1. The Journal of Arthroplasty Vol. 23 No. 8 2008
Does a Standard Outpatient Physiotherapy Regime
Improve the Range of Knee Motion After Primary
Total Knee Arthroplasty?
Brian James Mockford, MPhil, FRCS (Orth), Neville W. Thompson, MPhil, FRCS (Orth),
Patricia Humphreys, BSc (Hons), and David E. Beverland, MD
Abstract: The aim of this study was to investigate whether a standard course of
outpatient physiotherapy improves the range of knee motion after primary total
knee arthroplasty. One hundred and fifty patients were randomly assigned into one
of 2 groups. One group received outpatient physiotherapy for 6 weeks (group A).
Another received no outpatient physiotherapy (group B). Range of knee motion
was measured preoperatively and at 1-year review. Validated knee scores and an
SF-12 health questionnaire were also recorded. Although patients in group A
achieved a greater range of knee motion than those in group B, this was not
statistically significant. No difference either was noted in any of the outcome
measures used. In conclusion, outpatient physiotherapy does not improve the range
of knee motion after primary total knee arthroplasty. Key words: total knee
arthroplasty, physiotherapy.
© 2008 Elsevier Inc. All rights reserved.
In recent years, increasingly better functional results nique, and rehabilitation have been studied to
and greater patient satisfaction are being noted in determine their influence on postoperative knee
patients undergoing total knee arthroplasty (TKA). flexion. Many are retrospective and include data
Range of motion remains a rather unpredictable from a number of different surgeons, surgical
entity with postoperative range of motion not techniques, and prostheses [7].
always meeting patient demands. After the prime Most clinical studies have a final range of motion
goal of reducing pain, range of motion is probably that averages between 100° and 110° of flexion
seen as the next most important outcome measure which is adequate for most activities of daily living
after TKA and has therefore been the subject of a [8-13]; however, many patients undergoing TKA
number of studies [1-6]. are, however, becoming increasingly active and
Variables including age, sex, primary diagnosis, expect to achieve a greater degree of movement.
preoperative motion, implant design, surgical tech- The aim of this study was to determine whether a
standard course of postoperative outpatient phy-
siotherapy improved the range of knee motion 1
year after primary TKA.
From the Musgrave Park Hospital, United Kingdom.
Submitted March 8, 2006; accepted August 25, 2007.
Benefits or support was received from the Belfast Arthroplasty
Research Trust.
Reprint requests: Brian James Mockford, MPhil, FRCS (Orth), Materials and Methods
45 Waringfield Avenue, Moira, Co. Armagh, BT67 0FA Northern
Ireland, UK. All patients attending for primary TKA under the
© 2008 Elsevier Inc. All rights reserved.
0883-5403/08/2308-0003$34.00/0 care of one surgeon were targeted for entry into this
doi:10.1016/j.arth.2007.08.023 prospective study. All patients underwent TKA
1110

2. Standard Outpatient Physiotherapy Regime Mockford et al 1111
Table 1. Preoperative Patient Characteristics in the Oxford Knee Score (OKS) [14], Bartlett patellar
Each Group score (BPS) [15], and the Short-Form (SF-12)
Group A Group B general health questionnaire were completed.
(n = 71) (n = 72) Range of motion was measured using a goniometer.
Age, y (mean) 69.4 70.9
As soon as possible after surgery, general medical
Sex (women) 46 42 health permitting, all patients were mobilized fully
Diagnosis weight bearing with the use of either a walking
Osteoarthritis 66 71
Rheumatoid arthritis 5 1
frame or crutches. Inpatient physiotherapy com-
OKS 49 48 menced on day 1 and continued daily until
BPS 10.3 10.6 discharge. On days 1 and 2, the inpatient program
SF-12 PCS 27.3 28
SF-12 MCS 47 46.6
consisted of ankle exercises, static quadriceps and
Postoperative length of stay 4.2 4.4 hamstring exercises, straight leg raising and knee
flexion exercises, and walking practice. From day 3
PCS indicates physical component summary; MCS, mental until discharge, the physiotherapy was carried out in
component summary. the gym and consisted of heel slides, quadriceps bar
and hamstring pulley exercises, gait reeducation,
using the LCS rotating platform prosthesis (DePuy, and stair practice. Continuous passive motion was
Leeds, UK). The local ethics committee granted not used. All patients were given a home exercise
ethical approval. regime to follow on discharge. A letter was also sent
One hundred and fifty patients undergoing to the patient's general practitioner on day of
primary TKA were recruited. Subjects were ran- discharge requesting them not to organize out-
domized using a computer-generated randomiza- patient physiotherapy.
