Effect of Prehabilitation in Form of Exercise and/or Education in Patients Undergoing Total Hip Arthroplasty on Postoperative Outcomes—A Systematic Review

The Effects of Structured Prehabilitation on Postoperative Outcomes Following Total Hip and Total Knee Arthroplasty: An Overview of Systematic Reviews and Meta-analyses of Randomized Controlled Trials

OBJECTIVE: To evaluate the effects of prehabilitation on postoperative outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA). DESIGN: Overview of systematic reviews and meta-analyses of randomized controlled trials. LITERATURE SEARCH: Guided by the PRIOR (Preferred Reporting Items for Overviews of Reviews) statement, a systematic search of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL (Cochrane Register of Controlled Trials) was conducted using the following overarching topics: hip, knee, arthroplasty, and prehabilitation. STUDY SELECTION CRITERIA: Systematic reviews, meta-analyses, or meta-regressions of randomized controlled trials that investigated how postoperative outcomes differed between patients who underwent primary THA or TKA and engaged in a structured prehabilitation program (exclusively resistance training [RT]-focused or multimodal with RT) or non-RT exercising controls. DATA SYNTHESIS: THA and TKA data were analyzed separately, with results delineated based on RT components (ie, weekly sets, frequency, and load) and the follow-up period (ie, short term: 1-3 years; midterm: 5-7 years; and long term: ≥10 years). RESULTS: Three systematic reviews and 21 meta-analyses (19 THA randomized controlled trials, 1110 THA patients; 46 TKA randomized controlled trials, 3362 TKA patients) ranging from critically low- to moderate-quality evidence were included. Prehabilitation was favorable for reducing the rate of complications, improving strength, objective function, quality of life, and self-reported function in patients undergoing THA and TKA. Effects were attenuated over time and were generally confined to the first 6 months. RT volume did not affect postoperative outcomes in 2 meta-regressions. No analyses evaluated how the manipulation of RT components affected postoperative outcomes. CONCLUSION: Prehabilitation reduced complication rates and improved objective and subjective postoperative outcomes following THA and TKA, with effects generally confined to the first 6 months. J Orthop Sports Phys Ther 2025;55(5):1-22. Epub 3 April 2025. doi:10.2519/jospt.2025.13075.

Patient-centered perspectives: A qualitative evaluation of the Hip Instructional Prehabilitation Program for Enhanced Recovery (HIPPER)

Over 55,000 total hip replacement (THR) surgeries were performed in Canada in 2021, with the number rising each year. Excluding rehabilitation, the cost of hip replacement procedures exceeded $675 million, a large burden on the Canadian healthcare system. Considering this large financial impact, prehabilitation delivered through electronic health (eHealth) can improve post-surgical outcomes and reduce overall healthcare expenditures by enhancing recovery and reducing hospital length of stay. This study utilized grounded theory to examine user experience of the Hip Instructional Prehabilitation Program for Enhanced Recovery (HIPPER), an eHealth approach to prehabilitation education. Participants were purposively sampled and conventional content analysis was conducted on 18 transcribed semi-structured interviews with participants who completed the HIPPER program in preparation for THR surgery. We identified three categories and seven subcategories: 1) 'That wasn't so hard!', with the subcategories easy to use, learning information and appreciating HIPPER, which describe how participants were able to learn information and use the modules easily; 2) 'I'm ready', comprising of the subcategories being prepared for surgery and having a smooth and good experience which relates to how participants were prepared and confident going into surgery; 3) 'I'd like to have seen', including the subcategories having differing experiences and suggesting additions, which explore participants' constructive criticism and ideas for improvement. Our results show useful features to include in eHealth programs and demonstrate how educational prehabilitation in the form of eHealth is helpful and usable for older adults undergoing THR. We also discuss and inform the integration of feedback and development of eHealth programs for elective surgical procedures. This study was registered with ClinicalTrials.gov on November 21, 2016 with the registration number NCT02969512.

