Hemophilic pseudotumor: multicenter experience over a 25-year period

Hemophilic pseudotumor of the knee joint: Emphasizing prevention and early diagnosis in a rare disease

Key Clinical Message

Hemophilic pseudotumors are rare complications occurring in individuals with severe hemophilia, characterized by progressive cystic swellings in muscles and/or bones due to recurrent bleeding. Timely initiation of factor VIII replacement is crucial.

Abstract

Hemophilic pseudotumors are rare complications occurring in individuals with severe hemophilia, characterized by progressive cystic swellings in muscles and/or bones due to recurrent bleeding. Although their incidence has decreased with the advent of factor VIII replacement therapy, they still create challenges, particularly in regions with limited access to medical care. Here, we present a case report of a hemophilic pseudotumor of the knee joint in a 15-year-old male with hemophilia A. The patient presented with severe left knee pain, swelling, and restricted range of motion, prompting further investigation. Imaging studies revealed lytic lesions, and MRI bone signal changes consistent with hemophilic pseudotumors. Prompt initiation of factor VIII replacement therapy and supportive management led to a significant improvement in symptoms and joint functionality. Follow-up after 2 months showed that the swelling had significantly reduced in size, with marked improvement in the functionality of the knee joint. This case confirms what is already known in the hemophilia literature: how important it is to prevent, diagnose, and treat pseudotumors early in hemophilia. However, longer clinical and imaging follow-up of this case is necessary to determine whether the complaints associated with pseudotumors resolve with hematologic treatment or will require surgical treatment.

Surgical treatment for pelvic haemophilic pseudotumour: a retrospective analysis of 21 cases

Background

Due to the rarity of pelvic haemophilic pseudotumour (PHPT) and demanding surgical technique for PHPT excision, no study reports the mid-term follow-up outcomes of surgical treatment of PHPT in a relatively large cohort. PHPT with varying degrees of bony pelvic involvement and infection status necessitates different operative procedures, yet there is currently no classification system for PHPT based on surgical practice.

Methods

The study was conducted between June 25, 2004 and July 18, 2023, in Peking Union Medical College Hospital and Nanfang Hospital in China. We performed a retrospective analysis involving 21 patients with 24 PHPTs with a mean follow-up period of 7.1 years. The demographic information, PHPT characteristics, surgical data, and perioperative complications were analysed.

Findings

21 consecutive male patients with 24 PHPTs (21 primary PHPTs and three recurrent PHPTs) that underwent surgical treatment were involved in the study. A classification system including four subtypes was introduced as (I) PHPT confined to soft tissue; (II) PHPT involving bony pelvic without pelvic discontinuity; (III) PHPT causing pelvic discontinuity; (IV) Infectious PHPT. Of the 24 PHPTs, 11 (45.8%) were identified as Type I, five (20.8%) as Type II, three (12.5%) as Type III, and five (20.8%) as Type IV. At the time of surgery, the patients had a mean age of 37.0 ± 9.5 years (Range, 24-52 years). The mean maximum diameter of PHPTs upon surgery was 17.0 ± 7.7 cm (Range, 4.3-40.0 cm). The mean surgical duration was 192 ± 77 min (Range, 60-330 min) and the median intraoperative blood loss was 400 mL (IQR, 225-950 mL, Range, 100-3000 mL). One patient (4.8%) underwent intraoperative cardiopulmonary arrest and expired the following week. Four PHPTs (16.7%) presented postoperative wound infections and poor wound healing. During the follow-up period, five PHPTs (20.8%) experienced pseudotumour recurrence.

Interpretation

Our findings suggest that surgical treatment for PHPTs is feasible and relatively safe. Symptomatic and progressive PHPTs should undergo surgical intervention as early as possible to minimise the surgical risks. Intraoperative use of abundant gelatin sponges in PHPT excision draws attention to severe embolism complications.

Funding

There are no sources of funding for this manuscript.

Management of abdominal pseudotumours in haemophilia: a systematic review

AIM

Haemophilic pseudotumours are complications in patients with haemophilia A or B and result from locally repetitive bleeding, mainly in the musculoskeletal system. Abdominal haemophilic pseudotumours are exceptionally rare but may cause severe complications. This systematic review aimed to evaluate therapy strategies for symptomatic abdominal haemophilic pseudotumours.

METHODS

We systematically searched three databases (Medline [PubMed], Web of Science and EMBASE) for publications published between 1995 and 2023. Two reviewers independently selected the studies, extracted data and performed a quality assessment using the JBI critical appraisal checklist.

RESULTS

From a total of 1199 articles, 39 articles describing 41 cases were included for final analysis. Conservative or interventional treatment was performed in 12 cases. In eight cases, a step-up to surgical therapy after interventional treatment was indicated. Primary surgical therapy was performed in 21 cases. Failure to cure was documented in 50% (n = 6) of patients treated in the first group, with a mortality rate of 16.6% (n = 2). Interventional therapy with a step-up to surgery showed no morbidity or mortality. Primary surgical resection documented favourable results in 66.6% (n = 14), with failure to cure in 9.5% (n = 2) and a mortality rate of 14.3% (n = 3).

CONCLUSION

Primary surgical resection can be a first-line therapy for symptomatic, abdominal haemophilic pseudotumours, whereas preoperative embolisation could be used as a bridging therapy before surgery, especially in emergency settings. Diagnostic biopsy and percutaneous drainage should be avoided to prevent complications.

