衰弱和跌倒恐惧在老年TKA术后患者家庭亲密度和适应性与功能锻炼依从性的链式中介效应 [中文引用][英文引用]

目的  调查老年全膝关节置换（total knee arthroplasty，TKA）术后患者功能锻炼的依从性，并探讨衰弱和跌倒恐惧在家庭亲密度和适应性与功能锻炼依从性的链式中介效应，为优化术后康复干预提供理论依据。方法  采用便利抽样法，于 2024 年 9 月— 12 月，选取济南市某三级甲等综合医院 220 例老年 TKA 术后患者作为研究对象，采用一般资料调查表、骨科患者功能锻炼依从性量表、家庭亲密度和适应性量表中文版、中文版老年衰弱评估量表和简明国际跌倒效能感量表进行调查。采用 Process 4.1 宏程序分析衰弱和跌倒恐惧在老年 TKA 术后患者家庭亲密度和适应性与功能锻炼依从性的中介效应。结果  206 例患者完成研究。老年 TKA 术后患者功能锻炼依从性得分（55.1±10.0）分、家庭亲密度和适应性得分（124.2±14.9）分、衰弱得分（10.6±4.0）分、跌倒恐惧得分（17.4±5.8）分。家庭亲密度和适应性与功能锻炼依从性正相关（r=0.560，P<0.01），与衰弱和跌倒恐惧负相关（r=-0.483、-0.433，均 P<0.01）；衰弱与跌倒恐惧正相关（r=0.550，P<0.01），与功能锻炼依从性负相关（r=-0.659，P<0.01）；跌倒恐惧与功能锻炼依从性负相关（r=-0.795，P<0.01）。老年 TKA 术后患者家庭亲密度和适应性对功能锻炼依从性的直接效应为 0.127（β=0.127，P<0.001），占总效应的 34.0%；家庭亲密度和适应性对功能锻炼依从性的间接效应为66.0%，分为 3 个路径，衰弱的单独中介效应（0.081，95%CI：0.054~0.113），跌倒恐惧的单独中介效应（0.083，95%CI：0.037~0.128），衰弱和跌倒恐惧的链式中介效应（0.082，95%CI：0.057~0.112）。结论  衰弱和跌倒恐惧在老年 TKA 术后患者家庭亲密度和适应性与功能锻炼依从性间存在链式中介效应。临床医护人员可通过增强家庭亲密度和适应性，降低衰弱和跌倒恐惧水平，进而提高患者功能锻炼的依从性，优化术后康复效果。

Objective To investigate the adherence to functional exercise in elderly patients after total knee arthroplasty （TKA）and examine the sequential mediating effects of frailty and fear of falling in the relationship between family cohesion/ adaptability and exercise adherence，thereby providing a theoretical basis for optimising postoperative rehabilitation interventions. Methods A cross-sectional survey was conducted between September and December 2024，involving 220 elderly post-TKA patients，recruited via convenience sampling，from a Tier IIIA hospital in Jinan，Shandong Province. Data were collected using a general information questionnaire，the functional exercise adherence scale for oorthopaedic patients，family adaptability and cohesion evaluation scale，Tiburg frailty indicator，and short falls efficacy scale-International. SPSS 25.0 and the PROCESS 4.1 macro were used to analyse the mediating effects of frailty and fear of falling in the relationship between family cohesion/ adaptability and exercise adherence. Results A total of 206 patients completed the study. Among the elderly post-TKA patients， the scores of compliances with functional exercises，family cohesion and adaptability，frailty and fear of falling were（55.1±10.0）， 124.2±14.9），（10.6±4.0）and（17.4±5.8），respectively. Correlation analysis showed that family cohesion and adaptability were positively correlated with compliance with functional exercises（r=0.560，P<0.01），and negatively with frailty and fear of falling（r= -0.483，-0.433；both P<0.01）. Frailty was positively correlated with fear of falling（r=0.550，P<0.01）and negatively with compliance with functional exercises（r=-0.659，P<0.01）. Fear of falling was negatively correlated with compliance with functional exercises（r= -0.795，P<0.01）. For elderly post-TKA patients，the direct effect of family cohesion and adaptability on compliance with functional exercises was（β=0.127，P<0.01），accounting for 34.0% of the total effect. The indirect effect was 66.0% and functioned via three paths： the independent mediating effect of frailty（0.081，95%CI：0.054~0.113），the independent mediating effect of fear of falling（0.083，95%CI： 0.037~0.128），and the chain mediating effect of frailty and fear of falling（0.082，95%CI：0.057~0.112）. Conclusion Fraily and fear of falling exert a chain mediating effect between family cohesion and adaptability and compliance with functional exercises in elderly postTKA patients. Clinically，enhancing family cohesion and adaptability can reduce frailty and fear of falling，thereby improving patients' compliance with functional exercises and optimising postoperative rehabilitation outcomes.