Welcome to International Journal of Geriatric Orthopedics (IJGO)

Contact Us

Determinants and Barriers to Rehabilitation after Hip and Knee Surgery in the Elderly: A Cross-Sectional Analysis

Determinants and Barriers to Rehabilitation after Hip and Knee Surgery in the Elderly: A Cross-Sectional Analysis

Dr. Harsha M., Dr. Jishnu J., Dr. Avinash B., Dr. Venu Gopal S.M

Abstract

Background:
Rehabilitation after orthopaedic surgery in elderly patients is often hindered by medical, functional, and social barriers. Despite advances in surgical techniques, recovery of independence remains suboptimal, particularly in low- and middle-income settings such as India.

Aim:
To identify barriers to rehabilitation and predictors of poor functional recovery among elderly patients following orthopaedics surgery.

Methods:
A multicentre cross-sectional study was conducted in two tertiary hospitals (BIRRD Hospital, Tirupati and Sri Balaji Medical College Hospital & Research Centre, Tirupati.) from June 2024 to May 2025. A total of 750 patients aged ≥65 years, operated for orthopaedics hip and knee fractures, and enrolled in rehabilitation programs were included. Data on demographics, comorbidities, and rehabilitation barriers were collected using a structured questionnaire. Functional outcomes were measured using the Barthel Index and the Timed Up and Go (TUG) test at 4 weeks post-surgery. Logistic regression was performed to identify predictors of poor outcomes.

Results:
The mean age was 74.8 ± 6.2 years, with 62% females. At 4 weeks, the mean Barthel Index was 68.2 ± 14.5; only 38% achieved independence (≥80), while 72% had impaired mobility (TUG ≥20 seconds). Commonly reported barriers included pain (68%), fatigue (52%), fear of falling (47%), lack of caregiver support (42%), and cognitive impairment (12%). Independent predictors of poor outcomes were age ≥80 years (OR 1.9, 95% CI 1.3–2.8), female sex (OR 1.6, 95% CI 1.1–2.4), ≥2 comorbidities (OR 2.4, 95% CI 1.7–3.5), cognitive impairment (OR 3.1, 95% CI 2.0–4.8), and lack of caregiver support (OR 2.2, 95% CI 1.5–3.2).

Conclusion:
Rehabilitation outcomes after orthopaedics surgery in elderly patients remain poor, with social and medical barriers significantly affecting recovery. In the Indian context, fragmented rehabilitation pathways and limited caregiver support exacerbate these challenges. Strategies focusing on early mobilization, pain control, cognitive care, and caregiver involvement are urgently needed to improve independence and reduce disability in this vulnerable population.

Keywords:
Orthopaedics surgery, elderly, rehabilitation, barriers, hip fracture, Barthel Index, Timed Up and Go.

Introduction & Background

Fragility fractures in older adults — especially hip and proximal femur fractures — cause major morbidity, loss of independence, and increased mortality worldwide [1–3]. Rehabilitation after operative management is a cornerstone of recovery: appropriate inpatient and outpatient rehabilitation improves activities of daily living, mobility and reduces institutionalization [2,6]. International quality-improvement programs and audits (e.g., the UK National Hip Fracture Database) emphasize timely surgery, early mobilization, and structured multidisciplinary rehabilitation as key drivers of better outcomes [1,13,14].

Despite guideline recommendations, many older patients fail to regain pre-fracture function. Systematic reviews and cohort studies report substantial long-term disability after hip fracture, and identify clinical (pain, anemia, delirium, comorbidity) and service-level (physiotherapy frequency, delayed mobilization) determinants of poor recovery [3,11,14–16]. Rehabilitation self-efficacy and patient engagement are additional important determinants of recovery trajectory [4].

In India, the challenges are compounded by late presentation, limited rehabilitation infrastructure, socioeconomic constraints and variation in care pathways. Mixed-methods and prospective studies from India have documented delayed surgery, inadequate physiotherapy access, high dependency after fracture, and excess mortality among elderly hip-fracture patients [17–20]. Rath et al. identified barriers such as shortages of physiotherapy services and fragmented care coordination; Dash et al. reported low rates of return to independent mobility in multicentre Indian cohorts [17,18]. National and institutional efforts to build orthogeriatric pathways remain limited and inconsistent across centres.

