The FEAR Framework for Recovery After Total Hip and Knee Arthroplasty: A Systematic Review

Fear-related psychological barriers are increasingly recognized contributors to persistent pain, functional limitation, and dissatisfaction following total hip and knee arthroplasty. This systematic review synthesizes evidence on fear-related constructs and postoperative recovery and introduces the FEAR Framework as a structured model for clinical interpretation. This review (1) summarizes associations between fear-related constructs and postoperative outcomes; (2) organizes these constructs into four domains: Fall Confidence, Exposure Avoidance, Anticipatory Anxiety, and Reinjury Fear; (3) reviews validated patient-reported outcome measures; and (4) discusses clinical applications of FEAR-based assessment. Fear-related factors, particularly kinesiophobia and pain catastrophizing, are consistently associated with worse outcomes after arthroplasty. The FEAR Framework may provide a practical method for identifying modifiable psychological barriers and may help distinguish non-mechanical contributors to discordant recovery.