Annales de réadaptation et de médecine physique 50 (2007) 729–733

http://france.elsevier.com/direct/ANNRMP/

Professional practices and recommendations

What is the interest of rehabilitation in physical medicine

and functional rehabilitation ward after total knee arthroplasty?
Elaboration of French clinical practice guidelines
B. Barroisa,*, P. Ribinika, F. Gougeonb, F. Rannouc, M. Revelc
a
Service de MPR, centre hospitalier de Gonesse, 25, rue Pierre-de-Theilley, BP 30071, 95503 Gonesse cedex, France
b
Service d’orthopédie D, hôpital Roger-Salengro, rue Professeur-Émile-Laine, 59000 Lille, France
c
Service de rééducation, groupe hospitalier Cochin, APHP, université Paris-Descartes, 75014 Paris, France

Received 2 July 2007; accepted 20 August 2007

Abstract
Objectives. – To develop clinical practice guidelines concerning the interest of post-operative rehabilitation in physical medicine and func-
tional rehabilitation (PMR) ward after total knee arthroplasty (TKA).
Method. – The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic literature review,
collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used. Main outcomes were impairment,
disability, medico-economic implications and postoperative complications.
Results. – Post-operative rehabilitation in a PMR ward after TKA is recommended for patients because of preoperative joint stiffness, and/or
associated co-morbidities. The other parameters used by French physician for post-operative rehabilitation in a PMR ward after TKA are: the
self-governing of the patient at home, the wishes of the patient and the opinion of the surgeon on the post-operative functional evolution of the
patients. For patients in whom sustained rehabilitation is not necessary but who cannot return home, a stay in a non-specific (non-PMR) post-
operative centre could be recommended. Post-operative rehabilitation in a PMR ward after TKA could reduce the length of stay in a surgical
ward and increase the functional status of patients with co-morbidities. Studies with good methodological quality are needed to evaluate the cost/
benefit ratio in the French health care system.
Conclusion. – This study suggests a value of rehabilitation in a PMR ward after TKA, but good methodological quality studies are needed to
evaluate the cost/benefit ratio of rehabilitation in a PMR ward after TKA in the French health care system.
© 2007 Elsevier Masson SAS. All rights reserved.

Keywords: Osteoarthritis; Total knee arthroplasty; Practice guidelines; Rehabilitation ward; Indications

