Knee Surgery & Related Research 2018 Sep; 30(3): 215-226  https://doi.org/10.5792/ksrr.17.060
Does Discharge Destination Matter after Total Knee Arthroplasty? A Single-Institution Korean Experience
Vivek Tiwari1,*, Chang Kyu Park2,*, Seon Woo Lee2, Moon Ju Kim2, Jeong Seong Seong2, and Tae Kyun Kim2,3
1Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, MP, India, 2Department of Orthopaedic Surgery, Joint Reconstruction Center, Seoul National University Bundang Hospital, Seongnam, Korea, 3Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
Correspondence to: Tae Kyun Kim, MD, Department of Orthopaedic Surgery, Joint Reconstruction Center, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea, Tel: +82-31-787-7196, Fax: +82-31-787-4056, E-mail: osktk@snubh.org
Received: August 2, 2017; Revised: September 7, 2017; Accepted: September 7, 2017; Published online: September 1, 2018.
© Korean Knee Society. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Purpose

To compare extended care facility (ECF) and home as discharge destination after total knee arthroplasty (TKA) at a single high-volume tertiary center in South Korea.

Materials and Methods

We retrospectively analyzed 1,120 primary TKAs (614 patients) performed between January 2012 and December 2013. A telephonic survey was conducted to determine discharge destination. The data reviewed included demographic and surgical data, functional outcome at 2 years and complications within 3 months.

Results

ECF and home received 316 patients (51%) and 298 patients (49%), respectively. The ECF group had more bilateral TKA patients than the home group (272 vs. 234; p=0.014) and more patients with additional hospital stay (44 vs. 22; p=0.009). A higher tendency of complications was seen at home (n=8, 2.7%) than the ECF (n=2, 0.6%) (p=0.057). No significant differences were found in any functional outcome measure. Home patients had better patient satisfaction than ECF patients (81.9% vs. 54.3%; p<0.001).

Conclusions

Patients who returned home after discharge had similar functional outcome at 2 years after surgery and higher patient satisfaction than those in the ECF in spite of the higher tendency of complications. Patients need adequate counseling and education regarding advantages and limitations of the two discharge destinations.

Keywords: Knee, Arthroplasty, Discharge, Home, Extended care facility
Introduction

The destination where patients receive postsurgical rehabilitative care after discharge, following total knee arthroplasty (TKA), has important clinical implications. After TKA, patients are discharged to either of the two discharge destinations, home or extended care facility (ECF), with the latter including inpatient rehabilitation facility (IRF) and skilled nursing facility (SNF)1). However, in South Korea, the clinical pathway for discharge to a SNF is inadequately developed. The implementation of the bundled payment system has brought newer developments in patient care and the clinical pathways after TKA1,2). Its introduction has resulted in an increased need for efficient delivery of postoperative care and subsequently has led to an increasing interest in the selection of discharge disposition after TKA. Although this system has not yet found its place in the Korean healthcare system, it is expected to be introduced soon in the South Korean medical system.

In the West, multiple studies have investigated the effect of discharge destination on postoperative functional outcomes and complications after TKA1,3,4). However, a paucity of available data exists on this subject in Asian countries, and no such data are available in South Korea. Moreover, we could not find any study evaluating and comparing functional outcomes at 2 years after TKA. Furthermore, the influence of bilateral surgery on the choice of a discharge destination has not been investigated. Therefore, we aimed 1) to identify the status of discharge destination after TKA at this single high-volume tertiary center in South Korea; 2) to determine whether demographic and surgical factors, including bilateral TKAs, differ between patients discharged to an ECF and those discharged to home; and 3) to assess whether patients managed at ECFs had less complications, better functional outcome at 2 years, and better patient satisfaction than those cared at home.

Materials and Methods

1. Study Design and Setting

We retrospectively reviewed all primary TKA procedures performed at a single high-volume tertiary care institution in South Korea between January 2012 and December 2013. During the above-mentioned period, 1,371 primary TKAs were performed in 764 patients. The patients were treated with either unilateral or bilateral TKA, performed either in a staged or simultaneous manner based on the age and comorbidity profiles of the patients. The second procedure in staged bilateral TKA was performed 1 week after the index surgery.

