1. The Journal of Arthroplasty Vol. 20 No. 7 Suppl. 3 2005
Does Shortened Length of Hospital Stay Affect Total
Knee Arthroplasty Rehabilitation Outcomes?
Steven M. Teeny, MD,* Sally C. York, MN, RNC,*
Cindy Benson, MPT, OCS,y and Sondra T. Perdue, DrPH*
Abstract: Rehabilitation outcomes were compared after primary total knee
arthroplasty between patients who participated in a hospital joint arthroplasty
program implemented to decrease length of stay and patients who did not. Once
inclusion criteria were met, purposive sampling was used to select subjects for
retrospective medical records review. Range of motion and Knee Society scores at
preoperative and 3-, 6-, and 12-month postoperative intervals were then compared.
Preoperatively, there were no significant differences between groups. Program
implementation reduced length of hospital stay by a mean of 1.3 days, which
resulted in a decreased range of motion at discharge. No significant differences were
found between groups postoperatively at all intervals. Primary total knee
arthroplasty rehabilitation outcomes were not compromised by reduced length of
hospital stay.
n 2005 Published by Elsevier Inc.
Approximately 300 000 total knee arthroplasties However, the relationship between length of
(TKAs) were performed in the United States in TKA hospital stay and clinical outcomes, as defined
2003 [1]. The American Association of Orthopedic by measures such as the Knee Society score [5] and
Surgeons projects that, by the year 2030, this knee range of motion, has not been fully studied.
number will increase to 474,319 [2]. Because of Research in this area is important to ensure that
the large number of patients undergoing this patient outcomes are not compromised by the
procedure each year, even a small effect on average increasing economic pressures in health care,
length of stay or complication rates can have a large which may contribute to shorter length of hospital
effect on our nation’s use of medical resources. In stays [4,6].
an effort to reduce hospitalization costs, decrease The purpose of our study was to compare the
patient complications, improve quality of care, and short-term rehabilitation outcomes (up to 12
increase patient satisfaction, many hospitals are months postoperatively) of a single surgeon’s pri-
implementing comprehensive total joint arthro- mary unilateral TKA between patients who partic-
plasty programs [3,4]. ipated in a comprehensive hospital joint arthroplasty
program implemented to decrease length of stay
with TKA patients before program implementation.
From the *NorthWest Orthopaedic Institute, Tacoma, Washington; The hospital system involved in this study
and yPhysical Therapy Department, University of Puget Sound, selected and implemented the JointVentures Joint
Tacoma, Washington. Camp Program designed by TeleVisual Communi-
Submitted January 15, 2005; accepted April 29, 2005.
No benefits or funds were received in support of this study. cations of Clearwater, Fla. This program is a
Reprint requests: Steven M. Teeny, MD, NorthWest comprehensive approach to total joint rehabilita-
Orthopaedic Institute, P.O. Box 1878, Tacoma, WA 98401. tion that has been implemented in more than
n 2005 Published by Elsevier Inc.
0883-5403/05/1906-0004$30.00/0 250 hospitals in the United States and abroad [7].
doi:10.1016/j.arth.2005.04.025 Program emphasis is on expectation setting by the
39

2. 40 The Journal of Arthroplasty Vol. 20 No. 7 Suppl. 3 October 2005
patient, group orientation, a wellness focus, and quadricep sets, and short-arc quadricep exercises.
standardization of presurgical and postsurgical The remainder of group PT includes sit to stand
protocols among the medical team and participat- transfers, turning with a walker, gait training, and
ing facilities [8]. The inpatient phase is known as stair climbing. The final group PT session includes
Joint Camp. As the name implies, Joint Camp is gait training with a walker, stair climbing, and
intended to promote a sense of teamwork and miniature golf putting. Individual PT focuses on
camaraderie. Before surgery, patients receive stan- bed mobility, transfers, gait training, and a home
dardized outpatient briefings and an orientation to exercise program consisting of ankle pumps, gluteal
the Joint Camp philosophy and program. Patients sets, quadricep sets, heel slides, hamstring sets,
scheduled to undergo primary total hip or knee short-arc and long-arc quadricep exercises, and hip
arthroplasty are given the option of voluntarily abduction and adduction exercises.
participating in this program, which features daily
individual and group physical therapy (PT), and
other group activities. Methods
On the day of surgery, bcampersQ are admitted as
part of a small group. A key component of the A retrospective medical records review was
program is standardization of surgery schedules conducted of 110 patients after institutional review
and procedures to accommodate more consecutive board approval was obtained from the Franciscan
total joint cases by surgeons on regular days, Health System in Pierce County, Washington.
facilitating consistent use of operating rooms, Inclusion criteria consisted of patients who had a
anesthesiologists, assists, and surgical teams. This primary unilateral TKA by a single surgeon (the
aids the bgroupQ aspect of patient experiences senior author) at St Clare Hospital, Lakewood,
preoperatively and postoperatively while improv- Wash, and patients who had Knee Society scores
ing surgeon and hospital efficiency, and hospital [10] preoperatively and for at least 2 of the
cost containment. 3 postoperative intervals of 3, 6, and 12 months.
