Multimodal Prehabilitation of Frail Patients Undergoing Elective Knee or Hip Replacement

Out of all the patients screened the recruitment will be defined the proportion of patients who were randomized

Out of all the patients randomized, the proportion of patients who complete follow-up

Proportion of all patients invited for frailty screening (≥70 years and scheduled for arthroplasty) who are ultimately randomised into the trial.

Adherence to exercise prehabilitation, defined as completing ≥80% of the prescribed sessions or tasks.

If the assessment by the geriatrician lead to any changes to prescribed medications, new diagnoses or if evaluation on current diagnosis/treatment occurred among the patient in the intervention group. These will be noted.

Health status assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a 24-item self-administered questionnaire evaluating pain, stiffness, and physical function in patients with osteoarthritis.

Quality of life assessed using the EuroQol 5-Dimension 3-Level questionnaire (EQ-5D-5L). The EQ-5D-5L includes five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression).

Adherence to nutritional guidance assessed using a patient-completed questionnaire administered monthly during the prehabilitation period. Participants will answer the following question: "During the past month, how often did you follow the nutritional recommendations provided to you?"

Responses will be recorded on a 5-point Likert scale:

• Never (0 days per week)
• Rarely (1-2 days per week)
• Sometimes (3-4 days per week)
• Often (5-6 days per week)
• Always (7 days per week)

An average score ≥4.0 will be considered adherent.

Balance assessed using the four-stage balance test, measured as the ability to maintain progressively challenging standing positions:

• Stand with your feet side-by-side
• Place the instep of one foot so it is touching the big toe of the other foot.
• Tandem stance Place one foot in front of the other, heel touching toes
• Stand on one foot.

Not being able to hold the tandem stance (task number 3) for 10 seconds is an indication of increased risk of fall.

Lower body strength assessed using the 30-second chair stand test, measured as the number of full stands completed from a seated position within 30 seconds.

Mobility assessed using the Timed Up and Go test, measured as the time in seconds required to stand from a chair, walk 3 meters, turn, return, and sit down. Participants perform as fast as they can.

Length of the primary hospital stay after surgery, measured in days. Same-day discharge will be counted as 0, discharge on postoperative day 1 will be counted as 1, etc. A patient's readmission on the same day of discharge is considered a single continuous admission, unless the reason for readmission is clearly unrelated to the initial admission or surgery, in which case it will be considered a separate admission.

Non-home discharge will be identified as the postoperative hospital discharge to a nursing home or a rehabilitation center. Discharge to patient hotels will not be included. In addition, non-home discharge will not include patients who live in a nursing home prior to the surgery.

This outcome measures the incidence of adverse events after surgery and will be categorized based on the Clavien-Dindo classification grading system using the cut-off of ≥2; complications requiring pharmacological intervention (grade II), requiring additional procedures (grade III), life-threatening complications(grade IV) and a complication resulting in death (grade V).

: Patient reported or a fall noted in the electronic medical records.