A patient guide to hip resurfacing surgical management

Sanjeev Patil (Orthopaedic Hip Specialist)

Frank Gilroy (Senior Physiotherapist)

Joanne Dalglish (Student Physiotherapist)

Kevin Watson (Head of strength & conditioning at GSS)

Contents

• Anatomy of the hip
• Information on hip resurfacing
  • Why might you need hip resurfacing?
  • Eligibility for hip resurfacing surgery
• About the surgery
  • Surgical techniques
  • Possible advantages of hip resurfacing
• Post-surgery info
  • What to expect after the surgery?
  • Rehabilitation
• Pre-operative rehabilitation
• Immediate post-operative rehabilitation
• Phase 1
• Phase 2
• Phase 3
• Phase 4
• Phase 5
• References

Anatomy of the Hip

The hip is the main joint of the body which connects the trunk to the lower limb. It is known as a synovial, ball-and-socket joint consisting of the spherical head of the femur (ball) which fits in to the hollow acetabulum of the pelvis (socket). This structure allows for the joint to move in 6 motions:

• Flexion and extension
• Abduction and adduction
• External rotation and internal rotation

These motions are essential for movements used in activities such as walking, sitting or playing sport.

In the hip joint, bony surfaces of the ball and socket are covered with articular cartilage which is thicker in areas of weight bearing and allows for the smooth movement of bones. The joint is also encompassed by a synovial membrane which produces synovial fluid used to lubricate and reduce friction within the joint.

Unlike the flexibility in the ball-and-socket joint of the shoulder, the range of movement available at the hip is more restricted and is therefore considered to be one of the most stable joints within the body. This is because the hip has to be able to withstand weight bearing of the body in a variety of positions. Consequently, the hip joint receives support from surrounding anatomical structures and through its design.

These include:

1. Fibrocartilaginous ring (acetabular labrum)
2. Shape of the acetabulum creates a deep socket which encloses majority of the femoral head
3. Strong surrounding ligaments which are reinforced by their spiral structure and used to attach bone to bone
4. Surrounding muscles (glutes, iliopsoas, hamstrings, quadriceps, short lateral rotators, abductors, adductors) working in coordination to stabilise the joint

Information on Hip Resurfacing

Why might you need hip resurfacing?

Hip resurfacing is a form of hip surgery which may be used to help those suffering from arthritic changes. Damage is caused to the hip when cartilage covering our bone begins to wear away from overuse or injury and is commonly known as ‘wear and tear’. When cartilage degenerates, bone is exposed meaning there is less space inside our joints for normal movement. This then causes bone to rub on bone causing friction which will lead to the pain you are experiencing.

If hip resurfacing is to be considered, it should be noted that all other non-surgical treatment methods suggested by your Physiotherapist have been exhausted and are not proving effective.

Eligibility for hip resurfacing surgery

Hip resurfacing is a surgical option which may be offered to those experiencing ongoing pain. However, recommendation for the surgery is decided on an individual basis by a hip surgeon.

As hip resurfacing is a salvage operation, those with extreme arthritic changes and insufficient bone quality will not be considered and it may be recommended that a total hip replacement is more suitable. Bone must be of an adequate quality in order to reduce the risk of future damage or fracture. This is determined by the extent of the arthritic changes and the amount of intact, remaining bone.

Changes to the hip can be detected by x-ray or MRI/CT scan. This provides a clearer picture of the damage and arthritic changes within the joint.

Due to possible osteoporotic changes and gender specific differences in the structure of the hip, women tend not to be as well suited to this surgery as men.

The procedure of hip resurfacing is more commonly used in younger patients due to limitations in the longevity of a total hip replacement, generally about 15 years, increasing the likelihood of revision surgery being required later on in life for the patient.

If you experience any reduction in your quality of life or performance in sport caused by hip pain, it is worth exploring the option of hip resurfacing with your Surgeon.

Factors such as age, gender, weight and lifestyle would also be considered before decisions are made about the best treatment for your hip.

About the Surgery

Surgical techniques

Hip resurfacing is known as the alternative method to a traditional total hip replacement. The aim of the procedure is to reduce pain and increase mobility so you can achieve an improved quality of life with significantly increased function.

