Patient discharge after total joint arthroplasty (TJA) is dependent on a variety of factors, including pain control, status of the surgical wound, management of medical comorbidities, disposition planning, and progress with physical therapy.1–4 In-patient length of stay (LOS) following TJA has a tremendous impact on total cost of care, both to the patient and to the health care system.5,6 Among patients undergoing total hip arthroplasty (THA), Regenbogan et al6 reported that a shorter LOS was associated with nearly $3000 in decreased total surgical episode cost and no significant change in post-discharge spending. Regarding outcomes, patient satisfaction has been correlated with return to normal daily activities without pain.7,8 Singh et al9 reported that patients who had some or complete dependence on walking aids after total knee arthroplasty (TKA) had significantly higher odds of moderate-severe pain and activity limitation when compared with those who did not require walking aids.
Various studies evaluated whether preoperative functional status correlates with outcomes after TJA, and the conclusions are mixed.10–12 Kennedy et al13 found that higher preoperative scores with regard to the Western Ontario and McMaster Universities Osteoarthritis Index, the 6-minute walk test, and the timed up and go test all predicted better functional status at 1 week after THA or TKA. Petis et al14 showed that with every 5-second interval increase in the timed up and go test time, patients were twice as likely to stay in the hospital beyond 48 hours after THA.
Whether these short-term outcomes are clinically significant during a longer follow-up period remains unclear. In fact, a recent study found that patient-reported physical activity prior to TKA did not predict return to work postoperatively.12 Kwok et al15 performed a systematic review of 11 randomized trials and concluded that preoperative physical therapy did not lead to significant improvements in patient outcome scores, pain, range of motion, or LOS after TKA.
Recently, several investigators suggested that patient engagement with the recovery process may correlate with outcomes after TJA. One study concluded that preoperative beliefs and expectations were more predictive of returning to work after TJA when compared with preoperative physical activity.12 Andrawis et al16 examined patient activation, a measure of the propensity to engage in adaptive health behavior by taking into account beliefs such as optimism, hope, self-efficacy, and locus of control. They determined that higher preoperative patient activation correlated with improved patient-reported pain, symptoms, and satisfaction after TJA.16 Given these studies, the current authors sought to develop a screening tool that could be used to identify patients who are more likely to succeed after TJA.
The PrimePrehab Prehabilitation Exercise Program (NextPT, Boulder, Colorado) guides patients through a series of personalized modules preoperatively, with the goals of fostering more patient engagement and improving exercise tolerance in preparation for surgery. The current authors hypothesized that more preoperative engagement in rehabilitation prior to TJA would decrease LOS and hasten patients to return to function with decreased use of an assistive gait device.
Materials and Methods
This retrospective cohort study received institutional review board approval. All patients were excluded if their etiology of disease was not osteoarthritis or they received an aseptic revision surgery or surgery for an infection. Forty consecutive patients with osteoarthritis undergoing a posterior approach THA or medial parapatellar TKA performed by a single surgeon (J.I.H.) were given the PrimePrehab Exercise Program free of charge. The program guided patients through a series of modules on surgical expectations and rehabilitation prior to surgery, with a goal of fostering patient engagement in preparation for joint replacement. Participants were given an access code and directions for how to access the PrimePrehab Prehabilitation Exercise Program creation portal at the time of indication for joint replacement.
Following program registration, participants used a unique user ID and password to log in to the PrimePrehab website ( http://www.nextpt.me/primeprehab) and create a personalized preoperative education and exercise program. This was achieved by guiding the patient through a series of online questionnaires regarding the type of upcoming surgery, date of operation, current level of physical function, postoperative goals, presence of potential high fall risk factors. Using participant-specified information, the PrimePrehab website compiled a series of 8 educational readings and 5 exercise modules drawn from well-established, evidence-based physical therapy programs that were adjusted to the participant's initial ability level (Table 1).17,18
PrimePrehab Prehabilitation Exercise Program Educational Readings and Exercise Modules
At any time, participants were able to increase or decrease the level of difficulty of an exercise module (range, 1–5), fast forward or rewind the exercise, or move to the next or prior category of exercises. Points were awarded each time the participant viewed all 5 daily exercise videos and completed each educational reading. The number of points achieved by the patient preoperatively was considered as the “frequency” of program participation. Improvement was measured by change in difficulty level from program initiation to the maximum level reached preoperatively. Participants were instructed to exercise 5 times per week leading up to surgery and to complete all 8 educational lessons before the day of surgery.
