Changing the narrative for exercise-based prehabilitation: Evidence-informed and shared decision making when discussing the need for a total knee arthroplasty with patients.

Objective: To examine a novel application of exercise-based prehabilitation in severe knee osteoarthritis-termed "pre-evaluation exercise"-focused on supporting surgical decision-making and adherence to clinical guidelines, rather than attempting to enhance post-operative recovery. Design: This narrative review discusses the usage of exercise in the clinical decision process for total knee arthroplasty (TKA). It synthesizes data from studies on exercise-based prehabilitation, covering patient selection, implementation, and its effects on surgical choices. Emphasis is placed on multi-disciplinary coordination within an Enhanced Recovery After Surgery (ERAS) framework. Results: Evidence suggests that pre-evaluation exercise can improve symptom management and may lead to delayed or reduced surgical intervention. This approach shows significant potential in reducing the rate of TKA surgeries among patients with severe knee osteoarthritis by improving physical conditioning, addressing symptom variability, and enhancing informed, patient-centered surgical decisions. Conclusions: Pre-evaluation exercise in knee osteoarthritis is a viable strategy that complements existing ERAS initiatives by facilitating guideline-conformant surgical decision-making. Incorporating this into pre-surgical care pathways can foster improved patient-related outcomes and healthcare resource optimization.