Scientific committee Ribinik Patricia (Sofmer), service de MPR, centre hospita-

Coudeyre Emmanuel (Sofmer), centre de MPR Notre-
Dame, 63404 Chamalières, France
Genet François (Sofmer), service de MPR, groupe hospita-
lier Raymond-Poincare, 92380 Garches, France
Genty Marc (Sofmer), service de MPR, clinique Valmont,
1823 Glion, Suisse
* Correspondingauthor.
E-mail address: brigitte.barrois@ch-gonesse.fr (B. Barrois).
0168-6054/$ - see front matter © 2007 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.annrmp.2007.08.005
lier de Gonesse, BP 71, 95503 Gonesse, France
Rannou François (Sofmer), service de MPR, hôpital Cochin,
université Paris-V, 75014 Paris, France
Revel Michel (Sofmer), service de MPR, hôpital Cochin,
université Paris-V, 75014 Paris, France
Beaudreuil Johann (SFR [Société française de rhumatolo-
gie]), fédération de rhumatologie, hôpital Lariboisière, 75475
Paris, France
Lefevre-Colau Marie-Martine (SFR), service de MPR, hôpi-
tal Corentin-Celton, 92133 Issy-les-Moulineaux, France
Chevalier Xavier (SFR), service de rhumatologie, hôpital
Henri-Mondor, 94010 Créteil, France
730 B. Barrois et al. / Annales de réadaptation et de médecine physique 50 (2007) 729–733
Biau David (Sofcot), service de chirurgie orthopédique et de
traumatologie B, hôpital Cochin, université Paris-V, 75014
Paris, France
Anract Philippe (Sofcot), service de chirurgie orthopédique
et de traumatologie B, hôpital Cochin, université Paris 5,
75014 Paris, France
Reading committee
Kemoun Gilles (MPR)
Dauty Marc (MPR)
Nys Alain (MPR)
Tavernier Christian (rhumatologue)
Forestier Romain (rhumatologue)
Reboux Jean-François (rhumatologue)
Hamadouche Moussa (chirurgien orthopédique)
Cottias Pascal (chirurgien orthopédique)
Caton Jacques (chirurgien orthopédique)
Lorenzo Alain (médecin généraliste)
Favre Madeleine (médecin généraliste)
Marc Thierry (kinésithérapeute)
Fabri Stéphane (kinésithérapeute)
Pillu Michel (kinésithérapeute)
Granger Véronique (orthoprothésiste)
Jouhaneau Sylvie (assistante sociale)
Massaro Raymond (pédicure–podologue)
Hynaux Isabelle (érgothérapeute)
Matter Claire (infirmière)
Guillemin Dominique (patient)
1. Introduction
Mainly for medico-economic reasons, rehabilitation after
total hip arthroplasty (TKA) for osteoarthritis has evolved in
industrialized countries. In France, the HAS (French Health
Agency) guidelines [8] and fees tend to determine the length
of hospital stay and discharge to physical medicine and func-
tional rehabilitation (PMR) wards. We analyzed rehabilitation
practice after TKA as described in the literature as well as pro-
fessional practice in France by surveying PMR physicians and
orthopaedic surgeons [17] to determine the value of rehabilita-
tion in a PMR ward after TKA in France.
2. Method
We used the SOFMER 3-stage method for developing
guidelines, which involves the systematic literature review,
collection of information about professional practice and final
scientific committee review [17].
2.1. Systematic review of the literature
2.1.1. Study selection
Literature search professionals systematically searched the
PubMed, Pascal Biomed, and Cochrane Library databases for
articles published from January 1966 to January 2006 using
search terms defined by the scientific committee. Keywords
were proposed by the steering committee composed of PMR
and rheumatology physicians and orthopaedic surgeons. The
keywords were arthroplasty, replacement, hip, knee, rehabilita-
tion, physiotherapy, exercise, physical therapy, and continuous
passive motion. Selected were abstracts of studies of all design
that were published in English or French and investigated adult
human patients. The literature search professionals sent
abstracts to the scientific committee, who then narrowed the
selection of abstracts to analyze by ensuring that “rehabilitation
intervention” was present in the abstract, and then requested
the full-length articles of the selection from professional litera-
ture searchers. A second selection was made by two experts
from two different medical specialties (orthopaedic surgeon
(FG) and PMR physician (BB)) to retain only articles related to
post-operative rehabilitation after TKA. Finally, the abstracts
of articles cited as references were analyzed. The quality of
each manuscript was assessed according to the four-level grad-
ing scale of the French Agency for Accreditation and Evalua-
tion in Healthcare (Anaes) [17].
2.1.2. Outcomes
Four outcomes were assessed:
● impairment: pain, range of motion and muscular strength;
● associated co-morbidities;
● functional status, as measured by a validated questionnaire,
gait analysis or discharge criteria and ability to return home;
● medico-economic implications for length of hospital stay,
discharge destination after surgery (rehabilitation ward or
home) or total cost of peri-operative care.
2.2. Data analysis
Two blinded independent reviewers, an orthopaedic surgeon
(FG) and a PMR physician (BB), analyzed the data.
2.3. Daily practice
Daily practice related to post-operative rehabilitation after
TKA was recorded at the national congresses of rehabilitation
(Sofmer Congress, Rouen, France, October 18, 2006) and
orthopaedic surgery (Sofcot National Congress, Paris, Novem-
ber 7, 2006), by use of an electronic voting device. After the
vote, the literature data were presented by one of the two
experts (BB). Then, the session was open for questions and
comments. A medical secretary took notes during the ques-
tion-and-comment period [17].
2.4. Elaboration of recommendations and external review
by a reading committee
Practice guidelines based on literature review and daily
practice were written. These guidelines were reviewed by the
scientific committee before their validation by a reading com-
mittee [17].
 B. Barrois et al. / Annales de réadaptation et de médecine physique 50 (2007) 729–733 731