Joint Camp protocols focus on eliminating aspects Subjects were excluded from the study if they had
of postoperative care that often limit early postop- concurrent bilateral TKAs, contralateral TKA with-
erative ambulation and that also increase hospital in 6 months, total hip arthroplasty within 6 months,
costs. Whenever possible, Joint Camp patients’ total knee revisions, or if they had significant
intravenous fluids are discontinued on postopera- comorbidities unrelated to their rehabilitation that
tive day 1, instead of more commonly on postop- would make functional comparisons between
erative day 2. Indwelling urinary catheters inserted groups inappropriate (eg, prior cerebrovascular
during surgery are discontinued in Joint Camp accident with hemiparesis).
participants after a maximum of 24 hours, which The groups were selected using the method of
promotes ambulation the first postoperative day. purposive sampling, which involved selecting par-
Before Joint Camp, indwelling urinary catheters ticipants based on these specific inclusion criteria as
were usually left in up to 48 hours postoperatively. follows. Joint Camp was implemented at St Clare
Before and after Joint Camp implementation, PT Hospital on November 26, 2001. All patients in the
was started twice daily starting postoperative day 1. sample who underwent TKA between November
Continuous passive motion machine (CPM) is not 26, 2001, and March 3, 2003, participated in Joint
used in Joint Camp, which also reduces rehabilita- Camp. The first 55 of these patients to meet our
tion costs. bCoachingQ by family members or friends inclusion criteria comprised the Joint Camp group.
is encouraged [8,9] in Joint Camp, and patients For the non–Joint Camp group, the first patient
wear their own casual clothes during the day and included was the last to undergo surgery before
participate in recreational activities and meals as a November 26, 2001. We then counted back to
group. In Joint Camp, on the first day postopera- include a total of 55 consecutive TKA patients
tive, patients are assisted in dressing into their own before Joint Camp who met inclusion criteria;
clothes early in the morning and then evaluated by surgery dates for this group were between February
a physical therapist after breakfast. In the afternoon 10, 2000, and November 8, 2001. A study of this
of postoperative day 1, the patient participates in size has power of 0.74 to detect differences between
group PT if he or she is able and willing to do so. On 2 groups of 0.5 SDs when using t tests. For
the second and third postoperative day, the patient example, a difference of about 58 in knee passive
receives individual PT in the morning and group PT flexion would be significantly different.
in the afternoon. Group PT begins with warm-up Outpatient data were routinely obtained on all
activities consisting of ankle pumps, gluteal sets, joint arthroplasty patients by means of office

3. TKA Rehabilitation Outcomes ! Teeny et al 41
preoperative intake forms documenting age, sex, fixed, cruciate-substituting rotating platform, or
general medical and surgical history, primary and TC3 cruciate-substituting knee implants. Criteria
secondary knee diagnoses, previous nonimplant for implant selection was based on age, weight,
surgery on the affected knee, joint arthroplasty activity level, and preoperative knee alignment.
history, and previous nonoperative treatment. All pre–Joint Camp and post–Joint Camp
Knee Society score [5] evaluations were completed patients received the same deep vein thrombosis
preoperatively and postoperatively at 3, 6, and prophylaxis (dalteparin sodium, 5000 U subcuta-
12 months. Passive range of motion measurements neously daily, started at 12-24 hours, for 10 days
were included that were made at the 6-week postoperatively) in accordance with current
postoperative outpatient follow-up visit. In addi- American College of Chest Physician guidelines
tion, we documented the outpatient complications [10]. All patients in the study received individual
and interventions, and outpatient PT received in in-office preoperative education as well as hospital
type, number of visits, and range of motion preoperative group education classes; patients in
measurements at the initial and final visits. Joint Camp received an additional preoperative
Inpatient data collection from the inpatient hospital education manual containing detailed
medical records included the operative report with hospital care and home exercise program informa-
date of surgery, type of anesthesia, length of tion. Joint Camp patients and their families were
surgery, implant type; length of hospital stay, also preoperatively instructed to prepare for dis-
assistive device at discharge, discharge destination, charge, specifically on the third or fourth post-
inpatient complications and interventions, and use operative day.
of mechanical antithrombotic devices. Inpatient
PT data collected included total number of PT
sessions, CPM use, and range of motion measure- Results
ments at discharge.
