Knee and hip arthroplasty infection rates in persons with haemophilia: a 27 year single center experience during the HIV epidemic

Total hip and knee arthroplasty in HIV- and HCV-positive hemophilia patients: short term follow-up of 14 patients

BACKGROUND

Haemophilic arthropathy (HA) is a common comorbidity of haemophilia. Some people with haemophilia (PWH) were human immunodeficiency virus (HIV)-positive. Arthroplasty is an effective treatment for end-stage HA. This study was carried out to report the effectiveness and satisfaction following total hip arthroplasty (THA) or total knee arthroplasty (TKA) in PWH with HIV.

PATIENTS AND METHODS

All patients with haemophilia and HIV undergoing THA or TKA in our centre from January 2015 to June 2020 were reviewed. All patients were followed for at least twenty-four months. The improvements in postoperative indicators were evaluated at the latest follow-up, including the Visual Analogue Scale (VAS) score, range of motion (ROM), and validated joint scores such as Knee Society Score (KSS; clinical and functional) and Harris Hip Score (HHS). The complications and satisfaction were analysed likewise. Those were utilized to weigh the risks and benefits of the procedure in the population.

RESULTS

Fourteen patients (7 hips and 14 knees) were included in the study. The follow-up of the THA cohort was 53.3 months (range, 27-82) and the TKA cohort was 50.1 months (range, 25-85), respectively. The average VAS score was ameliorated from 7.3 to 3.0 and 6.6 to 2.8 in the two groups (P < .001, respectively). Similarly, two cohorts (THA and TKA) showed statistically significant changes in the extension and flexion ROM between the preoperative and the latest follow-up (P < .05, P < .001, respectively). Besides, statistically significant differences between the preoperative and final follow-up values of HHS (from 41.6 to 82.3), clinical KSS (from 34.8 to 72.8), and functional KSS (from 42.9 to 73.2) were observed (P < .001, respectively). Notably, there were 4 complications noted among 21 arthroplasties performed, giving a 19.0% complication rate. Based on the satisfaction score, the majority of patients were optimistic about the arthroplasty.

CONCLUSION

Given these findings, THA or TKA of the PWH with HIV is a worthwhile procedure and can be performed by an experienced and collaborative multidisciplinary team in a tertiary centre with a good haemophilia care system.

Total Knee Arthroplasty in Haemophilia: Long-Term Results and Survival Rate of a Modern Knee Implant with an Oxidized Zirconium Femoral Component

(1) Background: Total Knee Arthroplasty (TKA) in patient with haemophilia (PWH) has usually been performed with the use of cobalt-chrome femoral and titanium tibial components, coupled with standard polyethylene (PE) inserts. The aim of this retrospective study was to evaluate the long-term outcomes and survival rates of TKA in a series of consecutive PWH affected by severe knee arthropathy at a single institution. (2) Methods: We followed 65 patients undergoing 91 TKA, implanted using the same implant, characterized by an oxidized zirconium femoral component, coupled with a titanium tibial component, and a highly crosslinked PE. At 1, 6, and 12 months; then every year for 5 years; and finally, every other 3 years, all patients were scored for pain (VAS), function (HJHS; KSS), ROM, and radiographic changes. Kaplan-Meier survivorship curves were used to calculate the implant survival rates. (3) Results: The mean follow-up was 12.3 years (4.2-20.6). All clinical and functional scores improved significantly from preoperatively to the latest follow-up (VAS: from 6.9 to 1.3; HJHS: from 13.4 to 1.9; KSS: from 19.4 to 79; ROM: from 42.4° to 83.6°). The overall survivorship of the implants was 97.5% at the latest follow-up. (4) Conclusions: The present series showed a high survival rate of specific implants potentially linked to the choice of an oxidized zirconium coupled with a highly crosslinked PE. We promote the use of modern implants in these patients in order to ensure long-lasting positive outcomes.

Joint replacement and human immunodeficiency virus

The incidence of human immunodeficiency virus (HIV)-infected cases that need total joint replacement (TJR) is generally rising. On the other hand, modern management of HIV-infected cases has enabled them to achieve longevity while increasing the need for arthroplasty procedures due to the augmented dege-nerative joint disease and fragility fractures, and the risk of osteonecrosis. Although initial investigations on joint replacement in HIV-infected cases showed a high risk of complications, the recent ones reported acceptable outcomes. It is a matter of debate whether HIV-infected cases are at advanced risk for adverse TJR consequences; however, the weak immune profile has been associated with an increased probability of complications. Likewise, surgeons and physicians should be aware of the complication rate after TJR in HIV-infected cases and include an honest discussion of the probable unwelcoming complication with their patients contemplating TJR. Therefore, a fundamental review and understanding of the interaction of HIV and arthroplasty are critical.

