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The Role of Physical Therapy in Decreasing Length of Stay Following Total Knee Arthroplasty in a Public Hospital Setting

Michael J. Moses, David Novikov, Afshin A. Anoushiravani, Ajit J. Deshmukh, Lazaros Poultsides, Neville Crick, Ran Schwarzkopf

Michael J. Moses, David Novikov, Ajit J. Deshmukh, Lazaros Poultsides, Neville Crick, Ran Schwarzkopf, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th Street, New York, NY 10003, the United States
Afshin A. Anoushiravani, Division of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, the United States

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Ran Schwarzkopf, MD, MSc, Associate Professor, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, NY 12208, the United States.
Email: Schwarzkopf@nyumc.org
Telephone: +1-212-598-6000

Received: April 25, 2018
Revised: June 3, 2018
Accepted: June 6 2018
Published online: August 28, 2018

ABSTRACT

BACKGROUND: The goal of this study is to analyze how a modified PT protocol affects length of stay following TKA in the public hospital patient population.

METHODS: A retrospective review of 157 patients that underwent unilateral primary TKA was done. Basic demographics, perioperative and post-discharge characteristics were collected on TKA patients one year prior and one year following the initiation of a new PT protocol.

RESULTS: There were 94 patients in the non-intensive PT cohort and 63 in the intensive PT cohort. Hospital LOS was significantly shorter in the intensive PT cohort (2.0 versus 3.9 days; p < 0.001). There was no difference in complication rates, ED-visits within 90 days, or 90-day readmission rates between the non-intensive and intensive cohorts, respectively.

CONCLUSION: In this study, we found that an intensive PT regimen significantly decreased LOS and increased home discharge for patients after TKA without negatively affecting postoperative clinical outcomes.

Key words: Total knee arthroplasty; Physical therapy; Postoperative care; Postoperative outcomes; Rehabilitation

© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Moses MJ, Novikov D, Anoushiravani AA, Deshmukh AJ, Poultsides L, Crick N, Schwarzkopf R. The Role of Physical Therapy in Decreasing Length of Stay Following Total Knee Arthroplasty in a Public Hospital Setting. International Journal of Orthopaedics 2018; 5(4): 943-947 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/2321

INTRODUCTION

As the global population continues to age, there will be an increase in the number of total knee arthroplasties (TKA) performed annually. In the United States, the incidence of hip and knee replacements is estimated at greater than one million per year, with projections reaching 3.48 million procedures annually by 2030[1,2]. The increases in the volume of procedures is likely secondary to increased diagnosis of degenerative joint disease in conjunction with a growing patient population and improved life expectancy of those patients requiring operative intervention[2,3]. Alongside the increase in volume of these procedures, discussion surrounding overall healthcare and hospital costs will come to the forefront of operative planning.

One main factor that influences the cost of total knee arthroplasty (TKA) is patient length of stay (LOS) following surgery[4]. According to the Kaiser Family Foundation data, average daily hospital inpatient cost across the United States has doubled from $ 1000 per day in 1999 to over $ 2000 per day in 2015[5]. This dramatic increase in cost has likely been partially offset by the trend to decrease patient LOS after TKA surgery. Currently, the LOS following TKA averages 3.7 days in the Medicare population[6,7]. Certain perioperative factors have contributed to the overall decrease in patient LOS including systems-based practices to decrease complication rates, changes in implant design, minimally invasive techniques, multi-modal pain management, and physical rehabilitation protocols[8].

Physical therapy (PT) is one of the mainstays of postoperative management following TKA. PT has been shown to reduce swelling, increase range of motion, improve strength, and return individuals to a higher level of function following TKA[9-13]. There is limited data in the current literature, however, regarding the exact means and types of protocols that decrease LOS for patients following TKA. Some studies have found that implementation of PT protocols have decreased the hospital LOS by 1.3 days for patients undergoing TKA[14]. A recent systematic review has similarly found that for those patients undergoing total knee, hip or unicompartmental knee arthroplasty initiation of early PT significantly decreased LOS and overall hospital cost following these procedures[13]. One study that analyzed the role of postoperative day (POD) 0 PT solely found significant decrease in LOS for total hip arthroplasty (THA) patients, but not for TKA patients[15]. Thus, there remains uncertainty in the literature regarding the exact modality by which PT functions in the overall hospital course, LOS, and ultimately cost of an in-patient TKA episode of care.

