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2018 John N. Insall Award

Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA

A Randomized Trial

Fleischman, Andrew N., MD; Crizer, Meredith P., BS; Tarabichi, Majd, MD; Smith, Shelby, BS; Rothman, Richard H., MD, PhD; Lonner, Jess H., MD; Chen, Antonia F., MD, MBA

Clinical Orthopaedics and Related Research®: January 2019 - Volume 477 - Issue 1 - p 60–69
doi: 10.1097/CORR.0000000000000561

Background Concerns about the cost and convenience of postsurgical physical therapy (PT) have sparked interest in unsupervised, home-based rehabilitation. However, the effectiveness of unsupervised home exercise after primary TKA has not been previously evaluated.

Questions/purposes (1) Can unsupervised home exercise after surgery provide noninferior recovery of passive knee flexion compared with formal outpatient PT? (2) Does a web-based platform for home-based exercise provide an advantage compared with a printed PT manual?

Methods We conducted a randomized, noninferiority trial involving 290 patients (20% of the 1464 eligible patients who could be contacted) who underwent primary TKA from March 2016 to April 2018. We included patients > 18 years old who were undergoing primary, unilateral TKA and provided written consent. We excluded patients with preoperative knee flexion < 90°, patients considering surgical intervention in a hip or the contralateral knee, patients discharged to an extended care facility, and revision or conversion TKA. We randomized patients to one of three groups: outpatient PT, unsupervised home exercise using a web-based platform (web PT), or unsupervised home exercise using a printed paper manual (paper PT). We also implemented a “delayed recovery intervention” within the home exercise program, in which patients were obliged to begin outpatient PT if knee flexion was < 70° at 2 weeks or < 90° at 4 weeks. The primary outcome was change in knee flexion from preoperative baseline after 4 to 6 weeks and 6 months. Secondary outcomes included Knee Injury and Osteoarthritis Outcome Score (KOOS), time back to activities of daily living, and time off narcotics. All analyses were intention to treat, and the noninferiority margin was 5% with maximum flexion as the outcome of interest for this parameter.

Results Adjusted differences in change in passive flexion for web PT +3° (95% confidence interval [CI], -1.2° to 6.4°) and paper PT +5° (95% CI, 0.99°-8.6°) were not inferior to outpatient PT based on a predefined 5° margin. Change in knee flexion from baseline was 0° for outpatient PT, -2° for web PT, and -1° for paper PT after 4 to 6 weeks and 8°, 8°, and 12° for the three groups, respectively, after 6 months. Additionally, there was no difference in the change in KOOS from baseline at 4 to 6 weeks or 6 months postoperatively as well as time back to work, driving, and walking without an assistive device.

Conclusions Unsupervised home exercise is an effective rehabilitation strategy after primary TKA and was noninferior to formal outpatient PT in selected patients. It is worthwhile to reconsider the current practice of automatically designating patients for outpatient PT after primary TKA, because appropriately selected patients with adequate clinical support can achieve similar results at home.

Level of Evidence Level I, therapeutic study.

The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

A. F. Chen, The Rothman Institute, 125 S 9th Street, Suite 1000, Philadelphia, PA 19107, USA, email:

One of the authors (RHR) received personal fees from Stryker (Mahwah, NJ, USA), outside the submitted work. One of the authors (JHL) reports other from the American Journal of Orthopedics (Parsippany, NJ, USA), personal fees and other from Biomet (Warsaw, IN, USA), other from Blue Belt Technologies (Pittsburgh, PA, USA), other from Healthpoint Capital (New York, NY, USA), other from the Knee Society, personal fees from Saunders/Mosby-Elsevier (Maryland Heights, MO, USA), personal fees and other from Smith & Nephew (Memphis, TN, USA), personal fees from Springer (New York, NY, USA), personal fees from Wolters Kluwer Health (Philadelphia, PA, USA), and personal fees from Zimmer (South Holland, The Netherlands), outside the submitted work. One of the authors (AFC) reports personal fees from SLACK (Thorofare, NJ, USA), other from Joint Purification Systems (Solana Beach, CA, USA), personal fees from ACI (Bala Cynwyd, PA, USA), personal fees from Stryker, personal fees from bOne (Beijing, China), personal fees from DJO (Vista, CA, USA), other from Sonoran Biosciences (Scottsdale, AZ, USA), other from Graftworx (San Francisco, CA, USA), grants from the Orthopaedic Research and Education Foundation, personal fees from Pfizer (New York, NY, USA), personal fees from Haylard (Alpharetta, GA, USA), personal fees from Irrimax (Gainesville, FL, USA), personal fees from Convatec (Deeside, UK), personal fees from 3M (Maplewood, MN, USA), personal fees from Recro (Malvern, PA, USA), personal fees from Zimmer (Warsaw, IN, USA), and personal fees from Heraeus (Hanau, Germany), outside the submitted work.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.

Received December 01, 2017

Accepted October 15, 2018

© 2019 Lippincott Williams & Wilkins LWW
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