Surgical treatment of a distal radius and ipsilateral metacarpal hemophilic pseudotumor without recurrence or functional deficit: a case report

Background

Distal hemophilic pseudotumor (HP) occurring distal to the wrist appear to be secondary to intraosseous hemorrhage, which develops rapidly and should be treated primarily with long-term replacement therapy and cast immobilization. Surgical removal or even amputation is indicated when conservative management fails to prevent progression. Here, a practical strategy was described for those patients who cannot afford the cost of routine coagulation factor replacement therapy, namely immediate surgical curettage and bone grafting as well as continuous follow-up.

Case description

A 7-year-old boy with a history of mild hemophilia A was admitted to our medical center because of a 2-year history of progressive swelling and pain around right forearm and hand. Coagulation factor VIII level was 11.1% of normal with no inhibitor. Radiographs revealed expansile swelling, bone destruction, and deformity of the distal right radius and the second metacarpal bone. He was diagnosed with distal HP. Surgical procedure of curettage and bone grafting was performed. The function and appearance of the right wrist were almost normal without discomfort at the 101-month follow-up. Significantly, the same patient was hospitalized again because of a year-long progressive swelling and pain around the left hand when he was 14 years old. X-ray showed multiple bone destruction of the left proximal phalanges of left thumb, middle finger and little finger with local pathological fractures. Surgical procedure of HPs including curettage and bone grafting was performed. Postoperative recovery was good, and the last clinical follow-up at 18 months after the operation displayed a satisfactory shape and functional outcomes.

Conclusions

Curettage and bone grafting prove to be safe and feasible for patients with distal HP and continuous follow-up of patients with distal HP is very vital for timely finding and then treating successive HP in developing countries.

A Novel Surgical Classification for Extremity and Pelvic Hemophilic Pseudotumors: The PUMCH Classification

BACKGROUND

A hemophilic pseudotumor (HPT) is a rare and challenging complication of hemophilia for which there is no classification system that provides uniformity of descriptions or that can be used to guide management. We have developed such a classification based on anatomical site, HPT severity, and corresponding surgical treatment.

METHODS

The PUMCH (Peking Union Medical College Hospital) classification was developed on the basis of clinical manifestations and imaging features. Extremity and pelvic HPTs were divided into 4 types and 6 subtypes according to anatomical site and whether or not there was destruction of adjacent bone. Associations between the PUMCH classification and surgical treatment, preoperative comorbidities, operative time, intraoperative bleeding, and postoperative complication rates were analyzed.

RESULTS

Forty-five patients with 53 HPTs that were treated at PUMCH between December 2005 and October 2021 were included. The mean age at the time of surgery was 35.4 ± 11.9 years, and the median follow-up duration was 60.3 months. Twenty-eight HPTs were classified as type I (13 IA, 7 IB, 8 IC); 3, as type II; 6, as type III; and 16, as type IV. All 20 type-IA and IB HPTs were treated with excision, and the 3 type-II HPTs were treated with curettage and bone grafting. Fourteen type-IV pelvic HPTs underwent excision, 2 of which needed concomitant pelvic reconstruction. Six type-IC HPTs and 1 type-III HPT underwent excision and osseous reconstruction. Amputation was required for 1 type-IC and 3 type-III HPTs. Type-IC HPTs had the longest mean operative time (194.3 ± 28.2 minutes) and the greatest intraoperative bleeding (2,000 mL [interquartile range, 1,100 to 3,000 mL]). Postoperative infection was more common in patients with type-III (50.0%) and type-IC (28.6%) HPTs, but not significantly so.

CONCLUSIONS

The PUMCH classification is based on the anatomic pathology and surgical strategy for HPTs. The classification of HPTs corresponds to surgical outcomes, and may be helpful for decision-making regarding their surgical treatment.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The musculoskeletal manifestations of haemophilia: a review of the imaging findings

Haemophilia is a common hereditary cause of bleeding diathesis and the musculoskeletal system is frequently affected. Repeated episodes of haemarthrosis initiate a cascade towards haemophilic arthropathy, a disabling and deforming joint disease with both degenerative and inflammatory features, which include articular cartilage loss, bone erosions, and synovitis. Haemophilic pseudotumour and intra-muscular haematoma make up the remainder of the musculoskeletal manifestations of this systemic condition. Radiological assessment is vital in the assessment and follow-up of these haemophilic complications and MRI is the reference standard. This article summarises the radiological findings relevant to the diagnosis and monitoring of this complex patient group.

Resection and total femoral prosthesis reconstruction treatment of massive femoral hemophilic pseudotumor: A case report

Introduction and importance

Hemophilic pseudotumor is a rare and serious complication of hemophilia, often occurring in the long bones and muscle tissue of the extremities, with an incidence of about 1–2%. However, there is no effective surgical treatment for massive hemophilia pseudotumors of the extremities. Therefore, we would like to report this case to provide new ideas and methods for the treatment of massive hemophilic pseudotumors of the extremities through resection and total femoral prosthesis reconstruction.

Case presentation

After admission, the patient first underwent a month-long coagulation factor replacement therapy to maintain the patient's factor IX level at approximately 100%. Then, extensive resection of hemophilic pseudotumor and total femoral prosthesis reconstruction was performed in collaboration with several departments, and we collected the patient's preoperative, intraoperative and postoperative data for analysis.

Clinical discussion

After coagulation factor replacement therapy the patient's factor IX level was significantly increased and approached 100%. The surgical procedure was uneventful, and postoperative X-ray suggested a well-positioned prosthesis with postoperative pathological features consistent with a hemophilic pseudotumor. The patient was able to move around with the assistance of a walker 14 days after surgery, and there was no recurrence after one year of follow-up.

Conclusion

For treat the massive hemophilic pseudotumors of the extremities, extensive resection and prosthetic replacement with coagulation factor replacement therapy is a safe and effective treatment that can significantly improve the prognosis and quality of life of patients.