Given these gaps, there is a pressing need to systematically identify and quantify barriers to rehabilitation among patients who have already undergone orthopaedic surgery and are receiving rehabilitation, so that targeted service and clinical interventions can be developed and prioritised in the Indian context.

Methodology

Study design and setting

Cross-sectional observational study conducted across two tertiary care hospitals in Tirupati (BIRRD Hospital and Sri Balaji Medical College Hospital & Research Centre) between June 2024 and May 2025. Hospitals included tertiary teaching centres with orthopaedics and rehabilitation/physiotherapy services.

Study population and sample size

  • Sample: 750 consecutive elderly patients who met inclusion criteria and consented to participate.
  • Inclusion criteria: age ≥65 years; underwent operative management for a major lower-limb orthopaedic fracture (hip, femur, or related lower-limb procedures); and currently receiving structured rehabilitation (inpatient or outpatient physiotherapy/occupational therapy) at one of the two participating centres.
  • Exclusion criteria: patients those receiving only palliative care or with expected survival <3 months, or those who declined consent.

Data collection

Trained research staff collected data using a structured case report form and interviewer-administered questionnaire at the start of the rehabilitation episode (baseline) and recorded functional status at 4 weeks (or discharge if earlier).

Questionnaire / instruments used

The structured instrument included:

  • Demographics & social factors: age, sex, education, living arrangement, caregiver availability, socioeconomic indicators.
  • Clinical history & perioperative data: fracture type, date/time of injury, date/time of surgery, surgical procedure, comorbidities, medications, perioperative complications, haemoglobin (Hb) level.
  • Pain: Visual Analogue Scale (VAS) (0–10) for current pain and typical pain during physiotherapy sessions.
  • Cognition & delirium: Mini-Mental State Examination (MMSE) for cognitive screening; Confusion Assessment Method (CAM) for delirium where clinically indicated.
  • Rehabilitation participation & self-efficacy: an adapted Rehabilitation Therapy Self-Efficacy Scale (after Fortin sky et al.) to assess confidence in performing rehab tasks and likelihood of adherence [4]. Session frequency, session duration, and type of therapy (physiotherapy, occupational therapy) were recorded.
  • Functional outcome measures (primary outcomes):
    • Barthel Index (BI) — measures independence in activities of daily living across ten domains (feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfers, mobility, stair climbing). Score range 0–100; higher = greater independence. In this study BI <80 at 4 weeks was prespecified as indicating poor functional recovery / moderate-to-severe dependency (consistent with published rehabilitation literature) [2,6].
    • Timed Up and Go (TUG) test — patient rises from a chair, walks 3 metres, turns, returns and sits; time recorded in seconds. TUG >20 s used to indicate impaired mobility and higher fall risk [6].
  • Other relevant variables: fatigue (self-report), fear of falling, financial constraints affecting rehab access, and institutional factors (physiotherapist staffing, therapy scheduling, equipment availability).

Definitions used in analysis

  • Delayed mobilization: first assisted mobilization (sit out of bed / standing) >48 hours after surgery.
  • Low physiotherapy intensity: fewer than 3 formal therapy sessions per week during the first 2 weeks of rehab (threshold chosen based on local practice distributions and earlier audit evidence).
  • Anemia: Hb <11 g/dL (classified for descriptive purposes; regression models used Hb <10 g/dL as a sensitivity analysis consistent with earlier studies [14]).

