Abstract
Dear Editor,
In our paper “Introduction of an innovative day surgery pathway for unicompartmental knee replacement: no need for early knee flexion” [1] we reported on a novel approach to reduce post-operative length of stay.
The successful implementation of the accelerated UKR pathway in September 2016 resulted in a change in culture in our unit and by July 2017 length of stay following total knee replacement (TKR) was reducing as momentum from the UKR pathway took effect. In July 2018, the UKR principles were formally applied to all TKRs in a revised pathway based on our earlier work i.e. a consecutive unselected cohort, no additional pre-operative screening, regular analgesia, early mobilisation, and delayed flexion for those discharged by day 2. All patients were seen on day 5 to start knee flexion with instruction on a home exercise programme. We audited the impact of this in 455 consecutive patients over the first 18 months (July 2018 – December 2019) and compared it to the 285 patients in the previous 12 months using the standard pathway.
In our centre, over 50% of all knee replacements are UKRs and inevitably, the characteristics of those having TKR were more challenging as patients are older, with more co-morbidities than those in centres where TKR is the norm; 19% of our TKR population are 80 years or over and 16% undergo complex primary TKRs or have significant co-morbidities. However, we consistently discharged 50% of our TKR cohort by day 2.
Delaying knee flexion following TKR was not without its concerns as stiffness is a known post-operative complication. However, the new pathway led to no increase in MUAs or readmissions and no significant difference in the range of flexion at 6 weeks for those discharged by day 2; 99° in the delayed flexion cohort and 98° in the standard cohort (P = .55). Delaying flexion did not increase the demand for out-patient physiotherapy. Those with ongoing needs were referred to out-patients; 68% were seen in our unit with 30% requiring only one appointment. Eleven percent was referred locally and 21% required no further physiotherapy.
We have shown the delayed flexion TKR pathway to be safe and effective and it is now routine practice in our unit.