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Original Investigation
March 14, 2017

Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial

Author Affiliations
  • 1Braeside Hospital, HammondCare, Australia
  • 2South West Sydney Clinical School, University of New South Wales, Liverpool Hospital, Liverpool NSW 2170, Australia
  • 3South West Sydney Local Health District, Liverpool 2170, NSW, Australia
  • 4Whitlam Orthopaedic Research Centre, Australia
  • 5Ingham Institute of Applied Medical Research, Liverpool 2170, NSW, Australia
JAMA. 2017;317(10):1037-1046. doi:10.1001/jama.2017.1224
Key Points

Question  Does inpatient rehabilitation result in better mobility following total knee arthroplasty than a monitored home-based program?

Findings  This clinical trial randomized 165 adults free of significant complication after arthroplasty to 10 days of hospital inpatient rehabilitation followed by an 8-week, clinician-monitored, home-based program or home-based program only and were compared with an observation group of 87 patients who also participated in the home-based program. There was no significant difference in the 6-minute walk test between any of the groups at the primary end point of 26 weeks.

Meaning  For adults undergoing uncomplicated total knee arthroplasty, inpatient rehabilitation did not improve mobility compared with a monitored home program.


Importance  Formal rehabilitation programs, including inpatient programs, are often assumed to optimize recovery among patients after undergoing total knee arthroplasty. However, these programs have not been compared with any outpatient or home-based programs.

Objective  To determine whether 10 days of inpatient rehabilitation followed by a monitored home-based program after total knee arthroplasty provided greater improvements than a monitored home-based program alone in mobility, function, and quality of life.

Design, Setting, and Participants  In this 2-group, parallel, randomized clinical trial, including a nonrandomized observational group, conducted at 2 public, high-volume arthroplasty hospitals in Sydney, Australia (July 2012-December 2015), 940 patients with osteoarthritis undergoing primary total knee arthroplasty were screened for eligibility. Of the 525 eligible patients consecutively invited to participate, 165 were randomized either to receive inpatient hospital rehabilitation and home-based rehabilitation or to receive home-based rehabilitation alone, and 87 patients enrolled in the observation group.

Interventions  Eighty-one patients were randomized to receive 10 days of hospital inpatient rehabilitation followed by an 8-week clinician-monitored home-based program, 84 were randomized to receive the home-based program alone, and 87 agreed to be in the observational group, which included only the home-based program.

Main Outcomes and Measures  Mobility at 26 weeks after surgery, measured with the 6-minute walk test. Secondary outcomes included the Oxford Knee Score, which ranges from 0 (worst) to 48 (best) and has a minimal clinically important difference of 5 points; and EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) visual analog scale, which ranges from 0 (worst) to 100 (best), and has a minimal clinically important difference of 23 points.

Results  Among the 165 randomized participants, 68% were women, and the cohort had a mean age, 66.9 years (SD, 8.4 years). There was no significant difference in the 6-minute walk test between the inpatient rehabilitation and either of the 2 home program groups (mean difference, −1.01; 95% CI, −25.56 to 23.55), nor in patient-reported pain and function (knee score mean difference, 2.06; 95% CI, −0.59 to 4.71), or quality of life (EQ-5D visual analog scale mean difference, 1.41; 95% CI, −6.42 to 3.60). The number of postdischarge complications for the inpatient group was 12 vs 9 among the home group, and there were no adverse events reported that were a result of trial participation.

Conclusions and Relevance  Among adults undergoing uncomplicated total knee arthroplasty, the use of inpatient rehabilitation compared with a monitored home-based program did not improve mobility at 26 weeks after surgery. These findings do not support inpatient rehabilitation for this group of patients.

Trial Registration  clinicaltrials.gov Identifier: NCT01583153