Data management and statistical analysis

  • Data entered into a secure database and analysed using SPSS v26 (or equivalent).
  • Descriptive statistics: means ± SD for normally distributed continuous variables, medians (IQR) for skewed variables, and counts (percentages) for categorical variables.
  • Bivariate analyses: t-tests or Mann–Whitney U tests for continuous variables, chi-square tests for categorical variables comparing groups with good vs poor functional recovery (BI ≥80 vs <80).
  • Multivariable analysis: logistic regression modelling to identify independent predictors of poor recovery (BI <80) at 4 weeks. Candidate predictors included age, sex, baseline BI, Hb level, presence of cognitive impairment/delirium, pain (VAS ≥6), delayed mobilization (>48 h), physiotherapy intensity (<3 sessions/week), and comorbidity burden. Variables with p<0.10 on bivariate testing and clinically important variables were entered into the multivariable model. Adjusted odds ratios (aOR) with 95% confidence intervals were reported. Statistical significance set at p<0.05.

Results

Demographic and Clinical Characteristics

A total of 750 elderly patients (≥65 years) who underwent orthopaedic surgery and were receiving postoperative rehabilitation were included across three tertiary care hospitals from June 2024 to May 2025. The mean age was 74.8 ± 6.2 years, with 62% females and 38% males. Hypertension (54%), diabetes mellitus (41%), and osteoporosis (35%) were the most common comorbidities.

Table 1. Baseline demographic and clinical profile of participants (n = 750)

Characteristic n (%) / Mean ± SD
Age (years) 74.8 ± 6.2
Female sex 465 (62.0%)
Male sex 285 (38.0%)
BMI (kg/m²) 23.1 ± 3.8
Living alone 172 (22.9%)
Common comorbidities:
• Hypertension 405 (54.0%)
• Diabetes mellitus 308 (41.1%)
• Osteoporosis 263 (35.0%)
• Dementia / cognitive impairment 94 (12.5%)
Pre-fracture independent ambulation 610 (81.3%)

Rehabilitation Outcomes

At 4 weeks post-surgery, the mean Barthel Index was 68.2 ± 14.5, with only 38% achieving >80 (independence). The mean Timed Up and Go (TUG) score was 27.6 ± 6.3 seconds, indicating impaired mobility in the majority.

Table 2. Functional outcomes at 4 weeks post-surgery

Outcome measure Mean ± SD / n (%)
Barthel Index score (0–100) 68.2 ± 14.5
Independent (≥80) 285 (38.0%)
Dependent (<80) 465 (62.0%)
TUG test (seconds) 27.6 ± 6.3
Normal mobility (<20 sec) 210 (28.0%)
Impaired mobility (≥20 sec) 540 (72.0%)

Note: Barthel Index <80 indicates moderate-to-severe dependency. TUG ≥20 sec indicates impaired mobility and higher fall risk.

Barriers Reported to Rehabilitation

The most common barriers identified through the structured questionnaire were pain (68%), fatigue (52%), fear of falling (47%), lack of caregiver support (42%), and cognitive impairment (12%).

Table 3. Reported barriers to rehabilitation participation

Barrier n (%)
Pain (moderate to severe) 510 (68.0%)
Fatigue 390 (52.0%)
Fear of falling 353 (47.0%)
Lack of caregiver support 315 (42.0%)
Cognitive impairment 94 (12.5%)
Financial constraints 82 (10.9%)

Predictors of Poor Rehabilitation Outcome

On multivariable logistic regression, age ≥80 years (OR 1.9, 95% CI 1.3–2.8), female sex (OR 1.6, 95% CI 1.1–2.4), ≥2 comorbidities (OR 2.4, 95% CI 1.7–3.5), presence of cognitive impairment (OR 3.1, 95% CI 2.0–4.8), and lack of caregiver support (OR 2.2, 95% CI 1.5–3.2) were significantly associated with poor rehabilitation outcome (Barthel Index <80).

Table 4. Independent predictors of poor rehabilitation outcome (Barthel Index <80)

Predictor Adjusted OR (95% CI) p-value
Age ≥80 years 1.9 (1.3–2.8) 0.001
Female sex 1.6 (1.1–2.4) 0.02
≥2 comorbidities 2.4 (1.7–3.5) <0.001
Cognitive impairment 3.1 (2.0–4.8) <0.001
Lack of caregiver support 2.2 (1.5–3.2) <0.001
Pain (moderate-severe) 1.4 (0.9–2.1) 0.08
Fatigue 1.2 (0.8–1.9) 0.15

Note: Outcome defined as Barthel Index <80 at 4 weeks.

