BACKGROUND: Prehabilitation involving a planned exercise program before surgery is proposed to improve rehabilitation and postoperative outcomes. However, the current evidence on the efficacy of prehabilitation for patients awaiting total hip replacement is conflicting. The aim of this study was to evaluate efficacy of preoperative exercises and education (AktivA®) for adults 70 years or older awaiting total hip replacement. METHODS: In a two-armed randomized controlled trial we recruited 98 participants aged 70 years or older with a Harris Hip Score less than 60 awaiting elective primary total hip replacement. Participants were recruited at three hospitals in Norway between 2019 and 2022. Participants were randomly assigned to prehabilitation or usual care. The prehabilitation group received a tailored exercise program for 6-12 weeks in addition to patient education. Gait speed, the primary outcome, was measured by the 40 m Fast-Paced Walk Test. Secondary outcomes included performance-based tests (Chair Stand Test, Timed Up & Go Test, 6-Minute Walk Test, Stair Climb Test) and patient-reported outcomes (Hip Disability and Osteoarthritis Outcome Score (HOOS) and EQ-5D). Outcomes were assessed at baseline, post intervention, and further 6 weeks, 3-, 6-, and 12 months post-surgery. RESULTS: For the primary outcome gait speed at the primary endpoint (3 months post-surgery), no significant between-group differences were observed. However, post-intervention (before surgery), we found a significant improvement in favor of prehabilitation for both gait speed (0.15 m/s, 95% CI 0.02-0.28) and the HOOS quality of life subscale (11.93, 95% CI 3.38-20.48). No other significant differences were found at any post-surgery follow-up for these outcomes. For other secondary outcomes, there were no between-group differences at any point of assessment. Both groups showed improvement across all outcomes 3-12 months after surgery. CONCLUSIONS: The AktivA TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03602105-initial release: 06/06/2018.