3. Results plasty and rehabilitation) without being able to allow either

3.1. Literature review
3.1.1. Article selection
The scientific committee selected 147 manuscripts from
PubMed, 60 from Pascal Biomed, and ten from the Cochrane
database. Among these articles, each reviewer (FG and BB)
retained 19 articles corresponding to 18 different studies.
3.1.2. Methodologic quality of studies
The two experts did not differ in grading studies by use of
the ANAES scale (Table 1). Among the 18 selected studies,
none was graded level 1, 8 were level 2 and the others were
level 4 (Table 1).
3.1.3. Results of data extraction
Analysis of studies revealed heterogeneous rehabilitation
procedures, which made interstudy comparison difficult. Five
articles were exclusively devoted to TKA [7,11,13,14,16], and
14 included both TKA and total hip arthroplasty [1–6,8–10,12,
15,18–20].
3.1.4. Factors affecting the value of rehabilitation in a PMR
ward after TKA
No study specifically answered the question of the value of
rehabilitation after TKA.
One can wonder about the evaluation criteria that make
possible to choose the optimal rehabilitation procedure and
to determine the objective results of various procedures. As
Friesner et al. [7], one considers the risk to evaluate patients
with too general tools (for example the MIF) compared to
expected objectives of a specific procedure. Or, one evalu-
ates the effectiveness of the whole procedure on pain (arthro-
to arthroplasty and/or either to rehabilitation the final result
on pain. One can specify the difficulties to estimate the exact
level of direct costs and indirect costs related to early home
discharge compared with PMR discharge after surgery [4].
One must be able to estimate the individual benefit (func-
tional restoration) and the general benefit (total costs). Reha-
bilitation in PMR ward brings benefit to patients, which suf-
fers from respiratory and/or cardiovascular impairment but
no validated study appears for articular impairment. How-
ever, people with knee osteoarthritis have altered cardiovas-
cular capacity. One could suppose that these patients will
take advantage of rehabilitation in PMR ward [1].
3.1.4.1. Analysis of discharge practices and length of stay
in a surgical ward. Oldmeadow et al. [14,15], in two level-2
prospective cohort studies found that early discharge to rehabi-
litation ward decreases length of stay and cost in acute care.
Nevertheless, some discharges are not justified because
patients have got enough functional recovery to go back
home (ambulation with crutches, range of motion, heeling,
help at home) and it increases total costs. It seems necessary
to elaborate tools to point out patients who need rehabilitation
discharge after surgery (in these studies 28% of patients need
assistance). In a level-2 study, Brunenberg et al. [3] describes
and analyzes the implementation of a recovery program com-
bining education, preoperative exercises and post-operative
rehabilitation in groups. It shows an improvement of the qual-
ity of life, a decrease in length of hospital stay and cost saving.
3.1.4.2. Functional and analytical benefit from a rehabilitation
discharge after surgery. Moffet et al. [11], in a level-2 study,
described the benefit of an intensive rehabilitation. Although
the procedure is not specified, one observes a decrease in