The goal of this study is to analyze how changing the PT protocol from POD 1 to POD 0 and increasing PT frequency from 1 to 2 sessions a day may affect the LOS and secondary patient outcome measures and complications following TKA in a public hospital patient population. Our hypothesis is that the implementation of a more intense PT protocol, that includes PT initiation on POD 0 and an increased frequency of PT sessions, will significantly decrease the LOS for this patient population following TKA.

Materials and Methods

Design

A retrospective review at a public hospital was conducted. Data was collected on patients undergoing arthroplasty one year prior and one year following the initiation of a new PT protocol for arthroplasty patients.

Patients

Following institutional review board (IRB) approval, we conducted a retrospective review on all patients that underwent TKA at a public hospital in a large metropolitan city that serves a diverse patient population. Inclusion criteria included patients greater than 18-years old, primary TKA, and elective indication at the time of surgery. Exclusion criteria included any patient younger than 18-years old at the time of surgery, patients undergoing revision arthroplasty, patients presenting to the emergency department with indication for arthroplasty following acute trauma to the joint and non-elective arthroplasty. We collected data on patients undergoing arthroplasty one year prior and one year following the initiation of a new PT protocol for arthroplasty patients.

Procedures

Prior to June 2016, our post-operative PT protocol for TKA patients began on POD 0, however it was not required or strictly encouraged. POD 1 rehabilitation consisted of supervised transfers, stretching, knee flexion/extension, and ambulation with a PT therapist. POD 2 expanded on POD 1 activities, as well as included the addition of a stair climb. POD 3 rehabilitation consisted of more demanding POD 2 PT activities. The PT therapist supervised and worked with the patient once a day from POD 0 to POD 3. After June 2016, a more rigorous PT protocol was implemented with the goal of mobilizing postoperative TKA recipients earlier and expediting their hospital course. In brief, if the patient was able, it was now strongly encouraged for all patients to begin working with a therapist on POD 0. Additionally, beginning on POD 1, patients were now seen by a therapist twice a day instead of once, were encouraged to ambulate independently instead of supervised on POD 2, and were encouraged to attempt a stair climb on POD 1 instead of 2. A more detailed description of the PT protocols can be found in Table 1.

Table 1 Comparison of non-intensive and intensive PT protocols.
Time IntervalNon-intensiveIntensive
FrequencyOften seen 1x/dayPOD 0: 1x/day; POD 1-2: 2x/day or as needed*
Day of Surgery (POD 0)Supervised out of bed to chair transfers Supervised out of bed to chair transfers
Gastrocnemius stretching/Ankle pumps Gastrocnemius stretching/Ankle pumps
Quadriceps/Hamstring isometric stretchingQuadriceps/Hamstring isometric stretching
CPM machine: 0-30° (2 hrs/day) with full active flexion & extensionActive assisted knee flexion/extension as tolerated
POD 1Supervised out of bed to chair transfers Supervised out of bed to chair transfers
Gastrocnemius stretching/Ankle pumps Gastrocnemius stretching/Ankle pumps
Quadriceps/Hamstring isometric stretchingQuadriceps/Hamstring isometric stretching
CPM machine: 0-30° (2 hrs/day, 3 times per day) with full active flexion & extensionActive assisted knee flexion/extension to 60°
Supervised ambulation for 50 feet with walker/crutches WBAT Supervised ambulation for 50 feet with walker/crutches WBAT
Illustrated exercise program given to patient Supervised stair negotiation 4-6 steps, step to step pattern, WBAT
  Illustrated exercise program given to patient
POD 2 Independent out of bed to chair transfersIndependent out of bed to chair transfers
Gastrocnemius stretching/Ankle pumpsGastrocnemius stretching/Ankle pumps
Quadriceps/Hamstring isometric stretching Quadriceps/Hamstring isometric stretching
CPM machine: 45-60° (2 hrs/day, 3 times per day) with full active flexion & extensionActive assisted knee flexion/extension to 90°
Supervised ambulation for 100 feet with appropriate assistive device using walker/crutches WBAT Modified independent ambulation for 100 feet with appropriate assistive device using walker/crutches WBAT
Supervised stair negotiation Independent illustrated exercise program
Independent illustrated exercise program Patient discharged
POD 3 Independent out of bed to chair transfers 
Gastrocnemius stretching/Ankle pumps
Quadriceps/Hamstring isometric stretching
CPM machine: 60-90° (2 hrs/day, 3 times per day) with full active flexion & extension
Independent ambulation >150 feet with walker/crutches WBAT
? Independent stair negotiation
Review and modify illustrated exercise program
*Treatment could be 1-2x/day based on the patient's ability to: (1) Perform all transfers and bed mobility independently or modified independently; (2) Ambulate modified independently a minimum of 50 feet with a walker or cane (50 feet for a household ambulatory or 150 feet for a community ambulator). POD: post-operative day; CPM: continuous passive motion; WBAT: weight-bearing as tolerated; hrs: hours