Postoperative bleeding adversely affects total knee arthroplasty outcomes in hemophilia

BACKGROUND

Hemophilic arthropathy can result in severe degenerative arthritis and functional limitations in the knees of relatively young patients. Total knee arthroplasty (TKA) provides pain relief and gain of function in advanced-stage hemophilic arthropathy cases. However, little is known about the long-term effects of early major postoperative bleeding (MPOB) in people with hemophilia (PWH). The aim of this study was to evaluate the effects of early MPOB on the final functional outcome, complications, and implant survival of TKA in a single-center hemophilia cohort.

METHOD

PWH who underwent TKA between 1998 and 2019 in a single center were reviewed. Demographic data, clinical data, and radiographic images were evaluated. Hospital for Special Surgery (HSS), Knee Society Score (KSS), and Knee Society Function Score (KSS-F) scores were used to determine function. Patients with early bleeding complications (wound dehiscence, ecchymosis, hemarthrosis, hematoma formation, prolonged or recurrent bleeding attacks) were defined as the bleeding group. Patients who did not experience these complications were assigned to the control group. The bleeding group was compared with controls. Survival of the primary arthroplasty was analyzed by Kaplan-Meier curves.

RESULTS

Forty-five TKAs in 29 patients were included in the study. TKA led to an increase in the mean range of motion from 46.08° to 84.59° (P < 0.01). HSS scores increased from 48.33 preoperatively to 82.67 postoperatively (P < 0.01). There were improvements in both KSS and KSS-F scores from 34.22 and 53.3 preoperatively to 82.00 and 84.63 (P < 0.01), respectively. Ten patients (10 TKAs) (34%) experienced major bleeding during the postoperative period. Six of these patients had moderate hemophilia, and four had severe hemophilia. Three of these patients had hemarthroses (10.2%), one patient had a hematoma (3.4%), one patient had hemorrhagic bullae formation (3.4%), and five had excessive/prolonged bleeding from the wound (17%). The bleeding group (34%) had significantly worse HSS (63.78 vs 92.75, P < 0.001), KSS (61.78 vs 93.25, P < 0.001), and KSS-F (60.71 vs 96.25, P = 0.005) scores compared with controls. Preoperative and postoperative flexion contractures were positively correlated (+0.33, P = 0.003). One of the patients with postoperative hemarthrosis also had an accompanying transient common peroneal nerve palsy, and one patient (3.4%) had a periprosthetic fracture. Three knees (6.6%), two of whom were in the bleeding group, developed periprosthetic infections. Four knees (8.8%) in three patients underwent revision surgery, and two knees (4.4%) ended up in arthrodeses. Kaplan-Meier analysis revealed a mean survival duration of 17.04 years for the bleeding group and 22.15 years for the control group (P = 0.83). Survival rates were 80.0% for the bleeding group and 96.4% for the control group (P = 0.83).

CONCLUSIONS

In this study, MPOB after TKA in PWH was common and led to significantly worse function. MPOB after TKA in PWH was associated with a higher rate of complications and lower survival rates, although the differences were not statistically significant. Efforts must be made to avoid MPOB after TKA in PWH.

Total Joint Arthroplasty in HIV-Positive Patients in Malawi: Outcomes from the National Arthroplasty Registry of the Malawi Orthopaedic Association

In this observational study, we describe the medium-term outcomes of total joint arthroplasty (TJA) in human immunodeficiency virus (HIV)-positive patients in Malawi, a low-income country. With a high prevalence of HIV and increasing arthroplasty rates in low and middle-income countries, understanding the outcomes of TJA in this unique cohort of patients is essential to ensure that surgical practice is evidence-based.

Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs

Operations on patients with hemophilia A and B are complex. Studies evaluating postoperative outcomes and costs following total knee arthroplasty (TKA) in patients with hemophilia are limited. A retrospective review of the entire Medicare dataset from 2005 to 2014 was performed. International Classification of Disease 9th revision codes were used to identify patients with hemophilia A and B and they were matched to controls using a 1:1 random matching process based on age, gender, Charlson Comorbidity Index (CCI), and select comorbidity burden. The 90-day preoperative period was evaluated for comorbidities and the 90-day postoperative period was analyzed for outcomes and reimbursements. Logistic regression models were generated to compare outcomes between cases and controls. A total of 4,034 patients with hemophilia were identified as having undergone TKA. About 44.8% were between the ages of 65 and 74 and 62.4% were female. Although the CCI was identical in both cohorts, individual comorbidities not controlled for varied significantly. Medical complications were more frequent among the patients with hemophilia: postoperative bleeding (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2-2.3), deep venous thrombosis (OR: 2.3; 95% CI: 1.8-2.8), pulmonary embolism (OR: 2.9; 95% CI: 2.1-3.9), and blood transfusions (OR: 1.8; 95% CI: 1.6-1.9). Hemophilia was associated with higher odds of periprosthetic infection (1.78 vs. 0.98%, OR: 1.8 95% CI: 1.2-2.7). The 90-day reimbursements were higher for patients with hemophilia (mean: $22,249 vs. $13,017, p < 0.001). Medicare beneficiaries with a diagnosis of hemophilia experience more frequent postoperative complications and incur greater 90-day costs than matched controls following TKA. Surgeons should consider this when optimizing patients for TKA and payors should consider this for risk-adjusting payment models.

