The lived experience of frail older adults in postoperative activity following hip replacement: A qualitative study in Hangzhou, China

doi:10.21203/rs.3.rs-7021701/v1

Background: Hip fracture among older adults is a tremendous universal public health challenge associated with high morbidity and mortality, especially in China. However, the lived experiences and perspectives of frail older adults in early postoperative activity following hip replacement surgeries in China are rarely studied.

Aims This study aimed to describe frail older adults' experiences after hip replacement to provide recommendations for future intervention.

Methods: This was a descriptive qualitative study. Sixteen frail older patients who underwent artificial hip replacement at a local hospital in Hangzhou between January and August 2022 were recruited. Data were collected through participatory unstructured observation and face-to-face semi-structured interviews with the participants and were analyzed using qualitative content analysis.

Results: We identified four themes: (1) physical discomfort, (2) emotional distress, (3) uncertainty about the effectiveness of early postoperative activity (4) obstacles to early postoperative activity.

Discussion ：This study identified physical discomfort caused by early postoperative swelling and frailty as common symptoms experienced by frail older patients during early postoperative activities following hip replacement surgeries. Recognizing frailty as a limitation, these patients prioritize safety and security and may hesitate to participate in activities perceived as difficult or risky.

Conclusions:Findings suggest medical staff should focus on enhancing patients' disease awareness, alleviating their concerns, and improving their self-efficacy to promote early activity participation for frail elderly patients following hip replacement.

Trial registration number No. 2021KY085

hip replacement

older adults

frail

early postoperative activity

qualitative study

Strengths and limitations of this study

1. Focus on the experiences of older adults following hip replacement ，their immediate postoperative activities in the acute hospital setting.

2.Focusing specifically on frail older adults.

3.Offer deeper insights into the lived experiences of the vulnerable population and provide a reference for developing targeted patient-centered care.

4. the sample was recruited from a single center in Hangzhou City and may not represent patients in other hospitals and other regions.

5. we only focused on the patients' lived experiences related to early postoperative activity and did not include their caregivers, who played an essential role in supporting and assisting these patients.

Globally, hip fracture among older adults is a significant public health concern and a leading cause of disability and mortality among the older population, causing tremendous suffering to individuals and considerable burdens to families and society.¹According to data from the Global Burden of Diseases (GBD) 2019, the global incidence, prevalence, and years lived with disability (YLD) of hip fracture in patients aged ≥ 55 years were 681.35, 1191.39, and 130.78 per 100000 population, respectively. ²Hip replacement surgery, as the cornerstone treatment for hip fracture, has been shown to effectively correct deformities, alleviate pain, and improve function, thus enhancing the patient's quality of life.³ China is a middle-risk country for hip fractures, with an estimated 1.3 million hip fractures occurring in people aged 65 years by 2050.⁴Each year, approximately 400,000 hip replacement surgeries are performed in China, accounting for 40% of all hip replacement surgeries worldwide and 60% of all orthopedic joint surgeries in China. ^5,6Additionally, the number of hip replacement surgeries in China has increased by 25–30% yearly.

Despite advancements in hip replacement surgery, some patients, particularly frail older adults, struggle to achieve optimal rehabilitation outcomes. Frailty, characterized by an age-related decline in the physiological reserves across multiple organ systems, is a well-documented geriatric syndrome that increases vulnerability to stressors and complications in older adults.⁷Studies reported that frailty occurred in up to 41.8% − 50.3% of older surgical patients.^8,9 Frailty is a significant stressor, potentially disrupting physical function and further elevating the risk of postoperative complications and incidence of adverse events.¹⁰

A large body of studies have consistently shown that frailty is associated with more postoperative complications, prolonged hospital stay, increased likelihood of institutionalization, poorer functional outcomes, higher disability, and increased risk of mortality .^11–13Furthermore, frail older patients often experience low adherence to therapeutic recommendations and cooperation due to factors such as pain and fear, leading to worse outcomes and poor recovery.¹⁴ Therefore, frail older patients with hip replacement surgeries are a vulnerable group that warrant special clinical and research attention.

