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Thank you everyone for your thoughtful comments as to how you would proceed. I will start this blog post by providing you with my own take on the questions:
- What interventions or strategies do you presently employ to treat post-operative edema following a total hip procedure in the home health setting?”
ANSWER: The following interventions are commonly used in a home-health setting:
- Hip and leg exercises which include isometrics and AAROM / AROM
- Examples: Bridging, SLRs in all four planes, heel slides, ankle pumps and circles, with progression from supine exercises to exercises in standing.
- Functional exercises: Chair sit to stand and modified partial squats; heel raises.
- Gait training with assistive device and weight bearing as per protocol; encourage heel-toe gait as soon as possible.
- Possibly kinesiotaping of right hip.
- Pulsed ultrasound (not over hip prosthesis but over soft tissue bruising).
- General massage techniques.
- After examining the pictures of Mark’s right hip edema, do you consider the amount of edema as expected? Provide your clinical rationale.
Based on the picture, the swelling of the right thigh and the bruising is within the range of my expectation. There are many factors that influence the amount of post-operative edema in each client; however, this is what I consider “expected” based on the client’s age, past exercise history and general physical conditioning.
Mark is now 7 weeks post-op. He was discharged from home health physical therapy one week ago, and he has been referred to an outpatient orthopedic clinic for an evaluation and treatment per “total hip protocol.”
Mark is fully independent with all self-care activities; he ambulates with a cane for short distances, and uses a walker for distances > 250 feet. He is performing a home exercise program of straight leg raises, hip abduction, bridging, and ankle pumps: 2 sets of 15 repetitions daily. He also ambulates outside with his walker 15 minutes at a time, 2 X daily. Although able, he reports continued difficulty with sitting to stand transfers, overall fatigue, and that his right leg still feels weak.
Upon initial evaluation, the therapist at the outpatient clinic observes edema present in the right hip and entire thigh, to just above the knee on the right leg. Mark reveals that the swelling extends up to include the right pelvis, suprapubic region and scrotum. He reports he experienced a similar problem after the left total hip replacement and that the edema was very painful. He reports that the previous episode of edema involving the left hip took ~ 3 months to completely resolve; he’s hoping that it doesn’t take that long this time. Mark casually asks if this swelling has anything to do with him having prostate surgery secondary to cancer when he was 50 years old. (1 year prior to the L THR.)
Here are some additional questions to consider at this point:
- How does the presentation of edema affect your differential diagnosis process? What additional diagnoses could potentially explain this pattern of edema?
- What questions do you want answered to help you explain this pattern of edema?
- Does your treatment plan change as far as continuing with the total hip protocol? Does your treatment plan change with respect to specific interventions for edema management?
Enjoying this case study? Once you’ve had a chance to reflect and comment below, continue to the last part of Dr. Perdomo’s case study.