EFFECT OF PRE-OPERATIVE, POST-OPERATIVE & COMBINED REHABILITATION APPROACHES IN TOTAL KNEE REPLACEMENT
DOI:
https://doi.org/10.71000/3mzg6b72Keywords:
Arthroplasty, Knee, Exercise Therapy, Osteoarthritis, Physical Therapy Modalities, Postoperative Care, Randomized Controlled Trial, Rehabilitation.Abstract
Background: Total knee replacement (TKR) remains the definitive treatment for end-stage knee osteoarthritis, offering substantial pain relief and functional restoration. Despite its widespread success, up to 20% of patients experience suboptimal recovery, often due to inadequate rehabilitation strategies. While postoperative rehabilitation is widely practiced, recent attention has turned to prehabilitation—structured preoperative exercise programs—as a potential enhancer of post-surgical outcomes. However, the comparative efficacy of prehabilitation, postoperative therapy, and combined approaches requires further investigation.
Objective: To evaluate and compare the effects of pre-operative, post-operative, and combined rehabilitation strategies on functional and patient-reported outcomes following TKR.
Methods: A single-center randomized controlled trial was conducted over 6 months, including 30 participants (aged 45–75) undergoing primary unilateral TKR, allocated equally into three groups (n=10 each): Group A received 6 weeks of pre-operative rehabilitation; Group B underwent an 8-week structured post-operative program; and Group C followed both protocols. Interventions included progressive strength training, aerobic conditioning, neuromuscular re-education, and pain management. Functional mobility was measured using the Timed Up and Go (TUG) test, and quality of life was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline, 4 weeks, and 8 weeks post-surgery. Data were analyzed using non-parametric tests due to non-normal distribution.
Results: All groups showed statistically significant within-group improvements over time (p < 0.001). At 8 weeks, Group C (combined rehabilitation) reported the most favorable outcomes (TUG: 1.08 ± 0.29; WOMAC: 1.08 ± 0.29). Group B showed better early gains at 4 weeks (TUG: 2.75 ± 0.45; WOMAC: 2.75 ± 0.45), while Group A showed limited long-term benefit (WOMAC at 8 weeks: 3.67 ± 0.77). Kruskal-Wallis tests confirmed significant between-group differences in favor of combined rehabilitation (p < 0.001).
Conclusion: Combined pre- and post-operative rehabilitation provides the most effective functional recovery by 8 weeks post-TKR, surpassing either strategy alone. These findings support integrating structured, multi-phase rehabilitation protocols into standard TKR care to maximize mobility and quality of life.
References
Al-Jabri T, Ridha M, McCulloch RA, Jayadev C, Kayani B, Giannoudis PV. Periprosthetic distal femur fractures around total knee replacements: A comprehensive review. Injury. 2023;54(4):1030-8.
Alrawashdeh W, Eschweiler J, Migliorini F, El Mansy Y, Tingart M, Rath B. Effectiveness of total knee arthroplasty rehabilitation programmes: a systematic review and meta-analysis. Journal of rehabilitation medicine. 2021;53(6):2784.
Edwards RR, Campbell C, Schreiber KL, Meints S, Lazaridou A, Martel MO, et al. Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study. BMC musculoskeletal disorders. 2022;23(1):302.
Songsong J, Zhencheng F, Tianming D, Ruijia L, Qingqi M. Enhanced recovery after surgery combined with quantitative rehabilitation training in early rehabilitation after total knee replacement: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine. 2023;60(1):74.
Blasco J, Igual-Camacho C, Blasco M, Anton-Anton V, Ortiz-Llueca l, Roig-Casasus S. The efficacy of virtual reality tools for total knee replacement rehabilitation: A systematic review. Physiotherapy theory and practice. 2021;37(6):682-92.
Nguyen C, Boutron I, Roren A, Anract P, Beaudreuil J, Biau D, et al. Effect of prehabilitation before total knee replacement for knee osteoarthritis on functional outcomes: a randomized clinical trial. JAMA network open. 2022;5(3): e221462-e.
