Clinical synthesis based on the most recent meta-analyses and international consensus statements: GBD 2021, ERAS Society 2020, ICM 2018, Ismailidis 2021, Sato 2023, Adebero 2024.

Total hip arthroplasty (THA or THR), often described as the “operation of the century”¹, is a major orthopaedic procedure intended to relieve pain and restore function in patients with end-stage hip joint disease.² Its success depends not only on surgical technique but also, and critically, on a structured, evidence-based post-operative rehabilitation programme. 🎯

How is this procedure defined, who is affected and what are the risk factors?

THA consists of replacing the damaged joint surfaces of the hip (femoral head and acetabulum) with prosthetic implants.² The main indication is severe hip osteoarthritis (coxarthrosis). This article deals with the prosthesis fitted electively, in a patient who has chosen the date of their operation. When the prosthesis or hemiarthroplasty is fitted as an emergency, after a fracture of the proximal femur in an older person, the population, priorities and timetable are no longer the same: this situation is covered in femoral neck fracture in older adults. According to the GBD 2021 Osteoarthritis Collaborators, 595 million people were living with osteoarthritis in 2020 (7.6 % of the world population), with a projected increase of +78.6 % specifically for the hip by 2050.³

The main risk factors leading to THA are:

• Advanced age : the prevalence of symptomatic osteoarthritis increases significantly with age.¹
• Obesity : a high BMI is one of the most important modifiable risk factors for the development and progression of coxarthrosis.⁴
• A history of trauma : acetabular fractures are associated with frequent post-traumatic osteoarthritis requiring delayed THA.⁵
• Female sex : increased risk demonstrated (Srikanth 2005 meta-analysis), with a possible role for hormones and biomechanics.⁶

Regarding surgical approaches (posterior, lateral, direct anterior / DAA), the Aggarwal 2020 review (JBJS Reviews) stresses that no approach has shown robust long-term functional superiority. Each approach has a specific complication profile: the posterior approach favours posterior dislocations, while the direct anterior approach is associated with a higher incidence of femoral nerve injury.⁷

What happens in the body and how does recovery evolve naturally?

The operation is a controlled trauma that induces inevitable post-operative muscle weakness, particularly affecting the hip abductors and extensors.⁸ The reference meta-analysis Ismailidis 2021 (19 studies, 875 subjects) quantifies this recovery precisely.¹¹

Recovery breaks down into three predictable phases:

1. Immediate post-operative phase (0-4 weeks) 🏥: control of pain and oedema, prevention of deep vein thrombosis, very early mobilisation (often from day 0 within ERAS protocols), walking with assistive devices.¹³
2. Early recovery phase (4-12 weeks) : progressive strengthening of the gluteal muscles (medius, minimus, maximus) and the quadriceps. Persistent abductor weakness is directly linked to Trendelenburg gait and to functional instability.⁸,¹¹
3. Late phase and return to function (3-12 months and beyond) 🏃‍♂️: the Sato 2023 longitudinal cohort (n=1,898) shows that PROMs reach their MCID as early as 1 month, exceed the pre-operative baseline at 3 months, but gait quality and stair-climbing capacity only improve significantly at ≥ 12 months.¹⁰

How can recovery be assessed and diagnosed with certainty?

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Which questions should you ask to understand the patient and their history?

Initial assessment is based on a structured, in-depth history, the cornerstone of personalised management. ❓ The aim is not only to catalogue physical symptoms but also to understand the patient's expectations and psychosocial context, two major determinants of post-operative satisfaction. History taking must systematically explore:

• Pain characteristics : precise location (groin, trochanteric, buttock), type (mechanical, inflammatory, neuropathic), intensity (VAS 0-10), aggravating/relieving factors.
• Functional limitations : walking (distance, speed, limp), climbing/descending stairs, putting on shoes, getting out of a vehicle, prolonged standing.
• Post-operative history : surgical approach (posterior / lateral / DAA), date of the operation, any complications, rehabilitation protocol followed.
• The patient's expectations : sporting and occupational goals, leisure activities (a major predictive factor of satisfaction).
• Comorbidities : diabetes, cardiovascular disease, depression; in the Lan 2022 cohort, comorbidities are associated with more pain and less function after THR.⁷
• Psychosocial flags : kinesiophobia (in Morri 2020, it does not predict performance on day 5 but goes with poorer pre-operative function)⁸, depressive or anxious symptoms.

Which clinical tests should be performed and what other conditions must be ruled out?

Objective assessment combines two families of tools: PROMs (Patient-Reported Outcome Measures) and PBMs (Performance-Based Measures). 📋 No single test is sufficient: the combination gives a complete and balanced picture.

Should patients be classified into subgroups, and for what benefit?

The modern trend moves away from single protocols (“one-size-fits-all”) in favour of a stratified approach. The Sato 2023 longitudinal cohort (n=1,898 patients) confirmed 3 recovery trajectories identifiable early by algorithm.¹⁰

This stratification justifies differentiated rehabilitation:

• The substandard responders (36.1 %) can benefit from closer supervision and a prolonged strength programme.
• The late mental responders (13.2 %) require targeted psychological support (kinesiophobia, catastrophising).
• The standard responders (50.8 %) can follow an accelerated programme with guided self-management.