2. Surgical Procedure and Rehabilitation

All the surgeries were performed by a single surgeon (TKK) using the medial parapatellar approach. All the TKA procedures were performed using either a fixed bearing system (Genesis II Total Knee System; Smith & Nephew, Memphis, TN, USA) or a mobile bearing system (e.motion Total Knee System; B. Braun-Aesculap, Tuttlingen, Germany). A posterior-stabilized design was used in all knees. The selection of the implant was made at the surgeon’s discretion, without any preset selection criteria. The patella was routinely resurfaced, and all the implants were fixed with cement. Postoperative care was delivered according to a standardized clinical pathway.

3. Description of Discharge and Follow-up Routine

All the patients were discharged as per our standardized institutional protocol. The unilateral, simultaneous bilateral, and staged bilateral cases were discharged on the 7th, 10th, and 14th postoperative day, respectively. Those with wound problems, medical problems, inadequate pain control, or severe patient anxiety were allowed additional hospital stay. As part of the discharge planning, the patients were provided with information describing the postoperative care, including complications and rehabilitation. The decision for the discharge destination was made at the patient’s discretion without any specific intervention. The patients were regularly followed up based on the standardized care pathway, at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. At each follow-up visit, data including complications and postoperative function were prospectively collected. Postoperative function was assessed based on motion arc, American Knee Society (AKS) score5), Western Ontario and McMaster Universities Arthritis index (WOMAC) score6), and 36-item Short-Form Health Survey (SF-36) score7).

4. Telephone Survey

We conducted a telephone survey on all the patients to collect data regarding their discharge destination. As no previous study had been conducted with a similar purpose, we invented the survey questionnaire form after several research consensus meetings (Appendix 1). An independent investigator (JSS) called each patient twice a week for 2 consecutive weeks until the patient could be contacted to reduce missing responses. In the survey, we enquired about the type of discharge destination (ECF or home). In the ECF group, we asked about the admission route for ECF, reasons for selection, location of the facility, length of stay at the ECF, rehabilitation modality provided, and satisfaction with the discharge destination. In the home group, we asked who provided the postoperative care and about satisfaction with the home-based care. We also asked about the reasons for dissatisfaction of the unsatisfied patients in both groups.

5. Medical Record Review

We reviewed the prospectively collected clinical data from the medical records of all the patients. The data included demographic characteristics such as age, sex, weight, height, and body mass index (BMI) and surgical factors such as the number of bilateral TKA patients and those who required additional hospital stay. We excluded patients who had diagnoses other than primary osteoarthritis, had systemic comorbidities affecting knee function, were lost to 2-year follow-up, and had missing responses to a telephone survey. As a result, 1,120 TKAs in 614 patients (80% of the initial sample) were analyzed (Fig. 1). The primary outcome variables were WOMAC scores for pain, stiffness, and function at 2 years. The secondary outcome variables were motion arc, AKS score, and SF-36 score at 2 years; complications within 3 months after surgery, including wound complication, deep infection, deep vein thrombosis, and urinary tract infection; and patient satisfaction.

6. Statistical Analysis

All statistical analyses were performed using SPSS ver. 18.0 (SPSS Inc., Chicago, IL, USA), and p-values of <0.05 were considered significant. Quantitative variables were expressed as mean and standard deviation. Continuous and categorical variables were compared using the Student t and chi-square tests, respectively. To determine whether our sample size was adequate, we performed a priori power analysis using the two-sided hypothesis test at an alpha level of 0.05 and a statistical power of 80% to detect a minimal clinically important difference in WOMAC scores at 2 years after TKA. Sixty-four knees were required for each group to detect a 5° difference in motion arc and 6% difference in functional scores, which we considered as the minimal clinically important difference (motion arc was measured to the nearest 5°, and a 6% difference in maximum score has been suggested as the minimal clinically important difference for WOMAC and SF-36 scores8)). Thus, the sample size used in this study was regarded as adequate.