Table 1
Authors Population Anaes score Patients
Ashworth et al. [1] Various 4 Cochrane Review
Brander et al. [2] THA + TKA 4, retrospective 99
Brunenberg et al. [3] THA + TKA 2, comparative 160
Dow [4] THA + various 4, clinical cases 2
Forrest et al. [5] THA + TKA 4, retrospective 125
Forrest et al. [6] THA + TKA 4, retrospective 130
Friesner et al. [7] TKA 4, retrospective 122
Lin et Kaplan [9] THA + TKA 4, retrospective 808
Mahomed et al. [10] THA + TKA 4, retrospective 146
Moffet et al. [11] TKA 2, comparative, randomised, low power 77
Munin et al. [12] THA + TKA 2, comparative, randomised, low power 86 initially but at the end
15 patients for comparison
Olmeadow et al. [13] Primary and revision TKA in osteoarthritis 2, prospective cohort 105
and rhumatoid arthritis
Olmeadow et al. [14] Primary and revision TKA in osteoarthritis 2, prospective cohort 105
and rhumatoid arthritis Same patients [13]
Olmeadow et al. [15] THA + TKA 2, comparative 100
Ranawat et al. [16] TKA 2, prospective cohort 181
Roos [18] TKA 4, articles' synthesis No precision
Woo et al. [19] THA + TKA 2, prospective cohort 117
Zuckerman [20] THA + TKA 4 No precision
732 B. Barrois et al. / Annales de réadaptation et de médecine physique 50 (2007) 729–733
pain, an improvement of ambulation of 9% and improvement
of the functional status (SF36 measurement). Ranawat et al.
[16], in a level-2 prospective study showed decreasing pain
and improvement of range of motion with a rehabilitation pro-
gram; however the procedure is not specified. There is a good
correlation between preoperative stiffness and postoperative
improvement during rehabilitation. It is based on coordination
between anaesthesiology team, PMR team and social workers.
Woo et al. [19], in a level-2 study described an optimal clinical
pathway of functional and physical criteria for patients to
achieve in 5 days after TKA (no thromboembolic events, no
anaemia, no sepsis, and ambulate recovery). If early discharge
criteria are not reached, patients are discharged to a rehabilita-
tion ward. At 6 weeks post-operatively, a functional result
(evaluated by WOMAC) should be the same for patients dis-
charged home or to a rehabilitation unit. The studies of Bran-
der, Mahomed, and Roos et al. [2,10,18] were level-4 studies
of TKA and THA (total hip arthroplasty). The studies evalu-
ated functional improvement, but are not strictly comparable
because of different tools and criteria used. The authors
found an improvement in functional independence, better use
of stairs, decreased falls, and sometimes improved scores on
the MOS SF-36 with rehabilitation in a PMR unit. Four
level-4 studies were conducted by Forrest et al. [5,6], Lin et
Kaplan [9] and Roos [18] involved both TKA and THA. The
rehabilitation stay was correlated with level of dependence and
co-morbidities.
Two papers, by Munin et al. [12] and Zukerman [20],
described a randomized level-2 study [12], albeit with low
power (seven and eight patients in each arm) and investigat-
ing TKA and THA. The authors found that discharge to a
rehabilitation ward on post-operative day 3, with at least
three sessions per day, produced a faster functional result
than with discharge at day 7. The total cost and length of
stay decreased. However, the result at 4 months was identi-
cal in each arm.
3.2. Daily practice of physicians
The practices are different between PMR physicians and
orthopaedic surgeons. 72% of the orthopaedists discharge
their patients in PMR ward after TKA and 92% of PMR
physicians discharge them in PMR ward. The orthopaedists,
who do not discharge patients in PMR ward, discharge them
in nursing home (53%). The PMR physicians, who do not
discharge patients in PMR ward, discharge them at home
(58%).
PMR physicians and orthopaedic surgeons differed in daily
practice in terms of discharging patients to rehabilitation after
TKA. Of the orthopaedists, 72% discharged patients to a PMR
ward, as compared with 92% of PMR physicians. The ortho-
paedists, who did not discharge patients to a PMR ward, dis-
charged them in nursing home (53%), as compared with PMR
physicians, who discharged patient’s home (58%) if they did
not discharge to a PMR ward (Table 2).
Table 2
Comparison of clinical practices between PMR physicians and orthopaedic
surgeons in terms of postoperative rehabilitation after TKA (%)
Sofmer Sofcot
(a) After TKA, do you see patients or do you discharge them to a PMR ward?
Always 29 29
Often 63 43
Rarely 7 22
Never 1 6
(b) If patients are rarely or never discharged to a PMR ward, where do you
discharge them?
Nursing home 32 53
Home 58 44
Somewhere else 9 3
4. Discussion
This systematic review of the literature of rehabilitation in a
PRM ward after TKA entailed a restricted number of studies,
some with low power, and with results for both TKA and THA
and therefore does not give a complete picture of the value of
rehabilitation after TKA. All the studies involved various med-
ical insurance systems very different from that in France.
Therefore, more study is needed of clinical pathways in France.
It seems that rehabilitation stay makes possible easier decreas-
ing pain and earlier range of motion improvement. Some pre-
