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Young WH, Peterson BC, Kotzur TM, Singh A, Buttacavoli F, Moore CC. Patient-Level Factors, Outcomes, and Costs Associated With Facility Transfer Following Total Knee Arthroplasty: A Retrospective Database Study. J Arthroplasty 2025; 40:1218-1224.e1. [PMID: 39505285 DOI: 10.1016/j.arth.2024.10.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 10/23/2024] [Accepted: 10/28/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND Patient disposition following total knee arthroplasty (TKA) has major implications for patient outcomes and costs. Current studies are limited in sample size and dates of data collection. We evaluated patient factors, outcomes, and costs associated with disposition to a facility following TKA. METHODS This was a retrospective cohort study including 1,906,670 patients undergoing TKA from a nationwide database, from the years 2016 to 2020. Of these, 25,485 (1.34%) patients were transferred to a facility for rehabilitation. Demographic data, hospital-related outcomes, and postoperative complications were collected. Multivariate regression was performed to assess outcomes associated with facility transfer for rehabilitation. RESULTS Patients were more likely to be transferred if they were women (odds ratio (OR) = 1.10; P < 0.001), greater than 80 years (OR = 2.25; P < 0.001), had an increased Elixhauser comorbidity index (OR = 1.38; P < 0.001), or were in the lowest income quartile (OR = 1.38; P < 0.001). Transferred patients were more likely to experience medical (OR = 1.92; P < 0.001) and surgical complications (OR = 2.74; P < 0.001), including vascular complications (OR = 2.07; P < 0.001), neurologic complications (OR = 5.72; P < 0.001), and dislocation (OR = 2.01; P < 0.001). They also had greater hospital lengths of stay (OR = 5.27; P < 0.001) and hospital charges (OR = 1.88; P < 0.001); however, they were less likely to undergo reoperation within 30 days (OR = 0.61; P = 0.002). CONCLUSIONS Elderly, lower income patients who had more comorbidities are more likely to be transferred to a facility following TKA. While there are associated increased costs, complications, and hospital lengths of stay, there are lower rates of reoperation for those who transferred to a facility after TKA.
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Affiliation(s)
- William H Young
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
| | - Blaire C Peterson
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
| | - Travis M Kotzur
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
| | - Aaron Singh
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
| | - Frank Buttacavoli
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
| | - Chance C Moore
- Department of Orthopaedics, University of Texas Health - San Antonio, San Antonio, Texas
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Alves H, Di Tommaso S, Wegrzyn J, Mabire C. Risk assessment model used to predict discharge care after total hip and total knee arthroplasty: A population-based study. J Orthop 2025; 63:1-7. [PMID: 39524104 PMCID: PMC11546128 DOI: 10.1016/j.jor.2024.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 10/18/2024] [Accepted: 10/19/2024] [Indexed: 11/16/2024] Open
Abstract
Background Transfer to a post-acute care facility or hospital readmission after total joint arthroplasty represent additional costs and increased surgical and health care resource utilization. Accurate prediction of post-acute care factors could help providers to plan the patient's discharge destination and have a positive impact on postoperative outcomes and readmission rates. Objective To develop a risk assessment model to predict discharge care after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Design A retrospective longitudinal observational study. Settings and participants: This study included 209 patients who underwent primary unilateral THA or TKA at a major academic medical center in Switzerland from January 2018 to December 2019. Methods A collection of computerized- and paper-recorded data identified the discharge destination, socio-demographic factors, comorbidities, and other factors related to the patient. Univariate and multivariate analyses were performed to describe the predictors of post-surgical discharge destinations. Results The characteristics associated with post-acute care after primary unilateral THA or TKA were the absence of a caregiver, advanced age, female gender, presence of walking aids, high ASA score, and comorbidity severity. A prediction model demonstrated that these six characteristics were associated 52 % with discharge to a post-acute care destination. Conclusions This study allowed us to identify predictors of discharge to a post-surgical destination. Predictive models can be efficiently used to better predict which patients are predisposed to post-acute care after hospital discharge. Further studies are needed to determine the optimal criteria for different destinations.