Postoperatively, all patients received a standardized rehabilitation protocol that involved mobilization with physical therapy on the day of surgery. Inpatient physical therapy was then continued at least once daily while the patient was admitted to the hospital. Patients were deemed appropriate for discharge either to home or a skilled nursing facility based on their progress with therapy (eg, distance ambulated, number of stairs ascended) and home safety considerations (eg, help of another person, stairs, durable medical equipment). Postoperative LOS in the hospital and gait independence at 90 days postoperative (GI90; eg, none, cane, walker, or wheelchair [score range, 0–3, respectively]) were recorded.
Results were described as medians and ranges for demographics, means and standard deviations for continuous variables, and numbers and percentages for all categorical variables. Statistical analyses were conducted as either simple or multiple regression using SPSS version 26 software (IBM, Armonk, New York). The authors added an interaction term to the regressions to determine whether the effects of the exercise program were moderated by surgery type (either THA or TKA).
Median age of the cohort was 65 years (range, 49–86 years). Twenty-three (57.5%) participants were women and 17 (42.5%) were men. Median body mass index was 27.6 kg/m2 (range, 20.4–39.6 kg/m2). Twenty-five (62.5%) patients had a right-sided operation, 14 (35.0%) had a left-sided operation, and 1 (2.5%) had a simultaneous bilateral procedure. Median American Society of Anesthesiologists (ASA) classification score was 2 (range, 1–3). Twenty-three (57.5%) patients underwent TKA, whereas 17 (42.5%) underwent THA. Data on LOS were available for all 40 patients (100%), but gait aid data were documented for only 33 (82.5%) at 90-day clinic follow-up (Table 2).
Preoperatively, participants completed a mean of 6.9±13 exercise modules (1 outlier completed 65 modules) and showed a mean improvement of 31%±27.0% in exercise difficulty. No significant associations were found between sex and frequency of program completion (P=.286) or improvement in difficulty (P=.683).
Postoperatively, participants spent a mean of 62.3±16 hours in the hospital prior to discharge (1 outlier spent 178 hours). Four (10.0%) patients were discharged to a skilled nursing facility and 36 (90.0%) were discharged to home. Based on simple regression, no correlation was found between LOS and age (P=.146), sex (P=.207), weight (P=.483), or ASA classification (P=.476).
Controlling for age, sex, weight, and ASA classification, the number of preoperative exercise modules completed was significantly associated with shorter LOS (P=.037; Figure 1). This finding was not different between THA and TKA (P=.387). When controlling for the above demographic variables, improvement in exercise difficulty was not significantly correlated with LOS (P=.938).
A scatter plot of modules completed correlated with decreased length of stay. Preoperative exercise modules completed correlated significantly with decreased length of stay in hospital (P=.037) (A), but improvement in preoperative exercise difficulty did not (P=.938) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.
At 90-day follow-up, patients scored a mean of 0.76±1.3 for gait aid dependence (GI90 score ranged from 0 to 3 for no aid, cane, walker, and wheelchair). Paradoxically, there was a trend toward increased gait independence at 90 days (lower GI90 score) with higher patient weight (P=.051). No correlation was found between gait independence at 90 days and age (P=.119), sex (P=.071), or ASA classification (P=.959). Controlling for all demographic variables, no significant association was found between the number of modules completed and gait independence at 90 days (P=.213). However, a significant correlation was found between gait independence and preoperative improvement in exercise difficulty (P=.034; Figure 2). Again, this association was not significantly different between patients who underwent THA and TKA (P=.854).
A scatter plot showing improvement in exercise difficulty correlated with decreased gait aid use at 90 days. Preoperative exercise difficulty improvement correlated significantly with decreased gait aid use at 90 days postoperatively (P=.034) (A), but the number of preoperative exercise modules completed did not (P=.213) (B). Controlling for age, sex, weight, and American Society of Anesthesiologists status resulted in a “residualized” y-axis. Line of best fit through all data points is shown.
Accelerating recovery after TJA is important to patients and providers. Recently, several investigators have demonstrated that patient engagement may play a role in the recovery process, but none have looked specifically at ways to identify which patients will have favorable outcomes postoperatively. In this novel study, the current authors sought to use participation in a preoperative education and exercise program to demonstrate patient engagement with the recovery process, thereby correlating with improved outcomes after TJA. The findings indicate that increased participation with a preoperative exercise program correlates with a decreased hospital LOS and increased gait independence.