operative criteria such as joint stiffness and co morbidities
allow for determining discharge to rehabilitation in a PMR
ward. Finally, some evidence suggests that early discharge to
a PMR ward decreases acute-care costs. Appropriate decisions
about discharge must be based on a systematic analysis of clin-
ical and functional criteria (general status, articular recovery
and quality of ambulation).
5. Recommendations
Post-operative rehabilitation in a PMR ward after TKA is
recommended for patients because of preoperative joint stiff-
ness, and/or associated co morbidities. The other parameters
used by French physician for post-operative rehabilitation in a
PMR ward after TKA are: the self-governing of the patient at
home, the wishes of the patient and the opinion of the surgeon
on the post-operative functional evolution of the patients. For
patients in whom sustained rehabilitation is not necessary but
who cannot return home, a stay in a non-specific (non-PMR)
post-operative centre could be recommended. Post-operative
rehabilitation in a PMR ward after TKA could reduce the
length of stay in a surgical ward and increase the functional
status of patients with co morbidities. Studies with good meth-
odological quality are needed to evaluate the cost/benefit ratio
in the French health care system.
References
[1] Ashworth NL, Chad KE, Harrison EL, Reeder BA, Marshall SC. Home
versus center based physical activity programs in older adults. The
Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.:
CD004017. DOI: 10.1002/14651858.CD004017.
 B. Barrois et al. / Annales de réadaptation et de médecine physique 50 (2007) 729–733
[2] Brander VA, Malhotra S, Jet J, Heinemann AW, Stulberg SD. Outcome
of hip and knee arthroplasty in persons aged 80 years and older. Clin
Orthop Relat Res 1997;345:67–78.
[3] Brunenberg DE, van Steyn MJ, Sluimer JC, Bekebrede LL, Bulstra SK,
Joore MA. Joint recovery programme versus usual care: an economic
evaluation of a clinical pathway for joint replacement surgery. Med
Care 2005;43:1018–26.
[4] Dow B. The shifting cost of care: early discharge for rehabilitation. Aust
Health Rev 2004;28:260–5.
[5] Forrest G, Fuchs M, Gutierrez A, Girardy J. Factors affecting length of
stay and need for rehabilitation after hip and knee arthroplasty. J Arthro-
plasty 1998;13:186–90.
[6] Forrest GP, Roque JM, Dawodu ST. Decreasing length of stay after total
joint arthroplasty: effect on referrals to rehabilitation units. Arch Phys
Med Rehabil 1999;80:192–4.
[7] Friesner D, Neufelder D, Raisor J, Khayum M. Benchmarking patient
improvement in physical therapy with data envelopment analysis. Int J
Health Care Qual Assur Inc Leadersh Health Serv 2005;18:441–57.
[8] HAS. Recommandations de la HAS établies par consensus formalisé,
portant sur les actes chirurgicaux et orthopédiques ne nécessitant pas,
pour un patient justifiant des soins de massokinésithérapie, de recourir
de manière générale à une hospitalisation en vue de la dispensation des
soins de suite et de réadaptation mentionnés à l’article L 6111-2 du code
de la santé publique. Paris: France; 2006.
[9] Lin JJ, Kaplan RJ. Multivariate analysis of the factors affecting duration
of acute inpatient rehabilitation after hip and knee arthroplasty. Am J
Phys Med Rehabil 2004;83:344–52.
[10] Mahomed NN, Koo Seen Lin MJ, Levesque J, Lan S, Bogoch ER. Deter-
minants and outcomes of inpatient versus home based rehabilitation fol-
lowing elective hip and knee replacement. J Rheumatol 2000;27:1753–8.
733
[11] Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effec-
tiveness of intensive rehabilitation on functional ability and quality of life
after first total knee arthroplasty: a single-blind randomized controlled
trial. Arch Phys Med Rehabil 2004;85:546–56.
[12] Munin MC, Rudy TE, Glynn NW, Crossett LS, Rubash HE. Early inpa-
tient rehabilitation after elective hip and knee arthroplasty. JAMA 1998;
279:847–52.
[13] Oldmeadow LB, McBurney H, Robertson VJ. Hospital stay and dis-
charge outcomes after knee arthroplasty. J Qual Clin Pract 2001;21:56–
60.
[14] Oldmeadow LB, McBurney H, Robertson VJ. Hospital stay and dis-
charge outcomes after knee arthroplasty: implications for physiotherapy
practice. Aust J Physiother 2002;48:117–21.
[15] Oldmeadow LB, McBurney H, Robertson VJ, Kimmel L, Elliott B. Tar-
geted postoperative care improves discharge outcome after hip or knee
arthroplasty. Arch Phys Med Rehabil 2004;85:1424–7.
[16] Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilita-
tion protocol: what makes the difference? J Arthroplasty 2003;18:27–30.
[17] Rannou F, Coudeyre E, Ribinik P, Macé Y, Poiraudeau S, Revel M.
Establishing Recommandations for Rehabilitation Interventions: the Sof-
mer Methodology. Ann Readapt Med Phys 2007;50:106–10.
[18] Roos EM. Effectiveness and practice variation of rehabilitation after joint
replacement. Curr Opin Rheumatol 2003;15:160–2.
[19] Woo T, Bramwell M, Greenwood B, Gow S, Ackerman-Rainville R,
Corradetti P, et al. Integrated systems to reduce length of stay for knee
and hip joint replacement surgeries. Healthc Manage Forum 2000;13:60–
2.
[20] Zuckerman J. Inpatient Rehabilitation after total joint replacement.
JAMA 1998;279:880.