Abstract Objective To investigate the current status and influencing factors of fall alertness among elderly patients undergoing total hip/total knee arthroplasty (TH/TKA). Methods From August 2024 to April 2025, a convenience sampling method was employed to select 317 elderly TH/TKA patients from a tertiary Class A hospital in Shanxi Province as research subjects. Data collection involved general information questionnaires, fall alertness scales, hospital depression-anxiety scales, family support self-rating scales, and visual analog rating scales. Results The fall alertness scores for elderly TH/TKA patients ranged from (57.37±8.91) points. Regression analysis revealed that age, pain severity, number of comorbidities, muscle strength, anxiety levels, fall history, and family support were significant predictors of fall alertness (P<0.05). Conclusion The elevated fall alertness levels among elderly TH/TKA patients necessitate medical staff to prioritize patient awareness and implement personalized health education and fall prevention strategies to enhance safety and reduce fall incidence.