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This is the first report of such a large hemophilic pseudotumor of the proximal extremities with severe pathological fractures.

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This is the first report of the application of extensive resection and total femoral prosthetic reconstruction for the treatment of hemophilic pseudotumors of the extremities.

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Good prognosis achieved by standardized coagulation factor replacement therapy in combination with surgical treatment.

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We hope that this case report can provide new ideas for the treatment of hemophilia pseudotumors of the extremities and functional reconstructive surgery of the extremities.

Outcome of Surgical Management of Hemophilic Pseudotumor: Review of 10 Cases from Single-Center

Objective

To evaluate the operative methods and clinical results of surgical treatment in a case series of 10 patients with hemophilic pseudotumors.

Methods

Ten patients with hemophilic pseudotumors who received surgical resection treatment in our hospital from October 2017 to June 2020 were retrospectively reviewed. All patients were hemophilia A (factor VIII deficiency).The age range was 20–51 years. Preoperative imaging examination revealed the size of irregular mass from 8.2 cm× 3.3 cm× 2.3 cm to 22.3 cm× 15.5 cm× 17.0 cm. With the supplementary of recombinant coagulation factor VIII, five cases received complete resection; one received resection and skin grafting; one received cytoreduction surgery as the pseudotumor closing to iliac vessel and nerve; three cases received complete resection and construction as bone destruction. The perioperative variables were recorded and all the patients were followed in the outpatient clinic. Clinical and radiological assessments were conducted.

Results

In these patients, the average intraoperative blood loss volume was 783.1 mL (range, 240–2100 mL). Six patients received blood transfusion during perioperative period. The average duration of surgery was 140.7 min (range, 110–240 min). All wounds healed smoothly and there was no infection or chronic sinus formation. The average length of hospital stay was 16.3 days (range, 12–25 days). There is no iatrogenic vascular nerve injury in our series. Complete follow‐up was performed in all patients. Mean follow‐up duration was 14.2 months (range, 6–26 months). One patient with pseudotumor in the thigh had a recurrence 1 year after operation, then secondary operation was performed. In three cases who received complete resection and construction, patient 8 obtained bone graft and late fixation. X‐ray examination showed bone formation in the lesion at the 2‐year follow‐ups after operation. Patient 9 underwent knee replacement, his left knee showed flexion deformity in preoparation. At the last follow‐up, range of motion was improved from 0° to 40° compared with preoperative status. Patient 10 had pseudotumor in the distal femur, received long bone graft and intramedullary nail fixation.

Conclusions

Surgical resection for hemophilic pseudotumors is an effective and safe method. The choice of surgical procedure must be individualized according to the localization and progress of pseudotumor.

Haemophilic Pelvic Pseudotumour: A New Surgical Option

Background: Haemophilia is an inherited coagulopathy caused by the absence or dysfunction of clotting factor VIII or IX. Clinical manifestations are generally secondary to recurrent bleeding episodes mainly in the musculoskeletal system. Bleeding symptoms appear early in life and, when the disease is severe (when plasma factor VIII or IX activity is <1% of normal), joint and muscle bleeding may occur spontaneously. A pseudotumour is a recurrent, chronic, encapsulated, slowly expanding, muscle hematoma. Haemophilic pseudotumour is a rare complication of haemophilia which occurs, as a condition either from repeated spontaneous bleeding or coming from a traumatic origin, in 1–2% of haemophilic patients. Case report: A 32-year-old man with severe haemophilia A referred to our Clinic with a massive right iliac wing pseudotumour complicated by Staphylococcus aureus superinfection and skin fistulisation. In this report we describe the medical management and surgical treatment by the adoption of a novel surgical technique which involves the use of a pedicle-screw and rod system (PSRS), a polyglycolic acid MESH and bone cement in order to build up an artificial ilium-like bony mass. This case report highlights the importance of interdisciplinary approach and the efficacy of eradicating surgery as treatment, especially in the case of large and long-lasting lesions.

Surgical treatment for patients with hemophilic pseudotumor-related femoral fracture: a retrospective study

BACKGROUND

Hemophilic pseudotumor (HPT)-related fracture is a rare but severe complication in patients with HPTs. These fractures often occur in femurs. There is no consensus on the standard surgical protocol for HPT-related femoral fracture. The present retrospective study evaluated the outcomes of these patients treated with surgical interventions.

METHODS

Ten patients with HPT-related femoral fractures who were treated with 14 surgical procedures due to 11 fractures in our hospital from January 2014 to April 2020 were evaluated retrospectively. Demographic data, fracture location, complications after surgery, and follow-up outcomes were recorded and analyzed. The mean follow-up period was 39.7 months.

RESULTS

The mean age at surgery was 31 years. Closed reduction external fixation (CREF) was originally performed in 2 patients, open reduction internal fixation (ORIF) was performed in 4 patients, screw fixation alone was performed in 1 patient, brace immobilization was performed in 1 patient, and amputation was performed in 3 patients. Bone union was observed in 5 patients, and an adequate callus was visible in 2 patients. Both patients with CREF had pin infections. Nonunion combined with external fixation (EF) failure occurred in 1 patient, and the plate was broken after ORIF. Three patients underwent autogenous or allogeneic cortical strut grafting. Three patients had HPT recurrence.

CONCLUSIONS

It is necessary to perform surgery in patients with HPT-related femoral fractures. Surgical treatments must consider fracture stabilization and HPT resection. Internal fixation is preferable, and EF should only be used for temporary fixation. If the HPT erodes more than one third of the bone diameter, strut grafts are necessary for mechanical stability. Amputation is an appropriate curative method in certain situations.