Does Hemophilia Increase Risk of Adverse Outcomes Following Total Hip and Knee Arthroplasty? A Propensity Score-Matched Analysis of a Nationwide, Population-Based Study

BACKGROUND

End-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA.

METHODS

This retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1:4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital.

RESULTS

After propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval [CI] = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P < .001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups.

CONCLUSION

Hemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA.

Tranexamic acid may benefit patients undergoing total hip/knee arthroplasty because of haemophilia

BACKGROUND

The lower limb joints, including hip and knee, are the most commonly involved joints in haemophilic arthropathy. With a higher risk of transfusion, total hip and knee arthroplasty (THA and TKA) are still the first choice after failure of conservative treatment. In the present study, we aimed to analyze clinical outcomes and complications rate after total joint arthroplasty of the lower limbs using tranexamic acid (TXA) or not.

METHODS

Thirty-four patients with haemophilia A undergoing 24 TKA and 18 THA were evaluated in this retrospective study (No. 201302009). Based on using TXA or not, they were divided into either TXA (12 knees and 10 hips) or Non-TXA groups (12 knees and 8 hips). Total blood loss, intraoperative blood loss, total amount of FVIII usage, range of motion, inflammatory biomarkers, joint function, pain status, complication rate and patient satisfaction were assessed and compared at a mean follow-up of 68 months.

RESULTS

Usage of TXA can decrease not only the perioperative blood loss (p = 0.001), transfusion rate (p = 0.017) and supplemental amount of FVIII (p < 0.001) but also swelling ratio, surgical joint pain. Moreover, compared with non-TXA group, the patients in TXA group had a lower level of inflammatory biomarkers and better joint function.

CONCLUSION

The hemophiliacs treated with TXA had less perioperative blood loss, hidden blood loss, transfusion rate, a lower ratio of postoperative knee swelling, less postoperative joint pain, lower levels of inflammatory biomarkers and better joint function. Further studies need performing to assess the long-term effects of TXA in these patients.

Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review

Significant advances in the treatment of Human Immunodeficiency Virus (HIV) have occurred in recent times, with life expectancy now approaching the normal population. Therefore, patients with HIV will increasingly be undergoing joint replacement in the future, however concerns remain regarding the complications and outcome in this patient cohort. The aim was to assess the outcome of total hip and knee arthroplasty in HIV-infected patients. A systematic search of the literature using MOOSE reporting guidelines was performed to assess the outcome of hip and knee arthroplasty in HIV-infected patients. The primary outcome was infection. Secondary outcome was all-cause revision. The search yielded 552 results, of which 19 met the inclusion criteria, comprising 5.819.412 joint replacements. The overall quality of the studies was poor with significant heterogeneity between the studies. Infection and revision appeared to be more likely to occur in HIV positive patients compared to HIV negative patients. A subgroup analysis of four studies revealed a risk ratio of 3.31 and 2.25 for increase in infection and revision respectively in HIV positive patients. This systematic review and meta-analysis demonstrates an increased risk of infection and revision in HIV infected patients undergoing total hip and knee arthroplasty. However, these findings are based on poor quality evidence in a limited number of studies and need to be interpreted with caution. Further research should concentrate on large, well-designed, prospective studies, that control for co-morbidities and employ standardised outcome measures to allow for direct comparison.

Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients: A Concise Follow-Up at 10 to 14 Years

BACKGROUND

Advancements in the management of human immunodeficiency virus (HIV) now permit HIV-positive patients to have longer life spans, increasing their cumulative risk of developing an advanced degenerative joint disease, necessitating total hip arthroplasty (THA). The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population.

METHODS

This study is a follow-up on a previous study comprised of 41 hips in 31 HIV-positive THA recipients. At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date. A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point.

RESULTS

Since the last report, 2 additional hips were revised (one for aseptic loosening and one for a periprosthetic fracture), and 5 patients underwent contralateral THA. This resulted in a total of 5 (13.8%) hips requiring revision THA at the latest follow-up. The mean follow-up interval for the original cohort and for the contralateral 5 hips was 78.9 ± 50.2 months and 54.6 ± 45.3 months, respectively. Kaplan-Meier survivorship analysis with revision THA for any reason as the end point demonstrated survivorship of 93% (2 years), 90% (5 years), and 81% (10 and 14 years) after primary THA, respectively.

