Total Hip Replacement, Total Knee Replacement
&
Lower Back Surgery
These three procedures, total hip replacement, total knee replacement, and low back surgery all involve precautions related to bending. The following charts will review precautions for each operative procedure, occupational therapy treatment techniques, and adaptations to compensate for bending.
Total Hip Replacement
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| Surgical Approach | Precautions | OT Intervention | Adaptive Equipment | Photo/Video |
| Posterior approach – the surgical incision is made just posterior to the hip joint, along the outer edge of the buttock. -most common surgical approach |
1. Avoid hip flexion past 90 degrees. 2. Avoid hip adduction (no crossing legs). 3. Avoid hip internal rotation. 4. Patients may also have weight bearing precautions on the affected leg, depending on what kind of shape the supporting bones are in post surgery. -no weight bearing -toe touch weight bearing -limits in the percentage of weight bearing  |
1. Educate the patient and patient’s caregivers in hip precautions. 2. Train in use of adaptive equipment to compensate for bending during hygiene, dressing, mobility, light household activity. 3. Improve overall strength and endurance post surgery. 4. Reinforce adaptive transfer techniques to/from bed, chair and toilet. 5. Evaluate the home for safety and needed adaptations. |
-Bedside commode or raised toilet seat -Shower chair with grab bars -Non-slip tub mat -Hand held shower -Long handled bath sponge -Reacher -Dressing stick -Sock aide -Long handled shoe horn -Walker or reclining wheelchair depending on weight bearing precautions |
A patient education video demonstrating getting in and out of bed following hip replacement surgery. Therapists demonstrate a car transfer following hip replacement surgery. A woman demonstrates how to put on compression stockings using a sock aide. |
| Anterior approach – the surgical incision is made along the front of the upper thigh. -good candidates for this approach may have a shorter recovery time. |
1. No extension of the hip backward. 2. No external rotation of the hip. 3. No hip adduction. |
1. Educate patient and patient’s caregivers in post surgical precautions. These are not as extensive as for the posterior approach. 2. Train in use of any needed adaptive equipment. 3. Improve overall strength and endurance post surgery if needed. -candidates for anterior surgery are often in good physical condition prior to surgery. 4. Reinforce adaptations to mobility during ADL and IADL tasks. |
Similar to posterior surgery, may not need as many adaptations for bending. | 
Link to a website discussing anterior hip replacement surgery. Physical therapists discuss precautions following anterior hip replacement surgery. |
Hip Surgery Precautions
Total Knee Replacement
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| Precautions | OT Treatment | Adaptive Equipment | Photo/Video |
| 1. No squatting. 2. No kneeling on the affected knee. 3. No pivoting or twisting the affected knee. 4. Knee must be flat when lying in bed. 5. Knee may be immobilized post surgery – specific precautions may be ordered by the surgeon. |
1. Educate patient and patient’s caregivers in post surgical precautions. 2. Train in use of any needed adaptive equipment. 3. Improve overall strength and endurance post surgery if needed. |
1. Walker/wheelchair immediately post surgery. 2. Bedside commode or raised toilet seat. 3. Shower chair with grab bars. 4. Long handled sponge. 5. Reacher. 6. Sock aide. 7. Long handled shoe horn. -patient may only need long handled equipment if in a knee immobilizer or if knee mobility is limited. -patient may not need adaptive equipment long term. |
A doctor discusses precautions following total knee replacement surgery. |
Knee Surgery Precautions
Lower Back Surgery
| Precautions | OT Treatment | Adaptive Equipment | Photo/Video |
| 1. No bending at the waist. 2. No lifting – will have lifting precautions in place. 3. No twisting at the waist. |
1. Educate the patient in body mechanics to avoid bending at the waist, lifting and twisting. -bend at the hips and knees -turn entire body when moving or carrying items. -log roll in bed to avoid twisting. -cross foot over opposite knee to don socks and shoes. -sit and pivot to enter/exit a vehicle. -get help to move heavy items. -do not carry children except for very small infants. 2. Help patient adapt home and work environments to avoid lifting and twisting tasks. -sit to bathe and dress. -store frequently used items between eye and waist level. -use long handled tools for housework, gardening -use a utility cart to move items rather than carrying them. |
1. Elevated toilet seat. 2. Long handled sponge. 3. Reacher. 4. Long handled tools for housework and gardening. |
Physical therapists demonstrate precautions and body mechanics following low back surgery. |
Lower Back Surgery Precautions
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Adaptive Equipment
The following chart provides descriptions and photos of adaptive equipment more commonly used for hip, knee and low back surgery.
