk
• Long-term adherence to a home programme and prosthesis care

4. Management by phase

Phase I: Acute / maximum protection (POD 0 to 2 weeks), your patient is here

• Pain and swelling:
  • Cryotherapy 15 to 20 minutes, several times a day
  • Limb elevation
  • TENS as an adjunct
  • Coordinate analgesia with the doctor, and time therapy about 30 to 45 minutes after analgesia
  • Compression stockings or an ankle pump routine
• Positioning: keep the knee in extension when resting. Do not put a pillow under the knee, to avoid a flexion contracture.
• Prevention of complications:
  • Ankle pumps (10 each hour)
  • Deep breathing and incentive spirometry
  • Early mobilisation
  • Watch for calf swelling or pain and escalate if present
• ROM:
  • Active-assisted knee flexion with heel slides, wall slides or a strap
  • Gentle passive extension (a towel roll under the heel)
  • CPM is optional. It has not been shown to give lasting benefit over exercise alone.
  • Do not force flexion, because forced manipulation increases pain, swelling and stiffness.
• Strengthening:
  • Isometrics: quadriceps sets, gluteal sets, hamstring sets
  • Static quad with a towel roll
  • Straight leg raises once there is no lag
  • Hip abduction in lying
• Mobility:
  • Transfers
  • Walker gait training with a heel-to-toe pattern and an upright posture
  • Hospital stair training before discharge
• Education:
  • Pain-coping advice
  • HEP
  • Precautions

Phase II: Subacute / early strengthening (week 2 to 6)

• Heel slides, stationary cycling (a half-revolution rock first, then a full circle as flexion allows), and prone hangs for extension.
• Open and closed chain strengthening: mini-squats, terminal knee extension with a band, step-ups (low), and hip abductor and extensor work.
• Gait training: progress from the walker to a stick or cane, then to no aid when there is no limp and no lag.
• Balance and proprioception: weight shifts, tandem stance, and single-leg stance with support.
• Scar mobilisation and patellar mobilisation once the wound has healed.
• Continue ice and swelling control after sessions.

Phase III: Late strengthening / functional (week 6 to 12)

• Progressive resistance exercise (leg press in a limited range, hamstring curls, calf raises, step-downs).
• Balance on uneven surfaces and with eyes closed.
• Stairs: reciprocal pattern, and descending.
• Treadmill and outdoor walking with endurance training.
• Task-specific training for sit-to-stand, car transfers and toileting.

Phase IV: Return to function / maintenance (3 months onward)

• A maintenance programme: swimming, cycling and walking.
• Avoid high-impact activity (running, jumping) and heavy kneeling.
• Check ROM, strength and gait at 3 and 6 months, then yearly.
• Educate the patient on prosthesis care, antibiotic cover for dental or other invasive procedures per the surgeon, and fall prevention.

5. Red flags to refer back to the surgeon

• Pain that is increasing or out of proportion, with a hot, red or draining wound
• Fever
• Calf swelling or tenderness, or sudden breathlessness or chest pain (DVT/PE)
• An inability to straight leg raise, or extension loss that is getting worse
• Flexion that is still below 90° by 2 to 3 weeks (consider manipulation under anaesthesia)

1. Assessment (Hoppenfeld and Ebnezar format)

2. Problem list

• Postoperative pain
• Swelling and wound care
• Reduced hip ROM, with a risk of flexion and adduction contracture
• Weakness of the hip abductors, extensors and quadriceps from surgery, trauma and disuse
• Risk of prosthesis dislocation, depending on the approach
• Risk of DVT/PE, chest infection, pressure sores and constipation
• Poor balance and a risk of falls
• Dependence in bed mobility, transfers and walking
• Dependence in ADLs
• Limited participation (toilet use, floor sitting, community mobility)
• Poor cognition, delirium or low confidence, which is common in this age group