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Affiliation(s)
- Henrique Alves
- Institute of Higher Education and Research in Healthcare - IUFRS, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- University Hospitals of Geneva, Geneva, Switzerland
| | - Sebastien Di Tommaso
- Institute of Higher Education and Research in Healthcare - IUFRS, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- University Hospitals of Geneva, Geneva, Switzerland
| | - Julien Wegrzyn
- Department of Orthopaedic, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Cedric Mabire
- Institute of Higher Education and Research in Healthcare - IUFRS, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Stock LA, Johnson AH, Brennan JC, Turcotte JJ, King PJ, MacDonald JH. Outpatient physical therapy bundled payment models are feasible for total hip arthroplasty patients: an evaluation of utilization, cost and outcomes. ARTHROPLASTY 2023; 5:26. [PMID: 37170151 PMCID: PMC10176925 DOI: 10.1186/s42836-023-00179-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/07/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Various episode-of-care bundled payment models for patients undergoing total joint arthroplasty have been implemented. However, participation in bundled payment programs has dropped given the challenges of meeting continually lower target prices. The purpose of our study is to investigate the cost of outpatient physical therapy (PT) and the potential for stand-alone outpatient PT bundled payments for patients undergoing total hip arthroplasty (THA). METHODS A retrospective review of 501 patients who underwent primary unilateral THA from November 2017 to February 2020 was performed. All patients included in this study received postoperative PT care at a single hospital-affiliated PT practice. Patients above the 75th percentile of therapy visits were then classified as high-PT utilizers and compared with the rest of the population using univariate statistics. Stepwise multivariate logistic regression was used to assess the predictors of high therapy utilization. RESULTS Patients averaged 65 ± 10 years of age and a BMI of 29 ± 5 kg/m2. Overall, 80% of patients were white and 53% were female. The average patient had 11 ± 8 total therapy sessions in 42 days: one initial evaluation, one re-evaluation and 9 standard sessions. High-PT utilizers incurred estimated average costs of $1934 ± 431 per patient, compared to $783 ± 432 (P < 0.001) in the rest of the population. Further, no significant differences in 90-day outcomes including lower extremity functional scale scores, emergency department returns, readmissions, or returns to the operating room were observed between high utilizers and the rest of the population (all P > 0.08). In the multivariate analysis, women (OR = 1.68, P = 0.017) and those with sleep apnea (OR = 2.02, P = 0.012) were nearly twice as likely to be high utilizers, while white patients were 42% less likely to be high utilizers than patients of other races (OR = 0.58, P = 0.028). CONCLUSIONS Outpatient PT utilization is highly variable in patients undergoing THA. However, despite using more services and incurring increased cost, patients in the top quartile of utilization experienced similar outcomes to the rest of the population. If outpatient therapy bundles are to be developed, 16 visits appear to be a reasonable target for pricing, given this provides adequate coverage for 75% of THA patients.