Surgical treatment of haemophilic pseudotumor with severe bone destruction: a case report

Haemophilia is an X-linked congenital bleeding disorder caused by a deficiency of factor VIII/IX. Patients with haemophilia (PWH) experience spontaneous bleeding into joints and muscles. Recurrent joint bleeds result in painful and disabling haemophilic multi-arthropathy characteristic of elbows, knees and ankles. The standard of care for PWH is replacement of factor concentrate. Haemophilic pseudotumor (HPT) is one of the complications which can occur in PWH due to repeated bleeding. The occurrence of HPT is not uniform, so treatment needs to be tailored to the individual. We report the case of right distal femur HPT with multi haemophilic end-staged arthropathies (bilateral elbows, knees and ankles). He suffered from walking disability and right thigh pain. He showed functional limitations in those arthropathies, so he could not use crutches. To reduce excess loads on affected joints, we performed left total knee arthroplasty before excision of HPT of the right femur. This is the first case report of a 37-year-old man with haemophilia whose treatment combined en bloc excision of the HPT and reconstruction of distal femur using a tumour prosthesis with severe bone destruction after excision of HPT. At the 24-month postoperative follow-up, the patient was able to walk without any support. When the patients suffer from multi-joint haemophilic arthropathy and HPT, comprehensive and well-planned surgical treatment strategy under adequate factor VIII replacement therapy is necessary.

Treatment of pelvic haemophilic pseudotumour: A retrospective study

BACKGROUND

The incidence of a pelvic haemophilic pseudotumour is very low and is rarely seen in the clinic. Due to the lack of clear treatment standards, patients often suffer from the condition over a protracted period. The aim of this retrospective study was to present our institutional experience in the treatment of pelvic haemophilic pseudotumours over the past 8 years.

METHODS

We retrospectively analysed patients with a pelvic haemophilic pseudotumour who were treated in the Nanfang hospital between February 2012 and December 2019. The type and severity of haemophilia, the presence of inhibitors, comorbidities, pseudotumour imaging data, treatment and follow-up results were recorded and analysed.

RESULTS

Pelvic pseudotumours were identified in seven patients with haemophilia. Three patients had severe haemophilia, three had moderate haemophilia, one had mild haemophilia and inhibitors were present in two patients. Transfusion-related infectious diseases were noted in three patients. Spontaneous rupture and infection of the pseudotumour occurred in five patients. In addition, five patients underwent surgical treatment, two of whom healed well, two patients suffered recurrence of the pseudotumour, and one patient developed a postoperative haematoma twice. Two patients were treated conservatively, one of whom was unable to walk because of progression of the disease, while the other died from severe bleeding and infection.

CONCLUSIONS

Once a pelvic haemophilic pseudotumour is diagnosed, surgical resection should be performed as soon as possible. A delay in diagnosis and suboptimal treatment may lead to complications of the pelvic haemophilic pseudotumour.

Clinical characteristics and surgical treatment of haemophilic pseudotumor: A retrospective analysis of thirty-four patients

AIMS

Haemophilic pseudotumor (HPT) is a rare but challenging complication of haemophilia. This study was intended to provide our experience about clinical characteristics and surgical treatment of HPT.

METHODS

Clinical medical records were retrieved from the Hemophilia Center, Nanfang Hospital, to identify the patients who had been surgically treated from 1 January 2006 to 31 December 2017 with a definite diagnosis of HPT. Their clinical features, surgical management, outcomes and complications after surgery were analysed.

RESULTS

We identified 34 patients with HPT who had surgical treatment over a 12-year period and five of them had multiple HPTs. The incidence of HPT at this centre was 2.3% over the dozen years. A previous trauma leading to the development of HPT was reported in 18 cases (52.9%). The HPT affected only soft tissue in 7 patients, bone and soft tissue in 25 ones and joint in 2 ones. Preoperative infection and fistula formation happened in ten patients, two of whom were related to abdominal HPTs. Enterococcus faecalis was cultured in five cases with fistula formation. HPT associated with pathological fracture was observed in five cases, two of whom were treated by external fixation and 3 by HPT resection and metallic internal fixation. Amputation was performed for nine patients, 6 of whom had preoperative infection and fistula formation. Their follow-up duration averaged 4.2 ± 2.9 years (range, from 1 to 13.5 years) after surgery. Of all our cases, three suffered from postoperative infection, five from recurrence of HPT and two with external fixation from fracture non-union.

CONCLUSIONS

HPT patients with preoperative infection had worse prognosis than those without. Surgical treatment plus intensive replacement therapy was effective for HPT but with a high rate of complications. HPT resection and metallic internal fixation rather than external fixation should be recommended for HPT patients with pathological fracture.

Minimally invasive surgery for haemophilic pseudotumour of the limbs: 28 years of experience

INTRODUCTION

Haemophilic pseudotumour (HP) is an encapsulated haematoma in patients with haemophilia (PWH) which has a tendency to progress and produce clinical symptoms related to its anatomical location.

AIM

To show the experience of one surgeon who has been using mini-invasive technique to treat pseudotumours of limbs in PWH with and without inhibitors at one centre for 28 years.

MATERIALS AND METHODS

Thirty-three patients with 39 HP were treated. All patients had haemophilia A. Twenty-four patients had no inhibitors (72.8%), and 9 had inhibitors (27.2%). The mean follow-up was 16 years (1-25). All patients had x-rays and MRIs. All of them received Buenos Aires protocol as conservative treatment for 6 weeks. MRIs were repeated after 6 weeks' treatment to assess response to treatment. Surgery was performed in patients who did not respond to conservative treatment.

