Selecting and optimising patients for total knee arthroplasty

Abstract

Summary 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.

Perfil epidemiológico e clínico dos pacientes submetidos a artroplastia total do joelho

“…A avaliação pré-operatória visa otimizar clinicamente o paciente, minimizando seus riscos e facilitando sua recuperação. 19 Utilizamos o diagnóstico autorrelatado como ferramenta para listar as comorbidades, por se tratar de um método atrativo para doenças crônicas. Najafi et al 20 afirmaram que essa estratégia é confiável e eficiente, e apresenta algumas vantagens com relação à análise do prontuário, pois não depende do viés do notificador.…”

Do Knee Pain Phenotypes Have Different Risks of Total Knee Replacement?

“…Instead, Class 2 had the highest risk. This may reflect the complexity of the TKR decision-making process in clinical care where the individual decisions of both patient and surgeon have a role in determining a TKR [17,33]. It is possible that pain generated in Class 2 is mainly driven by peripheral structural damage, therefore, participants in Class 2 were more likely to benefit from TKR than those in Class 1.…”

“…This suggests that the phenotypes reflect distinct clinical syndromes. Given that pain is the most important factor for the physician's decision to make a referral for joint replacement [17], we hypothesised that the risk for having a TKR differs across these three phenotypes. Therefore, to validate these phenotypes being clinically relevant for TKR, we sought to examine whether distinct phenotypes have a different risk for TKR by linking to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) over a mean follow-up of 12.0 years.…”

A Bibliometric Analysis Using CiteSpace of Publications from 1999 to 2018 on Patient Rehabilitation After Total Knee Arthroplasty

“…With advances in medical technology, several protocols have been developed to improve for recovery following TKA [6,7]. However, there is no consensus regarding standardized methods for postoperative rehabilitation [8]. Therefore, research in this field continues and is important for the development of TKA rehabilitation with improvement in clinical outcome [9].…”