Paper in Focus

Frydendal T, Christensen R, Mechlenburg I, et al.
Total Hip Replacement or Resistance Training for Severe Hip Osteoarthritis.
New England Journal of Medicine. 2024;391:1610-1620.
DOI: 10.1056/NEJMoa2400141
PMID: 39476341

Opening Editorial: Editor’s Perspective

Severe hip osteoarthritis sits at the intersection of pain, function, quality of life, and shared decision-making. For many patients, total hip replacement is viewed as the definitive intervention, while exercise-based therapy remains an important component of conservative management. Yet despite the frequency of total hip arthroplasty worldwide, high-quality randomized evidence comparing surgery directly with nonsurgical treatment has historically been limited.

The PROHIP trial helps address that gap.

In this multicenter randomized controlled trial, patients 50 years of age or older with severe hip osteoarthritis and an indication for surgery were assigned to either total hip replacement or supervised resistance training. At 6 months, total hip replacement produced substantially greater improvements in patient-reported hip pain and function compared with resistance training. The Oxford Hip Score improved by 15.9 points in the total hip replacement group compared with 4.5 points in the resistance-training group, with a between-group difference of 11.4 points.

This result is clinically meaningful and supports what many orthopedic surgeons observe in practice: for appropriately selected patients with advanced symptomatic disease, arthroplasty can offer profound improvement in pain and function.

However, the study also leaves room for nuance. Resistance training was not ineffective. Some patients improved without surgery, and nearly one in four patients assigned to resistance training had not undergone total hip replacement by 24 months. This reminds us that conservative care still has a role, especially in patients who are not ready for surgery, have modifiable risk factors, or prefer to delay operative treatment.

The larger lesson is not simply “surgery wins.” Rather, the trial reinforces the importance of patient selection, timing, expectations, and shared decision-making. Total hip replacement may offer superior short-term improvement in severe hip osteoarthritis, but resistance training may still serve as a meaningful bridge, adjunct, or alternative for selected patients.

Why This Paper Matters

Total hip arthroplasty is one of the most successful procedures in orthopedic surgery, but the decision to proceed with surgery should still be evidence-based and patient-centered. This trial provides randomized data supporting total hip replacement over resistance training for patients with severe hip osteoarthritis who already meet surgical indications.

The study is especially important because it compares surgery against an active nonsurgical intervention rather than no treatment. Resistance training was structured, supervised, and progressive, making the comparison clinically relevant.

For orthopedic practice, this paper strengthens the argument that patients with advanced hip osteoarthritis and persistent functional limitation can reasonably expect greater improvement from total hip replacement than from resistance training alone.

Key Findings

In the intention-to-treat analysis, total hip replacement led to a significantly greater improvement in Oxford Hip Score at 6 months compared with resistance training.

The total hip replacement group also had greater improvements in several Hip Disability and Osteoarthritis Outcome Score domains, including pain, symptoms, function in activities of daily living, hip-related quality of life, and sports and recreation.

Serious adverse events were similar between groups at 6 months, occurring in 12% of patients in the total hip replacement group and 9% of patients in the resistance-training group. Most serious adverse events were known complications related to total hip replacement.

By 24 months, 77% of patients initially assigned to resistance training had undergone total hip replacement, suggesting that resistance training may delay surgery for some patients but does not eliminate the eventual need for arthroplasty in many cases.

Clinical Takeaway

For patients with severe hip osteoarthritis who meet surgical indications, total hip replacement provides superior improvement in pain and function at 6 months compared with supervised resistance training.

At the same time, resistance training remains valuable. It may help some patients improve, delay surgery, optimize preoperative conditioning, or participate more actively in shared decision-making.

This paper supports a balanced approach: surgery should not be delayed unnecessarily in patients with severe symptomatic disease who are appropriate candidates, but nonsurgical treatment still has a role in individualized care.

Reflection

The PROHIP trial highlights an important reality in orthopaedics: treatment decisions are rarely binary. Surgery and conservative care are not always opposing strategies. In many cases, they exist along the same continuum.

For severe hip osteoarthritis, total hip replacement remains a powerful intervention. But resistance training can still contribute to preparation, symptom management, and patient engagement. The best care comes from understanding not only which treatment works better on average, but which treatment best fits the patient in front of us.

Resource Acknowledgment

I would also like to respectfully acknowledge Orthobullets for its continued role as an orthopaedic learning resource. Conversations in Orthopaedics is always looking to highlight meaningful educational tools that support learning, discussion, and professional growth within the field. This acknowledgment is not intended to suggest a formal partnership or collaboration.

Scheduling Note

Conversations in Orthopaedics will be taking a brief pause for the next two weeks as I will be traveling to Japan. There will be no new issue during that time, but the newsletter will resume afterward with continued discussion of contemporary orthopaedic literature and clinical perspective.