Early postoperative activity is considered the gold standard for regaining hip joint function.^15,16 The Guidelines for Joint Arthroplasty released by the National Institute for Health and Care Excellence in 2020¹⁷ and the Best Practice Nursing Care Standards for Older Adults with Fragility Hip Fracture released by the International Collaboration of Orthopedic Nursing (ICON),¹⁸ advocate for initiating postoperative activity as early as 24 h after the surgery, barring any contraindications. These guidelines also emphasize the importance of daily exercise sessions, with the activity intensity tailored to individual patient tolerance. A randomized controlled trial by Duan et al.¹⁹demonstrated that early postoperative activity following hip replacement surgery reduces the risk of lower limb joint adhesion, atrophy, and deep vein thrombosis, accelerating joint function recovery.

Although extensive studies have explored the postoperative recovery of older adults following hip replacement, most evidence is based on quantitative evaluations using standard scales, which may lack a person-centered perspective by overlooking the unique, lived experiences of each individual. The existing limited qualitative research is predominantly conducted in Western countries, such as the UK and Canada, which have well-developed health systems and rehabilitation services.²⁰ However, little is known about the experiences of older adults following hip replacement in resource-limited developing countries such as China. In addition, most previous qualitative studies focus primarily on the long-term recovery of older adults following hip replacement in urban community settings²⁰, and much less is known about their immediate postoperative activities in the acute hospital setting.²¹ Furthermore, previous studies did not distinguish older adults based on frailty status, and there is a lack of studies focusing specifically on frail older adults.²² Compared to non-frail older adults, frail older adults are a heterogeneous vulnerable group exposed to a higher risk of comorbidities and functional impairment, which may lead to distinct rehabilitation and recovery experiences and needs .²³To address these gaps, we conducted the current qualitative study to investigate the experiences and perspectives of frail older adults related to early postoperative activity following hip replacement in a Chinese hospital setting. Our findings will offer deeper insights into the lived experiences of the vulnerable population and provide a reference for developing targeted patient-centered care to facilitate recovery and improve well-being.

2.1 Study design and participants

A descriptive qualitative study was conducted at a third-grade first-class hospital in Hangzhou from January 2022 to August 2022. Older adults who received artificial hip replacements were selected by purposive sampling using the maximum variation strategy. Inclusion criteria were as follows: (1) aged 65 years or older; (2) underwent total hip or femoral head (half-hip) replacement; (3) had a frailty assessment score of ≥ 3 as measured by The Frailty Scale (TFS) at admission; (4) had normal cognitive ability as assessed by the Mini-Cog; (5) could communicate in Chinese; (6) were aware of the disease; (7) understood the purpose and content of this study, and willingly participated in the interviews. Those with severe heart, brain, and lung dysfunction and concomitant extravertebral system lesions, such as Parkinson's disease, were excluded from the study. The sample size was determined by data saturation, meaning that no new theme or sub-theme emerged during data analysis. Finally, 16 patients were included in this study.

2.2 Data collection

The study was approved by the Ethics Committee of Hangzhou Traditional Chinese Medical Hospital (No. 2021KY085). We conducted and reported this study in compliance with the consolidated criteria for reporting qualitative research (COREQ) .²⁴Participants were approached by the ward nurses and fully informed about the study's purpose, procedure, risks, and benefits. All participants participated in this study voluntarily and provided written informed consent before participation in the study. This study utilized participatory observation and semi-structured interviews for data collection. Before each observation, we ensured minimal disruptions to the participants' activities, and photos and videos were taken only when necessary. The interviews were conducted in conversation rooms or single-patient rooms. The entire interview process was recorded on-site with the participants' consent, and the participants' accurate understanding of the information was confirmed. Nursing PhDs familiar with qualitative study assisted with conducting the research, including establishing and revising interview guides and techniques, transcribing and coding verbatim drafts, categorizing and extracting themes and key findings, and maintaining rigorous research quality.

2.2.1 Participatory observation

Participants' behaviors were investigated in a natural state by participatory observation from the first day of the surgery to 3 days after the surgery, as informed by a prior survey on the early postoperative activity of patients following hip replacement. This approach provided a practical basis for further interviews, distinguished between the patient's actual behavior and thoughts, and addressed the limitations of the interview method.

Per the observation design method in "Methods and Cases of Qualitative Study" ,²⁵we developed a framework to guide our observations of early postoperative activity. This framework focused on crucial aspects: "Who: Who was present, in addition to the participants?"; "What: What specific exercise did the participants perform? How did the people present react? What were the on-site interactions?"; "When: When was the exercise? What was the exercise duration?"; "Where: Where was the exercise performed?"; "What did the participants do after the exercise?" The outline order was not followed strictly during the observation; however, the patient's early postoperative activity was comprehensively described in as much detail as possible. Where necessary, video recordings were used to supplement the observations. A total of 16 patients, including 15 in the ward and one in the intensive care unit, were observed for 252 min, with an average of 15.75 min per person.