The procedure was first developed by consultant orthopaedic surgeon Derek McMinn in the 1960s and the most commonly used procedure is called the Birmingham Hip Resurfacing. Following agreed anaesthesia, the procedure begins by making a 15-20cm incision at the side of your hip. Your femoral head is then dislocated from the socket so the surgeon can trim away any damaged cartilage before reshaping the femoral head using special tools, ready for the prosthesis fitting. The hip joint is then relined by inserting a cup shaped, metal lining into the acetabulum and a metal cap is cemented over the femoral head before being relocated as a new hip joint. The incision is then stitched or stapled and dressed before you are returned to the ward for recovery.  The surgery usually lasts about 1½ to 3 hours in total.

Possible advantages of hip resurfacing compared to a total hip replacement:

• Preservation of bone – femoral head is not removed, just trimmed and capped
  • Reduced risk of complication for any future hip replacement surgeries

• Salvage hip operation
  • Can delay the need for a hip replacement

• Less risk of dislocation
  • Femoral head is anatomically matched to fit your acetabulum and the ball is large in size allowing for more stability
  • The ball in a total hip replacement is smaller, increasing risk of dislocation

• Greater range of movement achieved
  • It behaves like a normal hip allowing you to return to everyday activities

• The materials used in a Birmingham hip resurfacing are durable
  • Low wear rates

Post-surgery Information

What to expect after the surgery?

The aim of a hip resurfacing procedure is for you to regain significantly increased function in your hip. This will hopefully allow you to return to your normal daily activities with an improved range of movement. However, it is important you receive advice from your Surgeon on what they feel is achievable for your desired rehabilitation goals.

There is a lack of evidence on the life expectancy of a hip resurfacing procedure. Life-span of surgeries is dependent on factors such as age, gender and activity levels of an individual. Therefore, it may be that further surgery involving a total hip replacement is required in the future for some patients.

It is also important that you are committed to completing the following rehab programme, monitored by a Physiotherapist, in order to ensure the best results.

Rehabilitation

The recovery process after a hip resurfacing is similar to that of a total hip replacement. In general, it takes about 3 months for healing to occur but may take up to a year for full recovery, dependent on the individual. The recovery process is broken down into 6 phases:

Precautions to take whilst completing this programme (until advised otherwise by your Surgeon or Physiotherapist):

1. Do not bend your hip past 90 degrees
2. Do not cross your legs when standing, sitting or lying – you may find it comfortable to place a pillow under your knees (particularly if very swollen)
3. Do not allow your legs or feet to turn in
4. No running, jumping or twisting
5. If side lying when sleeping, place a pillow between your legs to prevent them from crossing over

NOTE:

Before starting the programme, please note that:

• Progressions throughout the programme, between and within phases, should be made only when advised by your Physiotherapist
• If at any point during your programme you begin to experience pain, stop the exercise and consult your Physiotherapist.  

Pre-op Rehabilitation

Aim: To help aid with your recovery post-op by exercising prior to surgery.

These exercises should be self-monitored and modified as appropriate because you want to be working at an intensity and for as long as you feel comfortable without aggravating your pain.

1. Cardiovascular exercise – most days per week

To help keep your heart and lungs healthy, do 20 to 30 minutes (depending on your fitness) of cycling, swimming or cross trainer to warm you up.

• This can be increased to 30-60 mins for more athletic individuals
• You should be working at a level which has you out of breath and unable to hold a full conversation

2. Gentle stretching – these stretches should be held for up to 30 seconds and repeated 2 to 3 times per day, 5 times per week ensuring not to aggravate the pain

Hamstring stretch:

Lying on your back and keeping your leg straight, use your hands/towel/strong resistance band to pull leg towards your body until you can feel a stretch at the back of your leg.

Calf stretch:

Place one foot in front of the other, keeping your toes and hips forward. Move your weight forward onto your front foot while keeping the back leg straight with your heel staying on the ground until you can feel a stretch at the back of your calf.

Quad stretch:

Standing on one leg with support if need be, hold your ankle. Gently bring your heel in towards your bottom until you can feel the stretch at the front of your thigh. Push your hips forward while tucking your bottom under to achieve a stronger stretch if needed.

Hip flexor stretch:

Kneeling on the floor with one knee, keep the front foot facing forwards. Push your hips forward while tucking your bottom under until you can feel the stretch at the front of the hip of your rear leg.

3. Range of movement – these movements should be repeated up to 15 times, 2 to 3 times every day

Hip flexion:

Lie with your back supported. Bring your hip and knee up towards your chest as far as comfortable and straighten back out.

Hip abduction:

Lie with your back supported. Keeping your leg straight, take your leg out to the side as far as comfortable and bring back in.

If appropriate, ask your Physiotherapist to instruct and supervise some of the following exercises – performed as dynamic stretches with a 10-30 second hold or as pain allows.