For the purposes of the study, we defined the PT protocol prior to June 1, 2016 to be non-intensive and the PT protocol after June 1, 2016 to be intensive. For both protocols, a patient was deemed safe to be discharged if they met the following goals: (1) Patient is able to perform all transfers and bed mobility independently or modified independently; (2) Patient is able to ambulate independently a minimum of 50 feet with a walker or cane (50 feet for a household ambulator or 150 feet for a community ambulator); (3) Patient has the ability to freely flex their knee 70-90°.

Patient baseline characteristics including age, gender, race, body mass index (BMI), American Society of Anesthesiologists (ASA) score, smoking status, discharge disposition, payer type, and date of surgery were collected. Perioperative details including hospital LOS, discharge disposition, and whether the patient received PT on POD 0 were collected. Post-discharge characteristics including complications related to the surgery, all 90-day emergency department (ED) visits, and all 90-day readmissions were collected.

Statistical Analyses

Data was collected, de-identified, and stored on Excel software. All descriptive and inferential statistics were conducted using SPSS v23 (International Business Machines, Armonk NY) statistics software. Chi-square and Fisher’s exact test were used to compare categorical baseline patient demographics. Comparative analysis using a paired two-tailed student’s t-test was used to compare means with variances among continuous variables between the two cohorts. A p-value < 0.05 was deemed statistically significant.

RESULTS

Patient Demographics

From January 2014 to June 2017, we identified 157 patients who underwent primary TKA at our institution and met our inclusion criteria. There were 94 patients in the non-intensive PT cohort and 63 in the intensive PT cohort. The mean age in the non-intensive cohort was 64.5 ± 9.6 and the mean age in the intensive cohort was 65.0 ± 10.3. The non-intensive cohort included 19 (20%) males and 75 (80%) females, while the comparator cohort included 16 (25.4%) males and 45 (74.6%) females. The mean BMI was 31.9 ± 4.9 kg/m2 in the non-intensive cohort and was 31.3 ± 5.7 kg/m2 in the comparator cohort. Seventy-one (75.5%) patients in the non-intensive PT cohort were discharged home, compared to 55 (90.2%) patients in the intensive cohort (p = 0.03). Insurance payer type amongst both cohorts was similar (p = 0.31), with most patients insured under Medicaid. Patients who had both Medicaid and Medicare were included in the Medicaid subgroup. Evaluation of age, gender, race, BMI, ASA score, smoking status, and insurance type revealed no statistically significant differences between the non-intensive and intensive PT cohorts (p > 0.05). Detailed information on race, ASA score, smoking status, and insurance type can be found in Table 2.