Results

More than half of the patients were discharged to ECFs after undergoing TKA. During the study period, 316 patients (51%) were discharged to ECFs, while 298 patients (49%) were discharged to home. The most common reason for selecting an ECF rather than home care was to aid in postoperative rehabilitation (69%). More than half (52%) of the patients stayed from 2 weeks to 1 month duration in the facility. Most (78%) of them received gradually increasing passive range of motion (ROM) exercises by physicians or family members, performed ROM exercises themselves, and used continuous passive motion. Among the patients discharged to home, 45% had to take care of themselves as opposed to receiving care from family members (39%), home visiting nurse service (2%), or any nearby outpatient care agency (14%) (Table 1).

A greater proportion of the patients who underwent bilateral TKAs and those who had prolonged stay in the primary care institution went to an ECF rather than home (Table 2). Eighty-six percent of the patients in the ECF group (n=272) underwent bilateral TKA as compared with 79% in the home group (n=234) (p=0.014). Among the patients who required extended hospital stay, 67% (n=44) went to an ECF and only 33% selected home as their discharge destination (n=22) (p=0.009). The patients in the ECF group tended to have higher BMIs than those in the home group (p=0.051), although the mean height and weight of the two groups were similar. No significant difference in mean age (ECF vs. home; 73.1 years vs. 73.2 years) or sex distribution (ECF vs. home; 95% females [n=301] vs. 93% females [n=276]) were found between the two discharge groups.

The ECF group tended to have lower complication rates, had similar functional outcome at 2 years, and had a less proportion of satisfied patients than the home group. Eight patients experienced a complication within 3 months after TKA in the home group as compared with only two patients in the ECF group (p=0.057) (Table 3). Wound complication was the main problem in both groups. The mean AKS scores for pain, knee, and function; WOMAC scores for pain, stiffness, and function; SF-36 scores for physical and mental component summary scales; and motion arc were found to be similar in the two groups at 2 years’ follow-up (Table 4). A significantly greater proportion (81.9%) of patients (p<0.001) in the home group than that in the ECF group (54.3%) was satisfied with their discharge destination (Table 5). Of the 50 patients who were unsatisfied with ECF, 30 (60%) complained of unavailability of sufficient postoperative care except rehabilitation (Table 6). Among the unsatisfied patients in the home group (n=23), the most common cause was psychological anxiety (48%).

Discussion

The choice of discharge destination following TKA and its economic, clinical, and social implications are controversial. Many studies on this aspect, mostly from the West, have been conducted over the last decade2,925). However, in an extensive literature search, we could not find any previous study about the status of discharge destination and its effect on functional outcome and patient satisfaction after TKA in an Asian country. To the best of our knowledge, this is the first study to address such issues in an Asian population.

We found that more than half of the patients were discharged to an ECF after TKA. This finding contradicts those of other published studies, mostly from the West, that reported that home-based care was more popular than an inpatient setting14,914,1622,24,25) (Table 7). Such results demonstrate the current pattern of discharge disposition in South Korea, which does not seem to follow the Western pattern, probably as the bundled payment system has not been introduced yet in the country. As about 55% of the cost incurred in TKA is for post-acute care and discharge to a non-home destination was reported to consume 36% of the total cost of care20), measures must be taken to reduce the number of inpatient facility discharges to mitigate the total cost of patient care after TKA.

Some of the various demographic and perioperative variables reported from the West to favor an inpatient facility as discharge destination after TKA include older age2,3,10,14,16,17, 20,21,24), female sex2,3,10,14,16,17,21), higher comorbidity index1,2,14,16,17,19,21), low socioeconomic status9,10), non-white race2,10), higher BMI16,17,21), longer operation time16,17), and longer length of stay in the acute-care hospital1,10–12,16,17,20,24). In our study, we did not find any difference in age and sex distribution between the two groups. Similar to our findings, two retrospective studies on total knee and hip arthroplasties also did not find any differences in age and sex distributions among the discharge destination groups15,23). Like most of the previous studies, our study revealed that among the patients with extended hospital stay, more were discharged to an ECF than to home. As in other studies, in our study, the patients in the ECF group tended to have higher BMIs than those in the home group, although the result was only close to reaching statistical significance (p=0.051). Besides the above-mentioned factors, we for the first time studied the difference in the number of bilateral TKAs between the home and ECF groups. More patients who underwent bilateral TKA were discharged to an ECF than home. These results further signify the importance of patients’ anticipations and apprehensions regarding their postoperative rehabilitative care in deciding their discharge location after TKA.

