Aim

External fixator knee arthrodesis is a salvage procedure mainly used in cases of end-stage infected total knee replacement (iTKR). A stable fixation combined with bone-ends compression is basic to achieve knee fusion in such a scenario but providing enough stability can be challenging in the presence of severe bone loss after multiple previous procedures. Compared with monoplanar configuration, a biplanar frame achieves improved coronal stiffness, while providing the advantages of good access to the wound and allowance of early ambulation. Our primary hypothesis stated that a biplanar frame would achieve higher and quicker fusion rate than a monolateral configuration.

Background

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). Degenerate discs are associated with accelerated cellular senescence. Cell senescence is associated with a secretory phenotype characterised by increased production of catabolic enzymes and cytokines. However to date, the mechanism of cell senescence within disc degeneration is unclear. Senescence can be induced by increased replication or induced by stress such as reactive oxygen species or cytokines. This study investigated the association of cellular senescence with markers of DNA damage and presence of cytoplasmic DNA (which in cancer cells has been shown to be a key regulator of the secretory phenotype), to determine mechanisms of senescence in disc degeneration.

I still remember as a green 16-year-old being completely seduced by Newman's portrait of a university – the ideal of a liberal education. I was completely charmed not only by Newman's seductive prose – but by the humanising ideals of the effects of an excellent education. The picture was compelling and inspirational to the daughter of a small farmer whose parents were forced to leave school at 12 years of age to go and earn a living. I was sitting in the “lap of luxury” in a boarding school for girls, whose excellent principal generated a huge respect for, and absolute belief in, the right to and the ability to gain from a rigorous and serious education – which for me at that time in the 1970s extended at least to the end of secondary schooling – a luxury no one in my family had access to in the previous generation. What are universities for? Many authors have considered this issue since Newman's time – in recent times for example Boyd (1979), Graham (2005), Collini (2012). They all, in different ways suggests the need not only to respond to societal / economic needs, but also the need for a more balanced, holistic conception of university activity. Leaders of universities in the 21^st century must try to articulate this, seek greater understanding of it. We must lobby government for greater recognition, understanding and support for the university's role not only for the present but also for the future. Contingency, vulnerability, adaptability, recognising the provisional nature of knowledge (and control); the caring versus the careless – all of this implies the need for diversity of disciplines, gender and experiences among university leadership in both the national and the international arena.

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). Degenerate discs are associated with accelerated cellular senescence. Cell senescence is associated with a secretory phenotype characterised by increased production of catabolic enzymes and cytokines. However, to date, the mechanism of cell senescence within disc degeneration is unclear. Senescence can be induced by increased replication or induced by stress such as reactive oxygen species or cytokines. This study investigated the association of cellular senescence with markers of DNA damage and presence of cytoplasmic DNA (which in cancer cells has been shown to be a key regulator of the secretory phenotype), to determine mechanisms of senescence in disc degeneration. Immunohistochemistry for the senescence marker: p16INK4A was firstly utilised to screen human intervertebral discs for discs displaying at least 30% immunopostivity. These discs were then subsequently analysed for immunopostivity for DNA damage markers γH2AX and cGAS and the presence of cytoplasmic DNA. The number of immunopositive cells for p16 INK4A positively correlated with the expression of γH2AX and cGAS. Senescent cells were also associated with the presence of cytoplasmic DNA. These new findings elucidated a role of cGAS and γH2AX as a link from genotoxic stress to cytokine expression which is associated with senescent cells. The findings indicate that cellular senescence in vivo is associated with DNA damage and presence of cytoplasmic DNA. Whether this DNA damage is a result of replicative senescence or stress induced is currently being investigated in vitro.

This cohort study investigated the influence of psychological factors, including perception of illness, anxiety and depression on recovery and functional outcome after total knee replacement surgery.

A total of 100 patients (55 male; 45 female) with a mean age of 71 (42 to 92) who underwent a primary total knee replacement for osteoarthritis were recruited into this study. In all 97 participants completed the six week and 87 the one year follow-up questionnaires.

Pre-operatively patients completed the revised Illness Perception Questionnaire, Hospital Anxiety and Depression Scale and Recovery Locus of Control Scale. Function was assessed pre-operatively, at six weeks and one year using Oxford Knee Score (OKS) and the goniometer-measured range of movement (ROM).

The results showed that pre-operative function had the biggest impact on post-operative outcome for ROM and OKS. In addition questionnaire variables and depression had an impact on the OKS at six weeks. Depression and anxiety were also associated with a higher (worse) knee score at one year but did not influence the ROM at either six weeks or one year.

Recovery from total knee replacement can be difficult to predict. This study has identified psychological factors that play an important role in recovery from surgery and functional outcome. These should be taken into account when considering patients for total knee replacement.

Cite this article: Bone Joint J 2014;96-B:210–16.

Background: Functional outcome and patient satisfaction after total knee arthroplasty can be variable. Up to 20% of patients have been reported to not be entirely happy with their knee replacement. Psychological factors, in particular illness perception – a patient’s beliefs about their illness – have been found to predict recovery from a range of conditions. Few studies have examined their impact within the orthopaedic context.

Aim: The aim of this study was to investigate the impact of psychological factors, including illness perception, anxiety and depression, on postoperative recovery and functional outcome after total knee arthroplasty.

Patients and Methods: 100 patients from two centres, who underwent a primary total knee arthroplasty for osteoarthritis between 2004 and 2006, took part in this prospective cohort study.

Before surgery patients were asked to complete a psychological questionnaire consisting of Revised Illness Perception Questionnaire (IPQ-r), Hospital Anxiety and Depression Scale (HADS) and Recovery Locus of Control (RLOC). Knee function was assessed preoperatively, at six weeks and one year using Oxford Knee Score (OKS) and range of motion (ROM).

Results: The mean OKS improved significantly at six weeks and further at one year. The mean ROM showed little change in the first six weeks, but was significantly improved at the one-year follow-up.

The psychological factors Consequences, Illness Coherence, Emotional Representation and HADS Anxiety showed a statistically significant correlation with the OKS at six weeks, the factors Consequences and HADS Anxiety and HADS Depression with the OKS at one year. We found no correlation with range of motion at six weeks, but ROM at one year was statistically significantly correlated with the factors Consequences and HADS Depression.

This indicates that patients who believed that their illness had less impact on their personal lives and patients with lower scores on the anxiety and depression scale showed a lower OKS and higher ROM at one year, indicating a better functional outcome.

Hierarchical regression analysis showed that, after controlling for demographics and baseline scores, the factor consequences explained 7% of the variance in ROM at one year. HADS Anxiety and Depression had a significant impact on OKS and accounted for 13.7% of the variance of OKS at one year.

Discussion: Recovery from TKA surgery can be difficult to predict. This study showed that functional outcome can be significantly influenced by psychological factors. These should be taken into account when considering patients for TKA surgery. Improving patient education, looking at home environment and social network as well as addressing anxiety and depression may help to improve overall outcome after TKA surgery.