The Importance of Prehabilitation for Total Knee and Hip Replacements.

In Australia, total hip and knee replacements are on the rise, driven by an aging population and an increase in lifestyle-related conditions like osteoarthritis. However, while these surgeries are often highly effective, they come with challenges such as long recovery periods, post-operative complications, and delayed rehabilitation. Prehabilitation (prehab) plays a crucial role, as this is the practice of preparing a patient both physically and mentally for surgery, potentially improving outcomes and enhancing recovery after the operation.

Prehabilitation, as a structured program of physical conditioning, education, and mental preparation before surgery, can help patients experience shorter hospital stays, reduced complications, and faster recovery. This blog explores the significance of prehabilitation in relation to total hip/knee replacements with a focus on Australian statistics and references to relevant studies.

Enhancing Physical Fitness and Strength Before Surgery

In Australia, osteoarthritis (OA) is one of the leading causes of elective joint replacement surgeries, with the Australian Institute of Health and Welfare (AIHW) reporting that in 2021 59,000 knee and 41,000 hip replacements were performed, and are projected to rise significantly by 2030. Many patients who undergo these surgeries suffer from chronic pain and impaired mobility, leading to physical deconditioning. A lack of muscle strength around the joint or surgical site can hinder the recovery process.

Prehabilitation aims to address these issues by enhancing strength, flexibility, and fitness before surgery. By focusing on strengthening the muscles surrounding the affected joint (such as the quadriceps before knee replacement surgery), prehab helps reduce stress on the joint, enhancing post-surgical outcomes. Evidently, a study by Higgins et al. (2018) demonstrated that preoperative exercise programs for hip and knee replacement patients significantly reduced postoperative pain and improved mobility, showing a clear benefit of prehabilitation in orthopaedic elective surgery.

Reducing Surgical Risks and Complications

While orthopaedic surgeries are generally safe, complications such as infections, blood clots, and delayed wound healing can occur. According to Baran et al (2024), a retrospective study that researched if modifiable factors increase the risk of post-operative complications after a total joint arthroplasty, the rate of increased post-operative medical and surgical complications after TJA increased with patients that had modifiable risk factors. These risk factors included narcotic abuse, tobacco use, and diabetes mellitus. Prehab programs focusing on strengthening exercise, nutrition, lifestyle decisions and cardiovascular fitness can aid in reducing post-operative and surgical complications.

Optimising Post-Surgical Recovery

The recovery process after total hip/knee replacements can be challenging, particularly for older adults or those with underlying health conditions. Prehabilitation not only improves physical fitness but also helps patients recover more quickly by preparing them to participate actively in post-surgical rehabilitation. A systematic review by Almeida et al (2021), demonstrated that prehabilitation reduced length of hospital stay by 1 to 2 days in total joint arthroplasties. 

Cost-Effectiveness of Prehabilitation

While prehabilitation requires an initial investment of time and resources, it can result in significant cost savings by reducing the likelihood of complications, shortening hospital stays, and speeding up recovery. This is particularly relevant in the Australian healthcare system, where the cost of treating complications and extended hospital stays can be substantial. A report from the AIHW in 2020 estimated that the direct cost of hospital care for elective joint replacement surgeries in Australia exceeded AUD 1 billion annually. By reducing the length of hospital stays and the need for extended physical therapy, prehabilitation can potentially lower these costs, making it a highly cost-effective intervention.

When to Start Prehabilitation

Starting prehabilitation can be started at the  6 week mark before the operation at latest, or preferably a prehab program can be up to 6 months in relation to knee and hip replacements. Studies have shown that patients who are going to undergo a total knee/hip replacement, and participate in water/land-based exercises focusing on strength, flexibility and aerobic capacity, it can reduce the probability of needing inpatient rehabilitation by up to 73% (Arthritis Foundation).

Conclusion

Prehabilitation is more than just a trend in orthopaedic surgery; it is an evidence-based approach that significantly enhances surgical outcomes, reduces complications, and speeds up recovery. Australian studies and healthcare professionals alike have recognized its value in preparing patients for surgery and improving their overall quality of life post-operatively.

From reducing surgical risks to optimizing recovery and long-term outcomes, prehabilitation is a critical element of the orthopaedic surgical journey. If you are preparing for a total hip/knee replacement, it’s essential to speak with a physiotherapist about incorporating prehabilitation into your surgical plan. By taking proactive steps to improve your physical and mental health before surgery, you are setting yourself up for a faster, more successful recovery.

 

References:

  • Higgins, T. et al. (2018). Effectiveness of preoperative exercise programs in patients undergoing hip and knee replacement: A systematic review. Australian and New Zealand Journal of Surgery.
  • Keogh, J. et al. (2019). Prehabilitation for joint replacement surgery: Impact on recovery and hospital stays. The Medical Journal of Australia.
  • AIHW. (2020). Hospital statistics: The cost of elective surgery in Australia.
  • Journal of Orthopaedic and Sports Physical Therapy. (2021). Prehabilitation and post-operative outcomes in joint replacement surgeries: Evidence from Australian research
  • Almeida, G. J., Khoja, S. S., & Zelle, B. A. (2020). Effect of Prehabilitation in Older Adults Undergoing Total Joint Replacement: an Overview of Systematic Reviews. Current Geriatrics Reports, 9(4), 280–287. https://doi.org/10.1007/s13670-020-00342-6
  • Baran, J. V., Rohatgi, A., Redden, A., Fomunung, C., Goguen, J., John, D. Q., Aghdas Movassaghi, Jackson, G. R., & Sabesan, V. J. (2024). Do modifiable patient factors increase the risk of postoperative complications after total joint arthroplasty? Archives of Orthopaedic and Trauma Surgery, 144(2). https://doi.org/10.1007/s00402-024-05588-9
  • Ackerman, I. N., Soh, S.-E., & de Steiger, R. (2022). Actual versus Forecast Burden of Primary Hip and Knee Replacement Surgery in Australia: Analysis of Data from the Australian Orthopaedic Association National Joint Replacement Registry. Journal of Clinical Medicine, 11(7), 1883. https://doi.org/10.3390/jcm11071883
  • Pre-hab for Surgery | Arthritis Foundation. (n.d.). Www.arthritis.org. https://www.arthritis.org/health-wellness/treatment/joint-surgery/preplanning/pre-hab-for-surgery

Written by: Brendan Micallef