Total Hip Precautions: Anterior, Posterior & Lateral Approaches

As a licensed physical therapist I have seen hundreds, if not thousands, of total hip replacement surgeries over the more than 4 decades of treating patients as a hospital-based physical therapist, outpatient physical therapy owner/operator, and for the past several years seeing total hip replacement patients in their homes just a day or two after their surgeries.

I have seen the transition from ALL surgeons doing posterior approach total hip surgeries, to the currently popular anterior approach, with some surgeons doing variations like the lateral approach to hip replacement.

Each hip replacement approach has its own specific restrictions.

Additionally, there are many variations of the Anterior, Posterior, and Lateral surgical approaches and each surgeon has their own range-of-motion restrictions.
Always follow the surgeon’s specific range-of-motion restrictions, the surgeon is the only one that knows exactly what was done during the surgery.

What are the range-of-motion precautions for Anterior, Posterior and Lateral total hip surgical approaches?

  • Anterior: No extreme hip extension with external rotation.
  • Posterior: No hip flexion past 90 degrees, crossing the legs, or internal rotation.
  • Lateral: Same as posterior PLUS no active hip abduction.

What are the range-of-motion precautions for Anterior total hip surgical approach?

  • No extreme hip extension combined with external rotation such as kneeling on the operated leg with foot turned in, then moving body weight forward onto the opposite foot.

What are the range-of-motion precautions for Posterior total hip surgical approaches?

  • No hip flexion past 90 degrees.
  • No crossing legs that bring the operated leg past mid-line.
  • No internal rotation.

What are the range-of-motion precautions for Lateral total hip surgical approaches?

  • No hip flexion past 90 degrees.
  • No crossing legs that bring the operated leg past mid-line.
  • No internal rotation.
  • No active hip abduction exercises.

What are the non-range-of-motion precautions for ALL total hip replacement procedures?

  • No driving for 2 weeks after a left total hip replacement.
  • No driving for 3 weeks after a right total hip replacement.
  • No driving until the patient is off all opioids.
  • No dental work for 3 months.
  • Antibiotic before any dental work for life.

Anterior Approach Total Hip Replacement Precautions:

No extreme hip extension combined with external rotation with Anterior Approach:

Hip Extension & External Rotation

This is the position the surgeon places the leg in when they are dislocating the femoral head from the acetabular socket (hip socket), which they do to be able to remove the femoral head and prepare the acetabulum to receive the socket component of the total hip replacement surgery.

There are no muscles that are cut during this procedure but the front of the joint capsule must be cut in order to access the femoral head and socket. The joint capsule seals the hip joint, much like a zip-lock baggie, to keep the lubricating fluids inside the capsule and bathing the hip joint in this fluid.

This capsule will need to have time to heal before it can withstand the pressure from the femoral head as it rotates forward when the patient moves into the range-of-motion of external rotation and extension. This is the same motion the surgeon used to dislocate the hip through the anterior portion of the joint capsule.

The motion that would put the new hip in this extreme extension with external rotation would be something like kneeling on the operated leg with the foot turned out, then moving body weight forward onto the opposite foot.

The anterior approach to total hip replacement has the least amount of restrictions of any of the total hip surgical approaches.

Posterior Approach Total Hip Replacement Precautions:

No hip flexion greater than 90 degrees, no crossing the legs, and no internal rotation of the leg:

Hip Flexion Greater Than 90 Degrees
Leg Crosses Mid-Line
Internal Rotation

In the Posterior Approach to Total Hip Replacement, the patient is placed side-lying and the operated hip capsule is cut posteriorly.

The hip is dislocated through this posterior incision in the joint capsule by the surgeon taking the patient’s leg into flexion, internal rotation (pigeon-toe), and adduction (across mid-line of the body) to expose the femoral head and acetabular (hip) socket for preparation to receive the replacement components.

After surgery, moving the operated leg into flexion past 90 degrees, abduction past mid-line and/or internal rotation can move the femoral head against the posterior capsule’s incision risking dislocation or stretching out the capsule before it heals.

The capsule is one of the primary dislocation prevention structures, so care is taken by restricting range-of-motion until the capsule is well healed and capable of resisting dislocation.

The first 6 weeks are critical to maintaining these range of motion restrictions and these restrictions will remain precautionary for the rest of life.

After 6 weeks the capsule is usually well-healed but 12 weeks is usually considered the time frame for the hip capsule to fully heal.

No hip flexion past 90 degrees with the Posterior Approach:

The most common way that rule is broken is getting up from sitting and leaning too far forward.

Getting up from sitting, the patient must consciously remember to scoot to the front of the chair, extend the operated leg’s knee, and push themselves up with their arms and unoperated leg while keeping their trunk erect.

Sit To Stand with less than 90 degrees flexion
Sit To Stand with less than 90 degrees flexion

This is counterintuitive to the normal way to get up from a chair by leaning forward and pushing up with the legs.
The legs will continue to supply most of the muscle power to stand from sitting, but the arms become important to keep the trunk erect coming from sitting to standing.

Many of my patients with a posterior total hip replacement decide to get an electrical lift recliner chair to eliminate the difficulty of coming from sitting in a recliner chair to standing erect.

Another place my posterior approach hip replacement patients break the no hip flexion past 90-degree rule is when they are sitting on the commode. It is just a natural instinct to bend forward and lean on the thighs when sitting on the commode.