Defining Clinically Meaningful Thresholds for 12-Month Patient-Reported Outcomes in Total Hip Arthroplasty; Toward Improving Threshold Accuracy

Background

Clinically meaningful thresholds for patient-reported outcomes are relevant to define and predict success of total hip arthroplasties (THAs). Defining and offering thresholds must consider preoperative symptom severity.

Methods

In this retrospective study of 40,213 primary total hip replacements registered in the Dutch Arthroplasty Register (2016-2018), receiver operating curve analysis was used to define minimal clinically important changes and patient-acceptable symptom states with the anchor transition in function. Subgroups were identified for which independent thresholds should be defined. Patient-reported outcome measures were symptoms (pain, Oxford Hip Score [OHS], Hip disability and Osteoarthritis Outcome Score) and quality of life (European Quality of Life 5 Dimensions 3L questionnaire).

Results

94.6% completed the anchor questions, of whom 80.1% reporting "much improved function" 1 year after surgery. Discriminative abilities of thresholds were not good (area under the curve < 0.8). Tercile-specific determination of thresholds improved discrimination and reliability (+10%). Minimal clinically important change values were higher for all outcomes (eg, change in OHS ≥ 24.5 vs ≥ 10.5) in patients with more severe preoperative symptoms. Patient-acceptable symptom state scores for European Quality of Life 5 Dimensions index (≥ 0.809) and OHS (≥ 40.5) showed good discrimination (area under the curve > 0.8). Patients with less symptoms required lower postoperative scores for reporting "much improved function" (postoperative OHS ≥ 38.5 vs 42.5). Tercile-specific thresholds did not improve accuracy of thresholds (Cohens kappa 42%).

Conclusions

The present study demonstrates that patients with more severe preoperative symptoms require greater change scores to achieve clinically relevant improvements than patients with less severe preoperative symptoms. This study suggests that current one-size-fits-all thresholds for success of THA should be replaced with more nuanced thresholds.

Level of evidence

Level III, Therapeutic Study.

Feasibility of a Multimodal Prehabilitation Program before Elective Knee and Hip Arthroplasty in Older Adults

OBJECTIVES

Hip osteoarthritis and knee osteoarthritis cause significant disability and pain in older adults, often leading to hip or knee replacement surgery. Prehabilitation programs have been established for these surgeries, but there are few programs for orthogeriatrics. We evaluated the feasibility of a new multimodal prehabilitation program (MPP) for older adults before hip or knee replacement due to arthrosis: the Prehabilitation for Os (PRE4OS) study.

DESIGN

We conducted a multicenter feasibility study in the Greater Paris area.

SETTING AND PARTICIPANTS

Eligible adults were aged ≥75 years old awaiting hip or knee replacement with at least a 6-week delay before surgery and able to participate in the MPP follow-up. The MPP included weekly hospital sessions providing nutritional, psychological, functional, and cognitive support, along with weekly home sessions featuring physiotherapist visits.

METHODS

The primary outcome was at least 80% of 1-day hospital (ODH) sessions performed by 80% of participants. Secondary outcomes included intervention achievement, quality of life, and nutritional and functional status changes. Participant's satisfaction was qualitatively assessed via structured phone interviews presurgery and at 30 days postsurgery.

RESULTS

From September 2021 to September 2023, a total of 27 individuals participated in the PRE4OS study. The mean (SD) age was 83 (4.3) years, with 7 males (26%) and median baseline Activities of Daily Living score 5.5 (interquartile range 5.5-6.0). Surgeries were for insertion of hip prosthesis in 17 participants (63%) and knee prosthesis in 10 (37%). The primary outcome was achieved in 89% of participants, with comparable rates for hip and knee prostheses. In total, 60% of participants rated the MPP as "excellent" presurgery and 100% at 30 days postsurgery, expressing a willingness to recommend the protocol to a friend or family.

CONCLUSION AND IMPLICATIONS

The MPP was feasible for individuals before hip or knee replacement and was well received. Further randomized trials are needed to assess its clinical impact.

