Does delayed physiotherapy following total knee replacement increase post-operative stiffness? A new angle on knee flexion


The NHS continues to adopt ways to safely reduce the length of stay (LOS) following surgery. This audit assesses the impact of the introduction of an innovative pathway for total knee replacement (TKR) allowing early mobilisation and a timely discharge. This followed the success of a similar pathway for unicompartmental knee replacement (UKR) which successfully reduced the LOS with no increase in complications (Jenkins et al 2019). This new TKR pathway would be compared to previous standard care in terms of day of discharge and post-operative range of movement. In our centre we perform approximately 850 knee replacements a year, so any improvements in LOS would bring significant benefits for patients and the service. We were conscious that increasing our productivity and reducing the LOS would not be at the expense of increased readmission rates or adverse events and these were closely monitored over this period.

mean flexion of 99°
at 6-weeks for those following the delayed flexion protocol (n=224)
mean flexion of 98°
at 6 weeks for those following the standard protocol/ immediate flexion (n=285)


By applying the PDSA methodology, by July 2017 our new UKR pathway was embedded in our unit. The TKR pathway was introduced in July 2018 based on similar principles, regular analgesia, early mobilisation and delayed knee flexion for those going home by day 2. All TKR patients initially followed the same pathway, transferring on day 3 from accelerated to standard management if they required a longer hospital admission. Those discharged by day 2 returned to hospital on day 5 to remove the surgical dressings, commence knee flexion exercises and gait re-education and advice. They were routinely referred for further out-patient physiotherapy to reduce the possibility of post-operative knee stiffness.


Results: Between July 2017 and June 2018, 285 consecutive patients followed the standard TKR protocol, with flexion starting immediately post-operatively, of these 122 (42%) were discharged between days 0 and 2. Between July 2018 to December 2019, 224 (53%) patients were discharged between days 0 and 2 following the delayed knee flexion protocol. At 6-weeks, those following the delayed flexion protocol had a mean flexion of 99° (SD 13), range 50-135, IQR 19. Mean flexion for the standard protocol was 98° (SD 15), range 40 -130, IQR 20 at 6- weeks. There were 4 (1.7%) MUAs in the delayed flexion group and 3 (2.4%) in the standard group. In July 2017 there were 7 patients (21%) discharged by day 2. This had increased to 15 patients (68%) by December 2019.

Conclusion(s): Delaying knee flexion following TKR until day 5 had no effect on flexion at 6 weeks. It encouraged and facilitated early mobilisation and a timely discharge. The shift in emphasis and culture in this unit to early mobilisation and discharge has had positive effects on the LOS following other procedures such as total hip replacements. Having an unselected cohort, with every patient initially following the same pathway, is its’ strength as patients are not screened and they all had the opportunity for early discharge.

Cost and savings

No further information. 


This pathway has been shown to be safe and effective and is now routine practice in this unit with much interest from other knee replacement surgical teams.

Top three learning points

No further information. 

Funding acknowledgements

No funding. Departmental audit