Discussion

Overview of Key Findings

This multicentre cross-sectional study of 750 elderly patients undergoing rehabilitation after orthopaedics surgery highlights several critical barriers to functional recovery. At four weeks post-surgery, only 38% of patients achieved independence (Barthel Index ≥80), and more than 70% had impaired mobility on the TUG test. Pain, fatigue, fear of falling, lack of caregiver support, and cognitive impairment emerged as prominent barriers. Multivariate analysis revealed that advanced age, female sex, multiple comorbidities, cognitive impairment, and inadequate caregiver support were independent predictors of poor rehabilitation outcomes.

These findings underscore the complexity of recovery in elderly orthopaedics patients, reflecting the interplay of physiological, psychological, and social determinants. Importantly, the results align with global evidence showing that timely, structured, and multidisciplinary rehabilitation is pivotal in optimizing functional recovery following hip and other fragility fractures [1,2,5,6].

Comparison with Global Literature

Several large-scale audits and cohort studies have shown similar trends. The 2023 National Hip Fracture Database (NHFD) report from the UK documented persistent variations in outcomes despite quality improvement efforts, with functional recovery still suboptimal in many older adults [1]. Studies emphasize the role of comprehensive orthogeriatric care in improving survival, mobility, and independence [2].

Our study’s findings on functional limitations are comparable with data from long-term disability reviews, which suggest that nearly 50% of hip fracture survivors fail to regain pre-fracture mobility [3]. Rehabilitation therapy self-efficacy has been linked with better outcomes, suggesting that motivation and psychological confidence also influence recovery trajectories [4]. However, barriers such as delayed mobilization and reduced physiotherapy intensity remain universal challenges [7–9].

Early mobilization is strongly associated with favourable outcomes. Evidence from UK national audits suggests that patients mobilized within 24–48 hours post-surgery have higher chances of discharge to home and improved independence [7,8]. In contrast, delayed mobilization significantly increases dependency and length of hospital stay. In our study, the high prevalence of dependency at four weeks mirrors the impact of systemic and patient-related barriers, such as pain and fear of falling. These are consistent with prior observational studies highlighting how fatigue, pain, and anxiety restrict mobility after surgery [10,11].

Cognitive impairment has been identified as a major determinant of disability and mortality [12,13]. Our results reinforce this, with patients having cognitive impairment showing over three times the risk of poor rehabilitation outcomes. This echoes findings from both European and North American studies, where dementia prevalence in hip fracture cohorts ranges between 20–40% and significantly worsens recovery [12,13]. Similarly, anemia and hidden blood loss are well-documented predictors of delayed recovery [14,15], while advanced pain management strategies such as fascia iliaca blocks have shown promise in improving postoperative mobility [16].

Barriers to Rehabilitation

The barriers identified in this study provide further insight into the multidimensional challenges faced by elderly orthopaedics patients. Pain and fatigue were the most frequently reported limitations. Previous evidence suggests that persistent postoperative pain impedes physiotherapy participation, prolongs immobility, and fosters fear-avoidance behaviours [11]. Fatigue similarly reduces tolerance to exercise and daily activities, restricting rehabilitation intensity [10].

Fear of falling was reported by nearly half of patients. This psychological barrier often leads to reduced confidence, avoidance of mobilization, and a vicious cycle of dependency. Previous studies confirm that fall-related anxiety is common in this population and significantly delays recovery [4].

Lack of caregiver support was another major barrier, highlighting the importance of social determinants. Rehabilitation requires consistent assistance for mobility, adherence to physiotherapy, and emotional encouragement. Absence of caregiver support was independently associated with twofold higher odds of dependency in our cohort. This aligns with international recommendations emphasizing the integration of family and community-based rehabilitation services [5,6].