Effects of Prehabilitation With Advanced Technologies in Patients With Musculoskeletal Diseases Waiting for Surgery: Systematic Review and Meta-Analysis

BACKGROUND

Prehabilitation delivered with advanced technologies represents a great chance for patients to optimize pre- and postoperative outcomes, reduce costs, and overcome travel-related barriers.

OBJECTIVE

We aim to evaluate the effects of prehabilitation delivered with advanced technologies on clinically relevant outcomes among patients affected by musculoskeletal diseases and waiting for surgery.

METHODS

We searched the PubMed, EMBASE, Cochrane Library, PEDro, and CINAHL databases up to February 2, 2023. ClinicalTrials.gov was also searched for registered protocols. Randomized controlled trials and nonrandomized intervention studies with adult participants of both sexes, affected by any musculoskeletal disease, and undergoing prehabilitation with advanced technologies or standard care were included. Study selection, data extraction, and critical appraisal were conducted in duplicate. Data were pooled for meta-analysis using random-effects models. Certainty of evidence was assessed for the primary outcome with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The primary outcome was function. Secondary outcomes were pain, strength, risk of fall, autonomy in the activities of daily living, patient satisfaction, health-related quality of life, adverse events, and adherence to treatment.

RESULTS

Six studies (7 reports), focusing on patients undergoing total knee or hip arthroplasty and primary meniscal tear and spine surgery were included. We found different prehabilitation programs: mindfulness-based stress reduction, exercise, education, or a combination thereof. Prehabilitation delivered with advanced technologies proved to be more effective in improving function in candidates for knee or hip replacement (Western Ontario McMaster Osteoarthritis Index "function" subscale before surgery: mean difference [MD] -7.45, 95% CI -10.71 to -4.19; I2=0%; after surgery: MD -7.84, 95% CI -11.80 to -3.88; I2=75.3%), preoperative pain (MD -1.67, 95% CI -2.50 to -0.48; I2=0%), risk of fall (MD -2.54, 95% CI -3.62 to -1.46; I2=0%), and postoperative stiffness (MD -2.00, 95% CI -2.01 to -1.99; I2=87%). No differences were found in pain 1 month after surgery. Data from studies including participants undergoing primary meniscal tear and spinal surgery could not be pooled.

CONCLUSIONS

Prehabilitation delivered with advanced technologies may be better than standard care in improving pre- and postoperative function among candidates for knee or hip arthroplasty. No quantitative results have been achieved on spine surgery candidates or other musculoskeletal diseases.

TRIAL REGISTRATION

PROSPERO CRD42022345811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=345811.

The use of digital health interventions to deliver prehabilitation in solid organ transplant recipients: are we there yet?

PURPOSE OF REVIEW

Prehabilitation, defined as preparing the body physically and psychologically for upcoming surgery is of increasing prominence in presurgical care. The aim of this review is to discuss the evidence base around prehabilitation in solid organ transplantation, the use of digital health as a tool to deliver these interventions, and consider future directions.

RECENT FINDINGS

Prehabilitation is of increasing interest as an adjunct to pretransplant care for individuals working up for solid organ transplantation. To date, research has shown that prehabilitation is acceptable and feasible; however, the literature base remains small. The majority of research has been delivered using in-person rehabilitation programmes, and the evidence base utilizing digital health as a means to deliver prehabilitation is limited.

SUMMARY

To date, the research evidence base in prehabilitation for solid organ transplantation is limited. Evidence in other surgical populations has demonstrated promising results, particularly in aerobic capacity, physical function and postoperative complications. Further high-quality randomized controlled clinical trials are required to strengthen the evidence base, understand how digital health can be harnessed and utilized to deliver multimodal prehabilitation with an aim to see how this may form part of routine care in the solid organ transplantation pathway.