Data analysis was performed using Statistical The sample size was 110 patients; 55 patients
Package for the Social Sciences (SPSS). An inde- were in each group. The mean age for the non–
pendent t test was used to analyze demographic Joint Camp group was 69 years (range, 41-84 years);
data, confounding variables at baseline, and out- the Joint Camp group had a mean age of 69.8 years
come measurements between groups. Scores for (range, 42-86 years). The non–Joint Camp group
both the functional and the knee rating portions of was composed of 39 women and 16 men; the Joint
the Knee Society evaluation [5] were calculated for Camp group was composed of 38 women and
each time interval. Range of motion and Knee 17 men. Two situations arose that caused us to
Society scores [5] at preoperative and 3, 6, and exclude patients who met the inclusion and exclu-
12 months postoperatively were compared, along sion criteria. First, 6 patients had 2 consecutive
with demographic and clinical data. bilateral TKAs that were performed more than
Before the implementation of Joint Camp on 6 months apart. We included each of these patients
November 26, 2001, all of the senior author’s TKA only once to eliminate bias. Secondly, 1 patient from
patients received routine inpatient postoperative PT the Joint Camp group was excluded as an outlier.
in a one-on-one format. Included were knee range This patient had a complex primary TKA due to a
of motion and strengthening exercises, and gait preoperative diagnosis of severe postseptic arthritis
training. Patients also received an inpatient occu- with a 208 varus deformity and 108 of medial laxity,
pational therapy consultation. After November 26, and a preexisting contralateral Charcot foot with an
2001, all of the senior author’s primary TKA established ankle fusion-nonunion.
patients participated in Joint Camp in lieu of the Medical history of the 2 groups was not
former treatments. All patients in the non–Joint statistically different ( P N .05) in weight, tobacco
Camp group used CPM for the duration of the use, respiratory disease, renal disease, hepatic
length of hospital stay, as well as during any skilled disease, diabetes, endocrine disease, neurologic
nursing facility or short-term acute rehabilitation conditions, history of thromboembolism, hyperten-
length of stay. None of the Joint Camp group used sion and other cardiovascular problems, gastroin-
CPM in any setting postoperatively. Before initia- testinal disease, peripheral vascular disease, cancer,
tion of Joint Camp, patients were usually operated gout, phlebitis, depression, anxiety, and spinal
on Thursdays; after initiation of Joint Camp, all stenosis. Preoperative diagnoses were also similar
patients were operated on Mondays. for the side of involvement, primary arthritis
All patients in the study received DePuy PFC diagnoses of osteoarthritis, rheumatoid, post-
Sigma cruciate-substituting or cruciate-retaining traumatic or inflammatory arthritis, previous non-

4. 42 The Journal of Arthroplasty Vol. 20 No. 7 Suppl. 3 October 2005
Table 1. Knee Society Evaluation Scores Table 3. Primary TKA Implant Type
Knee Society Non–Joint Joint Non–Joint Camp* Joint Camp*
score components Camp*O CampyO Implant type n n
DePuy PFC Sigma 46 42
Mean knee range of motion
PCL-substituting
Preoperative (8) 6-110 7-108
DePuy PFC Sigma 6 8
3 mo postoperative (8) 4-112 3-115
PCL-substituting
6 mo postoperative (8) 3-116 2-115
rotating platform
12 mo postoperative (8) 1-119 4-117
DePuy PFC Sigma 2 4
Mean knee scorez (SD)
PCL-sparing
Preoperative 40.2 (15.4) 37.5 (14.9)
DePuy PFC Sigma 1 1
3 mo postoperative 83.7 (12.8) 80.8 (12.7)
PCL-substituting TC3
6 mo postoperative 87.6 (13.2) 83.8 (13.8)
Total 55 55
12 mo postoperative 90.4 (12.5) 86.7 (15.18)
Mean functional scorez (SD)
Preoperative 47.5 (15.5) 45.6 (15.5) PCL indicates posterior cruciate ligament.
3 mo postoperative 66.2 (20.6) 61.3 (12.7) *There were no significant differences between groups for
6 mo postoperative 69.2 (22.9) 68.0 (23.7) implant type (v 2 = 1.4, df = 3, P = .70).