1. Lying hip rotations
2. Piriformis stretch
3. Butterfly stretch
4. Frog stretch
5. Pigeon stretch

4. Strength – 5 sec hold, 10-12 reps (or until tired), 2 to 3 times a day, 5 times per week

Side lying hip abduction:

Lie on your side. Keeping the leg straight and toes pointing forward, lift your top leg up to around mid-position, hold, and slowly lower back down. Make sure the leg does not drift forwards.

Straight leg raises:

Lie with your back supported. Keep the knee straight and tighten your quads. Lift your leg up towards the ceiling to around mid-position, hold, and slowly lower back down.

Sit to stand:

Start seated in a chair. With your arms across your body, slowly rise from the chair. Once standing, lower yourself back down into the chair without using your hands. Make sure to keep the movement controlled so you are not falling into the chair.

• For athletic individuals this can be completed as single leg or as a goblet squat with a kettlebell.

5. Pool work with range of movement – approximately 20-minute workout, 4 to 5 times per week

Aqua walking: walking in water using your arms and legs in the same motion as you would if you were on land.

Flexibility: perform stretching exercises while taking a rest in between walking sets.

Immediate Post-op Rehabilitation

Aim: To mobilise with assistance/crutches and gradually beginning to work on range of movement.

Criteria to enter immediate post-op rehab: first few days after surgery

Using your crutches:

Weight bearing and crutch use is dependent on Surgeon’s opinion so before progressing with mobility be sure to ask what they want you to do. Unfortunately, duration of your crutch use is indeterminable due to variation amongst individuals so be sure to follow Surgeon’s advice.

Follow advice on crutch technique from your Physiotherapist.

How to treat inflammation (swelling, redness, heat, pain, loss of function)

Protection: Protect the hip form any further injury

Rest: Reducing your activity level by use of task prioritising or using your crutches

Ice: Once advised by your Physiotherapist or Surgeon and wound is healing, start applying an ice pack every 2-3 hours for 20 mins. Don’t place ice directly on to the skin, instead wrap it in a damp towel to prevent burning the area

Compression: Use compression socks if required to reduce swelling

Elevation: Try to have the leg elevated when resting but ensure not to have the hip flexed past 90 degrees

Exercises

1. Circulation – 15 times, or as pain allows, every 2 hours

Ankle pumps:

Lie with your back supported and legs out straight. Point your toes towards you, then point your toes away from you.

Ankle circles:

Lie with your back supported and legs out straight. Circle your ankles, then turn your feet in towards each other, then turn your feet out away from each other.

2. Range of movement in lying – 15 times, or as pain allows, every 2 hours

Hip flexion:

Lie with your back supported. Bring your hip and knee up towards your chest as far as comfortable, no more than 90 degrees flexion.

Hip Abduction:

Lie with your back supported. Keeping your leg straight, take your leg out to the side as far as comfortable and bring back in.

3. Strength – hold for 5 seconds, repeat until muscles feel tired, 3-4 times per day, 5 days per week

Static quadriceps:

Lie with your back supported and place a pillow or towel under your knee. Gently press the knee in towards the bed, ensuring to squeeze your thigh muscles at the same time.

Static glutes:

Lying on your front, squeeze your bottom muscles together. Feel free to use your hands as guidance to ensure proper muscle activity.

Phase 1: Week 1 to 2

Aim: To reduce swelling, decrease pain and starting to regain some range of movement back into the hip. Start some basic isometric work to activate muscles again.

Criteria to enter phase 1:

• Discussed progression to phase 1 with your Physiotherapist
• Reduction in pain and inflammation
• Wound healing well with no signs of infection
• Beginning to weight bear more with assistance of crutches

At this stage it may be that you can start reducing the amount of support you have when walking whilst ensuring not to limp. Advice on what walking aid should be used will be advised by your Surgeon at this point.

Exercises

1. Range of movement – continue with circulation and lying exercises from immediate post-op phase. Add in standing exercises as advised by your Physiotherapist – 15 times, or as pain allows, every 2 hours

Hip flexion:

Stand with support. Bring your knee up towards your chest as far as comfortable and straighten back out – do not go past 90 degrees/hip height.

Hip Abduction:

Stand with support. Keeping your leg straight, take your leg out to the side as far as comfortable and bring back in.

2. Strength – hold for 5 seconds, repeat until muscles feel tired, 3-4 times per day, 5 days per week

Static quads:

Lie with your back supported and place a pillow or towel under your knee. Squeezing your thigh muscles gently press the knee in towards the bed.