2.2.2 Semi-structured interview

Grounded in the disease self-regulation model as the theoretical foundation,a semi-structured interview guide was developed based on the literature review, group discussions, and clinical expert consultations. The interviews were conducted and recorded in the ward by the researchers 1–2 days before discharge. Two patients were pre-interviewed (pilot) before the formal interview to ensure that the interview guide captured relevant information. Feedback from these pilot interview results informed iterative revisions, leading to the final interview guide.

The interview guide contained the following key questions: "1. We found... during the observation, why? 2. How did you approach your early postoperative activities? Could you please tell me what you found most impressive? 3. What discomforts did you experience during early postoperative activities? What were your concerns? 4. Could you please describe what happened when you first got out of bed? 5. Currently, early ambulation (getting out of bed) is recommended within 24 hours after surgery for patients with good post-surgical evaluation. What are your thoughts? 6. What factors do you think are affecting your early postoperative activities? 7. What kind of help do you expect the medical staff to provide you?" All the interviews were conducted by the first author, who is a psychologist with ten years of experience in qualitative research and interviews. A nurse PhD researcher assisted with the interview by recording the interviews, taking notes, and providing explanations when needed. Each interview took about 20–30 minutes and was audio-recorded with the participant's consent. The participants were informed that the recorded interviews were kept confidential and would be deleted immediately after the research. Sixteen interviews lasting for a total of 357 min were conducted, with an average of 22.3 min per person. Six patients had family members present during the interviews, and three of these patients' family members interfered with the patient's responses. After being politely reminded, the family members either left the ward or stopped responding.

2.3 Data analysis

Within 24 hours after observation, the observer organized their observation notes and annotated the participants' interactive expressions and dialogue tone. Each patient's observation records were encoded based on the research coding sequence, and their independent files were created. Following each interview, the researchers transcribed the recorded content into a Microsoft Word verbatim draft within 24 hours. Simultaneously, the non-verbal information, such as the interviewee's tone, speech, and pauses, was documented. The observation notes for each patient were numbered to correspond with their verbatim interview transcript.

Braun and Clarke's²⁶ thematic analysis of a qualitative study was applied to the data as follows: (1) Obtaining a sense of the overall text material: The researcher immersed themselves in the data by repeatedly listening to recordings and reviewing interview notes and reflective diaries to obtain a good understanding of the overall data. (2) Open coding: Essential ideas and concepts in the data were marked line by line and sentence by sentence for open coding. (3) Classifying similar codes into themes and sub-themes: Similar codes were classified into themes and sub-themes, and the relationships among themes were displayed using mind maps. (4) Defining themes and sub-themes and coding: As subsequent interview materials increased, previously summarized themes were disassembled, or new themes were added, and multiple comprehensive summaries were conducted. Each cycle was repeated until the data saturation was achieved. We also identified examples of corresponding excerpts from the data.

3.1 Sample characteristics

Table 1 shows the basic characteristics of the participants. Sixteen participants aged between 66 and 85 were interviewed, and 13/16 participants were female. Most participants were retired (15/16), married (15/16), and had primary or high school education (13/16). The majority had a disease diagnosis of femoral neck fracture (12/16), with a disease course ranging from 2 hours to 3 years. The most common surgery types included left artificial femoral head replacement (8/16) and right total hip replacement (4/16). All participants had a frailty score of 3, except one patient who had a score of 5.