CONCLUSION

Our study suggests that it is possible to achieve a low incidence of postoperative infection in HIV-positive THA recipients. In addition, our study demonstrates that non-hemophiliac HIV-positive patients have comparable revision rates to previously published reports on HIV-negative patients of similar age, underscoring the clinical efficacy of highly active antiretroviral therapy.

Hip arthroplasty in haemophilia: a systematic review

BACKGROUND

Rigorous haemostatic control and careful rehabilitation are essential for haemophilic patients undergoing total hip arthroplasty (THA).

AIM

to examine the current literature regarding THA in patients with haemophilia in order to determine clinical outcomes and complication rates.

METHODS

We included 11 case reports/series and 9 original articles. There was a total of 206 patients who underwent 226 THAs.

FINDINGS

The number of patients enrolled in the selected articles varied from 1 in case reports to 34 in the original articles. Gender was documented in 10. Mean age at surgery was 41 years. Mean follow-up was 73 months (standard deviation [SD] 35 months). All but 4 articles specified whether implants were cemented or uncemented, with 95% being uncemented, 3.5% being cemented, and 1.5% being hybrid (uncemented acetabular component, cemented femoral stem).

CONCLUSION

Controlled hypotensive anaesthesia (to reduce preoperative blood loss), consult with haematologist, precise control of haemostasis status per the guidelines defined by the World Federation joint replacement, can improve the success rate and hip replacement surgery can be performed safely.

Optimal timing for elective total hip replacement in HIV-positive patients

INTRODUCTION

Evidence about the optimal timing for total hip replacement (THR) in HIV-positive patients is scant.

HYPOTHESIS

Preoperative criteria: cluster of differentiation 4 (CD4) counts>200cells/mm³ and an undetectable HIV virus load before THR, improve infection rates, aseptic loosenings, and functional outcomes.

MATERIALS AND METHODS

We recruited 16 HIV-positive patients who had undergone 25 THRs between 2003 and 2015. None had hemophilia, and none were intravenous drug users (IVDUs).

RESULTS

Their mean age was 41.2 years (range: 24-60); minimum follow-up was 12 months (mean: 64.6); mean duration of prophylactic antibiotics was 2.9 days (range: 1-5); and mean hospital length of stay was 6.0 days (range: 4-11). No patients were treated with subsequent oral antibiotics. The mean preoperative CD4 count was 464.1±237.0 (range: 235-904)cells/mm³. There were no early superficial surgical site infections, late periprosthetic joint infections, or aseptic loosenings. Post-surgery Harris Hip score was significantly (p<0.001) better.

DISCUSSION

A preoperative CD4 count>200cell/mm³ and an undetectable HIV virus load might indicate optimal timing for elective THRs in HIV-positive patients without hemophilia and not IVDUs.

LEVEL OF EVIDENCE

IV, retrospective or historical series.

Risk factors for postoperative complications of orthopedic surgery in patients with hemophilia: Second report

This study was conducted to investigate the incidence in patients with hemophilia of postoperative complications and risk factors for these complications. Overall, 12 (6.5%) patients developed a postoperative infection. There were 6 (3.4%) postoperative surgical site infections. The presence of an inhibitor was the only risk factor for surgical site infection. Risk factors for delayed wound healing were older age, higher preoperative serum albumin level and procedures other than joint replacement or arthroscopy. HIV infection status was not a risk factor for postoperative complications.

No Decrease in Knee Survivorship or Outcomes Scores for Patients With HIV Infection Who Undergo TKA

BACKGROUND

HIV is prevalent worldwide and numerous patients with this diagnosis ultimately may become candidates for TKA. Although some studies have suggested that complications are more common in patients with HIV who undergo TKA, these studies largely were done before the contemporary era of HIV management; moreover, it is unclear whether patients with HIV achieve lower patient-reported outcome scores or inferior implant survivorship.

QUESTIONS/PURPOSES

We asked whether there were any differences in the outcomes of patients with HIV without hemophilia who undergo TKA compared with a matched control cohort in terms of: (1) patient-reported outcomes; (2) implant survivorship; and (3) complication rates.