Static inner quads:

Lie with your back supported and place a rolled-up towel underneath your knee. Tightening your quads and straighten your knee.

Static hamstrings:

Lie with your back supported. Bend your knee and dig your heel in towards the bed, ensuring to tighten the muscles at the back of your thigh. Do not flex the hip past 90 degrees.

Static adductors:

Lie with your back supported, bend both legs up and place a rolled-up towel or pillow between your knees. Gently squeeze your knees together so you feel the muscle on the inside of your thigh working. Do not flex the hip past 90 degrees.

Static glutes:

Lying on your front, squeeze your bottom muscles together. Feel free to use your hands as guidance to ensure proper muscle activity.

Phase 2: Week 3 to 6

Aim:  To gradually start increasing the load on the joint with strengthening exercises, using resistance if appropriate. Working on a normal walking pattern without crutches.

Criteria to enter phase 2:

• Discussed progression to phase 2 with your Physiotherapist
• Pain and inflammation are minimal
• Wound is healing well and no signs of infection, stitches/staples removed
• Range of movement has reached goals from phase 1

Exercises

1. Cardiovascular – 5 to 10 minutes, 5 times per week, LOW resistance

Bike: ensure bike is in a high seat position to prevent hip flexion past 90 degrees

Walking: as able but making sure not to limp

IF APPROPRIATE – check with Surgeon that wound is healed and stitches/staples removed before getting into the pool

2. Pool work with range of movement – approximately 20 to 30-minute workout, 4 to 5 times per week

Aqua walking/jogging: walking/jogging in water using your arms and legs in the same motion as you would if you were on land.

Flexibility: perform extension, flexion, abduction exercises whilst taking a rest in between sets.

3. Gentle stretching – these stretches should be held for up to 30 seconds and repeated 2 to 3 times per day, 5 times per week ensuring not to aggravate the pain

Hamstring stretch:

Lying on your back and keeping your leg straight, use your hands/towel/strong resistance band to pull leg towards your body until you can feel a stretch at the back of your leg.

Calf stretch:

Place one foot in front of the other, keeping your toes and hips forward. Move your weight forward onto your front foot while keeping the back leg straight with your heel staying on the ground until you can feel a stretch at the back of your calf.

Quad stretch:

Standing on one leg with support if need be, hold your ankle. Gently bring your heel in towards your bottom until you can feel the stretch at the front of your thigh. Push your hips forward while tucking your bottom under to achieve a stronger stretch if needed.

Hip flexor stretch:

Kneeling on the floor with one knee, keep the front foot facing forwards. Push your hips forward while tucking your bottom under until you can feel the stretch at the front of the hip of your rear leg.

4. Strength – hold for 5 seconds, repeat until muscles feel tired, 3-4 times per day, 5 days per week, increase resistance as advised by your Physiotherapist (no band > yellow > red > green > blue > black)

Straight leg raises:

Lie with your back supported. Keep the knee straight and tighten your quads. Lift your leg up towards the ceiling to around mid-position, hold, and slowly lower back down. For progression, add a resistance band around both ankles and perform the movement as normal.

Inner range quads:

Lie with your back supported and place a rolled-up towel underneath your knee. Tighten your quads and straighten your knee. For progression, add a resistance band around both ankles and perform the movement as normal.

Side lying hip abductions:

Lie on your side. Keeping the leg straight and toes pointing forward, lift your top leg up to around mid-position, hold, and slowly lower back down. Make sure the leg does not drift forwards. For progression, add a resistance band around both ankles and perform the movement as normal.

Glute bridging:

Lie on your back and bend your knees up to rest your feet on the floor, ensuring they are hip width apart. Tighten your core muscles and lift your bottom up off the floor, trying to keep your body in a straight line. Do not let your hips drop. Hold for up to 1 minute. For progression, add a resistance band around both knees and perform the movement as normal.

5. Gait re-education

• Ensure you are achieving enough hip flexion to clear the ground as you swing your leg through.
• Equal weight bearing on operated and unoperated side.
• Ensuring a step-through pattern is being achieved.
• No limping.

Phase 3: Week 7 to 9

Aim:  Considering return to work if Surgeon says it is appropriate to do so. Gradually progressing to performing light activities.