Factors associated with a poorer trajectory include multiple comorbidities (Lan 2022),⁷ and pre-operative depression, anxiety and somatisation (O'Connor 2022 SR).⁹ Pre-operative kinesiophobia, for its part, did not predict functional performance on day 5 in the Morri 2020 cohort, while going with poorer pre-operative function.⁸

Rehabilitation after THR has changed considerably over the past ten years, moving away from rigid protocols towards personalised approaches built into optimised care pathways. The aim is no longer only the recovery of mobility but a complete, rapid and lasting functional restoration. 🚶‍♂️

Where should you start? What is the hierarchy of interventions?

The modern hierarchy places patient preparation and immediate mobilisation at the top of the priorities. However, the 2024 data call for a more nuanced view of the role of prehabilitation for THR.

Immediately after surgery, the standard remains the application of ERAS (Enhanced Recovery After Surgery) protocols. The 2020 international consensus of the ERAS Society (published in Acta Orthopaedica) lists 17 key elements, including:

• Very early mobilisation from day 0 (first getting up and assisted walking).
• Multimodal analgesia, limiting opioids.
• Structured pre-operative education.
• Perioperative nutritional optimisation.
• Locoregional anaesthesia (spinal anaesthesia or femoral block).

The Stambough 2015 retrospective cohort (1,751 primary THRs across four successive perioperative protocols) reports a 52 % reduction in length of stay with the rapid-recovery protocol, without an increase in the overall 30-day readmission rate.³

What is the place of exercise, and is there a superior approach?

Contrary to a widespread belief, the superiority of progressive resistance training (PRT) over low-load exercise has not been demonstrated. 💪 The Saueressig 2021 meta-analysis (JAMA Network Open, 32 randomised trials, 1,753 patients), which does not compare PRT with low-load exercise but post-operative exercise with usual care or no exercise, finds no association between post-operative exercise and self-reported physical function, at 4, 12 and 26 weeks as well as at one year (low to moderate certainty of evidence); the hip muscle strength results there are non-significant, with very low certainty.⁵ Only the Chen 2021 meta-analysis (after THR and TKR, 1,021 patients) directly compares early PRT with standard rehabilitation; it finds no difference in functional capacity, strength or adverse events: PRT is an option without excess adverse events, not an approach established as superior.⁴ A more recent meta-analysis (Ye 2026: 17 randomised trials and 5 cohorts, 1,782 participants in total, with 9 datasets for short-term abduction) finds a gain in abduction strength after structured exercise, compared with usual care or a less intensive protocol, at less than 3 months (SMD 0.78 in favour of exercise; 95 % CI 0.36 to 1.19) and between 3 and 6 months (0.69; 0.29 to 1.10), with moderate certainty according to its authors, not found beyond 12 months; flexion strength is not changed. This result does not settle PRT against low-load exercise.¹²

Simply following range-of-motion or endurance exercises is not enough to correct strength deficits. Without targeted rehabilitation, compensations such as Trendelenburg gait can persist for up to a year or even longer (Ismailidis 2021).¹¹

Manual therapy and telerehabilitation: how effective are they really?

The Zhou 2024 meta-analysis (Disabil Rehabil, 10 studies) on telerehabilitation after THR concludes that results are equivalent to on-site rehabilitation: a better result on the get-up-and-go test, no difference on the other functional tests and questionnaires, from few and heterogeneous studies. 🏠 This approach promotes patient autonomy, reduces logistical constraints and allows asynchronous (video, IMU sensors) or synchronous (videoconference) supervision.⁶ The Khan 2008 Cochrane review (5 low-quality trials, 619 participants) compares organised multidisciplinary rehabilitation, in hospital or at home, with routine care; it includes no trial of outpatient centre-based programmes and no long-term outcome.⁷ Regarding manual therapies (joint mobilisations, soft-tissue massage), the evidence for efficacy as a main treatment is weak. They can be used as an adjunct to manage pain or stiffness in the short term, but must never replace a programme of active, progressive exercises.

Beyond the physical: education and psychological factors

The success of rehabilitation after THR does not depend solely on physical recovery. 🧠 Therapeutic education and the management of psychological factors are now central components.

• Pre-operative education : the Moyer 2017 meta-analysis (JBJS Reviews), which pools pre-operative exercise and education, finds after THR a small gain in pain and function, with no significant effect on anxiety.⁸ The McDonald 2014 Cochrane review (CD003526) remains the historical reference.¹⁰
• Kinesiophobia : in the Morri 2020 cohort (269 patients), pre-operative kinesiophobia did not predict functional performance on day 5; when high, it went with poorer pre-operative function.
• Pre-operative psychological factors : in the O'Connor 2022 systematic review, pre-operative depression, anxiety and somatisation go with more pain, less function and more complications after THR.¹¹
• Self-efficacy : trained patients report greater confidence in early weight bearing, which speeds up recovery.