Clark NC. Prehabilitation and rehabilitation for total knee replacement surgery: physiotherapy interventions in personalized medicine and charting a course towards optimal outcomes. Orthopaedics and Trauma. 2025.
Wang D, Wu T, Li Y, Jia L, Ren J, Yang L. A systematic review and meta-analysis of the effect of preoperative exercise intervention on rehabilitation after total knee arthroplasty. Annals of palliative medicine. 2021;10(10):109860996-10996.
Widmer P, Oesch P, Bachmann S. Effect of prehabilitation in form of exercise and/or education in patients undergoing total hip arthroplasty on postoperative outcomes—a systematic review. Medicina. 2022;58(6):742.
Fatoye F, Yeowell G, Wright J, Gebrye T. Clinical and cost-effectiveness of physiotherapy interventions following total knee replacement: a systematic review and meta-analysis. Archives of orthopaedic and trauma surgery. 2021; 141:1761-78.
Jacobs H, Seeber GH, Allers K, Hoffmann F. Utilisation of outpatient physiotherapy in patients following total knee arthroplasty–a systematic review. BMC musculoskeletal disorders. 2021; 22:1-11.
Woodland N, Takla A, Estee MM, Franks A, Bhurani M, Liew S, et al. Patient-reported outcomes following total knee replacement in patients aged 65 years and over—a systematic review. Journal of Clinical Medicine. 2023;12(4):1613.
Dutta S, Ambade R, Wankhade D, Agrawal P, WANKHADE D. Rehabilitation techniques before and after total knee arthroplasty for a better quality of life. Cureus. 2024;16(2).
Hashizaki T, Nishimura Y, Ogawa T, Ohno C, Kouda K, Umemoto Y, et al. Effectiveness of a 3-week rehabilitation program combining muscle strengthening and endurance exercises prior to total knee arthroplasty: a non-randomized controlled trial. Journal of clinical medicine. 2023;12(4):1523.
Kan A, Page K, Devine N, Rabajoli A, Sattler L. Preoperative lifestyle modifications combined with a structured exercise protocol on patient outcomes following total knee replacement surgery: A systematic review. Musculoskeletal Care. 2024;22(2): e1899.
Su W, Zhou Y, Qiu H, Wu H. The effects of preoperative rehabilitation on pain and functional outcome after total knee arthroplasty: a meta-analysis of randomized controlled trials. Journal of orthopaedic surgery and research. 2022;17(1):175.
Sakslová M. Kazuistika fyzioterapeutické péče o pacienta s diagnózou totální endoprotézy kolenního kloubu. 2025.
Tabassum H, Qaiser F, Bhatti H, Ashraf S, Ijaz A, Janjua U, et al. Efficacy of Mulligan MWMs along with Conventional Physical Therapy in Knee Osteoarthritis. Journal of Health and Rehabilitation Research. 2024; 4:1349-54.
Kan, A., Page, K., Devine, N., Rabajoli, A., & Sattler, L. (2024). Preoperative lifestyle modifications combined with a structured exercise protocol on patient outcomes following total knee replacement surgery: A systematic review. Musculoskeletal care, 22 2, e1899.
Su, W., Zhou, Y., Qiu, H., & Wu, H. (2022). The effects of preoperative rehabilitation on pain and functional outcome after total knee arthroplasty: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research, 17.
Dutta, S., Ambade, R., Wankhade, D., & Agrawal, P. (2024). Rehabilitation Techniques Before and After Total Knee Arthroplasty for a Better Quality of Life. Cureus, 16.
Omar, I., Kunutsor, S., Bertram, W., Moore, A., Blom, A., Lenguerrand, E., Whitehouse, M., & Wylde, V. (2023). Rehabilitation for revision total knee replacement: survey of current service provision and systematic review. BMC Musculoskeletal Disorders, 24.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Wajeeha Afzal, Kinza Arif, Hafiz Muhammad Abu Bakar Rashid, Muhammad Tariq, Javeria Khalid, Ayesha Mohsin, Junaid Gondal (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
