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A new study from Hospital for Special Surgery (HSS) has shown that with their “Quiet Knee” protocol, total knee arthroplasty (TKA) patients are likely to have significantly reduced postoperative opioid use compared with patents who followed a traditional postoperative recovery protocol, while also experiencing steady improvement in function and a low risk of complications.

The study results were shared at the recent annual meeting of the American Association of Hip and Knee Surgeons.

The Quiet Knee protocol, which some HSS surgeons began implementing several years ago, takes a more conservative approach to TKA recovery than traditional clinical protocols. The focus is on controlling inflammation and swelling postoperatively through restricted mobility, limited passive range of motion (ROM), and aggressive cryotherapy for the first 10 days immediately following surgery.

This contrasts with standard protocols, which often emphasize early and aggressive movement that can cause inflammation in healing surgical tissue.

No Pain, No Gain?

All HSS total knee replacement patients from 2020 to 2024 were retrospectively reviewed as part of the study. There were 3 cohorts:

• The Quiet Knee group received structured postoperative care and monitored telerehabilitation.
• A comparison group was given Quiet Knee guidance verbally.
• A second comparison group followed traditional early motion postoperative therapy.

“Patients are told they have to work really hard to get motion back after surgery – the ‘no pain, no gain’ type of mentality,” said Brian P. Chalmers, MD, a hip and knee surgeon at HSS and one of the study authors.

“The problem with that is that the more patients do in the early period of recovery – the more they bend, the more they are up and walking – the more the knee will swell.”

Every person undergoing TKA experiences pain and swelling after surgery, but the intensity differs, making the patient’s recovery process more challenging and often more painful than most other surgeries.

“It’s not uncommon to see a counterproductive early physical therapy program that is too aggressive,” Dr. Chalmers said. “In these cases, the knee becomes very swollen, which causes patients to have more pain. As the knee becomes more inflamed and patients are able to bend it less, it just becomes a cycle.”

Allowing the Body to Heal

Under the Quiet Knee protocol, patients avoid intensive physical therapy immediately after surgery, allowing the body time to heal before progressing to motion and other strength work.

Early results suggest this approach helps set the stage for a smoother long-term recovery:

• More same-day discharges and fewer prolonged hospital stays
• Opioid usage reduced by more than 25% over the first 90 days postop
• Lower risk of complications, including venous thromboembolism
• Function and pain scores similar to the other cohorts over 2 years

“This isn’t a surgeon-driven protocol or a research-driven protocol. It’s a physiology-driven protocol,” said Michael P. Ast, MD, Chief of the Knee Service and Chief Medical Innovation Officer at HSS and a study co-author.

“It is a recognition of what the human body goes through in recovery from surgery. It is a very logical way of respecting the body’s inflammatory response to trauma. Early on after surgery, less really is more. That is really the guiding principle of this protocol.”

Source

Bhatti P, Moeller L, Ast MP, Shen TS, Sculco PK, Mayman DJ, Chalmers B. A Retrospective Cohort-Based Analysis of the “Quiet Knee” Protocol After Primary Total Knee Arthroplasty (Poster 30-2025). Presented at the annual meeting of the American Association of Hip and Knee Surgeons, October 23-26, 2025, in Dallas, Texas.