RESULTS

After Buenos Aires protocol, four pseudotumours did not shrink (10.24%), 33 (84.61%) shrank, and two (5.12%) healed. Thirty-seven pseudotumours had surgery, 35 pseudotumours (94.59%) healed with minimally invasive treatment, and two did not heal (5.41%). No infection was observed with this treatment. The mortality rate for the series was 0%.

CONCLUSION

The minimally invasive treatment of pseudotumours was effective in 95% of the cases and resulted in no mortality in this series after 28 years.

Musculo-skeletal problems of the hand in haemophilia

Musculo-skeletal complications of the hand in the haemophilia patient are rare, and they include synovitis, arthropathy, pseudotumours, carpal tunnel syndrome and vascular aneurysms and pseudoaneurysms.

The best way to prevent the aforementioned musculo-skeletal complications is early continuous haematological primary prophylaxis (intravenous infusion of the deficient coagulation factor, ideally from cradle to death).

There is a wide range of procedures that a hand surgeon treating these patients should be able to manage, including synovectomy, prosthetic replacement of small joints, removal or curettage of pseudotumours, release of carpal tunnel and, occasionally, vascular reconstruction of aneurysms.

The treatment of these patients should be made at an institution with close collaboration between haematologists and hand surgeons (all surgical procedures must always be performed under cover of the deficient coagulation factor).

Cite this article: EFORT Open Rev 2020;5:328-333. DOI: 10.1302/2058-5241.5.190078

An Unusual Presentation of Hemophilia A: Pseudotumor of Distal End Radius-Masquerading as Giant Cell Tumor

Hemophilia is a coagulation defect caused by a functional or absolute deficiency of coagulation factors. Deficiency of factor VIII leads to hemophilia A; deficiency of factor IX causes hemophilia B. Pseudotumor may arise from hemorrhage into the muscle and within the subperiosteal space and can lead to destruction of the adjacent muscle, bone, nerves, and vessels. A 60-year-old man presented with the complaint of pain and swelling in right wrist. The patient consulted the general practitioner who misdiagnosed it as a case of giant cell tumor due to typical X-ray changes. Biopsy was done following which there was prolonged bleeding leading to worsening of clinical condition and the patient presented in our hospital with ulcerated swelling. Routine blood investigations were within normal limit. Prothrombin time was 12.1 seconds and activated partial thromboplastin time (aPTT) was 54.3 seconds. Raised aPTT led to suspicion of hemophilia, and factor VIII and IX levels were investigated. Factor IX level was within normal limit. Factor VIII level was 6.3%. The patient was managed conservatively. Factor VIII level was replaced according to standard protocol (40 IU/kg per dose thrice a week for 10 days). Daily dressing was done using tranexamic acid locally. Lesion healed completely in 6 months.

Pseudotumours in haemophilia: non-adherence, under-reporting bleeds or bad luck?

Pseudotumours are a rare, severe complication of haemophilia which can occur in a spectrum of bones and soft tissues. It consists of an encapsulated blood collection, and as the swelling increases causes compression and eventual slow destruction of surrounding structures. Presented here are two cases of patients with haemophilia and pseudotumours, which demonstrate the heterogeneity of presenting symptoms and of treatment options.

Unusual olecranon mass with ulnar nerve compressive neuropathy caused by a haemophilic pseudotumour

A 55-year-old man with a history of haemophilia A and bilateral haemophilic arthropathy of the elbows presented with an enlarging left elbow mass and worsening paresthesias in the ulnar distribution of the left hand. The mass, originally thought to be olecranon bursitis and treated as such, was found to be due to a haemophilic pseudotumour. The patient underwent successful excision of the haemophilic pseudotumour with concomitant ulnar nerve decompression and had sustained resolution of the pseudotumour and symptoms at 10 years of follow-up. This case demonstrates the need for consideration of haemophilic pseudotumour in the differential diagnosis for olecranon masses and cubital tunnel compressive neuropathy in patients with haemophilia, and highlights the viability of surgical excision as a therapeutic option for the treatment of haemophilic pseudotumours in the elbow.

Bilateral Forearm Pseudotumors in an Adult with Hemophilia A and Ollier Disease: A Case Report

CASE

A 29-year-old man with mild hemophilia A and Ollier disease presented with bilateral atraumatic forearm pseudotumors. Both forearm pseudotumors were successfully treated surgically with staged radical extirpation and factor VIII replacement therapy.

CONCLUSION

Pseudotumors typically occur in adolescents with severe, poorly controlled hemophilia A. The development of factor VIII replacement therapy has progressively reduced the incidence of pseudotumors in patients in the developed world. No standardized therapy exists for pseudotumors that continue to bleed into the muscles despite nonoperative measures. Persistent masses require surgical removal with careful preoperative planning and a team approach.

Management of Hemophilic Cysts and Pseudotumors of the Hand in Bleeding Disorders: A Case Series

PURPOSE

Hemophilic cysts and pseudotumors (HCPTs) of the hand are rare and are secondary to bleeding disorders such as hemophilia A and B. This is a report of our experience in the management of this rare condition.

PATIENTS AND METHODS

Seven male patients with hemophilia A presenting with progressive swelling of the hand were treated between 2004 and 2013 at a tertiary referral hospital. All patients had clotting factor replacement based on our previously reported protocol. The age of the patients ranged from 3 to 49 years (median age, 19 years).

