Every year, around 50,000 frail older patients in the NHS go into hip or knee replacement surgery weaker than they need to be. This trial tests whether a simple pre-surgery programme—daily home exercises plus a protein supplement—can get them through the operation and recovery with fewer days in hospital and better long-term function. Frailty affects one in four joint replacement patients and sharply raises their risk of complications, longer hospital stays, and worse pain after surgery. Yet no robust trial has tested whether a tailored, multimodal prehabilitation programme works for this specific group. The Joint PREP trial will randomise 488 frail patients across 20 NHS hospitals to either usual care or the prehabilitation programme, tracking function and hospital-free days for six months after surgery. If the intervention proves effective and cost-effective, it could change standard NHS practice for a large, vulnerable patient group. The researchers have already planned a training package and an Impact Accelerator Unit to support implementation—potentially improving recovery and cutting hospital time for roughly 50,000 frail patients each year.
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Question: Is multimodal prehabilitation clinically effective and cost-effective for improving function and the number of hospital-free days (HFDs) up to 6 months after surgery for frail older adults undergoing primary total hip replacement (THR) or total knee replacement (TKR)? Background: >200,000 THRs and TKRs are performed each year in the NHS and 25% of patients have moderate-severe frailty. Frailty is associated with increased risk of mortality, longer length of hospital stay, hospital admissions, and worse pain and function after joint replacement. Frailty is modifiable, with physical inactivity and inadequate nutrition being key contributors. However, there is a lack of evidence on the effectiveness of tailored prehabilitation for frail patients having joint replacement. Aim: To evaluate the clinical effectiveness and cost effectiveness of multimodal prehabilitation for frail patients undergoing primary THR or TKR. Design: Multicentre, pragmatic, individually randomised, unblinded, superiority RCT with internal pilot and health economic analysis. Setting: 20 NHS hospitals. Inclusion criteria: Frail patients =65 years old on the surgical waiting list for primary THR/TKR. Exclusion criteria: Contraindications to the intervention. Interventions: Multimodal prehabilitation programme, comprising a daily home-exercise programme and protein supplement from 4 weeks after listing for THR/TKR until surgery. The home exercise programme will be individualised in a 1-hour appointment with a physiotherapist and supported by regular remote follow-up in the first 10 weeks and then monthly information leaflets. Outcome measures: Co-primary outcomes: Self-reported function (WOMAC function) at 6 months after surgery and number of HFDs up to 6 months after surgery. Secondary outcomes: Joint pain and function, frailty, satisfaction, surgical complications, length of hospital stay, hospital preadmissions, hospital admissions, exercise self-efficacy, surgery proceeded, adverse reactions, quality of life, resource use and costs up to 6 months after surgery. Sample size: A sample of 488 patients will provide 90% power to detect an effect size of 0.3SD on the WOMAC function scale (assuming two-sided alpha 5%, correlation between baseline and 6-months post-operative score 0.5, and 20% loss to follow-up) and 90% power to detect a difference of 2 HFDs (assuming SD 0.95, two-sided alpha 5% and 10% loss to follow-up). Analysis: Primary statistical and economic analyses will be intention-to-treat and follow a prespecified analysis plan. Clinical outcomes will be analysed via mixed effects regression models; WOMAC via a linear model and HFDs via a negative binomial model. Cost-effectiveness analysis will establish whether the intervention is more cost-effective than usual care from the NHS and personal social services perspective. Timelines for delivery: Study duration of 42 months: 6 months set-up, 17 months recruitment and randomisation (9-month internal pilot), 13 months follow-up, 6 months analysis and dissemination. Anticipated impact and dissemination: Results will be disseminated to researchers, health professionals, the public, and stakeholders through open access peer-review publications, presentations, and other media. If effective, a training package will be developed and implementation supported through an Impact Accelerator Unit to improve health and reduce time spent in hospital for ~50,000 frail patients having TKR/THR each year.
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