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Affiliation(s)
- Laura A Stock
- Anne Arundel Medical Center, Annapolis, MD, 21401, USA
| | | | | | | | - Paul J King
- Anne Arundel Medical Center, Annapolis, MD, 21401, USA
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Özden F, Sarı Z. The effect of mobile application-based rehabilitation in patients with total knee arthroplasty: A systematic review and meta-analysis. Arch Gerontol Geriatr 2023; 113:105058. [PMID: 37172329 DOI: 10.1016/j.archger.2023.105058] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 05/07/2023] [Accepted: 05/07/2023] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Mobile applications have been used frequently in post-operative orthopedic rehabilitation in recent years. However, no systematic review has emphasized the importance of mobile applications in the rehabilitation process after total knee arthroplasty (TKA). This systematic review and meta-analysis aimed to evaluate the effectiveness of mobile application-based rehabilitation practices in patients with TKA. MATERIAL AND METHODS PubMed, Web-of-Science, Scopus, ScienceDirect and Cochrane databases were searched. The Physiotherapy Evidence Database (PEDro) and the Revised Cochrane risk-of-bias tool randomized trials 2 (RoB2) tools were used to demonstrate the methodological quality and risk of bias. RESULTS A total of 584 articles were screened. Finally, six papers were included in the systematic review. PEDro scores ranged from 4 to 7 (median: 5.5), indicating fair to good methodological quality. All studies were classified as "some concerns" in RoB2. Mobile application-based rehabilitation demonstrated better scores on pain, range of motion (ROM), objective and subjective function, satisfaction and compliance in general. Meta-analysis proved that mobile application-based telerehabilitation demonstrated better results on subjective function (ES:0.57, 95% CI: 0.11-1.02). CONCLUSION Compared to conventional rehabilitation, application-based telerehabilitation provides more effective results in function, pain and ROM. Furthermore, mobile application-based rehabilitation should also be considered regarding patient satisfaction and compliance.
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Affiliation(s)
- Fatih Özden
- Department of Health Care Services, Muğla Sıtkı Koçman University, Köyceğiz Vocational School of Health Services, Muğla, Turkey.
| | - Zübeyir Sarı
- Physiotherapy and Rehabilitation Department, Marmara University, Faculty of Health Sciences, İstanbul, Turkey
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Hori S, Ushida K, Momosaki R. Trends in outpatient rehabilitation practices in Japan: analysis using the National Database of Health Insurance Claims Open Data. J Rural Med 2022; 17:125-130. [PMID: 35847760 PMCID: PMC9263955 DOI: 10.2185/jrm.2021-051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/27/2022] Open
Abstract
Objective: Many countries have recently established registration databases in the field of rehabilitation to clarify their current status. However, these databases are primarily created for inpatients, with only a few large-scale databases for outpatients. The present study aimed to clarify secular changes, age distribution, and regional disparities in the implementation of outpatient rehabilitation in Japan using the National Database of Health Insurance Claims. Materials and Methods: Using the National Database of Health Insurance Claims Open Data published by the Ministry of Health, Labor, and Welfare, the number of outpatient rehabilitation units from 2014 to 2018 were extracted and examined. Results: The total number of units for outpatient rehabilitation increased gradually from 2014 to 2018. Orthopedic rehabilitation accounted for more than 80% of the total number of units for outpatient rehabilitation in 2018. The total number of units for outpatient rehabilitation according to age was highest among those in their late 70s, while cerebrovascular and dysphagia rehabilitation had the highest number of units in children. Conclusion: The total number of units for outpatient rehabilitation gradually increased from 2014 to 2018; whereas the number of total units for outpatient rehabilitation according to age was the highest among those in their late 70s. However, cerebrovascular rehabilitation and dysphagia rehabilitation had the highest number of units in children. The implementation status of rehabilitation in each region varied greatly among prefectures, suggesting the need for policy planning to eliminate regional disparities.
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Affiliation(s)
- Shinsuke Hori
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Japan
| | - Kenta Ushida
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Japan
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Zeng C, Koonce RC, Tavel HM, Argosino SE, Kiepe DA, Lyons EE, Ford MA, Steiner CA. Pre-Operative Predictors for Discharge to Post-Acute Care Facilities After Total Knee Arthroplasty. J Arthroplasty 2022; 37:31-38.e2. [PMID: 34619305 DOI: 10.1016/j.arth.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/16/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA). METHODS We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers). RESULTS Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs. CONCLUSION This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.