RESULTS

Four patients had soft tissue hemophilic cysts and 3 had bony hemophilic pseudotumors. Two patients had traumatic pseudoaneurysm of the ulnar artery in addition to the cysts. The soft tissue cysts required surgical excision in 3 patients under factor cover as per the protocol. The bony lesions were initially managed nonsurgically by factor replacement, but 2 patients failed to respond and required amputation of the fingers. The ulnar artery aneurysm was excised and artery ligated in 1 patient and the artery was vein grafted owing to poor hand perfusion in 1.

CONCLUSIONS

Based on our observations in the management of HCPTs of the hand and the existing literature, we conclude that the soft tissue cysts require surgical excision along with factor replacement and distal bony lesions smaller than 3 cm respond to factor replacement. Larger bony lesions require surgical treatment. Treatment of hemophilic cysts and pseudotumors should be undertaken only in centers with a major hematology backup.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Surgical Management of Haemophilic Pseudotumors: Experience in a Developing Country

AIM

Hemophilic pseudotumors result from repeated episodes of bleeding into bone, subperiosteum, and soft tissue. Since clotting factors became available, uncontrolled perioperative bleeding is a less significant problem for surgeons in developed countries. However, they are more difficult to come by in China. Additionally, patients often have to undergo surgery for giant masses and suffer complications. We wanted to present our experience in the surgical management of hemophilic pseudotumors over a 40-year period.

METHODS

We retrospectively reviewed 429 hemorrhagic coagulopathy patients between 1983 and 2015. Diagnosis of hemophilic pseudotumor was confirmed following clinical, radiological, and pathological criteria. The data were recorded and analyzed: type and severity of hemophilia, presence of inhibitor, etiological antecedent, localization of pseudotumors, clinical signs, surgical management and outcomes.

RESULTS

Eighteen pseudotumor patients underwent surgical treatment. All of them were male, with mean age of 34.3 years. Fifteen patients had hemophilia A and three patients had hemophilia B. There were twelve proximal and two distal pseudotumor patients. The mean follow-up was 51.9 months. For pseudotumors in the extremities, complete surgical resection was achieved. For four patients with pelvic or abdominal pseudotumors, complete surgical resection was only achieved in two patients because of preventing potential vital organs injuries. Delayed healing of the incision, allergic reactions, and ureteral injury were the major complications.

CONCLUSION

Surgery is an alternative method with safety and efficacy. Careful and individual treatment is required by the hematologist, orthopedic surgeon and other members of the team who collaborate and participate in hemophilic surgery.

Bone haemophilic pseudotumour of the ulna: A rare complication of haemophilia in a dog

OBJECTIVES

This case report describes for the first time a bone haemophilic pseudotumour in a dog.

CASE DESCRIPTION

A seven-month-old German Shepherd male dog was presented with the complaint of a forelimb weight-bearing lameness with major swelling that expanded dramatically after fine needle aspiration. Radiographs showed a large, well-defined ulnar diaphyseal cystic-like osteolytic lesion. Based on prolonged activated partial thromboplastin time (aPTT) and low factor VIII activity, haemophilia A was diagnosed. Bone scintigraphy, computed tomography, magnetic resonance imaging, and histological findings definitely ruled out malignant neoplasia or inflammation and strongly supported a bone haemophilic pseudotumour over an aneurysmal bone cyst. Segmental ulnar resection  and replacement by a polymethylmethacrylate spacer combined with perioperative bleeding management resulted in a successful outcome.

DISCUSSION

This case provided evidence that a bone haemophilic pseudotumour may be the sole presenting clinical sign of haemophilia A in dogs. Early diagnosis, based on history and magnetic resonance imaging findings, is imperative for prompt treatment leading to successful outcome. It is challenging as fine needle aspiration or biopsy is contraindicated. As described in humans, surgical excision of the lesion combined with management of severe postoperative bleeding was associated with successful outcome in the present case.

CLINICAL SIGNIFICANCE

A bone haemophilic pseudotumour should be considered in the differential diagnosis of expanding mass associated with osteolysis, especially in young male dogs. Perioperative monitoring of the bleeding disorder and subsequent FVIII replacement therapy was of paramount importance in the present case.

Surgical Treatment for Hemophilic Pseudotumor: Twenty-three Cases with an Average Follow-up of 5 Years

BACKGROUND

Hemophilic pseudotumor (HPT) is a rare disease with many challenges. Only a few reports on surgical treatment for HPT have been published.

METHODS

The cases of 23 patients with HPT who had surgical treatment from July 1996 to December 2014 were retrospectively reviewed. Demographic data, blood loss and transfusion during surgery, outcomes, and complications after surgery were analyzed.

RESULTS

Eleven patients underwent HPT resection; 4 underwent HPT excision, allograft transplantation, and absorbable screw fixation; 3 had HPT resection and metallic internal fixation; 2 had HPT resection, autogenous fibular grafting, and absorbable screw fixation; 2 underwent curettage and bone-grafting; and 1 patient received above-the-knee amputation. The average age (and standard deviation) of the patients at the time of surgery was 31.9 ± 12.8 years (range, 6 to 54 years) with an average follow-up of 5.3 ± 4.7 years (range, 1.1 to 19.6 years). The median duration of the surgery was 157 minutes (range, 90 to 315 minutes). The median amount of blood loss during surgery was 800 mL (range, 100 to 4,000 mL). Three patients (13%) had a postoperative infection, 2 (8.7%) had recurrence of HPT, and another 2 patients had fracture nonunion.

CONCLUSIONS

Surgical treatment of HPT with a modified protocol of coagulation factor replacement is safe and effective. It should be recommended for patients with HPT who have progressive enlargement of the mass, recurrent and massive bleeding, spontaneous perforation, bone erosion, or compression of surrounding tissues or who have had failure of conservative treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hemophilic pseudotumor in a non-hemophilic patient treated with a hybrid procedure of preoperative embolization of the feeding arteries followed by surgical resection-A case report

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Hemophilic pseudotumor is a rare complication of Hemophilia A and B.