Criteria to enter phase 3:

• Discussed progression to phase 3 with your Physiotherapist
• Walking unassisted and without a limp
• Range of movement goals from phase 2 have been reached
• Progression onto harder resistance bands have been made for strengthening exercises

Exercises

1. Continue with cardiovascular work from phase 2 – increase the resistance and duration as advised by your Physiotherapist

Cross trainer

Bike: ensure bike is in a high seat position to prevent hip flexion past 90 degrees

Walking: as able but making sure not to limp

2. Continue with pool work – 30-minute session

Aqua walking/jogging: walking/jogging in water using your arms and legs in the same motion as you would if you were on land.

Exercises for between walking/jogging sets – 15 reps on each leg – ask your physiotherapist to show you how to perform the following:

1. Squats (single leg and double leg)
2. Calf raises (single leg and double leg)
3. Step-ups (forward/backward and sideways)
4. Knee to chest with rotations
5. Cycling holding onto the wall

3. Continue with stretches from phase 2

4. Strength – hold for 5 seconds, repeat until muscles feel tired, 4 times per day, 5 days per week, increase resistance as advised by your Physiotherapist (no band > yellow > red > green > blue > black)

Wall Squats:

Start with your feet hip width apart, approx. 1 step away from the wall. Lean your back against the wall. Slowly slide down the wall to around 80 degrees hip flexion before sliding back up to the starting position. Do not perform a deep squat.

Kneeling kickbacks:

Start on your hands and knees. Tighten your core and without letting your back arch, lift your operated leg up to be in line with your back/hips. Keep the knee bent. Slowly lower back down and repeat on the alternate leg.

Plank:

Lie face down and push up on to your elbows and toes into the plank position. Keeping the body in a straight line without your hips dropping or bottom lifting, hold this position for up to 1 minute.

Single leg glute bridging:

Perform glute bridge as before but try with one leg lifted off the ground.

Side plank:

Lie on the unoperated side to start. Push up onto your elbow and lift your hips up off the ground. Keep your feet together. Hold for up to 1 minute. Switch on to the operated side and repeat.

Step ups:

Start in standing with the box or step in front. Leading with the operated leg, step up on to the box or step, followed by the unoperated leg. When coming down, step back with the operated leg leading, followed by the unoperated leg. Then repeat this exercise facing to the side to perform a side step up.   

5. Balance and proprioception – perform for 1 to 2 minutes, 4 to 5 times per week

Balance board:

Using the wobbleboard, place both feet on and try to stop the board from touching the ground.

Single leg standing:

Stand on one leg and try to hold your balance. You can hold on to a stable surface for support to begin with if need be. Reduce the hand support as you feel able.

Phase 4: Week 10 to 12

Aim:  Full range of movement achieved with no pain. Improve balance and proprioception. Start to prepare for return back to activity after 3 months if appropriate.

Criteria to enter phase 4:

• Discussed progression to phase 4 with your Physiotherapist
• Regained full range of movement
• Strength is improving, muscle bulk is increasing
• Able to perform light activities

Exercises

1. Continue with cardiovascular work from phase 2 – increase the resistance as advised by your Physiotherapist, 20-30 minutes continuous

Cross trainer

Bike: ensure bike is in a high seat position to prevent hip flexion past 90 degrees

Treadmill walking: ensure you are wearing good footwear and making sure not to limp

2. Continue with pool work from phase 3

Use pool as a light recovery session between days performing strengthening exercises.

3. Continue with stretches from phase 2

4. Strength – hold for 5 seconds, repeat until muscles feel tired, 4 times per day, 5 days per week, increase resistance as advised by your Physiotherapist (no band > yellow > red > green > blue > black)

Resisted side stepping:

Start standing with resistance band around both ankles. Take two steps to the right and then two steps to the left. Ensure tension is achieved in the resistance band whilst performing the movement.

Resisted hip circles:

Start standing with a resistance band around both ankles. Bring leg out in front and round in a semi-circular motion before returning to the starting position. Ensure tension is achieved in the resistance band whilst performing the movement. Repeat using the other leg.

Lunges (forwards and backwards):

Start standing with feet together. With one leg, lunge forward to around 80 degrees hip flexion before returning to the starting position. Repeat this process lunging backwards then switch legs. Do not perform a deep lunge and OR any weight at this stage.

Squats:

Start standing with your feet hip width apart, keeping the trunk upright and facing forward. Bend your knees and lower your body to about 80 degrees hip flexion before slowly returning to stand. Do not perform a deep squat OR use any weight at this stage.

Leg press:

Ask your Physiotherapist to show you how to set up and use the leg press machine before starting – if available and appropriate.