Home patients were found to have more complications within the first 3 months after TKA than ECF patients. Although the difference was remarkable, it did not reach statistical significance (p=0.057), probably because the complications were fewer over-all and the sample size was too small to decipher any difference. Although a prospective randomized study found no difference in the postoperative complication rate in the two discharge destinations4), most of the other studies from the Western world reported increased rates of early complications in patients discharged to an ECF as compared with those discharged to home3,14,16,17,19,24). The difference between our results and those of other studies could be because of the lower comorbidity profile of the patients discharged to ECFs in South Korea than that in Western countries. This hypothesis needs to be confirmed through future studies that evaluate the comorbidity index in the two discharge groups. Moreover, lack of a caregiver at home as admitted by a large number (45%) of the patients discharged to home could also be a contributing factor.

Only a couple of studies have compared functional outcome between home and non-home discharge destinations4,21). However, none of these studies evaluated the outcome at 2 years’ follow-up. We found no significant difference in functional outcome at 2 years between the two groups. In a retrospective study of 738 TKAs, the authors found that home-based rehabilitation was associated with greater 3-month postoperative patient-reported physical function improvement than non-home group, although no significant difference in ROM at 3 months was found21). A prospective randomized study found no significant difference in functional outcome evaluated using WOMAC and SF-36 scores at 3-month and 1-year postoperative periods between the two groups4). As functional outcome measures were reported to improve up to 2 years of follow-up after TKA26,27), a difference in outcome at 2 years more comprehensively indicates the role of discharge destination. These results need to be communicated with patients, preoperatively, so that they can make informed decisions about their discharge destination.

Home-based rehabilitation was found to provide better patient satisfaction than ECF in our study. In the only other published study that compared patient satisfaction assessed using the Hip and Knee Satisfaction Scale between the home and non-home groups, the authors did not find any difference4). We believe that by asking the patients directly through our telephone survey, we were in a better position to elucidate satisfaction levels with the discharge destination. The patients in the ECF group reported that insufficient postoperative care besides rehabilitation was the chief reason for their dissatisfaction. This signifies the importance of improving the inpatient rehabilitation facilities in South Korea, which are not so well equipped with modern rehabilitation instruments. When the ECF options after TKA are compared, IRF is reported to have shorter length of stay than SNF with superior functional outcomes, although at an increased cost28,29). On the other hand, SNF patients are reported to be more independent in self-care after discharge following lower-extremity joint replacements30). Since SNF facilities after TKA are not adequately developed in South Korea, attention needs to be given on improvement of the nursing facilities. Moreover, as psychological anxiety was the main cause of dissatisfaction in the home patients (48%), adequate psychological counseling needs to be provided before discharging patients to home.

Our study had a number of strengths, including use of a standardized clinical pathway, use of validated outcome measures, and the 2 years of follow-up. A further strength was the relatively large proportion (80%) of the original sample included in the analysis. Moreover, a post hoc power analysis confirmed the adequacy of the sample size. However, this study had some limitations that should be considered while interpreting the results. First, it was a single-institution-based study. Thus, whether the results are applicable to the TKA population of the country at large needs consideration. However, being a large-volume tertiary care referral institution, with patients coming from all parts of the country, we boast of a sufficiently heterogeneous patient population, similar to the national population. Second, as it was a retrospective study, selection bias cannot be ruled out. As we selected the consecutive patients from the two groups, an attempt was made to mitigate the bias. The other limitations included recall bias in the telephone survey and variable bias inherent in retrospective studies. We did not study the effect of race, insurance, socioeconomic status, comorbidity index, blood transfusions, and unplanned readmissions in our study. Additional comprehensive studies in the future are required to evaluate the influence of the above-mentioned variables on the discharge destination following TKA in South Korea.