METHODS

Forty-five patients with HIV who had undergone 50 TKAs at three institutions with a minimum followup of 4 years between 2005 and 2011 were identified. An additional three patients were lost to followup before the fourth-year annual visit. All patients with HIV underwent thorough preoperative optimization with their primary care physician and infectious disease specialist. There were 31 men and 14 women with a mean age of 57 years and mean followup of 6 years (range, 4-10 years). These patients were compared with a matched cohort of 135 patients (one-to-three ratio) who did not have HIV and who had undergone a primary TKA by the same surgeons during this same period using the same implant. Matching criteria included patient age (within 2 years), BMI (within 2 kg/m²), surgeon performing TKA, followup (within 6 months), minimum followup of 4 years, sex ratio, and primary diagnosis (degenerative joint disease versus osteonecrosis). Approximately 10% of patients in the matching group had not returned for followup after their sixth annual visit. Outcomes evaluated included The Knee Society objective and function scores, University of California, Los Angeles (UCLA) activity scores, overall implant survivorship (free of revision) using Kaplan-Meier analysis, and complications. With the numbers available, there were no differences in preoperative Knee Society score or UCLA activity scores among the cohorts.

RESULTS

With the numbers available, there were no differences in the mean Knee Society objective scores between patients with HIV (89 ± 11 points) and the matching cohort (91 ± 14 points) (95% CI, -7 to 3; p = 0.38). There were no differences among the Knee Society functional component as well (88 ± 12 points versus 90 ± 13 points; 95% CI, -6 to 2; p = 0.36) at latest followup. Similarly, there were no differences with the numbers available in the UCLA activity scores (6 ± 5 points [range, 4-7] versus 6 ± 7 points [range, 4-8]; p = 0.87) between the cohorts. With the numbers available, Kaplan-Meier analysis showed no significant difference in the overall implant survivorships between patients with HIV (98%; 95% CI, 94%-99%) compared with the matching group (99%; 95% CI, 98%-100%; p = 0.89). Postoperative complications were also comparable between the two groups.

CONCLUSIONS

With the numbers available, we found that patients with HIV had no differences in clinical scores and implant survivorship compared with patients without the disease at mid-term followup. We believe practitioners should not be reluctant to perform TKA on this patient population. However, we believe the preoperative optimization process is crucial to achieving good outcomes and minimizing the risk of complications. Future comparative studies should have longer followup and a larger sample size with greater power to determine if there are differences in complications and implant survivorship.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Revision Knee Arthroplasty in Patients with Inherited Bleeding Disorders: A Single-Center Experience

Background

The results of total knee arthroplasty (TKA) in patients with inherited bleeding disorders (IBDs) are poorer when compared with those in the general population, with a notably higher risk of complications and higher revision rates. Thus, revision procedures are becoming a growing concern in this group of patients. The aim of this study was to evaluate the results of revision TKA in patients with IBD.

Material/Methods

A retrospective cohort study with longitudinal assessment of hemophilia patients scheduled for revision TKA between January 2010 and September 2015 was performed. The clinical status of the patients was assessed based on the Knee Society Score, and the Numeric Rating Scale was used to assess knee pain severity and patient satisfaction with the surgery. Radiological examination, post-operative complications, and reinterventions were recorded and analyzed.

Results

Very good results were obtained in all patients treated for aseptic loosening of the implant. However, inferior results were found in cases with infection. All patients operated on for aseptic loosening required only single-stage TKA, whereas patients with infection underwent multiple interventions. Complications were observed only in cases with infection.

Conclusions

Our study clearly outlined the differences in results based on failure mode, with far inferior results obtained in cases with infection. Given the lack of data in this area as well as the high specificity of this population, further high-quality studies are needed.

Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced

BACKGROUND

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) and allowed patients to live for many decades. HIV and HAART are known risk factors for osteonecrosis of bone, osteopenia, and osteoporosis. Therefore, the demand for total joint arthroplasty (TJA) in HIV-infected patients is on the rise. We attempted to determine whether modern treatments for HIV have impacted the rate of periprosthetic joint infection (PJI).

METHODS

Conducting a systematic review, 25 studies with a total of 722 TJAs were identified. We extracted data on rates of PJI after primary TJA in HIV-infected patients with and without hemophilia and data on administration of HAART at the time of arthroplasty.

RESULTS

Three hundred eighty-one TJAs were performed in 293 patients with HIV infection without hemophilia. The follow-up ranged between 1.5 months and 11 years. Nine patients developed PJI. In patients with both HIV and hemophilia, 341 primary TJAs were performed. Forty-five received treatment for PJI. Follow-up ranged between 1 year and 26 years. Rates of PJI were 2.28% and 10.98% for HIV-only patients and patients with HIV and hemophilia, respectively. This difference was statistically significant (P < .0001) with a 5.28 odds ratio for hemophilia. HAART was associated with fewer infections overall (odds ratio, 0.12).

CONCLUSION

The rates of PJI after TJA in HIV-only patients are lower than those in patients with both HIV and hemophilia. Treatment of patients with HAART and optimization of underlying comorbidities appears to lower the rate of PJI in this patient population.