Several other studies examined the impact of preoperative physical therapy on postoperative outcomes, but those therapy protocols were not clearly defined or the results were mixed.19,20 Rodgers et al19 examined the effect of preoperative physical therapy for 6 weeks on postoperative muscle strength after TKA, concluding that there were no significant differences between groups regarding strength testing. However, their study only included 10 patients in each treatment arm and did not specifically evaluate clinically relevant outcomes such as distance walked, use of a gait aid, or LOS.19 A 2017 study in Denmark examined patients undergoing preoperative neuromuscular group exercise supervised by a physical therapist for 8 weeks before THA or TKA.21 Those authors concluded that patients in the intervention group had moderate improvement in quality of life measures only at 1 year postoperatively, but they did not study any functional outcomes.21 A systematic review by Kwok et al15 examined 11 randomized controlled trials evaluating preoperative physical therapy in primary TKA. The quality of studies was deemed to be poor due to small sample sizes, and furthermore, there were no significant differences in pooled outcome scores, strength, pain, range of motion, and hospital LOS.15
By comparison, the current study is distinct in that the authors used a standardized training program that was individualized to the patient's preoperative functional status and progress. They were also able to specifically track patient use of the program, allowing them to correlate preoperative engagement to postoperative clinical outcomes. The authors believe their data will guide larger comparative case-control studies and randomized controlled trials in the future, with the goal of ultimately incorporating personalized, interactive rehabilitation programs into a standard preoperative care pathway that will be used to identify patients who are engaged and portend favorable outcomes, as well as preemptively targeting more intensive and proactive resources toward the patients who are less engaged in this portion of the care pathway.
Several limitations exist for this study. First, this pilot study combined patients undergoing both THA and TKA. However, the authors believe that future studies focusing specifically on each operation should yield similar results, particularly given that they added an interaction term to their analyses to determine whether effects were moderated by surgery type. In addition, it is possible that some of the variations in use of the program could be attributed to differences in patients' familiarity and comfort with using technology needed to access the education material and exercises. Next, although statistically significant, it is difficult to determine whether the decrease in hospital LOS is clinically meaningful. That is, it is challenging to discern whether shorter LOS, often less than 1 day, has any impact on cost or satisfaction. Furthermore, the authors recognize that a variety of nonmedical factors may contribute to the exact time of discharge and, as such, individual data points should be interpreted with caution. That given, the authors believe that the general trend likely holds true.
Finally, this study does not specifically measure whether these outcomes of shorter LOS and gait aid independence are correlated with long-term clinical outcomes or increased satisfaction. Previous studies demonstrated that both of these variables affect a patient's perception of care,9,22,23 but the current work does not specifically evaluate this.
The authors have demonstrate that patient engagement with a preoperative education and exercise program correlates with decreased LOS and improved gait independence following TJA.
- Sikora-Klak J, Zarling B, Bergum C, Flynn JC, Markel DC. The effect of comorbidities on discharge disposition and readmission for total joint arthroplasty patients. J Arthroplasty. 2017;32(5):1414–1417. doi:10.1016/j.arth.2016.11.035 [CrossRef] PMID:28041771
- Golladay GJ, Balch KR, Dalury DF, Satpathy J, Jiranek WA. Oral multimodal analgesia for total joint arthroplasty. J Arthroplasty. 2017;32(9S):S69–S73. doi:10.1016/j.arth.2017.05.002 [CrossRef] PMID:28705543
- Karim A, Pulido L, Incavo S. Does accelerated physical therapy after elective primary hip and knee arthroplasty facilitate early discharge?Am J Orthop (Belle Mead NJ). 2016;45(6):E337–E342. PMID:27737293
- Sharareh B, Le NB, Hoang MT, Schwarzkopf R. Factors determining discharge destination for patients undergoing total joint arthroplasty. J Arthroplasty. 2014;29(7):1355–1358.e1. doi:10.1016/j.arth.2014.02.001 [CrossRef] PMID:24631127
- Molloy IB, Martin BI, Moschetti WE, Jevsevar DS. Effects of the length of stay on the cost of total knee and total hip arthroplasty from 2002 to 2013. J Bone Joint Surg Am. 2017;99(5):402–407. doi:10.2106/JBJS.16.00019 [CrossRef] PMID:28244911
- Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS. Costs and consequences of early hospital discharge after major inpatient surgery in older adults. JAMA Surg. 2017;152(5):e170123. doi:10.1001/jamasurg.2017.0123 [CrossRef] PMID:28329352
- Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW. Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature. J Arthroplasty. 2017;32(12):3854–3860. doi:10.1016/j.arth.2017.07.021 [CrossRef] PMID:28844632
- Scott CEH, Bugler KE, Clement ND, et al. Patient expectations of arthroplasty of the hip and knee. J Bone Joint Surg Br. 2012;94(7):974–981.