3.2 Observation results

Theme	Description
The early out-of-bed activity was slightly stressful.	Four participants were as nervous as first-time walkers, focusing intently on their hands and feet. Despite reminders from the medical staff to stay relaxed and stand on their lower limbs, the participants remained nervous. P1: This participant gripped the armrests tightly for support and was instructed to shift their weight to their feet instead of their hands. The participant initially kept their head bowed for stability and gradually lifted their head after feeling secure. The participant was guided to stand firmly. She slowly lifted the unaffected limb first and then the injured limb, revealing a limited range of motion in the injured limb.
Fear of engaging in early postoperative activity, exaggerating symptoms, and exhibiting avoidance behaviors	P8: Despite assurance by the medical staff that he could move, the participant was only willing to engage in slight distal joint movements in bed. He requested the medical staff's assistance with the exercises. He refused 'excessive exercise,' stating, "I'm a coward who is afraid of pain" and "Can I do this tomorrow?" P13: The participant lay in bed accompanied by her husband. She appeared weak and dispirited. She was receiving an intravenous infusion. When requested to perform an early postoperative activity, she managed a minimal ankle pump movement and said, "This is the best I can do now, and I'm still tired. Can I do it later when I recover? This should not be in a hurry."
Symptoms such as pain and frailty may affect early postoperative activity	P3 was in the ICU: After completing eight ankle pumps, the participant asked the nurse: "When can I be transferred to the ward?" The nurse explained the typical one-day timeframe but emphasized that it depended on his condition the following day. The participant acknowledged this and said, "I still felt pain when I flipped over just now." P12: This participant lay on the bed with his head slightly raised and appeared less active than required for early postoperative activity. When the medical staff asked the patient, "Why didn't you do early postoperative activity?" he performed a few ankle pumps and refused to continue, stating: "I've been feeling nauseous and weak, so weak."

3.3 Interview results

Four themes and 12 sub-themes emerged from the data analysis, including symptoms of early postoperative activity, emotional distress caused by pain and fear, uncertainty about the efficacy of early postoperative activity, and obstacles to early postoperative activity.

3.3.1 Theme 1: Physical discomforts

Frail older patients are more likely to develop various symptoms than non-frail patients during the perioperative period, including discomforts caused by early postoperative swelling and frailty. These symptoms can negatively impact their willingness to participate in early postoperative activity.

3.2.1.1 Discomforts caused by early postoperative swelling

Postoperative limb swelling, typically subsiding within 5-7 days after surgery with medication and physical therapy, caused significant discomfort for the patients and a sensation of heaviness in the affected limb. P2: "I feel a bit swollen in the area without surgery sometimes, and sometimes there is a slight swelling in this area, but it doesn't hurt if I don't touch it. However, it feels like it's not my leg anymore." P12: "I feel bad after walking a bit, but I have not consulted a doctor before."

3.2.1.2 Discomforts caused by frailty

Frail patients frequently reported physical weakness and fatigue in the early postoperative period, likely due to their weakened physical reserve. This highlights the importance of implementing self-protection measures. P13: "I've been lying for a long time, and I feel heavy and weak. If I have to stand up immediately, I'm a bit worried that I may not have enough strength to support me." Dizziness was also a common discomfort complaint. P8: "I am dizzy and nauseated when sitting up, and I don't want to eat anything, which causes slow recovery and weak physical strength."

3.2.2 Theme 2: Emotional distress

Some patients, particularly those with fractures, experienced swelling and limited mobility after surgery and developed local deformities. This caused significant pain and stress, especially when turning over in bed. Consequently, these patients were hesitant to turn over or make any additional movement during bed rest to prevent any pain that could result from the early postoperative activity.

3.2.2.1 Increased pain sensitivity

Frail patients reported experiencing more pronounced postoperative pain, potentially due to heightened pain sensitivity (the pain and tolerance threshold to external stimuli). P9: "The doctor told us to conduct out-of-bed activity yesterday, but I did not want to because I was afraid of pain." P14: "It hurts whenever I move, so I dare not move anymore. Look, I cannot lift this leg."

3.2.2.2 Anxiety about pain

Pain and discomfort can also trigger psychological anxiety in patients. This can manifest as the fear of developing more severe physical discomfort, and some patients may even imagine scenes of potential pain during movement. P9: "There may be a slight pain in the wound (during the activity). Will it be even more painful to get off the bed, or will the wound be torn open?"

3.2.2.3 A cautious attitude

During the early postoperative activity, patients repeatedly emphasized "take it slow," particularly for their first out-of-bed activity. P14: "It's okay to move slowly, and then I can do it slowly. I would stop immediately when it hurts or I feel tired." P10: "I am quite careful, and I must hold it firmly."

3.2.3 Theme 3: Uncertainty about the efficacy of early postoperative activity

Some patients readily participated in early postoperative activities and were aware of their benefits. However, there were still knowledge gaps regarding the efficacy of accelerated rehabilitation. Some patients feared that early postoperative activity could cause prosthesis detachment and questioned the effectiveness of the process, potentially affecting their motivation to participate.