Orthopedic disorders of the knee in hemophilia: A current concept review

The knee is frequently affected by severe orthopedic changes known as hemophilic arthropathy (HA) in patients with deficiency of coagulation factor VIII or IX and thus this manuscript seeks to present a current perspective of the role of the orthopedic surgeon in the management of these problems. Lifelong factor replacement therapy (FRT) is optimal to prevent HA, however adherence to this regerous treatment is challenging leading to breakthrough bleeding. In patients with chronic hemophilic synovitis, the prelude to HA, radiosynovectomy (RS) is the optimal to ameliorate bleeding. Surgery in people with hemophilia (PWH) is associated with a high risk of bleeding and infection, and must be performed with FRT. A coordinated effort including orthopedic surgeons, hematologists, physical medicine and rehabilitation physicians, physiotherapists and other team members is key to optimal outcomes. Ideally, orthopedic procedures should be performed in specialized hospitals with experienced teams. Until we are able to prevent orthopedic problems of the knee in PWH will have to continue performing orthopedic procedures (arthrocentesis, RS, arthroscopic synovectomy, hamstring release, arthroscopic debridement, alignment osteotomy, and total knee arthroplasty). By using the aforementioned procedures, the quality of life of PWH will be improved.

HIV and Orthopaedics: Musculoskeletal Manifestations and Outcomes

➤Advances in combined antiretroviral therapy (cART) in recent years have transformed HIV infection into a chronic disease when treatment is available, increasing a patient's life expectancy and the chances that orthopaedic surgeons will encounter such patients in their clinical practice.➤Musculoskeletal manifestations in patients with HIV infection are common and sometimes are the initial presentation of the disease. Knowledge about neoplasms and associated conditions affecting muscle, bones, and joints is essential for successful management.➤Since the advent of cART, total joint arthroplasty has been shown to be a safe procedure; however, perioperative infection is still a small risk in patients with uncontrolled viral loads or CD4 counts of <400 cells/mm(3).➤With regard to trauma surgery, the rates of early and late infection around implants, as well as union rates, are comparable with those in the HIV-negative population; however, there is an increased risk of pulmonary, renal, and infectious or septic complications in the polytrauma setting.➤Factors such as CD4 count, nutritional status, cART therapy, viral load count, and other comorbidities (hemophilia, infection among intravenous drug users, etc.) should be considered when treating these patients in order to optimize their clinical outcomes.

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.

Complications After TKA in Patients With Hemophilia or Von Willebrand's Disease

Little is known about perioperative complications following total knee arthroplasty (TKA) in patients with bleeding disorders. This study utilized a national database to evaluate postoperative complication rates and up to 8-year revision rates after TKA in patients with hemophilia (n=3396) and von Willebrand's disease (n=1379) compared to a matched cohort of patients without a bleeding disorder (n=427,132 and n=394,657 respectively). Hemophilia and von Willebrand's disease were associated with significantly higher rates of infection, transfusion of blood products, medical complications, and revision after TKA compared to matched controls. Hemophilia was associated with significantly higher rates of venous thromboembolism and transfusion compared to patients with von Willebrand's disease and matched controls after TKA.

Total hip replacement in HIV-positive patients

We report the short-term follow-up, functional outcome and incidence of early and late infection after total hip replacement (THR) in a group of HIV-positive patients who do not suffer from haemophilia or have a history of intravenous drug use. A total of 29 patients underwent 43 THRs, with a mean follow-up of three years and six months (five months to eight years and two months). There were ten women and 19 men, with a mean age of 47 years and seven months (21 years to 59 years and five months). No early (< 6 weeks) or late (> 6 weeks) complications occurred following their THR. The mean pre-operative Harris hip score (HHS) was 27 (6 to 56) and the mean post-operative HHS was 86 (73 to 91), giving a mean improvement of 59 points (p = < 0.05, Student’s t-test). No revision procedures had been undertaken in any of the patients, and none had any symptoms consistent with aseptic loosening. This study demonstrates that it is safe to perform THR in HIV-positive patients, with good short-term functional outcomes and no apparent increase in the risk of early infection.

Cite this article: Bone Joint J 2014; 96-B:462–6.

Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty

We hypothesized that infection rates following total joint arthroplasty (TJA) in those with the human immunodeficiency virus (HIV) without hemophilia or drug use would be similar to rates in HIV-negative patients. Records at an urban HIV referral hospital were searched for patients who underwent primary total hip and knee arthroplasty from 2003 to 2010. The primary outcome was revision for infection. 372 HIV-negative and 22 HIV-positive TJA patients met inclusion criteria. The HIV-positive group had more deep infections than the HIV-negative group (9.1% v 2.2%, P=0.102). There were no infections in those with AIDS-defining CD4 counts. Those with HIV may have a higher risk of developing a deep infection. A low CD4 count is not an absolute contraindication to TJA in HIV positive patients.