Application of sensory and motor training in AIDET communication mode in patients after knee arthroplasty

BACKGROUND

Patients with knee arthroplasty often have problems such as slow recovery of knee function, which may cause negative emotions and affect their postoperative rehabilitation. The application of sensory and motor training in the Acknowledge, Introduce, Duration, Evaluation, Thank You (AIDET) communication mode in patients after knee arthroplasty can provide reference for the selection of postoperative rehabilitation training measures.

AIM

To explore the sensory and motor training effects in AIDET communication mode on knee function recovery and resilience of patients after knee arthroplasty.

METHODS

One hundred patients who underwent knee arthroplasty at our hospital between January 2022 and January 2024 were randomly divided into two groups. The control group (n = 50) received routine rehabilitation training. In the observation group (n = 50), the AIDET communication mode was used to perform sensory and motor training, in addition to routine rehabilitation training. The rehabilitation training was administered for 8 weeks. After surgery, knee function, balance ability, walking ability, proprioception, and resilience were compared between the two groups.

RESULTS

The New York Hospital for Special Surgery knee scores of the observation group at the time of discharge and 8 weeks after intervention were (65.23 ± 6.84, 84.53 ± 5.27), which was higher than those of the control group (61.03 ± 7.15, 74.92 ± 6.52) (P < 0.05). The balance ability of the observation group at the time of discharge and 8 weeks after the intervention was higher than that of the control group, the time of time up to go test was shorter than that of the control group, and proprioceptive function was higher than that of the control group (P < 0.05). The resilience level in the observation group after the intervention was higher than that in the control group (P < 0.05).

CONCLUSION

Sensory and motor training in AIDET communication mode promotes knee function recovery of patients after knee arthroplasty, improves their limb walking ability and balance function, and increases their resilience level.

Prehabilitation before general surgery: Worth the effort?

Prehabilitation, or interventions before surgery aimed at improving preoperative health and postoperative outcomes, has various forms. Although it may confer benefit to patients undergoing general surgery, this is not certain. Furthermore, although it may yield a net monetary gain, it is also likely to require substantial monetary and non-monetary investment. The impact of prehabilitation is highly variable and dependent on multiple factors. Physical function and pulmonary outcomes are likely to be improved by most forms of prehabilitation involving physical and multimodal exercise programmes. However, other surgical outcomes have demonstrated mixed results from prehabilitation. Within this issue, the measures used for evaluating baseline patient biopsychosocial health are important, and collecting sufficient data to accurately inform patient-centred prehabilitation programmes is only possible through thorough clinical and laboratory investigation and synthesised metrics such as cardiopulmonary exercise testing. Although a multimodal approach to prehabilitation is the current gold standard, societal factors may affect engagement with programmes that require a significant in-person activity. However, this is weighed against the substantial financial and non-financial investment that accompanies many programmes. The overall effectiveness and optimal mode of intervention across the discipline of general surgery remains unclear, and further research is needed to prove prehabilitation's full worth.

Resistance exercise training to improve post-operative rehabilitation in knee arthroplasty patients: A narrative review

Knee osteoarthritis is associated with deficits in muscle strength, muscle mass, and physical functioning. These muscle-related deficits are acutely exacerbated following total knee arthroplasty (TKA) and persist long after surgery, despite the application of standardized rehabilitation programs that include physical/functional training. Resistance exercise training (RET) has been shown to be a highly effective strategy to improve muscle-related outcomes in healthy as well as clinical populations. However, the use of RET in traditional rehabilitation programs after TKA is limited. In this narrative review, we provide an updated view on whether adding RET to the standard rehabilitation (SR) in the recovery period (up to 1 year) after TKA leads to greater improvements in muscle-related outcomes when compared to SR alone. Overall, research findings clearly indicate that both muscle strength and muscle mass can be improved to a greater extent with RET-based rehabilitation compared to SR. Additionally, measures of physical functioning that rely on quadriceps strength and balance (e.g., stair climbing, chair standing, etc.) also appear to benefit more from a RET-based program compared to SR, especially in patients with low levels of physical functioning. Importantly though, for RET to be optimally effective, it should be performed at 70%-80% of the one-repetition maximum, with 3-4 sets per exercise, with a minimum of 3 times per week for 8 weeks. Based upon this narrative review, we recommend that such high-intensity progressive RET should be incorporated into standard programs during rehabilitation after TKA.