3.2.3.1 Worrying about prosthesis detachment

Prosthesis dislocation is a severe surgical complication and a significant concern for most patients undergoing first-time surgery who are unfamiliar with the process. Some patients are nervous that early postoperative activity may increase the risk of prosthesis dislocation. P16: "I'm afraid that in the future, walking will cause pain and inconvenience. The doctor declared a dislocation before surgery, so is it possible to be as flexible as before surgery?" P7 underwent a second revision surgery due to a previous prosthesis infection. This complication caused the patient to experience a range of emotions from anger to helplessness and then despair. However, with the support of her family, she regained confidence and proceeded with the surgery. After 7 months, the patient stood up, feeling both joyful and apprehensive. P7: "I'm afraid that it (the prosthesis) will slip off. Will it slip off?"

3.2.3.2 Doubting the efficacy of early postoperative activity

While 12 interview respondents acknowledged the importance of early postoperative activity, they were only willing to try early postoperative activity within the limits of their physical abilities. This is because they still harbored some doubts about the effectiveness of early postoperative activity. P1: "Previously, it was impossible to move. I must move now. At least, the position is fine. The recovery of motor nerve function is definitely prolonged. Thus, I should move. However, I am still conservative about the time point." P2: "It is impossible to lie down all the time, and I must move. If I move too much, will it have an impact?"

3.2.3.3 Uncertainty about the timing of postoperative activity

Many participants expressed uncertainty and concerns about whether their frail physical condition could handle the intensity of early postoperative activity. Consequently, they emphasized the importance of a gradual approach to the exercise process, believing that progressing steadily and gradually would lead to better rehabilitation outcomes. P2: "The activity should have a certain degree, and hasty should be avoided, right?" P14: "It's okay to move slowly, and then I can do it slowly. I would stop immediately when it hurts or I feel tired."

3.2.4 Theme 4: Obstacles to early postoperative activity

3.2.4.1 Negative emotions

Patients' emotional states can fluctuate throughout their hospital stay, from admission to surgery and postoperative recovery. P9, who was admitted due to a car accident, displayed initial frustration and irritability and had difficulty accepting the injury. The patient repeatedly emphasized that the accident could have been avoided if they (the responsible party) had driven more slowly. The limited mobility in the early stages further exacerbated her negative mood. P9: "I can't do many things when I'm lying here, and I'm depressed." After a successful surgery, the patient could perform out-of-bed activities, and she experienced a positive mood shift. She focused less on the car accident and more on how soon she could exercise. Other patients did not need to participate in daily activities. Patients who developed complications during early postoperative activities experienced higher anxiety and lower motivation to participate in these activities. P8: "The injury is not severe, and it's just a stabbing pain after urination, which makes me anxious. I want to get better quickly. I know exercise, but I just want to make my urine smooth first."

3.2.4.2 Economic burden

Following hospitalization, some patients expressed feelings of guilt and concerns about increased family burden. For these patients, early postoperative activity can help reduce family burden, especially financial burden. P13: "My daughter prepares meals for me every day, which affects her work. Moreover, during the pandemic, the cost of renting a house is high. I was supposed to help them, but I am a burden on her." Some patients raised concerns about the cost of early postoperative activity and worried that it would be expensive. P3: "Is it free to participate in postoperative exercise?"

3.2.4.3 Weak family support system

Older patients have a strong sense of belonging to their families. However, hospital visits were restricted because of the pandemic. Some patients whose families did not accompany them experienced a temporary emotional void. The lack of a family support system negatively impacts patients' motivation for early postoperative activity and leads to significantly reduced activity levels. P3: "I won't come down unless my son is here." Patients who engage in early postoperative activity may feel uncertain and require a sense of safety and security. P14: "I dare not leave the bed without my daughter. I'm afraid of slip and fall, but my daughter has to go to work…"

3.2.4.4 Absence of professional support

Low education levels and a lack of knowledge related to postoperative exercise are common among older patients. They expressed a strong desire for professional guidance. P4: "I want professionals to help me, but no one has come for the past two days. I am willing to exercise, but I don't know (how to move)." Some patients reported inadequate guidance due to the high number of patients being supervised by nurses during hospitalization. P16: "I think all of you are in a hurry. Is it because Xiao Luo is responsible for too many patients? Rehabilitation guidance is crucial." Professional support also involves providing patients with quantitative exercise indicators, although still limited in terms of targeted clinical solutions. P2: "I haven't considered this issue. Neither the doctor nor the nurse discussed that with me. "I would like to go outside with my aunt or my son, but I will walk alone indoors."