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Diagnosis requires a high index of suspicion-especially in non-hemophilic patients.

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Radiographic findings are similar to that of malignant tumors.

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Surgical intervention remains the mainstay of treatment.

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Pre-operative embolization has been shown to reduce intra-operative bleeding.

Introduction

Hemophilic pseudotumor is a rare but well documented complication seen in approximately 1–2% of patients with hemophilia. The incidence continues to decrease, likely because of increasingly sophisticated techniques in managing factor deficiency. We present a case of hemophilic pseudotumor in a patient without hemophilia, an exceptionally rare entity, and outline a hybrid approach to treatment.

Presentation of case

The patient presented with a left sided iliopsoas mass and associated radiculopathy, with a history of a poorly characterized bleeding diathesis and Noonan’s syndrome. He had no history of trauma and was not being treated with anti-coagulation. Of note, factors VIII, IX and XI were normal. An open biopsy was consistent with hemophilic pseudotumor. The patient underwent a hybrid procedure of preoperative embolization of the left internal iliac and left deep circumflex arteries followed by surgical debridement and resection, with an excellent outcome.

Discussion

Hemophilic pseudotumor is rarely seen in patients with hemophilia, and even less frequently in patients without. Trauma is often the inciting event. A high index of clinical suspicion is required in order to secure the diagnosis, as the radiographic appearance is non-specific. Our patient had no history of trauma, although we question whether his underlying bleeding diathesis may have predisposed him to developing the pseudotumor. Surgery remains the cornerstone of management in these cases.

Conclusion

Within the literature, there are only two other cases of hemophilic pseudotumor occurring in a non-hemophiliac patient, highlighting the rarity of this case and the associated diagnostic dilemma.

Perioperative Period of a Hemophilia-related Osteoarthropathy Therapeutic Regimen and Analysis of Complications

OBJECTIVE

To investigate the effectiveness of our department's therapeutic regimen and treatment of complications during the perioperative period of hemophilia-related osteoarthropathy.

METHODS

In this retrospective study, data on 101 patients with hemophilia who had undergone operative treatment in our hospital from January 2000 to August 2014 were assessed. Ninety-one of the patients had hemophilia A and 10 hemophilia B. All patients were male. Changes in Hospital for Special Surgery (HSS), Harris and American Orthopedic Foot and Ankle Society (AOFAS) scores, occurrence of complications during the perioperative period and the clinical treatment and prognosis pre- and postoperatively and during follow-up were analyzed. Relevant clinical data were obtained through telephone calls, outpatient follow-up, and medical clinical record searches.

RESULTS

The 101 patients who were followed up (for an average of 96 months) had 147 orthopedic operations, including joint replacement, hemophilia-related false tumor resections, and tendo-achillis lengthening. The HSS scores for knee surgeries increased from 52 points preoperatively to 86 postoperatively, Harris scores for hip joint surgery from 26 to 87 points, respectively, and AOFAS scores for foot and ankle surgeries from 39 to 81 points, respectively. Eight patients had wound complications, four intra-articular hematomas, two peroneal nerve injuries, one a proximal femur splitting fracture and one deep venous thrombosis.

CONCLUSIONS

Surgical treatment is a safe and reliable choice for addressing complications including hemophilia-related osteoarthropathy given the implementation of effective measures for treatment during the perioperative period.

CT and MRI Aspects of an Abdominal Hemophilic Pseudotumor

We report the computed tomography (CT) and magnetic resonance imaging (MRI) aspects of a rare case of a patient with a large abdominal hemophilic pseudotumor, a chronic, encapsulated, slowly expanding hematoma occurring in severe hemophilia, without involvement of iliopsoas muscles and iliac bones.

Surgical management of hemophilic pseudotumor complicated by destructive osteoarthropathy

Hemophilic pseudotumor gradually erodes bone and induces fracture or deformity, causing joint dysfunction or destructive osteoarthropathy. Reports about surgery for hemophilic pseudotumor complicated by destructive osteoarthropathy are scarce. The object of this study was to evaluate the results and complications of surgical management for patients of pseudotumor complicated by destructive osteoarthropathy. We retrospectively reviewed records from July 1996 to July 2013, and found eight patients with pseudotumor complicated by destructive osteoarthropathy. We recorded their demographic data, time of surgery, amount of blood loss and transfusion, bone union, and complications. Seven patients were diagnosed with hemophilia A and one with hemophilia B. The mean age at surgery was 31.9 ± 8.3 years. Two of the eight underwent excision of the pseudotumor and metallic fixation, one had amputation, and five underwent autogenous or exogenous bone grafting and fixation with an absorbable screw. The median operating time was 170 min (135-315 min). The median amount of intraoperative blood loss was 1350 ml (100-4000 ml). The amount of red blood cells, plasma, and whole blood transfusion after surgery were 0-24 units, 0-2000 ml, and 0-4600 ml, respectively. After a median follow-up of 75 months, the numbers of pseudotumor recurrence, fracture nonunion, coagulation factor inhibitor formation, and wound complications were one, one, two, and four, respectively. Surgery is an effective treatment for hemophilic pseudotumor complicated by destructive osteoarthropathy. However, the incidences of wound infection, coagulation factor inhibitor formation, hemophilic pseudotumor recurrence, and fracture nonunion are high.