Preoperative Sarcopenia Severity and Clinical Outcomes after Total Hip Arthroplasty

The outcome of total hip arthroplasty (THA) in patients with end-stage arthritis of the hip is associated with preoperative physical status. This study was performed to examine the relationship between the preoperative severity of sarcopenia and clinical outcomes after THA. This retrospective cohort study was performed among 306 consecutive patients (mean age: 63.7 ± 12.9 years, 222 women) undergoing THA at a university hospital. The severity of sarcopenia was determined based on the skeletal muscle mass index (SMI), handgrip strength, and gait speed according to the criteria of the Asian Working Group for Sarcopenia 2019. The severe sarcopenia prevalence rate was 10.6%. Severe sarcopenia was significantly associated with the risk of delayed functional recovery (adjusted odds ratio, 2.82; 95% confidence interval, 1.03-7.72; p = 0.043) compared with the non-sarcopenia group after adjusting for pre-existing risk factors, including preoperative hip function and physical activity. The addition of SMI, handgrip strength, and gait speed to the model for risk of functional recovery delay significantly increased the area under the receiver operating characteristic curve (p = 0.038). Severe sarcopenia was significantly associated with poorer hip function and patient-reported outcomes at 6 months after surgery compared with the non-sarcopenia group. Severe sarcopenia was adversely associated with postoperative clinical outcomes in patients undergoing THA.

[Exercise-Based Prehabilitation In Orthopaedics, Cardiology And Oncology]

Prehabilitation (prehab) aims to prepare patients for surgery, to reduce perioperative complications and to improve postoperative recovery. Pre-operative interventions depend on the indication and the specific patient characteristics and life circumstances. In orthopaedics, the focus is on preoperative improvement of physical performance, function and muscle strength through specific strength, mobility and sensomotoric training. In cardiology, endurance training and respiratory therapy are used in the preoperative phase, as well as coordination and strengthening exercises and occupational therapy to improve physical fitness and performance and reduce cardiovascular risk factors. In oncology, prehab is used preoperatively and also in addition to chemotherapy or radiotherapy to reduce medical side effects and to increase tolerance to cancer therapies (e. g. surgery, chemotherapy, radiotherapy). Exercise interventions in oncology differ according to the type of cancer (e. g. combined strength and endurance training, respiratory therapy, high-intensity interval training and walking). Study results often show positive effects on health resources using prehab. However, further high-quality clinical intervention studies are needed to confirm the clinical benefits of prehab for implementation in routine care.

The Effectiveness of Preoperative Outpatient and Home Rehabilitation and the Impact on the Results of Hip Arthroplasty: Introductory Report

A total hip replacement is the treatment of choice for end-stage hip osteoarthritis. Rehabilitation performed before surgery (called prehabilitation) is used to improve the results of surgical treatment. However, the results of studies have not unquestionably confirmed the effectiveness of preoperative rehabilitation and its impact on the outcome of surgery. The aim of this study is to assess the effectiveness of preoperative outpatient and home rehabilitation in relation to a control group not subject to these forms of influence. A total of 61 patients qualified for primary hip arthroplasty were randomly assigned to a group with outpatient rehabilitation before surgery, exercises performed at home, or a group without any intervention before surgery. Three weeks after surgery, the patients were re-qualified and underwent three weeks of outpatient rehabilitation in the day rehabilitation department. The patients from all three groups were evaluated in terms of functionality and pain using point scales upon enrolment in the study, on admission to the day rehabilitation department, and after 3 weeks of rehabilitation in the department. A total of 50 subjects completed the study. The study results did not reveal statistically significant differences between preoperative rehabilitation and no intervention. Patients rehabilitated at home gave up self-therapy more often than those undergoing outpatient rehabilitation.

