Should You Go Home After a Hip or Knee Replacement?

When Karen Lootens Chantry had her arthritic right hip replaced five years ago, at 67, she heeded her surgeon’s advice to recuperate at a well-regarded rehabilitation center. But rehab didn’t go so smoothly, recalls the clinical psychologist, who is now 72 and still practicing.

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“They encouraged me to be too gung-ho” about rehab exercises, leaving Chantry's leg and hip painfully bruised, she says. After her surgery was revised in a second operation, she opted to recover at her home in Winthrop Harbor, Ill., north of Chicago, with the help of a visiting nurse, a physical therapist and her husband, John. Being home, surrounded by her own things and following her own schedule, “made a huge difference,” Chantry says.

So when she needed a knee replacement two years later, she knew exactly what she wanted to do: head straight home for two weeks of rehab before six weeks of outpatient therapy. The combination proved just right, she says. “I recuperated very, very quickly,” recalls Chantry.

More than a million Americans will undergo knee or hip replacements this year, according to the National Institutes of Health. Most of them will be 45 or older and suffering painful joint damage from osteoarthritis. In the past, many were routinely directed to inpatient facilities to rebuild their strength and reduce pain after the operation — especially if they were of Medicare age and lived alone.

But a wave of influential studies over the last five years has demonstrated that home rehab can be just as effective, less costly and even less risky for many patients. Now, with Medicare’s recent emphasis on “value-based care,” the tide has shifted and most knee or hip replacement patients are homeward bound.

“Our consensus is to encourage people to go home,” says Dr. Douglas Padgett, chief of the Adult Reconstruction and Joint Replacement Service at New York’s Hospital for Special Surgery (HSS). He estimates that 95 percent of his patients return home in a day or two.

Multiple recent studies support this policy change. An authoritative 2015 analysis of 2400 knee patients at HSS by Padgett and others, carefully adjusted for demographic factors, showed no difference in pain relief or functioning two years after surgery between those who went home and those who entered inpatient therapy.

Two other studies at HSS, presented this spring at the annual meeting of the American Academy of Orthopedic Surgeons, found that at-home patients were less likely than those in rehab to develop complications after hip or knee replacement.

Those findings are in line with a 2012 report by Medicare’s Office of the Inspector General. It analyzed Medicare patients treated in rehab facilities after illness, accidents or surgery (usually, knee and hip replacements), and found that nearly one-third suffered adverse events — slightly higher than the percentage in hospitals, but lower than in nursing homes.

Home recovery can be suitable even for those who live alone, according to groundbreaking research by Dr. William Hozack, professor of orthopedic surgery at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, and others.

The study, published in The Journal of Bone Surgery, compared 138 homebound patients who lived by themselves with 631 who lived with others, and found no significant differences 90 days after hip or knee surgery in their level of complications, mobility, pain or satisfaction. (Few study subjects were totally on their own, however; 80 percent said they had friends or family living within 15 minutes who were willing and able to help when needed.)

Researchers also found a dramatic reduction in cost for the homebodies, even though they generally spent an extra night in the hospital before release: $10,776 per person. Most importantly, “We’ve shown that it’s safe and effective to go home alone,” Hozack says. “Home is a nice place to be, and a hospital has other risks.”

Still, some patients decide that rehab centers are the best place for them. They may face bigger challenges after replacing both knees or hips at once. Perhaps they live far from family or friends, or are isolated in a walk-up apartment with steep stairs. Mobility might be limited by their age, obesity or other infirmities.

And some simply prefer the easy access to medical care and expert physical therapy that good rehab hospitals can provide.

After his knee surgery five years ago, for instance, my husband welcomed the rigorous physical therapy program (three hours every day) at the hospital-run rehab he selected. A friend of ours, writer Deborah Waroff of Manhattan, has experienced recovery from both sides, and declares rehab facilities the winner.

“Even if you have a partner at home, it is just so much better to be in a good rehab where everything is set up to cover whatever you need,” she says. “You don’t have to schlep up to the doctor if you have a fall.”

If you do choose home rehab, how do you make the most of your recovery? After consulting your doctor, try the well-tested advice of those who have already succeeded. Here are five tips from 10 former hip or knee replacement patients who went home after their surgeries:

• If you don’t work out regularly, ask your doctor to prescribe a few sessions of “prehab” with a physical therapist to strengthen your muscles for the new demands they’ll have to meet. (Note, though, that these may be subtracted from the post-op PT sessions your insurer will cover.)
• Fall-proof your home. Remove dangling extension cords, slippery rugs and anything else that might trip you up. Add secure grab bars in the bath or shower.
• Check out assistive devices online and with friends. Some may be covered by insurance, provided by your doctor, rentable or loanable.
• The most recommended home helps: raised toilet seats, shower stools (armless if they go in tubs), home icing machines (with names like “Game Ready”) and compression socks to reduce swelling.
• Make sure your bed is firm, low enough to plant your feet firmly on the floor and near a bathroom or portable commode.

Above all, say former stay-at-homes, step up. Your motivation and involvement are crucial. Get yourself going as soon as you can, do all your prescribed exercises and tell the visiting nurse or therapist about any difficulties you encounter.