This study identified physical discomfort caused by early postoperative swelling and frailty as common symptoms experienced by frail older patients during early postoperative activities following hip replacement surgeries. Recognizing frailty as a limitation, these patients prioritize safety and security and may hesitate to participate in activities perceived as difficult or risky. Shan et al.²⁷linked symptom distress to poor rehabilitation behavior. Additionally, Yuan et al.²⁸found that young and middle-aged patients with total hip replacement needed pain control during early postoperative activity. In this study, weakness and pain emerged as the most common physical discomforts mentioned by respondents. Research suggests that frail patients are more prone to developing pain and other complications compared to non-frail individuals.²⁹

Furthermore, older patients with higher levels of fear of falling often report more symptoms of anxiety and depression.³⁰ This highlights the importance of comprehensive patient evaluations to address physical discomfort and related fear and anxiety during early postoperative activity. Medical staff should provide timely and appropriate intervention for those experiencing physical discomforts to address their concerns and improve their confidence in recovery. Xi XL³¹emphasized the need for optimized rehabilitation strategies that incorporate support from medical staff, family, and peers and the availability of rehabilitation resources. Also, it is important to acknowledge that fear of falls can keep patients alert to fall risks and guide them toward appropriate activities with proper assessment and safety protection, which ultimately promotes functional outcomes and patient safety.

This study identified negative emotions as a significant barrier to early postoperative activity in frail elderly patients. Some frail elderly patients who underwent hip replacement surgery struggled with the sudden trauma. They experienced cognitive biases in understanding their disease condition and the benefits of early postoperative activity. Some patients misinterpreted "early postoperative activity" as "out-of-bed activity" and avoided it. They also had concerns about the effectiveness of early postoperative activities. The patients expressed doubts about their ability to complete the rehabilitation exercise successfully, resulting in low self-efficacy. Here, self-efficacy refers to the patient's belief in their ability to successfully perform rehabilitation exercises. Self-efficacy is positively correlated to the degree of physical rehabilitation, and patients with lower self-efficacy may have worse rehabilitation outcomes. The interview responses revealed that patients could handle early physical activity and adjust in-bed exercises to their tolerance levels. However, the prospect of early out-of-bed activity, particularly walking, triggered doubts despite their desire to participate. As the patients gradually recovered and understood early postoperative activity, their motivation to participate increased. This study emphasizes the need for individualized approaches with targeted education and guidance based on their specific needs and limitations to early postoperative activity for frail older patients.

This study identified a significant correlation between family factors and patient participation in early postoperative activity. Patients expressed particular concern about causing financial and caregiving burdens on their children. Accidental injuries increased the self-perceived burden..Self-perceived burden refers to the psychological feeling of being a burden on family members due to illness and increased care needs, which makes patients rely more on their family for care, emotions, and finances. It is recommended that patients' self-perceived burden should be assessed during the early stages of admission and post-surgery. In addition, patients should be involved in the planning of early postoperative activities to enhance their motivation and cooperation in following the plan and to evaluate the effect in a timely manner.

According to expert consensus and guidelines, ^32,33early postoperative rehabilitation exercises are beneficial for maintaining body function and preventing pulmonary complications. Frail patients are encouraged to participate in out-of-bed activity, and those unable to stand are advised to perform functional exercises in bed. However, the rehabilitation system in China has certain limitations. Generally, there is limited guidance from healthcare professionals during rehabilitation exercises and a lack of targeted early postoperative activity for frail older patients, which can create feelings of insecurity when patients attempt out-of-bed activities. Interview responses in our study indicate that professional support is a key factor influencing frail older patients' participation in early postoperative activity after hip replacement. It is suggested that more professional training and education should be provided to the patients to improve their knowledge and awareness of early postoperative activity and establish activity plans as early as possible after hip replacement surgery.

