HSS Journal ®

, Volume 15, Issue 3, pp 234–240 | Cite as

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

  • Shweta PathakEmail author
  • Cecilia M. Ganduglia
  • Samir S. Awad
  • Wenyaw Chan
  • John M. Swint
  • Robert O. Morgan
Rehabilitation and Musculoskeletal Health / Original Article



Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature.


We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care.


This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models.


The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care.


Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.


total joint arthroplasty physical therapy readmission 


Compliance with Ethical Standards

Conflict of Interest

Shweta Pathak, PhD, MPH, Cecilia M. Ganduglia, MD, DrPH, Wenyaw Chan, PhD, John M. Swint, PhD, and Robert O. Morgan, PhD declare that they have no conflicts of interest. Samir S. Awad, MD, MPH, reports personal fees from TELA Bio, Applied Medical, Abbott Laboratories, and Pacira Pharmaceuticals, as well as grants and personal fees from Miromatrix Medical, outside the submitted work.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

11420_2019_9685_MOESM1_ESM.pdf (38 kb)
ESM 1 (PDF 37 kb)
11420_2019_9685_MOESM2_ESM.pdf (29 kb)
ESM 2 (PDF 29 kb)


  1. 1.
    Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46:399–424.CrossRefGoogle Scholar
  2. 2.
    Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472:188–193.CrossRefGoogle Scholar
  3. 3.
    Centers for Medicare & Medicaid Services. Comprehensive care for joint replacement model. Center for Medicare & Medicaid Innovation. 2016. Available at [Accessed February 11, 2016].
  4. 4.
    Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physiother. 2013;59:219–226.CrossRefGoogle Scholar
  5. 5.
    Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012;308:1227–1236.CrossRefGoogle Scholar
  6. 6.
    Doran JP, Zabinski SJ. Bundled payment initiatives for medicare and non-medicare total joint arthroplasty patients at a community hospital: bundles in the real world. J Arthroplasty. 2015;30:353–355.CrossRefGoogle Scholar
  7. 7.
    Froemke CC, Wang L, DeHart ML, Williamson RK, Ko LM, Duwelius PJ. Standardizing care and improving quality under a bundled payment initiative for total joint arthroplasty. J Arthroplasty. 2015;30:1676–1682.CrossRefGoogle Scholar
  8. 8.
    Froimson MI, Rana A, White RE, et al. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28:157–165.CrossRefGoogle Scholar
  9. 9.
    Health Quality Ontario. Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Ont Health Technol Assess Ser. 2005;5:1–91.Google Scholar
  10. 10.
    John Hopkins Bloomberg School of Public Health. The Johns Hopkins ACG® System technical reference guide version 10.0. 2011. Available at: [Accessed August 9, 2015].
  11. 11.
    Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87:1487–97.PubMedGoogle Scholar
  12. 12.
    Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467:2606–2612.CrossRefGoogle Scholar
  13. 13.
    Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014;96:624–630.CrossRefGoogle Scholar
  14. 14.
    Liebs TR, Herzberg W, Rüther W, Haasters J, Russlies M, Hassenpflug J, Multicenter arthroplasty aftercare project. Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Arch Phys Med Rehabil. 2012;93:192–199.CrossRefGoogle Scholar
  15. 15.
    Madsen M, Larsen K, Madsen IK, Søe H, Hansen TB. Late group-based rehabilitation has no advantages compared with supervised home-exercises after total knee arthroplasty. Dan Med J. 2013;60:A4607.PubMedGoogle Scholar
  16. 16.
    Mallinson TR, Bateman J, Tseng H-Y, Manheim L, Almagor O, Deutsch A, Heinemann AW. A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Arch Phys Med Rehabil. 2011;92:712–720.CrossRefGoogle Scholar
  17. 17.
    Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335:812.CrossRefGoogle Scholar
  18. 18.
    Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskelet Disord. 2009;10:98.CrossRefGoogle Scholar
  19. 19.
    Mont MA, Issa K. Updated projections of total joint arthroplasty demands in America. Commentary on an article by Steven M. Kurtz, PhD, et al.: “Impact of the Economic Downturn on Total Joint Replacement Demand in the United States. Updated Projections to 2021.” J Bone Joint Surg Am. 2014;96:e68.CrossRefGoogle Scholar
  20. 20.
    Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplasty. 2016;31:1400–1406.e3.CrossRefGoogle Scholar
  21. 21.
    Ong KL, Lotke PA, Lau E, Manley MT, Kurtz SM. Prevalence and costs of rehabilitation and physical therapy after primary TJA. J Arthroplasty. 2015;30:1121–1126.CrossRefGoogle Scholar
  22. 22.
    Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56:e1–e25.CrossRefGoogle Scholar
  23. 23.
    Pathak S, Ganduglia CM, Awad SS, Chan W, Swint JM, Morgan RO. What factors are associated with 90-day episode-of-care payments for younger patients with total joint arthroplasty? Clin Orthop Relat Res. 2017;475(11):2808–2818.CrossRefGoogle Scholar
  24. 24.
    Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877–892.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Arch Phys Med Rehabil. 2009;90:745–755.CrossRefGoogle Scholar
  26. 26.
    Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol. 2003;15:160–162.CrossRefGoogle Scholar
  27. 27.
    Schairer WW, Sing DC, Vail TP, Bozic KJ. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthop Relat Res. 2014;472:464–470.CrossRefGoogle Scholar
  28. 28.
    Sibia US, Mandelblatt AE, Callanan MA, MacDonald JH, King PJ. Incidence, risk factors, and costs for hospital returns after total joint arthroplasties. J Arthroplasty. 2017;32:381–385.CrossRefGoogle Scholar
  29. 29.
    Warren M, Kozik J, Cook J, Prefontaine P, Ganley K. A comparative study to determine functional and clinical outcome differences between patients receiving outpatient direct physical therapy versus home physical therapy followed by outpatient physical therapy after total knee arthroplasty. Orthop Nurs. 2016;35:382–390.CrossRefGoogle Scholar
  30. 30.
    Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States delphi study. Arthritis Care Res (Hoboken). 2014;66:411–423.CrossRefGoogle Scholar
  31. 31.
    Whitman E. Divided over bundled payments. Mod Healthc. 2016. Available at: [Accessed October 7, 2016].
  32. 32.
    Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. J Bone Joint Surg Am. 2013;95:1869–1876.CrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2019

Authors and Affiliations

  1. 1.School of Public HealthUniversity of Texas Health Sciences CenterHoustonUSA
  2. 2.University of North Carolina Eshelman School of PharmacyChapel HillUSA
  3. 3.Operative Care Line, Surgery ServiceMichael E. DeBakey VA Medical CenterHoustonUSA
  4. 4.Department of SurgeryBaylor College of MedicineHoustonUSA
  5. 5.Center for Clinical Research and Evidence-Based MedicineMcGovern Medical School at University of Texas Health Science Center at HoustonHoustonUSA

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