12 mo postoperative 72.9 (24.6) 70.0 (20.9)
Mean total Knee Society score§
Preoperative 87.7 83.1 scores [5], and range of motion (Table 1). Among
3 mo postoperative 149.9 142.1 all of the subscores, the only significant differences
6 mo postoperative 156.8 151.8
12 mo postoperative 163.3 156.7 preoperatively found were in pain; the Joint Camp
participants had more pain in the affected knee
*Number of non–Joint Camp patients included are preoper- with walking (Joint Camp mean pain score, 3.45/4;
ative, n = 55; 3 months postoperative, n = 47; 6 months
postoperative, n = 42; and 12 months postoperative, n = 46. non–Joint Camp mean pain score, 3.15/4; P = .004)
yNumber of Joint Camp patients included are preoperative, and more pain with stairs (Joint Camp mean pain
n = 55; 3 months postoperative, n = 49; 6 months postoperative, score, 3.44/4; non –Joint Camp mean pain score,
n = 45; and 12 months postoperative, n = 38.
zMaximum score, 100. 3.18/4; P = .047).
§Maximum score, 200. The operating room time, number of PT sessions,
ONo significant differences were found between the non–Joint knee passive range of motion at discharge, pain
Camp group and the Joint Camp group at the .05 level of
significance. score at discharge, and length of stay are presented
in Table 2. Seventy-eight percent of the non–Joint
Camp group compared with 54% of the Joint Camp
group received spinal anesthesia or a combination
implant surgery on the ipsilateral knee, previous of spinal and general, whereas 22% of the non–
hip involvement, prior contralateral knee arthro- Joint Camp group and 46% of the Joint Camp group
plasty, contralateral knee problems without arthro- received general anesthesia alone. Implant distri-
plasty, multiple joint arthritis, or medical infirmity. bution between the 2 groups is presented in Table 3.
Five patients in the Joint Camp group reported Although the Joint Camp group was discharged
osteoporosis as opposed to none in the other group. from the hospital 1.3 days sooner than the non–
There were no significant differences between Joint Camp group, without the use of CPM, the
the overall preoperative Knee Society scores [5] discharge destination profile was similar. Upon
between the non–Joint Camp group and the Joint discharge, 38 patients in the non–Joint Camp group
Camp group, the Knee Society knee and functional and 32 in the Joint Camp group went home,
Table 2. Inpatient Outcomes
Non–Joint Camp Joint Camp
Outcome n Mean n Mean P*
Operative time 46 85 min 39 73 min .003
PT sessions 54 7.7 sessions 50 5.7 sessions .001
Knee passive extension at discharge (SD) 44 1.98 (3.48) 39 8.68 (3.88) .001
Knee passive flexion at discharge (SD) 44 70.68 (11.08) 39 74.08 (10.88) .165
Pain scorey at discharge 40 2.85 50 2.62 .669
Length of stay 54 5.7 d 50 4.4 d .022
*P value is based on independent t test for the differences between groups.
yScale of 0 to 10; 0 indicates no pain, 10, extreme pain.

5. TKA Rehabilitation Outcomes ! Teeny et al 43
Table 4. Postoperative Complications
Inpatient Posthospital discharge
Non–Joint Camp Joint Camp Non–Joint Camp Joint Camp
Complication n n n n
Deep vein thrombosis 1 0 6 3
Deep vein thrombosis with pulmonary embolus 1 1 0 1
Respiratory 1 2 0 0
Cardiac 1 0 0 0
Arthrofibrosis requiring manipulation 0 0 3 1
Delayed wound healing requiring secondary closure 0 0 2 1
Heel decubitus 0 0 0 1
Total complications 4 3 11 7
Counts are provided as description only. Numbers are too small for statistical comparisons.
whereas 4 in the non–Joint Camp group and 5 in addition, Steele et al [13] presented some Joint
the Joint Camp group went to an inpatient Camp outcomes at Anne Arundel Medical Center.
rehabilitation facility, and 12 of the non –Joint Patient satisfaction was measured by questionnaire
Camp group and 14 of the Joint Camp group went in 1999 with a range of 4.28 to 4.74 on a 5-point
to a skilled nursing facility. The incidences of scale, Joint Camp. Mahomed et al [14] evaluated
inpatient and outpatient complications are pre- the relationship between patient expectations of
sented in Table 4. total joint arthroplasty and health-related quality of
By the 6-week follow-up visit, no significant life plus satisfaction at 6 months after surgery.