Cognitive impairment emerged as one of the strongest predictors of poor outcomes. Patients with dementia or delirium have impaired engagement in therapy, reduced adherence, and higher rates of complications [12,13]. Interventions such as delirium prevention, geriatrician-led multidisciplinary care, and cognitive stimulation strategies have been shown to improve outcomes in this subgroup [2,12].

The Indian Context

While much of the global evidence comes from Europe and North America, data from India provide unique insights into contextual challenges. Hip fracture care in India is complicated by late presentation, limited access to orthogeriatric services, and socioeconomic disparities [17]. Rath et al. [17] highlighted that current care pathways are fragmented, with inconsistent availability of rehabilitation facilities and poor integration between orthopaedic and geriatric care. Our findings of inadequate caregiver support as a major barrier resonate strongly in the Indian context, where family structures are changing, and reliance on informal care is increasingly strained.

Prospective Indian studies, such as those from Bhubaneswar, have shown high mortality rates and poor functional recovery following fragility fractures, reflecting both medical and systemic barriers [18]. Excess mortality among Indian hip fracture patients remains a persistent concern, with recent data demonstrating significantly worse outcomes compared to high-income countries [19]. Furthermore, limited rehabilitation infrastructure, financial constraints, and cultural perceptions of disability all exacerbate recovery challenges.

Pharmacological interventions, such as the use of zoledronic acid in osteoporosis management, have demonstrated potential in improving long-term outcomes for elderly patients with fragility fractures in India [20]. However, without adequate rehabilitation services, pharmacological benefits alone are insufficient to restore functional independence. Thus, our study adds to the growing body of Indian evidence emphasizing the urgent need for integrated, multidisciplinary rehabilitation models tailored to local realities.

Clinical and Policy Implications

Our findings underscore several actionable priorities:

  • Early mobilization protocols must be standardized to ensure patients begin physiotherapy within 24–48 hours, consistent with international recommendations [5,7].
  • Pain management strategies, including nerve blocks and multimodal analgesia, should be incorporated into perioperative care pathways to facilitate rehabilitation [11,16].
  • Targeted interventions for cognitive impairment, such as delirium prevention bundles and geriatric co-management, are essential to improve participation in rehabilitation [12,13].
  • Strengthening caregiver support systems through training programs, community rehabilitation, and financial subsidies can address the social determinants of poor recovery, particularly in India [17,18].
  • Policy-level initiatives must integrate orthopaedics, geriatric, and rehabilitation services into a continuum of care, moving beyond surgical fixation to holistic recovery [1,2,17].

Strengths and Limitations

The strengths of this study include its large multicentre design, use of validated functional measures (Barthel Index and TUG test), and comprehensive assessment of rehabilitation barriers. Including both clinical and psychosocial determinants provides a holistic understanding of the problem.

However, several limitations warrant consideration. Being cross-sectional, the study captures outcomes at only four weeks, limiting insights into long-term recovery trajectories. Self-reported barriers may be subject to recall or reporting bias. Additionally, while the study included three tertiary hospitals, findings may not be generalizable to rural or resource-limited settings where access to rehabilitation is even more constrained.

Future Directions

Future research should focus on longitudinal follow-up to evaluate long-term functional outcomes and mortality. Randomized controlled trials of targeted interventions—such as early mobilization bundles, caregiver training, or community-based rehabilitation programs—are needed in the Indian context. Health system strengthening, including workforce development in physiotherapy and geriatrics, will be critical to address the rising burden of fragility fractures in India’s aging population.

Conclusion

This study demonstrates that rehabilitation outcomes after orthopaedic surgery in elderly patients remain suboptimal, with less than 40% regaining independence at four weeks. Pain, fatigue, fear of falling, lack of caregiver support, and cognitive impairment were major barriers, while age, female sex, multiple comorbidities, and social support deficits independently predicted poor outcomes.

Findings are consistent with international evidence but also highlight context-specific challenges in India, including limited rehabilitation infrastructure, fragmented care pathways, and socioeconomic barriers. Strengthening early mobilization, pain management, cognitive care, and caregiver support, along with policy-level integration of geriatric and rehabilitation services, is crucial to improving outcomes. Future research should explore long-term recovery trajectories and evaluate community-based interventions tailored to the Indian healthcare system.