Adductor machine:

Ask your Physiotherapist to show you how to set up and use the adductor machine before starting – if available and appropriate.

Hamstring curl machine:

Ask your Physiotherapist to show you how to set up and use the hamstring curl machine before starting – if available and appropriate.

Knee extension machine:

Ask your Physiotherapist to show you how to set up and use the knee extension machine before starting ­– if available and appropriate.

Plank:

Perform plank as before but try with a single leg and adding a resistance band around both ankles.

Side plank:

Perform side plank as before but try with a single leg and adding a resistance band around both ankles.

5. Balance and proprioception – perform for 1 to 2 minutes

Balance board with eyes shut:

Perform balance board as before but try closing one or both eyes.

Single leg standing:

Perform single leg standing as before but try closing one or both eyes.

Single leg catching/throwing:

Standing on one leg, get someone to help you by throwing and catching the ball or alternatively you can throw the ball off of the wall. The smaller the ball, the harder it will be.

Phase 5: 3 to 6 months onwards

Suitable for those who aim to return to sport but you must discuss this with your Surgeon BEFORE starting this phase to find out whether this an appropriate option for you.

AIM: if appropriate, returning to sport performed prior to surgery

Criteria to enter phase 5:

• Discussed with your Surgeon and Physiotherapist about your suitability to return to sport
• Good range of movement
• Good muscle strength
• Able to perform light activities with ease

Advice:

Returning to your sport will require individual demands and therefore will determine which form of rehab is appropriate for you. We advise that you talk to your Physiotherapist or Coach to agree on a sport specific programme which is going to help you meet the skills required for your sport of choice.

Suggestions of exercises you may wish to include in order to get you ready to return to sport involve:

• Strengthening
• Flexibility
• Cardiovascular
• Balance
• Plyometric

Testing:

Before returning to sport it is also important that you complete all testing required to ensure you are fit enough following your surgery.

Testing methods used will be decided in conjunction with your Physiotherapist.

Running

If your Surgeon and Physiotherapist allow a gradual return to running, please follow the Frank Gilroy ‘Calf Injury Rehabilitation Programme’ online for instruction.

• The Gilroy ‘Return to Running’ model can be found in the ‘Phase 4 – General Mobility and Cardiovascular Programme’ section of the programme. 

References

BARKER, K. L., NEWMAN, M. A., HUGHES, T. et al., 2013. Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme. Clinical Rehabilitation. 27(9), pp. 771-784. Available from:   https://journals.sagepub.com/doi/pdf/10.1177/0269215513478437

JOGI, P., OVEREND, T. J., SPAULDING, S. J. et al., 2015. Effectiveness of balance exercises in the acute post-operative phase following total hip and knee arthroplasty: A randomized clinical trial. 3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679229/

KOLBER, M. J., BRUEILLY, K., SCHOENFELD, B. J. et al., 2013. Post-Rehabilitation Exercise Considerations Following Hip Arthroplasty. Strength and Conditioning Journal. 35(4), pp.19-30. Available from: https://www.researchgate.net/publication/258698884_Post-Rehabilitation_Exercise_Considerations_Following_Hip_Arthroplasty/link/59dc0572458515e9ab45284d/download

MARKER, D. R., SEYLER, T. M., BHAVE, A. et al., 2010. Does commitment to rehabilitation influence clinical outcome of total hip resurfacing arthroplasty? Journal of Orthopaedic Surgery and Research. 5(20). Available from: https://josr-online.biomedcentral.com/articles/10.1186/1749-799X-5-20

NHS, 2019. Hip Resurfacing. NHS. Available from: https://www.dchft.nhs.uk/patients/departments-G-O/hip/Pages/Hip-Resurfacing.aspx

SIVERLING, S., FELIX, I., CHOW, S. B. et al., 2012. Hip resurfacing: not your average hip replacement. Current Reviews in Musculoskeletal Medicine. 5(1), pp.32-38. Available from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535122/

SU, D. C., YUAN. K, WENG, S. et al., 2015. Can Early Rehabilitation after Total Hip Arthroplasty Reduce Its Major Complications and Medical Expenses? Report from a Nationally Representative Cohort. BioMed Research International. 2015(641958). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471248/

VILLALTA, E. M. & PEIRIS, C. L., 2013. Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopaedic surgery: a systematic review and meta-analysis. Archive of Physical Medicine and Rehabilitation. 94(1), pp. 138-148. Available from: https://www.ncbi.nlm.nih.gov/books/NBK126935/