tion program into 2 groups. Both the surgeon and
inpatient physiotherapy team were blinded to the Statistical Analysis
study grouping. To detect a clinically significant
Analysis was carried out on an intention-to-treat
difference of 10° (estimating a within-group SD of
basis. No adjustment needed to be made for any
16° at 90% power and at a 5% significance level),
baseline differences. Statistical analysis was per-
a sample size of 54 patients in each arm of the
formed using the independent samples T test and
study was required. Recruitment of patients took
the 1-sample T test using the SPSS version 11
place on the day of admission to hospital.
software package (SPSS, Inc, Chicago, Ill).
Sufficient numbers were entered into the trial to
allow for dropouts.
Seven patients were lost to follow-up or died and Results
therefore excluded from the study. This left 71
patients in group A and 72 in group B. Group A The baseline characteristics of the 2 groups were
received a standard outpatient physiotherapy similar (Table 1). No significant differences were
regime, whereas group B did not. Measurements noted between the 2 groups.
of knee range of motion were taken preoperatively, The mean number of outpatient physiotherapy
at 3-month and 1-year reviews after surgery, and sessions attended in group A was 7.3 (range, 0-9).
Table 2. Measurements of Knee Motion and Analysis of Mean Differences of Each Parameter
Parameter Group Preoperative 1y Mean difference P value
Active extension A 3.7° 1.5° 2.2° .98
B 3.5° 1.3° 2.2°
Passive extension A 3.6° 1.3° 2.3° .78
B 3.3° 1.2° 2.1°
Active flexion A 97.8° 107.9° 10.1° .18
B 100.4° 106.6° 6.2°
Passive flexion A 101.9° 109.9° 8° .48
B 103.5° 109.3° 5.8°
Active ROM A 94° 106.3° 12.3° .23
B 96.8° 105.2° 8.4°
Passive ROM A 98.3° 108.6° 10.3° .48
B 100.2° 108.1° 7.9°
ROM indicates range of motion.

3. 1112 The Journal of Arthroplasty Vol. 23 No. 8 December 2008
Table 3. Validated Outcome Scores Table 5. Walking Distance Before and
(Mean Differences) Before and After Surgery in Each Group
After Surgery in Each Group
Group A Group B
Group A Group B P value Preoperative 1y Preoperative 1y
OKS 23 23.5 .77 Unlimited 1 28 1 30
BPS 15.7 14.4 .22 N1000 m 3 20 2 20
SF-12 PCS 11.7 11 .67 500-1000 m 8 15 12 9
SF-12 MCS 3.3 3.4 .97 b500 m 53 6 52 10
Housebound 6 2 5 3
Forty-three patients attended for all 9 planned
sessions. One patient in group B attended potential for this, it is necessary to evaluate common
physiotherapy, requested by his GP. He received factors that may influence the amount of knee
9 sessions. motion achieved after TKA. Postoperative rehabili-
The mean absolute values for each range of tation, of which physiotherapy plays a large part, is
motion parameter are outlined in Table 2. The considered an important factor.
difference between the 2 means was then calculated The range of motion at 1 year is felt to be an
and compared. No significant differences were noted appropriate end point with no improvement in the
between the 2 groups. range of knee motion thereafter [16-20].