Outcomes of total hip arthroplasty in human immunodeficiency virus-positive patients

Today, patients with human immunodeficiency virus (HIV) live long enough to develop chronic degenerative and HIV-associated joint disease. There is a growing population of patients infected with HIV who are candidates for total hip arthroplasty (THA). A total of 31 HIV-positive, non-hemophilic patients undergoing 41 THAs at our institution between 2000 and 2012 were identified. In-hospital medical complications were reported in 5 of 41 hips, all of which resolved prior to discharge. Deep infection developed in 1 of 41 hips and revision was required in 3 of 41 hips. These results suggest that low rates of complications and revision can be achieved in the HIV-positive, non-hemophilic population. We believe that with careful patient selection, THA may improve the quality of life in the HIV-positive population.

Outcomes of cementless primary THA for osteonecrosis in HIV-infected patients

BACKGROUND

Symptomatic osteonecrosis of the joint is a frequent debilitating complication in patients who have been infected with the human immunodeficiency virus (HIV). In earlier reports, outcomes of primary total joint arthroplasty in such patients have been poor due to early failures, high infection rates, and increased complication rates. We report on the clinical and radiographic outcomes of primary total hip arthroplasty (THA) in nonhemophilic, HIV-infected patients as compared with the outcomes in a cohort of osteonecrosis patients who did not have this disease.

METHODS

Thirty-four HIV-infected patients (forty-four hips) who underwent primary THA for the treatment of osteonecrosis during the period of 2001 through 2008 were compared with a control cohort of seventy patients (seventy-eight hips) who also underwent THA for the treatment of osteonecrosis but did not have HIV or other high-risk factors for revision. The patients in the HIV study group (eleven women and twenty-three men) had a mean age of forty-eight years (range, thirty-four to eighty years) and were followed for a mean of seven years (range, four to eleven years). Evaluated outcomes included implant survivorship, Harris hip score, infection rate, activity score, postoperative Short-Form 36 (SF-36) health survey score, and radiographic outcome.

RESULTS

Kaplan-Meier survival analysis demonstrated no significant difference in aseptic implant survivorship between the HIV and comparison cohorts at the five-year (100% vs. 98%, respectively) and ten-year (95% vs. 96.5%, respectively) follow-up times. In addition, at the time of final follow-up, the mean postoperative Harris hip scores (85 points in the HIV group vs. 87 points in the comparison group), activity scores (5.7 points in the HIV group vs. 6.1 points in the comparison group), and SF-36 physical (43 points in the HIV group versus 46 points in the comparison group) and mental component summary scores (54 points in the HIV group versus 57 points in the comparison group) were statistically similar between the two cohorts. There were two late infections in the HIV cohort as compared with none in the comparison cohort.

CONCLUSIONS

Our results demonstrated excellent implant survivorship, clinical and radiographic outcomes, and minimal complications at the time of midterm follow-up in the HIV-infected patient group. We believe that the outcomes associated with primary THA are improving in this patient population as a result of better medical management; however, late infections are potential complications.

Special issues involving periprosthetic infection in immunodeficiency patients

Chronic systemic illnesses such as diabetes mellitus, chronic kidney disease (CKD), liver cirrhosis, neoplasia, etc. have been clearly associated with high rates of SWI. However, the exact mechanisms underlying these observations are still under investigation.

Chronic kidney disease (CKD) is a growing problem in our society. Many of these patients will require an arthroplasty and it appears that the prosthetic infection risk for these types of patients is much higher than in the normal population. The risk of complications due to infection seems to be lower in patients with kidney transplants than in patients undergoing haemodialysis. Both prophylaxis and treatment of infection in patients with CKD should be carried out with a strict monitoring of potentially nephrotoxic antibiotics.

The literature on the prognosis and risk of infection in patients with haematopoietic stem cell transplant is scarce and occasionally contradictory. The optimal time for the surgery should be determined by taking into account the immunological state of the patient and should be avoided, as much as possible, during the first year after the HSCT.

Child’s classification system is the most widely used method of stratifying the surgical risk for patients with cirrhosis; the infection appeared to be associated in a statistically significant way with advanced age and a Child B pre-operative classification.

The prevention of prosthetic joint infections in HIV-infected patients should not be significantly different from the prevention for any other patient. Those patients that receive adequate antiretroviral treatment and periodic laboratory control show infection rates and periprosthetic complications that are similar to those for patients not affected by HIV. Therefore, the patient’s level of immunodeficiency is the most important prognostic factor for prosthetic infection.

The particular immunological condition of these patients can lead to infections due to particular microorganisms that immunocompetent patients do not have to deal with. Of all possibilities, because of their frequency and difficulty to treat, infections caused by methicillin-resistant S. aureus and fungus are highlighted.

