Consensus on pre-operative total knee replacement education and prehabilitation recommendations: A UK-based modified Delphi study

Anna M. Anderson, Christine Comer, Toby O. Smith, Benjamin T. Drew, Hemant Pandit, Deborah Antcliff, Anthony C. Redmond, Gretl A. McHugh

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Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n=30) or professionals (n=30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists’ importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as ‘Important’ or ‘Very important’ by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

Fifty-five panellists (92%) (patients n=26; professionals n=29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.
Original languageEnglish
Article number352
JournalBMC Musculoskeletal Disorders
Publication statusPublished - 14 Apr 2021


  • total knee replacement
  • total knee arthroplasty
  • pre-operative care
  • education
  • prehabilitation
  • exercise
  • Delphi study
  • Total knee arthroplasty
  • Pre-operative care
  • Total knee replacement
  • Exercise
  • Education
  • Prehabilitation

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