Ankle fusion in hemophilic patients

Structural alterations and pain perception at the ankle joint in patients with haemophilia

BACKGROUND

Patients with haemophilia (PwH) suffer from chronic pain due to joint alterations induced by recurring haemorrhage.

OBJECTIVES

This study aimed to investigate the relationship between structural alterations and pain perception at the ankle joint in PwH.

PATIENTS/METHODS

Ankle joints of 79 PwH and 57 healthy controls (Con) underwent ultrasound examination (US) and assessment of pain sensitivity via pressure pain thresholds (PPT). US discriminated between joint activity (synovitis) and joint damage (cartilage and/or bone degeneration) applying the HEAD-US protocol. Based on US-findings, five subgroups were built: PwH with activity/damage, PwH with activity/no damage, PwH with no activity/no damage, controls with activity/no damage and controls with no activity/no damage.

RESULTS

Joint activity and joint damage were significantly increased in ankles of PwH compared to Con (p ≤.001). Subgroup analysis revealed that structural alterations negatively impact pain perception. This is particularly evident when comparing PwH with both activity/damage to PwH with no activity/no damage at the tibiotalar joint (p = .001). At the fibulotalar joint, no significant differences were observed between PwH subgroups. Further analysis showed that both joint activity and joint damage result in an increase in pain sensitivity (p ≤.001).

CONCLUSION

The data suggest a relation between joint activity, joint damage and pain perception in PwH. Even minor changes due to synovitis appear to affect pain perception, with the effect not intensifying at higher levels of inflammation. In terms of joint damage, severe degeneration leads to a sensitised pain state most robustly, whereas initial changes do not seem to significantly affect pain perception.

Ankle arthrodesis and total ankle replacement in patients with congenital bleeding disorders suffering from severe ankle arthropathy

INTRODUCTION

In patients with congenital bleeding disorders suffering from severe ankle arthropathy, when conservative treatment and joint-preserving surgical techniques fail, there are two possible non-joint-preserving options: ankle arthrodesis (AA) and total ankle replacement (TAR).

AREAS COVERED

The scope and aim of this article was to analyze the current role of AA and TAR in patients with congenital bleeding disorders suffering from severe ankle arthropathy.

EXPERT OPINION

In patients with congenital bleeding disorders, both TAR and AA provide good results, mainly in terms of pain relief, although they are not exempt from complications (between 0% and 33% in TAR and between 5% and 23.5% in AA). The current controversy about which of the two surgical techniques, TAR or AA, gives better results, the current literature is not able to resolve it in patients with congenital bleeding disorders. While this question is being answered, my opinion regarding patients with congenital bleeding disorders is that the age of the patient must be taken into account. Given known prosthetic survival rates, the older the patient, the more we might be inclined to indicate TAR. Conversely, AA may be more appropriate for relatively young patients.

Comparison of Total Ankle Replacement and Ankle Arthrodesis for Ankle Arthropathy in Patients With Bleeding Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population.

METHODS

This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool.

RESULTS

Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA.

CONCLUSION

Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population.

Clinical and patient reported outcome in total ankle replacement compared to ankle fusion in end-stage haemophilic arthropathy

BACKGROUND

Ankle arthropathy is a frequent complication of haemophilia, reducing the patients' quality of life. Despite intensive conservative therapy, end-stage arthropathy requires surgical treatment, either by ankle fusion (AF) or total ankle replacement (TAR).

METHODS

Eleven consecutive AFs were performed in nine patients and 11 TARs were implemented in 10 patients. Outcomes were assessed clinically by AOFAS score and radiologically by the Pettersson and Gilbert scores.

RESULTS

The mean age of the patients in these groups were 35.7 years and 49.4 years, respectively. Of the 11 ankles that underwent fusion, 10 showed bony consolidation not later than 12 weeks after surgery, whereas one still showed non-union after 6 months. VAS pain scores decreased significantly in both groups. Mean AOFAS scores also improved significantly, from 28.1 before to 80.3 after AF and from 21.5 before to 68.0 after ankle replacement. No perioperative complications were observed in either group. Late deep infection was observed in two patients that underwent TAR, which required removal of the implant.

CONCLUSION

Our data indicate that both AF and TAR result in significantly reduced pain in patients with haemophilia with end-stage haemophilic arthropathy. While TAR is associated with a higher risk of deep infection and minimal persistent pain, it preserves the pre-operative range of motion. AF on the other hand is associated with the risk of non-union and a longer post-operative recovery period but results in greater pain reduction.

Pain management in hemophilia: expert recommendations

INTRODUCTION

As a typical consequence of bleeding into muscles and joints, patients with severe hemophilia suffer from acute and chronic pain. In spite of its high prevalence, pain in this patient group is not always sufficiently considered or treated in an effective manner.

AIM

The recommendations presented in this paper address possible improvements in pain management in hemophilia patients and particularities that have to be taken into account in this patient group.

METHOD

The manifold aspects of pain management in hemophilia patients were discussed within the framework of an expert meeting. Based on the available literature and the experts' clinical experience, the participants developed a set of recommendations presented in this paper.