An improvement was also noted in all validated Our study concurs with those authors who
outcome measures as expected. No significant differ- suggest that the most important factor in influencing
ences were noted between the 2 groups (Table 3). the range of motion after TKA is the preoperative
One-way analysis of variance revealed no statis- value [7,16,21,22]. Regarded by most as the most
tical difference in any of the parameters between important parameter, active flexion was not sig-
that preoperatively and at 1 year in groups receiving nificantly improved by 1 year after a course of
no outpatient physiotherapy, 1 to 8 sessions, or all 9 outpatient physiotherapy.
sessions of physiotherapy. It was, however, noted that in group A the
There was no difference noted between the 2 range of motion was improved at 3 months
groups in the type of walking aid used (Table 4) or compared to the nonphysiotherapy group B but
walking distance attained at 1 year (Table 5). not significantly. Like other physiotherapy mod-
Four complications were noted in each group. In alities such as continuous passive motion [23,24]
group A, 1 proximal deep vein thrombosis, 1 and muscle strengthening exercises [25], we
pulmonary embolism, 1 supracondylar fracture, and could conclude that physiotherapy allows a faster
1 superficial wound infection were seen, and in group return to a functional range of motion but
B 1 proximal deep vein thrombosis, 1 superficial ultimately no benefit at 1 year or beyond.
wound infection, 1 deep infection, and 1 hematoma Furthermore, when considering the individual
requiring drainage. None were directly attributable to groups, patients tended to migrate toward a
the outpatient physiotherapy intervention. middle range, that is, those with poor preopera-
tive active flexion gained flexion after TKA
whereas those with good preoperative active
Discussion flexion lost flexion. Contrary to other studies
[1,3,4,16,17,25,26], we found an overall improve-
The restoration of a functional range of knee ment in extension and flexion, active and passive,
motion is important in TKA. To maximize the compared to that preoperatively in both groups.
The physiotherapy group had a mean improve-
ment of 3.9° over the no-physiotherapy group.
Table 4. Walking Aid Use Before and After Surgery This was not statistically different and did not
in Each Group elevate the number of patients into a higher
functional range of motion. Kettlekamp et al [27]
Group A Group B felt 93° of active flexion was necessary for
Preoperative 1y Preoperative 1y everyday function. Six patients (13%) in group
No support 30 54 33 51 A and 9 patients (12%) in group B did not
1 stick 37 15 33 18 achieve this goal postoperatively.
2 sticks 1 0 2 1
Crutches or walker 3 2 4 2 The ability to passively flex the limb to beyond 93°
is advantageous, and if 105° is manageable then

4. Standard Outpatient Physiotherapy Regime Mockford et al 1113
elevation to a higher functional status is achieved 6. Schurman DJ, Matityahu A, Goodman SB, et al.
allowing patients to get up comfortably from the Prediction of postoperative knee flexion in Insall-
seated position. Seventy-three percent of patients in Burstein II total knee arthroplasty. Clin Orthop 1998;
group A and 75% of patients in group B achieved 353:175.
7. Thompson NW. Factors influencing range of motion
105° of passive flexion.
following total knee replacement. MPhil Thesis,
Our results were in agreement with the results of Queens University Belfast, 2003.
a similar study by Rajan et al [28]. Although 8. Figgie III HE, Goldberg VM, Heiple KG, et al. The
adjustment was required to account for baseline influence of tibial-patellofemoral location on function
differences between the groups preoperatively, they of the knee in patient's with the posterior stabilized
found no statistical difference between the 2 groups condylar knee prosthesis. J Bone Joint Surg 1986;
at any of the review times of 3 months, 6 months, or 68A:1035.
1 year. 9. Ryu J, Saito S, Yamamoto K, et al. Factors
Outpatient physiotherapy did not improve the influencing the postoperative range of motion in
ability to walk further nor did it decrease the total knee arthroplasty. Bull Hosp Joint Dis 1993;53:
necessity for walking aids. 35.
10. Ranawat CS, Luessenhop CP, Rodriguez JA. The
The economic gains of not having to undergo
press-fit condylar modular total knee system four-to-
outpatient physiotherapy are considerable particu- six-year results with a posterior-cruciate–substituting
larly in transport and staffing costs. design. J Bone Joint Surg 1997;79A:342.
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living. Phys Ther 1972;52:34.
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