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Affiliation(s)
- Chan Zeng
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO
| | - Ryan C Koonce
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Highlands Ranch, CO
| | - Heather M Tavel
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO
| | | | - Denise A Kiepe
- Kaiser Permanente Colorado, Orthopedics Department, Denver, CO
| | - Ella E Lyons
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO
| | - Morgan A Ford
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO
| | - Claudia A Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO; Colorado Permanente Medical Group, Denver, CO
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Krueger CA, Courtney PM, Austin MS. Medicare Total Knee Arthroplasty Patients Need Not Stay 2 Midnights for Full Facility Reimbursement. J Arthroplasty 2021; 36:412-415. [PMID: 32950338 DOI: 10.1016/j.arth.2020.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Health care systems are concerned that facility reimbursements will be reduced based on patient length of stay (LOS) of <2 midnights with the removal of total knee arthroplasty (TKA) from the inpatient-only list. The purpose of this study was to evaluate the effect of LOS and postdischarge disposition on facility reimbursement. METHODS We evaluated a consecutive series of 470 primary Medicare TKA patients performed at a single institution from 2018 to 2019. We analyzed facility reimbursement based on patient LOS and discharge disposition. Descriptive statistics were analyzed using chi-square test, analysis of variance, and Student t test calculations. RESULTS Overall, the facility was fully reimbursed in 401 patients (85%) at a mean of $11,169. The facility received full reimbursement for 323 of 326 (99%) patients with an LOS of <2 midnights who were discharged to home at a mean of $11,156. This reimbursement was significantly (P < .001) higher than patients who had an LOS <2 midnights who were discharged with home health (mean, $9773) or to a facility (mean, $10,095). For those with LOS >2 midnights, there was no difference in mean reimbursement among discharge dispositions ($11,202 vs $11,249 vs $11,085, P = .65). CONCLUSION In this study, Medicare TKA patients with LOS <2 midnights were fully reimbursed 99% of the time as an inpatient as long as they are discharged to home without home health or to a rehabilitation facility. Those discharged before 2 midnights who require home health service or inpatient facility are more likely to be reimbursed at a lower penalized rate.
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Akoh CC, Fletcher AN, Chen J, Wang J, Adams SA, DeOrio JK, Nunley JA, Easley ME. Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery. Foot Ankle Int 2021; 42:96-106. [PMID: 32875812 DOI: 10.1177/1071100720949200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). METHODS We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. RESULTS The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001). CONCLUSION While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Craig C Akoh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Juanto Wang
- Department of Foot and Ankle Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Samuel A Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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The effect of immediate post-operative knee range of motion photographs on post-operative range of motion after total knee arthroplasty : An assessor-blinded randomized controlled clinical trial in sixty patients. INTERNATIONAL ORTHOPAEDICS 2020; 45:101-107. [PMID: 33230607 DOI: 10.1007/s00264-020-04877-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/09/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE We attempted to determine the effect of immediate post-operative knee range of motion (ROM) photographs on improving ROM after total knee arthroplasty (TKA). METHODS Sixty patients, scheduled for unilateral primary TKA, were randomized into two groups. The photo group (n = 30) were immediately shown post-TKA knee ROM photographs as motivation for rehabilitation. The non-photo group (n = 30) received identical post-operative pain control and rehabilitation programs. Post-operative knee ROM and Knee Society Scores (KSS) at day three, six weeks, three months, six months, one year, and two years were evaluated. Outcome assessors were blinded to the groups during the study. RESULTS Patients in the photo group had better knee flexion on day three (99.9° ± 15.3°, 95% confidence interval (CI) 94.1-105.7° vs. 92.3° ± 11.4°, 95% CI 87.9-96.8°; p = 0.038) and at six weeks (120.9° ± 13.4°, 95% CI 115.7-126.0° vs. 112.5° ± 13.6°, 95% CI 107.2-117.8°; p = 0.023); however, there were no differences in range of flexion beyond six weeks post-operatively. Knee extension did not significantly differ throughout. Clinical KSS was significantly higher in the photo group at six weeks (90.7° ± 6.2° vs. 86.6° ± 6.4°, p = 0.017). Functional KSS showed no differences between groups during follow-up. CONCLUSION Showing knee ROM photographs seemed to result in significant improvement of knee flexion and clinical KSS in the first 6 weeks post-TKA and may be recommended as part of post-TKA rehabilitation.
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