Home or hospital? What the evidence says about rehab after knee replacement
For years, a stay in an inpatient rehabilitation unit has been a routine step after total knee replacement (TKR) for many Australian patients, particularly in the private system. The assumption was simple: more supervision means a better recovery. The evidence now tells a more nuanced story.
The trial that changed the conversation
The HIHO trial, run across two high volume public arthroplasty hospitals in Sydney, randomised 165 adults after uncomplicated TKR. One group received 10 days of inpatient rehabilitation, followed by an eight week home program monitored by a clinician. The other received the monitored home program alone.
At 26 weeks, there was no meaningful difference in mobility. The adjusted difference in six minute walk distance was about one metre. The authors concluded their findings do not support inpatient rehabilitation for this group of patients (Buhagiar et al., JAMA, 2017).
Not a one off result
A 2019 systematic review and meta analysis by the same group pooled six randomised trials with 917 participants. Rehab in a clinic or inpatient unit showed no clinically important difference from home programs in mobility, pain or function, at both 10 to 12 weeks and 52 weeks. The authors described home rehabilitation as an appropriate first line of therapy after uncomplicated TKR for patients with adequate social support (Buhagiar et al., JAMA Network Open, 2019).
Yet practice varies widely
In the private sector, the use of inpatient rehabilitation after TKR rose from 31% of patients in 2009 to 45% in 2016, across more than 35,000 claims. Hospital and surgeon factors explained about three times as much of that variation as patient factors. The authors suggested some of this care is low value, and estimated around $50 million a year could be saved by returning to 2009 rates (Schilling et al., MJA, 2018).
What this means for clinicians
The trials don't say home rehab is effortless. The home programs studied were structured and monitored by clinicians. That is the part that is hard to deliver at scale with phone calls and paper handouts.
Three practical takeaways:
Match setting to need. Reserve inpatient rehab for patients with complications, poor social support or specific functional risks, rather than as a default.
Make home programs structured. A clear, progressive program with defined dosage is what the evidence supports, not a generic sheet of exercises.
Keep visibility. Monitoring was part of the successful model. Clinicians need a way to see what patients are actually doing between visits and step in early.
Where digital tools fit
This is the gap platforms like BIBO are built for: delivering the program a clinician prescribes into the home, guiding the patient through each session, and reporting adherence and progress back to the care team. The evidence has already answered where rehab can happen. The next challenge is making sure every home program is as well supported as the ones in the trials.
This article is general information for health professionals and is not clinical advice.
