St George and Sutherland Clinical School, UNSW, Sydney, NSW.
St George Hospital, Sydney, NSW.
Med J Aust. 2019 Feb;210(3):135-141. doi: 10.5694/mja2.12109. Epub 2019 Jan 18.
The minimum requirements for total knee arthroplasty (TKA) are significant, prolonged symptoms with supporting clinical and radiological signs. Despite interest in screening tools, there is limited evidence for a specific symptom threshold that justifies surgery. Non-operative treatments including medications, exercise and weight loss are unlikely to reverse radiographic changes, but they may improve symptoms and delay the need for surgery. Many patient factors such as mental health and obesity affect both the level of symptomatic improvement after surgery and risks of surgery, but none have been identified as contraindications for the procedure as significant health gains can still be achieved. Although age and sex are associated with patient-reported outcomes and risk of revision, these factors cannot be used to restrict access to TKA, and age cut-offs are not recommended. Evidence regarding pre-operative optimisation of patients to improve post-operative TKA outcomes is limited by the few interventional trials available, particularly in the areas of patient expectation, diabetes, obesity and vascular disease. There is good evidence from randomised controlled trials that pre-operative rehabilitation primarily focusing on exercises for the joint or limb has minimal effect on post-operative TKA outcomes, and there is some evidence from randomised controlled trials that an intensive smoking cessation program before surgery may improve post-operative outcomes. Detailed international guidelines exist on the optimisation of the cardiorespiratory status of surgical patients, and these should be followed for TKA surgery.
全膝关节置换术 (TKA) 的最低要求是有明显、长期的症状，并伴有支持性的临床和影像学迹象。尽管人们对筛选工具很感兴趣，但目前还没有具体的症状阈值的证据来证明手术是合理的。非手术治疗，包括药物治疗、运动和减肥，不太可能逆转影像学的改变，但可能会改善症状并延迟手术的需要。许多患者因素，如心理健康和肥胖，会影响手术后症状的改善程度和手术的风险，但这些因素都没有被确定为手术的禁忌症，因为仍然可以获得显著的健康收益。尽管年龄和性别与患者报告的结果和手术风险有关，但这些因素不能被用来限制 TKA 的准入，也不建议使用年龄截止值。由于可供选择的干预试验很少，因此关于术前优化患者以改善 TKA 术后结果的证据有限，特别是在患者期望、糖尿病、肥胖和血管疾病等领域。随机对照试验有很好的证据表明，术前主要侧重于关节或肢体运动的康复对 TKA 术后结果的影响很小，并且有一些随机对照试验的证据表明，术前进行强化戒烟计划可能会改善术后结果。详细的国际指南存在于手术患者心肺状态的优化方面，这些指南应该在 TKA 手术中遵循。
