Companion to the Arthroplasty Quick Reference (perioperative pathway) and the patient hip replacement guides. Terminology here matches what patients are taught in those guides.
Approach & Evidence
With a modern posterior approach and a posterior soft-tissue (capsule/short-external-rotator) repair, recent high-level evidence shows that strict hip precautions do not reduce dislocation and do not improve early recovery. This protocol therefore uses minimal restrictions to speed return to normal function, with only common-sense avoidance of the extreme provocative position early. (If no posterior repair was performed or dislocation risk is high, apply standard precautions per surgeon.)
Precautions (Minimal)
- Weight bearing as tolerated with a walker/crutches, progressing to a cane and then none as gait normalizes. (Cementless implants may be protected per surgeon.)
- No formal ROM limits for routine cases. Early on, simply avoid the extreme combined position of deep hip flexion + adduction + internal rotation — patients are taught this as their “one position rule”: pulling the knee up high toward the chest while the leg turns inward and crosses the midline, for the first 6 weeks. Normal sitting, bending, stairs, and side sleeping are allowed as comfortable.
- No abduction pillow required — patients are explicitly told no pillow between the legs is needed. Resume normal daily activities as tolerated.
What the Patient Arrives With
- Spinal anesthetic + periarticular injection — expect a comfortable first day, with pain rising as it wears off. Walker use is emphasized during that window.
- Waterproof antimicrobial (silver) dressing, left undisturbed 5–7 days — showering with it on from POD 1 is expected. Sutures/staples out at the ~2-week visit.
- Scheduled multimodal analgesia: dexamethasone 16 mg PO on POD 1; celecoxib 200 mg BID (patients may substitute OTC naproxen or ibuprofen); acetaminophen 1,000 mg q8h × 2 weeks; opioids rescue only.
- Aspirin 81 mg BID × 4 weeks for VTE prophylaxis — note the longer course than TKA (a DOAC instead if elevated-risk). Mobilized the day of surgery.
- No abduction pillow, no strict precautions. Patients are told to take it relatively easy for ~6 weeks while bone grows into the implant, and that walking is most of their program.
Phase 1 · Weeks 0–2 (Mobilize Early)
- Get up and walk early and often; weight bearing as tolerated with an assistive device.
- Edema control and DVT prophylaxis; incision care.
- Ankle pumps; quad and glute sets; heel slides; hip abduction; glute bridges; standing hip exercises as tolerated.
- Gait training and stair training.
Phase 2 · Weeks 2–6 (Restore Gait & Strength)
- Wean from walker to cane to none as gait normalizes and quadriceps/abductor control returns.
- Progress hip strengthening — abductors (gluteus medius), extensors, and quadriceps; closed-chain mini-squats and step-ups; stationary bike; balance work.
- Resume normal ADLs (sitting low, bending, stairs) as comfortable.
Phase 3 · Weeks 6–12 (Strength & Endurance)
- Progressive resistance training; single-leg balance and proprioception; treadmill walking; advance functional activities.
- Return to driving and to work (desk ~2–4 weeks; physical/manual labor ~3–6 months) per surgeon.
Phase 4 · 12 Weeks+ (Return to Activity)
- Full strengthening and endurance; low-impact recreation (walking, cycling, swimming, golf, doubles tennis) as cleared; high-impact activity generally discouraged for implant longevity.
- Goals: symmetric hip and abductor strength, a normal gait without a Trendelenburg lurch, and full functional ROM.
References
- Hip precautions after posterior-approach THA do not influence early recovery: a systematic review and meta-analysis (8,835 patients). Acta Orthopaedica, 2023.
- Do hip precautions after posterior-approach THA affect dislocation rates? A systematic review of 7 studies (6,900 patients). PMC8023879.
- Are postoperative hip precautions necessary after primary THA using a posterior approach? Preliminary results of a prospective randomized trial. J Arthroplasty, 2020.
- A scoping review on the recommendations of hip precautions after posterior total hip arthroplasty. 2025.
Minimal-restriction protocol supported by current evidence for posterior-approach THA with posterior soft-tissue repair. Individualize to fixation, tissue quality, dislocation risk, and surgeon direction.