The performance of high flexion postures such as cross legged sitting, are not part of the assessment criteria to assess either function of a natural knee joint or after Total Knee Replacement (TKR) surgery, in assessment systems used by the orthopaedic fraternity today. This is probably because TKR was initially developed and widely employed in the western countries. However, increasing numbers of this surgery are being performed in the eastern parts of the world, comprising more than half of the global population, where postures such as cross legged sitting are a basic necessity of activities of daily living.

It has been a general perception that achieving flexion beyond 120 degrees after Total Knee Replacement surgery is not a routine result. The implant manufacturing industry has recognized this need and put implant designs on the market with accompanying literature which would suggest that the implant design itself contributes towards a higher range of movement post surgery.

We have performed a prospective study involving a hundred Total Knee Replacements using standard implants (PFC Sigma, Cruciate Sacrificing design, Depuy, J& J, NJ, USA). This implant is not supposed to be specifically designed to deliver a high range of flexion. We found that incorporating certain specific surgical steps as a standard part of the operative procedure delivers a high range of flexion greater than 135 degrees in seventy five percent of patients which allowed them to adopt the cross legged sitting posture after surgery.

This paper conveys the message that achieving a high range of flexion after surgery does not need any special implant design. It discusses the surgical steps which seem to contribute towards this result. The implications in terms of cost saving for health care system are immense.