The Impact of Sarcopenia Risk on Postoperative Walking Independence in Older Adults Undergoing Total Joint Arthroplasty

BACKGROUND AND PURPOSE

Sarcopenia is known to be associated with poor outcomes after arthroplasty; however, no study has reported the relationship between sarcopenia and postoperative walking independence. This study aimed to determine the impact of sarcopenia risk screening using the SARC-CalF questionnaire and calf circumference on the time to walk independently after total hip or knee arthroplasty in older patients.

METHODS

We included 599 nonobese patients aged 65 years and older who underwent unilateral and primary total hip or knee arthroplasty. Preoperative sarcopenia risk was assessed using the SARC-CalF or calf circumference. The outcome of this study was the time to independent walking after surgery; it was calculated as the number of days from the date of surgery to the date when the patient was able to walk independently. The association between preoperative sarcopenia risk and time to independent walking after surgery was analyzed using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

Among the 599 patients undergoing total joint arthroplasty, 175 (29.2%) were determined to be at risk of sarcopenia using SARC-CalF and 193 (32.2%) using calf circumference. The Kaplan-Meier curve showed that sarcopenia risk assessed by SARC-CalF or calf circumference was associated with a prolonged time to independent walking in patients undergoing hip arthroplasty (log-rank test, P < .001 and P < .001, respectively). In patients undergoing hip arthroplasty, the Cox proportional hazards model showed that SARC-CalF score of 11 points and greater or a calf circumference less than the cutoff was a risk factor for delayed time to independent walking (hazard ratios: 0.55 and 0.57, P < .001 and P = .001, respectively). There was no association between preoperative sarcopenia risk and postoperative time to independent walking in patients who underwent knee arthroplasty.

CONCLUSIONS

Sarcopenia screening tools, such as SARC-CalF or calf circumference, should be useful for planning postoperative rehabilitation in older adults scheduled for hip arthroplasty. However, the accuracy of SARC-CalF or calf circumference measurement in patients scheduled for knee arthroplasty may be low.

Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 3: Rehabilitation and Exercise

Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from 5 presentations given on hip-related rehabilitation at the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City.

Total Hip Arthroplasty-Current Challenges

In 1891, Professor Themistocles Glück in Germany was the first to replace a femoral head in hip joints destroyed by tuberculosis using ivory [...].

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis

Importance

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.

Objective

To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.

Data Sources

Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.

Study Selection

Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.

Data Extraction and Synthesis

Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Pain, function, muscle strength, and health-related quality of life (HRQOL).

Results

Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

Cost-Effective Healthcare in Rehabilitation: Physiotherapy for Total Endoprosthesis Surgeries from Prehabilitation to Function Restoration

Knee and hip joint replacements for the elderly are increasingly placing a burden on healthcare. Our aim was to verify the efficiency of the prehabilitation program among patients with knee arthroplasty (TKA) and hip arthroplasty (THA), taking into account the length and cost of postoperative rehabilitation and the restoration of function. We introduced a two-week preoperative physiotherapy program for patients awaiting knee and hip replacement surgery. We measured the duration and costs of the hospital stays, the active and passive range of motion of the hip and knee joints, and the quality of life. In the study, 99 patients participated (31 male, 68 female), with a mean age of 69.44 ± 9.69 years. We showed that, as a result of the prehabilitation program, the length of postoperative hospital stay decreased (THA: median 31.5 (IQR 26.5-32.5) vs. median 28 (IQR 21-28.5), TKA: median 36.5 (IQR 28-42) vs. median 29 (IQR 26-32.5)), and the patients' quality of life showed a significant improvement (TKA: median 30.5 (IQR 30-35) vs. median 35 (IQR 33-35), THA: median 25 (IQR 25-30) vs. median 33 (IQR 31.5-35)). The flexion movements were significantly improved through prehabilitation in both groups. Based on our positive results, we recommend the introduction of prehabilitation into TKA- and THA-related care.