Conclusions

ECF was slightly more popular than home as discharge destination after TKA, more so in bilateral cases and after prolonged hospital stay. However, home-based care had similar functional outcome at 2 years and higher patient satisfaction albeit with a higher tendency of complications. These results provide an insight into the status of discharge destinations after TKA in South Korea. Patients need to be adequately counseled and educated about the advantages and limitations of the two equally efficacious discharge destination options.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Supplementary Information
Figures
Fig. 1. Flowchart showing patient enrolment and exclusion criteria.
Tables

Results of the Telephone Survey Regarding Discharge Destination

Discharge destinationSurvey questionAnswerNo. of patients (%)
ECF316
Admission route1. By the primary hospital181 (57.3)
2. By oneself (including recommendation by acquaintances)135 (42.7)
Reasons for selecting ECF1. For rehabilitation (therapeutic purpose)219 (69.3)
2. No help at home31 (9.8)
3. Inconvenience at home (physical discomfort)53 (16.8)
4. Anxious to go home (psychological discomfort)8 (2.5)
5. Others5 (1.6)
Location of ECF1. Near the primary hospital121 (38.3)
2. Near home (including family’s address)195 (61.7)
Length of stay at ECF1. 1 week48 (15.2)
2. 2 weeks51 (16.1)
3. 2 weeks to 1 month165 (52.2)
4. More than 1 month52 (16.5)
Rehabilitation modality of ECF1. ROM exercise by oneself after education17 (5.4)
2. ROM exercise using CPM including #153 (16.8)
3. Gradually increasing passive ROM exercise by physician or family including #2246 (77.8)
Home298
Postoperative care option at home1. Alone133 (44.6)
2. Family116 (38.9)
3. Home-visiting nurse services7 (2.3)
4. Outpatient care agency near home42 (14.1)

ECF: extended care facility, ROM: range of motion, CPM: continuous passive motion.

Comparison of Demographic and Surgical Factors

VariableECF group (n=316)Home group (n=298)p-value
Demographic
 Age (yr)73.1±6.173.2±6.10.804
 Gender (female)301 (95.3)276 (92.6)0.170
 Height (cm)154.8±7.2153.2±6.60.164
 Weight (kg)62.4±9.262.9±9.50.338
 BMI (kg/m2)27.3±3.626.7±3.10.051
Surgical factor
 Bilateral surgery272 (86.1)234 (78.5)0.014
 Additional hospital stay44 (13.9)22 (7.4)0.009

Values are presented as mean±standard deviation or number (%).

ECF: extended care facility, BMI: body mass index.

Comparison of Complications

VariableECF group (n=316)Home group (n=298)p-value
Wound complication24-
Deep infection01-
Deep vein thrombosis01-
Urinary tract infection02-
Total (%)2 (0.6)8 (2.7)0.057

ECF: extended care facility.

Comparison of Functional Outcome

VariableECF group (588 knees /316 patients)Home group (532 knees /298 patients)p-value
Motion arc
 Flexion contracture0.5±1.80.6±1.80.068
 Maximum flexion131.9±11.8133.2±12.10.693
AKS score
 Pain (50)47.9±4.148.1±4.20.531
 Knee (100)95.3±6.096.1±6.00.118
 Function (100)93.2±9.693.3±9.70.960
WOMAC score
 Pain (20)2.9±3.12.8±3.30.842
 Stiffness (8)2.0±1.81.9±1.70.385
 Function (68)16.4±1.216.0±12.00.341
SF-36 score
 Physical CS43.3±8.944.9±8.40.091
 Mental CS54.2±10.753.0±11.10.252

Values are presented as mean±standard deviation.

ECF: extended care facility, AKS: American Knee Society, WOMAC: Western Ontario and McMaster Universities Arthritis index, SF-36: 36-Item Short Form Health Survey, CS: component summary.

Comparison of Satisfaction Level

VariableECF group (n=316)Home group (n=298)p-value
Unsatisfied50 (16.0)23 (7.7)
Neutral93 (29.7)31 (10.4)<0.001
Satisfied173 (54.3)244 (81.9)

Values are presented as number (%).

ECF: extended care facility.