- Singh JA, Lewallen DG. Dependence on walking aids and patient-reported outcomes after total knee arthroplasty. J Arthritis. 2015;4:1–5.
- van der Sluis G, Goldbohm RA, Elings JE, et al. Pre-operative functional mobility as an independent determinant of inpatient functional recovery after total knee arthroplasty during three periods that coincided with changes in clinical pathways. Bone Joint J. 2017;99-B(2):211–217. doi:10.1302/0301-620X.99B2.BJJ-2016-0508.R1 [CrossRef].
- Alattas SA, Smith T, Bhatti M, et al. 2017. Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty. Knee Surg Sports Traumatol Athrosc. 2017;25(11):3403–3410. doi:10.1007/s00167-016-4314-8 [CrossRef]
- Hoorntje A, Leichtenberg CS, Koenraadt KLM, et al. Not physical activity, but patient beliefs and expectations are associated with return to work after total knee arthroplasty. J Arthroplasty. 2018;33(4):1094–1100. doi:10.1016/j.arth.2017.11.032 [CrossRef] PMID:29276119
- Kennedy DM, Hanna SE, Stratford PW, Wessel J, Gollish JD. Preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty. J Arthroplasty. 2006;21(4):559–566. doi:10.1016/j.arth.2005.07.010 [CrossRef] PMID:16781410
- Petis SM, Howard JL, Lanting BA, Somerville lE, Vasarhelyi EM. Perioperative predictors of length of stay after total hip arthroplasty. J Arthroplasty. 2016;31(7):1427–1430. doi:10.1016/j.arth.2016.01.005 [CrossRef]
- Kwok IH, Paton B, Haddad FS. Does preoperative physiotherapy improve outcomes in primary total knee arthroplasty? A systematic review. J Arthroplasty. 2015;30(9):1657–1663. doi:10.1016/j.arth.2015.04.013 [CrossRef] PMID:25913232
- Andrawis J, Akhavan S, Chan V, Lehil M, Pong D, Bozic KJ. Higher preoperative patient activation associated with better patient-reported outcomes after total joint arthroplasty. Clin Orthop Relat Res. 2015;473(8):2688–2697. doi:10.1007/s11999-015-4247-4 [CrossRef] PMID:25758378
- Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14(1):4–9. doi:10.1016/j.jsams.2010.08.002 [CrossRef] PMID:20851051
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- Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J, Bedard J. Preoperative physical therapy in primary total knee arthroplasty. J Arthroplasty. 1998;13(4):414–421. doi:10.1016/S0883-5403(98)90007-9 [CrossRef] PMID:9645522
- van Leeuwen DM, de Ruiter CJ, Nolte PA, de Haan A. Preoperative strength training for elderly patients awaiting total knee arthroplasty. Rehabil Res Pract. 2014;2014:462750. doi:10.1155/2014/462750 [CrossRef] PMID:24693435
- Fernandes L, Roos EM, Overgaard S, Villadsen A, Søgaard R. Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial. BMC Musculoskelet Disord. 2017;18(1):5. doi:10.1186/s12891-016-1369-0 [CrossRef] PMID:28061841
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PrimePrehab Prehabilitation Exercise Programa Educational Readings and Exercise Modules
|Educational Readings||Exercise Modules|
|Information on the upcoming surgical procedure||Static balance training|
|Recommended home safety modifications||Dynamic balance training|
|What to expect on surgery day||Quadriceps strengthening|
|What to bring to the hospital||Gluteus medius strengthening|
|Potential postoperative discharge destinations||Hamstrings strengthening|
|Details of each discharge destination|
|Correct icing techniques at home|
|Therapist recommendations for an efficient recovery|
|Age, median (range), y||65 (49–86)|
|Male/female, No. (%)||17 (42.5)/23 (57.5)|
|BMI, median (range), kg/m2||27.6 (20.4–39.6)|
|ASA class, median (range)||2 (1–3)|
|TKA/THA, No. (%)||23 (57.5)/17 (42.5)|
|Preoperative gait aid, No. (%)|
| None||25 (62.5)|
| Cane||10 (25.0)|
| Walker||5 (12.5)|
|Length of stay, median±SD, h||62.3±16|
|Discharge disposition, No. (%)|
| Home||36 (90.0)|
| Skilled nursing facility||4 (10.0)|
|90-day gait aid,a No. (%)|
| None (GI90 score 0)||22 (66.7)|
| Cane (GI90 score 1)||8 (24.2)|
| Walker (GI90 score 2)||2 (6.1)|
| Wheelchair (GI90 score 3)||1 (3.0)|