References

  • Royal College of Physicians: 15 years of quality improvement: the 2023 National Hip Fracture Database report on 2022. 2023. Available from:
    https://www.nhfd.co.uk/2023report
  • Dyer SM, Perracini MR, Smith T, Fairhall NJ, Cameron ID, Sherrington C, Crotty M. Orthogeriatrics: The Management of Older Patients With Fragility Fractures. Cham: Springer International Publishing; 2021.
  • Dyer SM, Crotty M, Fairhall N, Magaziner J, Beaupre LA, Cameron ID, Sherrington C. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr. 2016;16:158.
  • Fortinsky RH, Bohannon RW, Litt MD, et al. Rehabilitation therapy self-efficacy and functional recovery after hip fracture. Int J Rehabil Res. 2002;25:241–246.
  • National Institute for Health and Care Excellence. Hip fracture: management. NICE; 2023.
  • Lahtinen A, Leppilahti J, Harmainen S, et al. Geriatric and physically oriented rehabilitation improves ability of independent living and reduces mortality: a randomised comparison of 538 patients. Clin Rehabil. 2015;29:892–906.
  • Goubar A, Ayis S, Beaupre L, et al. The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: UK national linked audit data. Osteoporos Int. 2022;33:839–850.
  • Sheehan KJ, Goubar A, Martin FC, Potter C, Jones GD, Sackley C, Ayis S. Discharge after hip fracture surgery in relation to mobilisation timing by patient characteristics: linked secondary analysis of the UK National Hip Fracture Database. BMC Geriatr. 2021;21:694.
  • Almilaji O, Ayis S, Goubar A, et al. Frequency, duration, and type of physiotherapy in the week after hip fracture surgery: implications for discharge, readmission, survival, and recovery of mobility. Physiotherapy. 2023;120:47–59.
  • Said CM, Delahunt M, Ciavarella V, Al Maliki D, Boys AM, Vogrin S, Berney S. Factors impacting early mobilization following hip fracture: an observational study. J Geriatr Phys Ther. 2021;44:88–93.
  • Münter KH, Clemmesen CG, Foss NB, Palm H, Kristensen MT. Fatigue and pain limit independent mobility and physiotherapy after hip fracture surgery. Disabil Rehabil. 2018;40:1808–1816.
  • Cartei A, Mossello E, Ceccofiglio A, et al. Independent, differential effects of delirium on disability and mortality risk after hip fracture. J Am Med Dir Assoc. 2022;23:654–659.
  • Seitz DP, Adunuri N, Gill SS, Rochon PA. Prevalence of dementia and cognitive impairment among older adults with hip fractures. J Am Med Dir Assoc. 2011;12:556–564.
  • Lawrence VA, Silverstein JH, Cornell JE, Pederson T, Noveck H, Carson JL. Higher Hb level is associated with better early functional recovery after hip fracture repair. Transfusion. 2003;43:1717–1722.
  • Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br. 2006;88:1053–1059.
  • Hao C, Li C, Cao R, et al. Effects of perioperative fascia iliaca compartment block on postoperative pain and hip function in elderly patients with hip fracture. Geriatr Orthop Surg Rehabil. 2022;13:21514593221092883.
  • Rath S, Yadav L, Tewari A, et al. Management of older adults with hip fractures in India: a mixed methods study of current practice, barriers and facilitators, with recommendations to improve care pathways. Arch Osteoporos. 2017;12:55.
  • Dash SK, Panigrahi R, Palo N, Priyadarshi A, Biswal M. Fragility Hip Fractures in Elderly Patients in Bhubaneswar, India (2012–2014): A Prospective Multicenter Study. Geriatr Orthop Surg Rehabil. 2015;6(1):11–15.
  • Excess mortality in elderly hip fracture patients: An Indian experience. PubMed. 2023.
  • Siwach R, et al. Clinical outcomes of post-surgery osteoporosis treatment in elderly intertrochanteric fracture patients: a prospective study. Int J Res Orthop. (New Delhi).