Table 2 Primary TKA Patient Demographics.
Patient CharacteristicsNon-intensive PT (n = 94)Intensive PT (n = 63)p-value
Age y ± SD (range)64.5 ± 9.6 (20-82) 65.0 ± 10.3 (37-85)p = 0.08
Sexp = 0.38
Male n (%)19 (20.0%)16 (25.4%) 
Female n (%)75 (80.0%)45 (74.6%) 
Racep = 0.19
White n (%)10 (11.0%)2 (3.8%) 
Black n (%)23 (25.3%)12 (23.1%) 
Hispanic n (%)43 (47.3%)33 (63.5%) 
Asian n (%)15 (16.5%)5 (9.6%) 
BMI kg/m2 ± SD (range) 31.9 ± 4.9 (20.7-42.8) 31.3 ± 5.7 (21.6-43.2)p = 0.46
ASA scorep = 0.22
I n (%)8 (8.5%)3 (5.0%) 
II n (%)76 (80.9%)45 (75.0%) 
III n (%)10 (10.6%)12 (20.0%) 
Smoking status p = 0.28
Never smoker n (%)65 (69.2%)45 (73.8%) 
Former smoker n (%)5 (5.3%)6 (9.8%) 
Current smoker n (%)24 (25.5%)10 (16.4%) 
Discharge disposition p = 0.03
Home n (%)71 (75.5%)55 (90.2%) 
SAR n (%)7 (7.4%)2 (3.3%) 
SNF n (%)16 (17.0%)2 (3.3%) 
Shelter n (%)01 (1.6%) 
Eloped n (%)01 (1.6%) 
Insurance p = 0.31
Medicaid n (%)54 (57.4%)42 (66.7%) 
Medicare n (%)4 (4.2%)1 (1.6%) 
Private n (%)01 (1.6%) 
Unknown n (%)36 (38.4%)19 (30.1%) 
PT: physical therapy; BMI: body mass index; ASA: American Society of Anesthesiologists; SAR: subacute rehab; SNF: skilled nursing facility;

Analysis of Perioperative Characteristics

Perioperative characteristics were evaluated to assess the effect more intensive PT has had on a primary TKA patient’s perioperative course (Table 3). The majority of patients (81%) did not receive PT on POD 0 in the non-intensive cohort while the majority of patients (65.6%) did receive PT on POD 0 in the intensive cohort (p < 0.001). This demonstrates the effective implementation of the modified PT protocol. Hospital LOS was significantly shorter in the intensive PT cohort (2.0 versus 3.9 days; p < 0.001).

Table 3 Primary TKA perioperative characteristics.
Perioperative characteristicsNon-intensive PTIntensive PTp-value
Hospital LOS days ± SD (range)3.9 ± 2.56 (1-13)2.0 ± 1.11 (1-7)p < 0.0001
PT POD 0 p < 0.0001
Yes n (%)18 (19%)40 (65.6%) 
No n (%)76 (81%)21 (34.4%) 
PT: physical therapy; LOS: length of stay; POD: postoperative day.

Analysis of Post-discharge Characteristics

Post-discharge characteristics, including complications, 90-day ED visits, and 90-day readmission rates, were collected and analyzed to assess the safety of the modified PT protocol (Table 4). Ten patients (10%) and 5 patients (16.7%) had complications related to their primary TKA in the non-intensive and intensive cohorts, respectively (p = 0.78). There was no difference between ED visits for any reason within 90 days after surgery between the non-intensive (26.4%) and intensive (21.7%) cohorts (p = 0.57). There was no difference in 90-day readmission rates between the non-intensive (9.6%) and intensive (9.5%) cohorts (p = 0.99) (Figure 1).

Figure 1 Timeline showing the difference in average hospital length of stay before and after implementation of an intensive physical therapy protocol. PT: Physical therapy.

DISCUSSION

As the demand for TKA continues to increase, a greater focus has been placed on delivering high quality orthopaedic care. Our study sought to identify the role of intensive PT in decreasing LOS for patients following TKA in a public hospital setting. Currently, there is a paucity of literature assessing the role of PT protocols in TKA, specifically as it relates to LOS and other postoperative quality metrics.

In our current study, the implementation of same-day PT (POD-0), and twice a day sessions significantly decreased the LOS for patients following TKA (p < 0.01) from a mean of 3.9 days to 2.0 days, without any increase in adverse outcomes. In previous studies, decreased LOS for patients undergoing TKA has similarly been reported. For example, Isaac and colleagues utilized an accelerated rehabilitation protocol to decrease LOS for patients undergoing TKA, which included infiltration of bupivacaine and adrenaline to the divided tissue layers at the time of surgery, spinal anesthesia, and mobilization on the day of surgery[16]. This interdisciplinary rehabilitation protocol was successful in reducing overall LOS for patients after TKA. Labarca et al also found that initiation of PT within 24-hours of surgery was correlated with decreased LOS for patients after TKA[17]. However, there are few studies in the current literature that describe the role of same-day and more frequent PT protocols in decreasing LOS for patients. To the contrary, Karim, et al found that PT protocols initiated on POD 0 provided no statistically significant benefit in decreasing LOS, as compared to our study which did find a decrease in LOS[15]. This may be due to a multitude of factors such as differing patient demographics and PT protocols utilized for TKA patients between the two studies. Furthermore, it is unclear if they utilized identical PT protocols for both their TKA and THA patients, respectively. Thus, our study appears to be one of the first to exemplify how a rigorous PT protocol can decrease LOS among TKA candidates.

