# Mobilisation After Total Knee Replacement Within an Enhanced Recovery Pathway: A Two-Cycle Clinical Audit

## TL;DR

This study shows that implementing audit recommendations improved early mobilization after knee surgery, but pain and lack of early physiotherapy remain challenges.

## Contribution

The study evaluates the impact of audit-driven changes on early mobilization compliance and identifies persistent barriers in an ERAS pathway.

## Key findings

- Mobilization within 24 hours increased from 66% to 90.5% after implementing audit recommendations.
- Postoperative pain was the most common barrier to early mobilization and was linked to longer hospital stays.
- No physiotherapy assessments on postoperative day 0 were documented, with routine reviews starting from day 1.

## Abstract

Background: Early mobilisation following total knee replacement (TKR) is a key component of Enhanced Recovery After Surgery (ERAS) pathways and is associated with improved functional recovery and reduced length of stay. An initial local audit (MAKE1) identified delays in mobilisation related to postoperative pain and lack of physiotherapy input on postoperative day (POD) 0.

Aim: To assess compliance with early mobilisation standards following implementation of audit recommendations and to identify factors associated with delayed mobilisation and discharge after TKR.

Methods: A retrospective two-cycle clinical audit was conducted in the Orthopaedic Department at James Paget University Hospital. Patients undergoing primary TKR between June and July 2025 were included. Outcomes included time to first mobilisation, length of stay, documented barriers to mobilisation, timing of physiotherapy assessment, and recorded anaesthetic technique. Findings were compared with the initial audit cycle. The audit was registered with the hospital audit department.

Results: A total of 64 patients underwent TKR, and 63 were included in the final analysis due to incomplete documentation for one patient. Mobilisation within 24 hours was achieved in 57/63 patients (90.5%), compared with 35/53 (66%) in the first audit cycle. The median length of stay remained two days. Postoperative pain was the most frequently documented barrier to early mobilisation and was associated with prolonged admission (mean = 5.2 days). Other barriers included delirium, deep vein thrombosis or cellulitis, vasovagal episodes, and fatigue (mean = 4.8 days). No POD 0 physiotherapy assessments were documented; early mobilisation was supported by ward-based staff, with routine physiotherapy review occurring from POD 1. No clear differences in mobilisation timing or discharge were observed between spinal and general anaesthesia.

Conclusion: The descriptive data show higher compliance with mobilisation within 24 hours in MAKE2 compared with MAKE1 following implementation of audit recommendations. Persistent barriers related to pain management and lack of POD 0 physiotherapy input remain key targets for ongoing quality improvement within ERAS pathways.