Our study has several limitations. First, the sample was recruited from a single center in Hangzhou City and may not represent patients in other hospitals and other regions. Future studies in different populations are needed to compare with our findings. Second, we only focused on the patients' lived experiences related to early postoperative activity and did not include their caregivers, who played an essential role in supporting and assisting these patients. Future studies should consider exploring caregivers' experiences and perspectives to get a more comprehensive understanding.

Frail older patients with hip replacement experienced significant physical discomfort caused by limb swelling and pain. These complications were compounded by high psychological distress and negative emotions, leading the patients to question the effectiveness of early postoperative activity and reducing their motivation to participate. To address these challenges, medical staff should thoroughly evaluate frail patients and develop personalized rehabilitation plans based on their physical conditions and psychological needs. Other strategies include improving their understanding of the disease and early postoperative activity, addressing their concerns, enhancing their self-efficacy, and obtaining family support to increase the participation of frail elderly patients in early postoperative activity after hip replacement.

Acknowledgements

We extend our gratitude to all patients who generously participated in the study and shared their valuable insights, thereby contributing to the enhancement of services.We would like to thank Dr. Zhou for her valuable contributions to this research.

Author contributions

Y.C. made the design of the work, created methodology, carried out data collection, analysis and interpretation, prepared original draft. Dr.Zhou reviewed and edited the first draft, substantively revised and edited the work. H.W. is a orthopaedics practitioner.He contributed to this study from a practitioner’s perspective and participated in some analyse sessions. All authors have made substantial contributions to the conception of the work and approved the final manuscript.H.W. as corresponding author is also responsible for the overall content as guarantor.

Funding

The authors declare there was no funding associated with the work featured in this article.

Competing interests None declared.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by the Ethics Committee of Hangzhou Hospital of Traditional Chinese Medicine (ethics number: 2021KY085). All participants gave informed consent and joined voluntarily. They had the option to withdraw at any point and review their transcripts. Anonymity was assured for all published materials.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: Data are available upon reasonable request.

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Table 1 General and demographic information of participants (n=16).

No.	Gender	Age	Occupation	Marital status	Education	Disease diagnosed	Course of disease	Frailty score	Surgery
1	F	73	Retired	Married	Polytechnic school	Femoral head necrosis	10 months	3	Artificial femoral head replacement
2	M	76	Retired	Married	Junior high school	Femoral neck fracture	2 days	3	Left total hip replacement
3	F	85	Retired	Widowed	Junior high school	Femoral neck fracture	1 day	3	Right artificial femoral head replacement
4	F	83	Retired	Married	Illiterate	Femoral neck fracture	1 day	3	Left artificial femoral head replacement
5	M	72	Retired	Married	Primary school	Femoral neck fracture	5 h	3	Left artificial femoral head replacement
6	M	68	Retired	Married	Junior high school	Femoral head necrosis	3 years	3	Left total hip replacement
7	F	73	Retired	Married	Primary school	Hip joint prosthesis disorder	7 months	5	Left artificial total hip revision
8	F	73	Retired	Married	Junior high school	Femoral neck fracture	5 h	3	Left artificial femoral head replacement
9	F	68	Retired	Married	Primary school	Femoral neck fracture	7 h	3	Left artificial femoral head replacement
10	F	81	Retired	Married	Primary school	Femoral neck fracture	1 day	3	Left artificial femoral head replacement
11	F	67	Self-employed	Married	Primary school	Femoral head necrosis	3 months	3	Right total hip replacement
12	F	71	Retired	Married	Primary school	Femoral neck fracture	12 h	3	Right total hip replacement
13	F	66	Retired	Married	Bachelor	Femoral neck fracture	3 h	3	Right total hip replacement
14	F	73	Retired	Married	Junior high school	Femoral neck fracture	2 h	3	Right total hip replacement
15	F	83	Retired	Married	Junior high school	Femoral neck fracture	6 h	3	Left artificial femoral head replacement
16	F	70	Retired	Married	Senior high school	Femoral neck fracture	3 h	3	Left artificial femoral head replacement

No competing interests reported.

The lived experience of frail older adults in postoperative activity following hip replacement: A qualitative study in Hangzhou, China

Status:

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Abstract

Article Summary

1. Background

2. Methods

2.1 Study design and participants

2.2 Data collection

2.2.1 Participatory observation

2.2.2 Semi-structured interview

2.3 Data analysis

3. RESULTS

4. DISCUSSION

5. CONCLUSION

Declarations

References

Table 1

Additional Declarations

Status:

Version 1