The PT protocol that we initiated for the intensive cohort (PT on POD 0, and twice a day sessions) eliminated the use of the continuous passive motion (CPM) machine, as compared to the non-intensive protocol. The CPM machine functions to passively and repeatedly move the knee through a specified range of motion[18]. A recent Cochrane review found that the use of the CPM machine did not have clinically important effects on knee range of motion, function, or overall quality of life. For these reasons, when we devised our novel PT protocol we removed the CPM machine as a component of the protocol. Instead, we replaced the CPM machine with physical therapist active-assisted knee flexion and extension. Additional differences between our intensive and non-intensive regimens can be found in Table 1.

Another impact of the initiation of the new intensive PT program was that patients were less likely to be discharged to rehabilitation facilities and were more likely to be discharged back home. We found that 90.2% of patients undergoing the intensive PT protocol were discharged home, as compared to only 75.5% of patients who participated in non-intensive PT protocol (p < 0.03). Although these values are substantially higher than those reported in other studies, they demonstrate similar outcomes--rigorous postoperative PT enables patients to be discharged home sooner[19]. Additionally, Brennan et al[20]. found that patients who were discharged home and who started outpatient PT sooner had better outcomes when compared to patients who waited longer to start outpatient PT following discharge. Thus, our PT rehabilitation protocol functions to decrease LOS, increase home discharge, and further highlights the importance of PT in the overall rehabilitation of patients following TKA.

Lastly, we did not find a significant difference in postoperative complication, 90-day emergency department (ED) visits, and 90-day readmission rates for the non-intensive and intensive PT protocols, as seen in Table 4. This is particularly important and timely as the U.S. Centers for Medicare and Medicaid services initiated mandatory 90-day bundle payments for TKA in 2016[21]. Hospitals are tasked with covering the cost for all patient readmissions within 90-days following TKA in Medicare and Medicaid patients. Given that a majority of patients in our public hospital system fall into this insurance group, decreasing cost incurred to the hospital is of the utmost importance. We found that initiating an intense PT protocol on POD 0 reduced the LOS and had no clinically significant influence on readmission rates thereby reducing the healthcare burden.

Our study is not without limitations. One limitation of our study is inherent to its retrospective design, potentially exposing the study to collection error. In order to minimize such errors, trained researchers collected data from our institution’s electronic medical record. Another limitation of this study is the lack of validated patient reported outcomes (PROs) such as Knee Injury and Osteoarthritis Outcomes Scores (KOOS) pre- and postoperatively. However, this is impractical due to the underserved patient population included in this study. Despite these limitations, our study clearly establishes that robust PT with a trained clinician may significantly reduce LOS while enhancing the quality of care the TKA recipient receives.

Table 4 Primary TKA post-discharge characteristics.
Post-discharge characteristicsNon-intensive PTIntensive PTp-value
Complicationp = 0.78
Yes10 (10%)5 (16.7%) 
No83 (90%)55 (83.3%) 
90-day ED visit p = 0.57
Yes24 (26.4%) 13 (21.7%) 
No67 (73.6%)47 (78.3%) 
90-day readmission p = 0.99
Yes9 (9.6%)6 (9.5%) 
No85 (90.4%)57 (90.5%) 
PT: physical therapy; ED: emergency department.

Conclusion

The number of TKA cases to be performed annually is projected to increase to 3.5 million by 2030[2]. Accompanying this exponential growth will be a greater focus on healthcare system cost and overall patient outcomes. One method by which the two aforementioned foci can be improved is through decreased LOS by initiating intensive PT protocols on POD 0 after TKA. In this study, we found that an intensive PT regimen significantly decreased LOS and increased home discharge for patients after TKA without negatively affecting postoperative clinical outcomes. Further studies will be required to analyze the long-term outcomes for these types of patients and discuss other methods by which protocols may be developed to decrease the overall cost burden to our ever-changing healthcare system.

REFERENCES

1. Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone and Joint Surgery American volume 2015; 97: 1386-97. [DOI: 10.2106/JBJS.N.01141].