The success of a THR is measured not only by the quality of the surgical procedure but above all by the patient's ability to regain optimal function and maintain the benefits over the long term. 🚶‍♀️ Lasting recovery rests on a synergy between structured rehabilitation, active prevention of complications and patient involvement.

How can the patient become an active participant through self-management?

Patient autonomy (patient empowerment) is a strong determinant of long-term outcomes. Moving from the role of passive recipient to that of main actor in one's own rehabilitation radically changes the prospects of success. This transition must be initiated as early as possible, ideally even before the surgery. Supervised self-management programmes (education, guided home exercises, SMART goals) aim to improve function and quality of life in the short and medium term. Telerehabilitation supports this autonomy, with results equivalent to on-site rehabilitation.¹⁰ One essential point: continuing an exercise programme over the long term, because strength deficits, particularly of the abductors, can persist beyond 24 months and constitute a risk factor for limping, instability and falls.⁸ 💪

When and how should a safe return to sport be planned?

The current trend is moving away from a purely chronological approach (“return at 3 months”) towards adopting a progression based on functional criteria. However, the numerical criteria genuinely validated for THR are rare: ACL criteria must not be extrapolated.

Consensus validation criteria (no strict numerical thresholds) before considering a return to sport:

• Absence of pain during activities of daily living.
• Near-complete recovery of joint range of motion (particularly extension and external rotation).
• Muscle strength recovering progressively: the trajectory matters more than a cutoff (86.3 % before surgery → 93.4 % beyond 24 months, Ismailidis 2021).⁸
• Success on functional tests (TUG, 30-s chair stand, stairs) without visible compensation.¹⁰
• The patient's subjective confidence and absence of marked kinesiophobia.

The Pan 2024 meta-analysis (Orthop Rev, direct anterior approach) reports a return-to-sport rate of 76 % (95 % CI 63-86 %).⁴ Hoorntje 2018 (meta-analysis, Sports Med) reports approximately 82 % return to the pre-symptomatic level.⁵ The realistic composite figure is therefore 76-85 %, and not an absolute “>80 %”.

The AAHKS consensus (Klein/Mont 2007, Swanson 2009) remains the quantified reference for recommended activities:²,³

While meta-analyses provide general guidelines, the study of published clinical cases in the scientific literature offers essential insight into their real-world application. 🧐 All the cases presented below are real PubMed/PMC case reports, verified, and not fictional constructions.

Classic case: the fast-track trajectory

A “classic” case represents the ideal course of a patient undergoing THR and following an accelerated rehabilitation protocol (“fast-track”). Take the composite example of a 67-year-old man, active and without major comorbidity, operated on for primary coxarthrosis by the posterior approach.

According to the Sato 2023 classification, this profile corresponds to a “standard responder” (50.8 % of the cohort): improvement in PROMs from 1 month, exceeding the pre-op baseline at 3 months, normalised gait quality at 12 months.

The diagnostic challenge: when pain after THR hides something else

Post-operative pain is expected, but its persistence or atypical location should raise concern. Case reports are particularly instructive for documenting these diagnostic “pitfalls”.

Complex case studies: dislocation, periprosthetic fracture

Applying evidence-based recommendations requires not only knowing what to do, but also how to integrate it, when to collaborate and how to measure the impact. This chapter provides a practical framework for translating evidence into clinical action. 👨‍⚕️

When, and to which professionals, should patients be referred?

The modern physiotherapist with direct access must be able to triage and refer. The system of diagnostic flags structures this decision.

🟡 Yellow flags (psychological)

Negative beliefs about pain, catastrophising, fear of movement (kinesiophobia), depressive or anxious symptoms. Screening tool: Örebro Musculoskeletal Pain Screening Questionnaire (Nicholas 2011).⁵ In the Morri 2020 cohort, pre-operative kinesiophobia does not predict functional performance on day 5 after THR.

🔵 Blue flags (work-related perceptions)

Work perceived as too demanding, lack of employer support. The Psychologically Informed Practice approach (Keefe, Main, George 2018).⁶ When these factors predominate and are the main obstacle to recovery, interprofessional collaboration (psychologist, occupational medicine, pain specialist) is called for; the evidence of its effect comes from other settings (interprofessional education, Reeves 2013 Cochrane review; biopsychosocial rehabilitation of chronic low back pain, Kamper 2015).⁷,⁸

How can outcomes be measured and the obstacles to EBP overcome?

Combine PROMs and performance tests with, ideally, a Core Outcome Set (COS) validated for the condition. 📈

🚧 Barriers to EBP in physiotherapy

The Scurlock-Evans 2014 review (Physiotherapy) and the mixed-methods study by Gleadhill 2022 identify the common barriers:¹²,¹³

• Lack of time for critical reading (the most cited barrier).
• Lack of skills in methodological appraisal.
• Limited access to databases and full text.
• Inertia of practice habits.
• Lack of organisational support.

✅ Validated facilitators

• Mentoring by experienced peers.
• Institutional subscription to the Cochrane Library / PEDro / PubMed.
• Dedicated time for literature searching and case discussion.
• Systematic use of clinical practice guidelines (CPGs) that synthesise the evidence.
• Continuing education with an emphasis on critical reading.