| Name of Device | Description | Photo/Video |
| Raised toilet seat | A seat extension that is placed on the rim of the toilet, raising the sitting surface by 3 to 6 inches. |  |
| Shower chair | A plastic waterproof chair that may be placed in a shower. The chair may or may not have hand rails. |  |
| Bath bench | A bench or chair that extends across the top of the tub, allowing the person to sit on the edge, pivot the feet in the tub, and slide across until positioned over the tub. A bath bench may extend beyond the edge of the tub and may have legs that support it on the bathroom floor. |  |
| Hand held shower | A shower head attached to a handle and a hose that is mounted on the bath spigot or permanently mounted on the wall. When the shower is turned on, the shower head may be held by the handle and the water directed to different parts of the body. |  |
| Long handled sponge | A bath sponge mounted on a long plastic handle, used for bathing legs and feet without bending. |  |
| Reacher | A metal stick with a trigger handle on one end and a claw on the other. The claw closes when the trigger is pulled. |  |
| Dressing stick | A wooden dowel with plastic covered hooks on both ends. Used to hook and maneuver clothing. |  |
| Sock aide | A plastic curved device attached to two straps or a strap loop. The plastic may be cloth covered. The device is designed to allow a sock to be placed over the top, leaving an opening for the foot. The device curves around the bottom of the foot and holds the cuff of the sock as it is pulled on to the foot. |  |
| Long handled shoe horn | A metal or plastic shoe horn that is 24 to 31 inches long. |  |
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Special Considerations
The following chart addresses special circumstances and co-morbidities that might occur with total hip, total knee and low back surgeries.
| Co-morbidity or Circumstance | Considerations | OT Treatment |
| Alzheimer’s disease or senile dementia
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1. The patient may not have the cognitive ability to follow hip precautions or learn to use adaptive equipment. 2. The patient may not live independently due to his or her cognitive status. 3. If the patient does live independently, he or she may forget precautions or may not have the problem solving ability to adapt daily activities. |
1. Be sure to provide education to the patient’s caregivers. These may include family members, home health care staff, or nursing home/assisted living staff. -if the patient displays severe confusion, evaluate and document the patient’s cognitive status to allow staff to decide if the patient requires alarms or restraints to prevent injury. 2. Simplify precautions and write them in simple, large lettering for the patient. (i.e. “don’t bend to touch your feet”). 3. Work with family or caregivers to adapt the patient’s home environment. -remove safety hazards such as clutter, throw rugs -place frequently used items at easy to reach heights -label cupboards and closets if changes have been made |
| Osteoporosis
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1. The patient may have continued joint or back pain following surgery. 2. The patient may be on more stringent precautions due to the risk of repeat fractures. 3. The patient may take longer to heal. |
Follow physician’s orders regarding precautions, especially related to weight bearing and mobility. |
| Arthritis
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1. The patient may have other joints in need of replacement or may have had other joint replacement surgeries. 2. The patient may have mobility limitations in other parts of the body that may complicate or prolong rehabilitation. |
1. Check the patient’s medical history through documentation or interview to identify any other joint limitations or surgeries. 2. If the patient has had a similar surgery in the past, find out what they remember and what equipment they still have. Treatment may be shortened if the patient is familiar with precautions and equipment. 3. Adapt activities to accommodate other joint limitations, not just the surgical site. |
| Infection – the patient develops an infection in the surgical incision or develops a respiratory infection as a result of hospitalization.  |
1. The patient may be placed under additional precautions to allow the infection to heal, including additional activity restrictions. 2. Staff members, including therapists, may be required to follow Universal Precautions when treating the patient. 3. The patient will take longer to recover from surgery. |
Be aware of and follow all precautions prescribed for both the patient and staff. |
| Diabetes
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1. The patient may have limitations in tactile sensation or vision that interfere with daily activities. 2. The patient may take longer to recover from surgery. 3. The patient may be at higher risk for problems with skin integrity due to limited mobility. |
1. Provide the patient with positioning equipment that will help prevent skin breakdown. -gel or Roho cushion in wheelchair or sitting chair -heel and elbow protectors when in bed -special mattress for bed 2. Educate the patient in skin inspection techniques 3. Adapt activities to compensate for the patient’s other limitations. |
| Worker’s Compensation – if the patient’s surgery is the result of an injury from work. -may be a single incident or repetitive  |
1. The patient may be dealing with resistance from his or her workplace regarding reimbursement of medical expenses. -the patient may be involved in legal action against the workplace. 2. The patient may be experiencing pressure to return to work. 3. The patient may be questioning his or her ability to continue working in the same job or career. |
1. Frame the occupational therapy evaluation to address work related issues and eventual return to work. -develop short and long term goals that lead to return to work 2. Be aware of the documentation the workers compensation insurance company requires and make sure to address those requirements when writing notes and reports. -be sure to recertify occupational therapy treatment at the frequency required by the insurance company 3. Recommend or perform a functional capacity evaluation once the patient has been released from mobility restrictions to document ability to return to work. 4. Complete a work site evaluation prior to the patient’s return to work and recommend any needed adaptations to prevent additional injury. |