2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of Bone and Joint Surgery American volume 2007; 89: 780-5. [DOI: 10.2106/JBJS.F.00222].

3. Reginster JY. The prevalence and burden of arthritis. Rheumatology 2002; 41 Supp 1: 3-6

4. Healy WL, Ayers ME, Iorio R, Patch DA, Appleby D, Pfeifer BA. Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome. The Journal of Arthroplasty 1998; 13: 266-76

5. Hospital Adjusted Expenses per Inpatient Day by Ownership. The Henry J Kaiser Family Foundation 2016

6. Ehrenpreis ED, Zhou Y. Hospital costs, length of stay and prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease. World Journal of Gastroenterology 2017; 23: 4752-8. [DOI: 10.3748/wjg.v23.i26.4752].

7. Cram P, Lu X, Kaboli PJ, Vaughan-Sarrazin MS, Cai X, Wolf BR, Li Y. Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008. JAMA 2011; 305: 1560-7. [DOI: 10.1001/jama.2011.478].

8. El Bitar YF, Illingworth KD, Scaife SL, Horberg JV, Saleh KJ. Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database. The Journal of arthroplasty 2015; 30: 1710-5. [DOI: 10.1016/j.arth.2015.05.003].

9. Bruyere O, Ethgen O, Neuprez A, Zegels B, Gillet P, Huskin JP, Reginster JY. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Archives of orthopaedic and trauma surgery 2012; 132: 1583-7. [DOI: 10.1007/s00402-012-1583-7].

10. Dailiana ZH, Papakostidou I, Varitimidis S, Liaropoulos L, Zintzaras E, Karachalios T, Michelinakis E, Malizos KN. Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC musculoskeletal disorders 2015; 16: 366. [DOI: 10.1186/s12891-015-0814-9].

11. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, Phillips C, Partridge AJ, Belisle P, Fossel AH, Mahomed N, Sledge CB, Katz JN. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis and rheumatism 1999; 42: 1722-8. [PMID: 10446873]; [DOI: 10.1002/1529-0131(199908)42: 8<1722:: AID-ANR22>3.0.CO; 2-R].

12. Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med 2001; 161: 454-60

13. Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PloS one 2017; 12: e0178295. [DOI: 10.1371/journal.pone.0178295].

14. Teeny SM, York SC, Benson C, Perdue ST. Does shortened length of hospital stay affect total knee arthroplasty rehabilitation outcomes? The Journal of arthroplasty 2005; 20: 39-45. [DOI: 10.1016/j.arth.2005.04.025].

15. Karim A, Pulido L, Incavo S. Does Accelerated Physical Therapy After Elective Primary Hip and Knee Arthroplasty Facilitate Early Discharge? American journal of orthopedics 2016; 45: E337-E42

16. Isaac D, Falode T, Liu P, I’Anson H, Dillow K, Gill P. Accelerated rehabilitation after total knee replacement. The Knee 2005; 12: 346-50. [DOI: 10.1016/j.knee.2004.11.007].

17. Labraca NS, Castro-Sanchez AM, Mataran-Penarrocha GA, Arroyo-Morales M, Sanchez-Joya Mdel M, Moreno-Lorenzo C. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil 2011; 25: 557-66. [DOI: 10.1177/0269215510393759].

18. Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. The Cochrane database of systematic reviews 2010: CD004260. [DOI: 10.1002/14651858.CD004260.pub2].

19. Ponnusamy KE, Naseer Z, El Dafrawy MH, Okafor L, Alexander C, Sterling RS, Khanuja HS, Skolasky RL. Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty. The Journal of bone and joint surgery American volume 2017; 99: e55. [DOI: 10.2106/JBJS.16.00166].

20. Brennan GP, Fritz JM, Houck LT, Hunter SJ. Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty. The Journal of arthroplasty 2015; 30: 885-90. [DOI: 10.1016/j.arth.2014.12.013].

21. Williams J, Kester BS, Bosco JA, Slover JD, Iorio R, Schwarzkopf R. The Association Between Hospital Length of Stay and 90-Day Readmission Risk Within a Total Joint Arthroplasty Bundled Payment Initiative. The Journal of arthroplasty 2017; 32: 714-8. [DOI: 10.1016/j.arth.2016.09.005].

Peer Reviewer: Bakir Kadum

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