range of motion differences remained between Before surgery and 6 months postsurgery, self-
groups as shown in Table 5. Outpatient PT was report questionnaires were used. The Short Form
similar in type of treatment and treatment setting, 36, WOMAC, and a satisfaction scale were the
and the mean number of outpatient PT visits for the measures of outcome [14]. The researchers found
non –Joint Camp group was 11.7 as compared with that patient expectations, particularly expectation
the Joint Camp group mean of 11.4. of complete pain relief after surgery and expecta-
No significant differences were found between tion of low risk for complications, were important
the postoperative Knee Society functional or rating independent predictors of functional outcome and
scores at 3, 6, and 12 months (Table 1). Both satisfaction after total joint arthroplasty. Expect-
groups had significant improvements between all ations were not found to correlate to preoperative
Knee Society scores preoperatively and at all functional status [14]. The average length of
intervals measured postoperatively. stay decreased from 5.2 to 3.7 days between 1994
Radiographic analysis of the 2 groups was not and 1998 [13]. This study would support the
performed for purposes of this study. Although notion that setting expectations for patients with
radiographic misalignment is known to be a factor regard to rehabilitation goals can assist in reaching
in the long-term durability of total knee compo- these goals.
nents; durability of components was not a focus of Standardizing surgery scheduling of total joint
this study and not expected to have much impact cases to regular specific days of the week to allow
on the short-term rehabilitation outcomes. for maximizing the number of consecutive cases
done in 1 day contributed to improved consistency
Discussion and efficiency of the surgical team. This may have
been a factor in the decreased operative time for
A review of the literature on Joint Camp each case of 12 minutes in the Joint Camp patients,
produced 2 journal articles that were descriptive along with the surgeon’s increased experience
in nature of the program concepts [11,12]. In over time.
Table 5. Six-Week Postoperative Passive Knee Range of Motion
Non–Joint Camp Joint Camp
Knee range of motion n Mean (SD) (8) n Mean (SD) (8) P*
Knee passive extension 54 5.0 (5.1) 48 3.5 (4.2) .112
Knee passive flexion 54 107.7 (13.5) 47 105.5 (12.2) .395
*P value is based on independent t test for the differences between groups.

6. 44 The Journal of Arthroplasty Vol. 20 No. 7 Suppl. 3 October 2005
Implementation of comprehensive hospital total participants. Because the literature related to Joint
joint arthroplasty programs and clinical pathways Camp–type programs is so limited, additional
may also alter orthopedic surgeons’ TKA rehabili- studies exploring effectiveness of comprehensive
tation protocols, in addition to reducing length of rehabilitation programs are needed, especially in
hospital stays. The Joint Camp program is an patient satisfaction, after total hip arthroplasty and
example in that it does not include the use of in relation to other specific clinical outcomes.
CPMs postoperatively for TKA rehabilitation. The Implant position and balancing, and use of
use of CPM remains controversial in the literature computer-assisted surgery may be other factors,
[6,15-17]. We found that the use or nonuse of the which may influence clinical outcomes related to
CPM did not seem to make a difference in average accelerated hospital stays and warrant further
knee range of motion between the Joint Camp study; therefore, postoperative radiographic align-
group and the non–Joint Camp group by 6 weeks ment as measured by the Knee Society radio-
after surgery. The fact that CPM was not used in graphic scores should be included in future
Joint Camp and the length of stay was still shorter research in this area.
bears notice, especially in light of the lack of In summary, this study demonstrates that reha-
increase in manipulations in Joint Camp patients. bilitation outcomes in the 12 months after primary
This contrasts with Mauerhan et al [6], who unilateral TKA as measured by Knee Society scores
express the concern that decreased PT exposure [5] and range of motion were not compromised by
due to decreased length of stay, with CPM use, participation in a hospital program which, reduced
may be a contributing factor to impaired func- length of stay.
tional range of motion in the 6-week postopera-
tive period.
Of particular interest, patients in the Joint Camp Acknowledgments
group did not experience more inpatient or outpa-
tient complications or readmissions because of Kathie Hummel-Berry, PhD, PT, is acknowledged
changes in immediate postoperative care and for her assistance with the study design. Kevin
shorter length of hospital stay. The number of Ching, SPT; Pamela Drake, SPT; and Lori Hassell,
cases with wound healing complications and SPT, of the University of Puget Sound Physical
arthrofibrosis with the need for knee manipulation Therapy Program, Tacoma, Wash, are acknowl-
also did not increase. With the initiation of Joint edged for their assistance in data entry for this study.
Camp and surgeries regularly performed on Mon- Kathy Bressler, MN, ONC, and Debi Williams, RN, of
days, we were able to discharge most of our the Franciscan Health System, Tacoma, Wash, are
patients before the weekend, which also eased the also acknowledged for their assistance and support.
burden of weekend hospital coverage. Outpatient
management of TKA patients after discharge to
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