Reasons for Dissatisfaction in the Two Groups

AnswerNo. of patients (%)
Extended care facility group50
 Worse than expected rehabilitation (expertise, number of rehabilitation sessions, etc.)11 (22.0)
 Uncomfortable facilities (diet, bedding, etc.)9 (18.0)
 Insufficient postoperative care except rehabilitation30 (60.0)
Home group23
 Unavailability of family5 (21.7)
 Psychological anxiety (complication, rehabilitation, accident such as falling, etc.)11 (47.8)
 Lack of rehabilitation instruments7 (30.4)

Comparison of Our Study with Previous Studies on Discharge Destination after Total Knee Arthroplasty (TKA)

No.StudyYearCountryTotal no.of arthroplastiesType of studyDischarge destinations for TKAUse of Questionnaire regarding discharge destinationUnilateral vs. Bilateral TKAsLength of stay for TKAPostoperative complication rateFunctional outcome (Home vs. ECF)Satisfaction of patients
1Ramos et al.1)2014USA3,533 (1,668 TKAs+1,865 THAs)Retrospective65% home, 35% ECFNoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
2Schwarzkopf et al.2)2016USA28611 TKAsRetrospective70% home, 30% ECFNoNot comparedNot evaluatedNot evaluatedNot evaluatedNot evaluated
3Bini et al.3)2010USA9,150 (5,718 TKAs+3,432 THAs)Retrospective85% home, 15% ECFNoNot comparedECF>homeECF>homeNot evaluatedNot evaluated
4Mahomed et al.4)2008Canada234Prospective RCT59% home, 41% ECFNoNot comparedHome>ECFNo differenceNo difference at 3 months and 1 yearNo difference
5Courtney et al.9)2017USA4,168 (2870 TKAs+1,298 THAs)Retrospective80% home, 20% ECFNoNot comparedNot givenNot evaluatedNot evaluatedNot evaluated
6Inneh et al.10)2016USA7,924Retrospective64% home, 36% ECFNoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
7Pitter et al.11)2016Denmark549 (232 TKAs+317 THAs)Prospective93.1% home, 6.9% ECFNoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
8Nichols and Vose12)2016UK526,481 (349,157 TKAs+177,324 THAs)Retrospective76.8% home, 23.2% ECF (primary TKAs)NoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
9Schairer et al.13)2014USA1,408Retrospective66% home, 34% ECF (primary TKAs)NoNot comparedNot comparedNot evaluatedNot evaluatedNot evaluated
10Gholson et al.14)2016USA107,300Retrospective69.2% home, 30.8% ECFNoNot comparedNot evaluatedECF>homeNot evaluatedNot evaluated
11Keswani et al.16)2016USA9,973Retrospective66% home, 34% ECFNoNot comparedECF>homeECF>homeNot evaluatedNot evaluated
12Keswani et al.17)2016USA106,360 (64,763 TKAs+41,597 THAs)Retrospective70% home, 30% ECFNoNot comparedECF>homeECF>homeNot evaluatedNot evaluated
13Menendez et al.18)2016USA744 (446 TKAs+298 THAs)Retrospective57% home, 43% ECFNoNot comparedNot comparedNot evaluatedNot evaluatedNot evaluated
14Rossman et al.19)2016USA995Retrospective52% home, 48% ECFNoNot comparedNot comparedECF>homeNot evaluatedNot evaluated
15London et al.20)2016USA14,315 (7,677 TKAs+6,638 THAs)Retrospective52% home, 48% ECFNoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
16Rissman et al.21)2016UK738Retrospective74.4% home, 25.6% ECFNoNot comparedNot evaluatedNot comparedNo difference in 3 months ROM 3 months physical function: home>ECFNot evaluated
17Mesko et al.22)2014USA1,291Retrospective65% home, 35% ECFNoNot comparedNot comparedNot evaluatedNot evaluatedNot evaluated
18Sharareh et al.23)2014USAFirst 100 patients (54 TKAs+46 THAs)Retrospective50% home, 50% ECF (sample deliberately chosen)NoNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
19Halawi et al.24)2015USA372 (260 TKAs+112 THAs)Retrospective71% home, 29% ECFNoNot comparedECF>homeECF>homeNot evaluatedNot evaluated
20Tan et al.25)2014Singapore569Prospective90% home, 10% ECFYesNot comparedECF>homeNot evaluatedNot evaluatedNot evaluated
21Our studySouth Korea1,120Retrospective49% home, 51% ECFYesBilateral TKAs: ECF>homeECF>homeHome>ECFNo difference at 2 yearsHome>ECF

ECF: extended care facility, THA: total hip arthroplasty, RCT: randomized controlled trial, ROM: range of motion.

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