The lower the commode the more difficult the problem.
Comfort height commodes greatly decrease the patient’s tendency to lean more forward than allowed and makes it easier to come to standing without bending the hip more than 90 degrees.

Raised toilet seats or a 3-in-1 commode chair may be required for the patient to be compliant with flexion restrictions.

3-1 Commode Chair (Bedside, Toilet, Shower)

The 3-in-1 commode chair offers the additional benefit of having handholds to help with standing AND can be used in the shower as a shower chair.

3-1 Commode Chair Used As Shower Chair

No crossing legs with the Posterior Approach:

“No crossing the legs” is probably the most confusing instruction my patients receive.
See my article on No Crossing The Legs…..

They have been told not to cross their legs at the knee or the ankles.

They understand the concept of not crossing their legs at the ankles but most of my patients do not know what “don’t cross your legs at the knee” instructions mean. They think the restriction does not allow them to place the operated ankle on top of the unoperated knee in a “figure 4” configuration.
That Is Wrong!

Not crossing the legs at the knee really means not crossing the knee by sitting with their legs crossed with one knee stacked on top of the other knee. That is completely different from sitting with the ankle stacked on top of the knee forming a “figure- 4” type appearance.

“Knee Stack” Leg Crossing
“Figure-4” Leg Crossing

Crossing the leg at the knee and ankle would be more clear if the restriction simply said: “don’t cross the mid-line with the operated leg”.

A common way the “No Crossing Mid-line” rule is broken is by sleeping on the unoperated side and allowing the operated leg to drop down to the bed crossing the mid-line.

This mistake can be avoided by placing a body pillow between the legs when lying on the unoperated side, but the operated leg MUST be supported from the groin to past the ankle. A simple pillow will not work as it allows portions of the leg to be unsupported which develops a “fulcrum point” that translates into the operated hip.

Leg Crosses Mid-Line
Leg Supported With Pillows

No internal rotation with the Posterior Approach:

The most common way that rule is broken is by pivoting on the operated leg when turning in that direction.

Leg Is Internally Rotated

The example I give my patients is:
“Say you are standing and your spouse calls to you while standing on the side of the new hip.
In response to that call, you turn to the operated side by moving the unoperated leg across the front of the operated leg as the first step while the operated leg stays firmly planted on the floor.
You have now broken TWO of the restriction rules: the no internal rotation PLUS the no crossing midline restriction rules.

The solution is to ALWAY lead with the operated leg when turning toward the operated side.

Lead With The Operated Leg When Turning To That Side

Lateral Approach Total Hip Replacement Precautions:

The lateral approach to hip replacement, like the posterior approach, cuts the joint capsule in the posterior of the hip and the surgeon dislocates the femoral head through that incision to expose the femoral head and acetabular socket for preparation to receive the replacement components.

These same range-of-motions that are used to dislocate the hip at the surgery are the same range-of-motion movements that are restricted.

The same range-of-motion restrictions from the Posterior Surgical Approach (outlined above) apply to the Lateral Surgical Approach PLUS the restriction of no ACTIVE hip abduction (bringing the leg out to the side).

This restriction is in addition to the posterior approach restrictions because of the cutting or splitting of the hip abductors during surgery.

Passive range of motion into hip abduction is permissible but it must be totally passive with the patient completely relaxed and someone else passively moving the leg into abduction.

Many surgeons will prescribe a hip abduction brace to remind the patient they are not allowed to actively abduct the leg.

How long do hip precautions last after hip replacement?

Being compliant with range-of-motion restrictions for 12 weeks after Anterior, Posterior or Lateral hip replacement approach allows the joint capsule to heal and shrink enough to resist dislocation.
Posterior and Lateral surgical approach restrictions are completely different than for an Anterior surgical approach.

Over my career, I have seen several posterior approach total hip replacement dislocations, some as many as 20 years after surgery before they experienced their first dislocation.

Because of this, I recommend my posterior approach hip replacements follow the three restrictions for the rest of their lives. I don’t expect my patients to be as strict with the restrictions after 12 weeks but I do expect them to be aware of the restrictions and follow them as best they can after the 12-week mark.

I have yet to see a hip dislocation that has undergone an anterior approach to total hip replacement.

Anterior hip replacements are far less likely to dislocate than a posterior or lateral approach to hip replacement.

A research paper published in the US National Library Of Medicine: “Are Hip Precautions Necessary Post Total Hip Arthroplasty?” backs up my observation that Anterior Surgical Approach total hips restrictions having little or no effect on dislocations.

Happy Total Hip Recovery Without Dislocation

Perhaps you are approaching or already retire and wondering how you could earn extra money in retirement.
One option would be to do as I am doing.
Read my article How To Generate Retirement Income: Cash In On Your Knowledge.

See My Other Total Hip Replacement Articles:

How To Choose A Surgeon For Hip Replacement
Speed Up Recovery After Total Hip Replacement
Can I Sit In A Recliner After Hip Replacement
Crossing Legs After Total Hip Surgery: (A PT’s Complete Guide)
Stairs After Total Hip Replacement: A Physical Therapy Guide
Ice After Total Knee Replacement: A PT’s Complete Guide

Paying It Forward

Dr. Robert Donaldson

Dr. Donaldson is dually licensed; physical therapy in 1975 and doctor of chiropractic in 1995. He held credentials of Orthopedic Clinical Specialist in physical therapy for 20 years, QME in California, and taught at USC. He owns and operates an orthopedic physical therapy practice. See "About Me" page.

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