A pelvic pseudotumor in a nonhemophilic patient: an unusual presentation

Hemophilic pseudotumor is a rare complication of hemophilia, occurring in 1 to 2 percent of individuals with severe factor VIII or factor IX deficiency. A 35-year-old male presented with a swelling in the right lower abdomen for 3 months. There was no history of trauma. Examination revealed a swelling over the right iliac fossa. Right hip showed 30° flexion deformity. Blood investigations like complete blood count, APTT, PT, bleeding and clotting time, and fibrinogen were all normal. Plain radiograph and MRI showed a lytic lesion in the right iliac wing. Excision biopsy of the swelling showed organized hematoma with a fibrous capsule suggestive of a pseudotumor. Further haematological workup like factors VIII and IX was normal. At 2 years follow-up, there was no recurrence. We report this case of pseudotumour in patient without any bleeding disorder. Such case has not been reported in literature to the best of our knowledge.

Haemophilic pseudotumour: surgical management of a rare case

Haemophilia is a common cause of genetically inherited bleeding disorders. Pseudotumours occur in 1-2 % of persons with severe forms of haemophilia. These are a result of repeated haemorrhage into soft tissues, subperiosteum or a site of bone fracture with inadequate resorption of the extravasated blood. There are a number of therapeutic alternatives for this dangerous condition: surgical removal, percutaneous management, irradiation, embolization etc. In this case report, we describe the natural history, clinical course and successful surgical management of a patient with haemophilia who presented with a massive pseudotumour. We also briefly review the relevant literature on the various therapeutic modalities that have been implemented in the management of this rare complication. Though surgeons may be averse to operate on haemophiliacs, primary surgical management as done in our case may prove to be the definitive treatment option for such patients.

Hemophilic Pseudotumor: An Important Differential Diagnosis of an Intracranial Mass

Hemophilic pseudotumor is a rare complication of hemophilia. We present the case of a male toddler with moderate hemophilia A and cranial hemophilic pseudotumor managed with factor VIII infusions. We also provide a review of the literature. Recognition of this rare manifestation of this complication of hemophilia is important to provide correct treatment and avoid unnecessary investigations, particularly biopsy, which is contraindicated in this condition.

Preliminary results for the use of knee mega-endoprosthesis in the treatment of musculoskeletal complications of haemophilia

Complications of haemophilia in the knee region are rare and difficult to treat. Use of surgical treatments such as total knee arthroplasty cannot satisfactorily restore knee function in patients with these complications, which include massive haemophilic pseudotumour, fracture around the knee and haemarthrosis. To analyse the postoperative results of patients suffering from complications of haemophilia and treated with a knee mega-endoprosthesis, to discuss and compare this type of surgical management with other types of treatments used in similar cases. We retrospectively analyse the surgical results of patients who were treated with a knee mega-endoprosthesis for complications of haemophilia. Three severe haemophilic arthritic knees, of which two were combined with femoral condylar fractures, were treated in a one-stage surgery, and another two knees which presented with massive haemophilic pseudotumours and bony defects were treated in a two-stage operation. Mean age at time of surgery was 28.5 years old and mean follow-up time was 22.8 months; the mega-endoprosthesis surgery was successfully performed in four cases and the mean range of motion increased from 29.5° preoperatively to 96.75° postoperatively. The Knee society score function score value increased from 25 to 82.5. One knee was amputated because of uncontrollable recurrent haemorrhage. Roentgenograms did not show any signs of loosening of the prostheses. Use of Mega-endoprosthesis in the treatment of complications of haemophilia can offer patients suffering from massive pseudotumours with bone defect, severe contracture knee haemophilic arthritis and fractures around a haemophilic knee a viable treatment option.

Intraosseous pseudotumor in a child with hypofibrinogenemia

Intraosseous pseudotumor (i.e. chronic, encapsulated, hemorrhagic fluid collection that can be seen in any portion of the tubular bones) is an uncommon complication of severe hemophilia; however, it can occur with other rare bleeding disorders. We present the case of an 11-year-old girl with hypofibrinogenemia who had multiple intramedullary lesions that were consistent with intramedullary pseudotumor associated with this rare bleeding disorder. Percutaneous biopsy of a pseudotumor is contraindicated due to the high prevalence of complications, including life-threatening bleeding. Therefore, radiologists should make the diagnosis with characteristic MR imaging findings in a patient with a severe coagulation disorder.

Osseous haemophilic pseudotumour and concurrent primary hyperparathyroidism: a diagnostic conundrum

Pseudotumours are rare, occurring in 1-2% of severe haemophiliacs. Osseous locations are far less frequent than soft tissue location. We report a case of a 43-year-old man with haemophilia A, who presented with a gradually enlarging left thigh mass for 8 months. There were no constitutional symptoms. Plain radiograph showed an expansile lytic lesion with 'soap-bubble' appearance arising from the left femur diaphysis. On MRI, it appeared as a non-enhancing, multilobulated lesion expanding the medullary and subperiosteal spaces. The mass exhibited concentric ring sign with heterogeneous intermediate signal intensity in the core lesion, reflective of chronic haematoma with blood degradation products of different stages. A diagnosis of haemophilic pseudotumour was made. Hypercalcaemia, however, raised a diagnostic dilemma as bone malignancy needed to be considered. An open excisional biopsy and subsequent amputation confirmed the diagnosis of osseous haemophilic pseudotumour. Nuclear medicine study later revealed a concurrent parathyroid adenoma.

Surgical treatment of the haemophilic pseudotumour: a single centre experience

PURPOSE

Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.

METHODS

We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.

RESULTS

The mean age at surgery was 45.9 (range, 40-61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4-24) years, normal healing with no recurrence was observed.

CONCLUSIONS

The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.