RESULTS

Pain management in patients with hemophilia is often insufficient, a fact that not only influences the patients' quality of life but also implies the risk of difficult to manage chronic pain. Both the prevalent polypharmacy (due to comorbidities) as well as the underlying disease itself present special challenges to pain therapy in this patient group. The present review and recommendations are intended to support medical professionals in recognising the risks of pain chronicity, applying basic principles of multimodal pain therapy, including the options of psychological intervention and modalities of physical medicine in therapy concepts, and reaching a comprehensive understanding of the range of analgesic options available.

Ankle hemophilic arthropathy: literature review

Hemophilia is a bleeding disorder characterized by the deficiency of a coagulation factors. The hemarthrosis is the most common and earliest manifestation. Repeated hemarthrosis over time causes the development of hemophilic arthropathy. Among most involved joints, the ankle is the one where much uncertainty remains about the best course of action in managing the various degrees of hemophilia manifestations. These manifestations range from simple acute swelling and pain to devastating deformity. The purpose of our review is to draw a comprehensive picture of ankle hemophilic arthropathy epidemiology, pathophysiology, clinical symptoms and signs, radiological features and all the treatments available at present days. This review confirms that the first line of treatment considered should be the replacement therapy of the coagulation deficient factors that, preventing hemarthrosis, stops the development and progression of ankle's joint damage. The treatments proposed in literature for advanced stage of arthropathy are many and vary according to the severity of the case. They range from conservative ones such as physiotherapy, orthosis, intra-articular injections, laser therapy, external beam radiation therapy, radio-synovectomy and oral drug to invasive surgical treatment such as ankle arthrodesis and total ankle replacement. Whatever is the chosen treatment, according to the arthropathy severity we believe that it must be carried out in reference centers for foot and ankle surgery assisted by expert hematologists.

Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective

Introduction: In underdeveloped countries, patients with hemophilia often experience repetitive ankle joint hemorrhages due to a shortage of coagulation factors (factor VIII [FVIII] and factor IX [FIX] for hemophilia A and B, respectively).Areas covered: This is a narrative literature review in which we searched the Cochrane Library and PubMed for articles related to ankle arthrodesis in patients with hemophilia. The searches covered the period from the databases´ inception to 28 February 2021. In the event of unsuccessful hematologic prophylaxis and conservative measures (e.g. analgesics, cyclooxygenase-2 inhibitors, taping, intra-articular injections of hyaluronic acid and corticosteroids, physical and rehabilitation medicine, orthoses, radiosynovectomy, and joint-preserving surgery (e.g. removal of the distal tibia by open surgery or by arthroscopic surgery, joint debridement by arthroscopic surgery), the classical surgical solution is ankle arthrodesis, which does not preserve the ankle joint.Expert opinion: Ankle pain is reduced after ankle arthrodesis (75% of patients experience no pain). Approximately 5% of patients require reoperation due to lack of fusion, and deep infection occurs in 2.5%. After tibiotalar fusion, a self-reported activity scale shows that approximately 12% of patients improve, 9% worsen, and 79% show no improvement. The results of ankle arthrodesis therefore appear to be poor.Therefore, although 75% of the patients stopped having ankle pain after arthrodesis, according to a self-reported activity scale 88% of them did not improve or worsened.

Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods

BACKGROUND

Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA.

METHODS

A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation.

RESULTS

We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance.

CONCLUSION

This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA.

LEVEL OF EVIDENCE

Level IIa.

The role of total ankle replacement in patients with haemophilia and end-stage ankle arthropathy: A review

Haemophilia is the most common X-linked bleeding disorder, affecting over 1 million individuals throughout the world. Patients are subclassified into mild, moderate and severe disease based on per cent factor activity level. Nearly, all patients with haemophilia develop haemophilic arthropathy (HA) by age 30 and HA is known to have a negative impact on physical health subscores in Haem-A-QOL, a validated quality of life scoring system for patients with haemophilia. Unfortunately, many patients progress to end-stage HA of the ankle, which is characterized by pain, contractures, decreased range of motion and muscle atrophy. Ankle arthrodesis (AAD) has been the standard of care in the definitive surgical management of end-stage HA of the ankle. While AAD is a safe surgical procedure known to improve HA-related pain, it decreases functional mobility and has been associated with secondary hindfoot arthritis as well as subtalar degeneration. In recent years, total ankle replacement (TAR) has emerged as an alternative surgical procedure that strives to improve functional mobility, pain and quality of life in end-stage HA of the ankle. However, the safety, durability, and efficacy of this procedure in these patients are unknown. In this review, we analyse the clinical studies investigating TAR in patients with end-stage HA of the ankle. We also discuss important considerations in the perioperative management of patients with haemophilia and compare the risks and benefits of AAD and TAR for patients with end-stage HA of the ankle.

Postoperative weightbearing following ankle arthrodesis

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Patients and Methods

MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates.

Results

A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis.

Conclusion

Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262