3. Short-term goals (1 to 2 weeks)

• Pain at or below 3/10 at rest, and tolerable with activity
• Wound clean and swelling reduced
• No complications (DVT, chest infection, pressure sores)
• Independent bed mobility with the hip precautions followed
• Sit-to-stand and bed-to-chair transfers with minimal help
• Standing and walking with a walker, weight bearing as prescribed
• Hip flexion within the safe limit (90° for posterior approach), with knee and ankle ROM full
• Quadriceps, gluteal and hamstring strength at grade 3 or better
• Patient and family can state the precautions and perform the home exercise programme

4. Long-term goals (6 to 12 weeks and beyond)

• Pain-free or minimal pain
• Functional hip ROM for ADLs (flexion about 90 to 110° and good abduction)
• Strength grade 4 to 5 in the hip abductors, extensors and quadriceps
• Normal, safe gait with no Trendelenburg sign
• Walking independently, first with a stick and then without a device
• Stairs, car transfers and toilet use independently
• Independence in all ADLs
• Good balance and a low fall risk
• Return to prior household, community and recreational activity
• Long-term adherence to the home programme and bone health care (calcium, vitamin D, osteoporosis review)

5. Management by phase

Phase I: Acute (day 0 to about 2 weeks)

• Rockwood's principle is "Everything OUT, Everyone UP": get the patient out of bed on day 1, with weight bearing as tolerated using a frame. The text notes that older people cannot reliably limit weight bearing, and restriction leads to bed rest and deconditioning (Rockwood and Green's Fractures in Adults 10th ed, p. 2650).
• Pye's Surgical Handicraft says the patient normally gets out of bed on the first postoperative day and walks with a Zimmer frame the next day (Pye's Surgical Handicraft 22nd ed, p. 170).
• Positioning:
  • Keep the leg in slight abduction in bed, with a pillow between the knees if adduction is restricted.
  • For a posterior approach, avoid hip flexion beyond 90°, adduction past the midline and internal rotation. Use a raised toilet seat and a high chair.
  • If the approach was anterior or anterolateral, the surgeon may relax these restrictions.
• Pain and swelling: cryotherapy, elevation, positioning, and analgesia timed with therapy.
• Breathing: deep breathing, incentive spirometry and chest physiotherapy.
• Circulation: ankle pumps, calf muscle pumps and stockings. Watch for calf swelling or pain and refer promptly.
• Exercises:
  • Isometric quadriceps, gluteal and hamstring sets
  • Active ankle and knee exercises
  • Active-assisted hip abduction in lying, within the allowed range
  • Heel slides, within the flexion limit
• Mobility:
  • Bed mobility using a log-roll technique and a bridge
  • Transfers toward the operated side
  • Walker gait with a heel-to-toe pattern and weight bearing as tolerated
• Education: precautions, skin care and the home exercise programme.

Phase II: Subacute (week 2 to 6)

• Progress strengthening with active exercises: standing hip abduction, extension and flexion with support, mini-squats, and a bridge.
• Strengthen the abductors specifically (side-lying or standing, then with a light resistance band).
• Balance training: weight shifts, tandem standing, and standing on the operated leg with support.
• Gait: progress from the walker to elbow crutches or a stick when the pattern is steady. Correct any Trendelenburg gait.
• Stair practice with the good leg going up first and the operated leg going down first.
• Stationary cycling with a raised seat, if allowed.
• Continue the precautions, as advised by the surgeon.

Phase III: Strengthening and function (week 6 to 12)

• Progressive resisted exercises for the abductors, extensors, quadriceps and calf.
• Advanced balance and proprioception work.
• Walking endurance training, indoors and outdoors.
• Task-specific ADL training, including toilet use, car transfers and household activity.
• Wean off the stick as the gait and strength allow.
• Relax the precautions according to the surgeon.

Phase IV: Return to function (after 3 months)

• A maintenance programme of walking, swimming and cycling.
• Fall prevention advice and home modification.
• Avoid high-impact activity.
• Follow-up with X-rays and review for loosening, acetabular erosion and leg length.

6. Red flags to report to the surgeon

• Sudden severe pain, a shortened or rotated leg, or inability to bear weight (possible dislocation)
• Wound discharge, fever or redness
• Calf swelling, chest pain or breathlessness
• Increasing confusion or delirium
• Falls or uncontrolled pain