The risk of elective orthopaedic surgery for haemophilia patients: Japanese single-centre experience

Haemophilic arthropathy causes pain and a severely restricted range of motion, and results in a significant reduction in quality of life. When conservative treatments have failed, orthopaedic surgery is recommended for these patients with severe haemophilic arthropathy. However, surgery for haemophilia patients is challenging due to high complication rate such as infection, delayed wound healing and mortality. The aim of this study was to evaluate the incidence of early complications and identify preoperative risk factors of surgery for haemophilia patients. We report a series of haemophilia patients undergoing elective orthopaedic surgery between 2006 and 2012. During this period, 119 surgeries in 81 patients were prepared and 118 surgeries in 80 patients were actually performed. Four deep bacterial infections and four delayed wound healings occurred within 6 months postoperatively. One patient died preoperatively and four patients died postoperatively. Only the presence of inhibitor was a significant risk factor for infection. We found no risk factor related to delayed wound healing. Our data revealed alkaline phosphatase, albumin, platelet, alpha-fetoprotein, presence of ascites and child classification C as predictors of perioperative mortality following elective orthopaedic surgery. Our role is to identify potential patients who present with risk factors for complications and attempt to seek the best determination of treatment strategy for these people.

Comorbidities and perioperative complications in HIV-positive patients undergoing primary total hip and knee arthroplasty

BACKGROUND

Highly active antiretroviral therapy has prolonged the lifespan of individuals infected with human immunodeficiency virus (HIV). We hypothesized that the number of primary total joint arthroplasties performed in this population has been increasing and that HIV infection is not an independent risk factor for postoperative complications.

METHODS

The Nationwide Inpatient Sample for the years 2000 through 2008 was queried to identify patients who underwent primary total joint arthroplasty. HIV, comorbidities, and complications were identified with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Data were analyzed with use of multivariate logistic regression, the Pearson chi-square test, and the Mann-Kendall trend test.

RESULTS

Of the estimated 5,681,024 admissions for primary total hip and knee arthroplasty in the United States during this period, 8229 (0.14%) were in patients who had HIV. Compared with HIV-negative patients (controls), infected patients were more likely to be younger, be male, and have a history of osteonecrosis, liver disease, drug use, and coagulopathy. The number of total hip and total knee arthroplasties in HIV-positive patients increased from 2000 to 2008 (p &lt; 0.05). Seventy-nine percent (6499) of the total joint arthroplasties in the HIV-positive patients involved the hip. Compared with HIV-negative patients undergoing total hip arthroplasty, HIV-positive patients were more likely to develop acute renal failure (1.3% compared with 0.8%, p = 0.04), develop a wound infection (0.6% compared with 0.3%, p = 0.02), and undergo postoperative irrigation and debridement (0.2% compared with 0.1%, p = 0.01). They were less likely to have a myocardial infarction (0.4% compared with 0.9%, p = 0.04). There was no difference in total complications (8.3% compared with 7.8%, p = 0.52). Similarly, there was no difference in total complications in patients undergoing total knee arthroplasty (7.8% compared with 8.0%, p = 0.76). HIV was not an independent risk factor for complications in total hip arthroplasty (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.95 to 1.47) or total knee arthroplasty (OR, 0.78; 95% CI, 0.49 to 1.25).

CONCLUSIONS

The incidence of primary total joint arthroplasty in HIV-positive patients has been increasing. These patients were at slightly higher risk of certain immediate postoperative complications because of a higher rate of medical comorbidities. HIV infection was not an independent risk factor for the total rate of perioperative complications.

LEVEL OF EVIDENCE

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

Total joint arthroplasty in human immunodeficiency virus positive patients

Recent advances in the medical management of patients with human immunodeficiency virus (HIV) have led to improvement in their life expectancy. The growing numbers of HIV-positive patients are now living long enough to develop end-stage arthritis, as well as other long-term musculoskeletal complications of HIV infection and treatment. This has resulted in an increased demand for total joint arthroplasty among these individuals. However, the safety and outcomes of such procedures are frequently questioned in published reports. Although increased complication rates have often been reported, most studies have reported on joint arthroplasties in HIV patients with hemophilia. The most widely reported complications in both HIV-negative and positive hemophiliac patients are aseptic loosening and postoperative infection. A possible relationship between the rate of these complications and cluster of differentiation (CD4) lymphocyte count has also been proposed. In addition to hemophilia, other factors frequently comorbid with HIV infection, such as intravenous drug use, can further complicate the clinical outcomes of these individuals following total joint replacement procedures. Physicians treating HIV positive patients must remain aware of the risks and outcomes of total joint surgery in this group when counseling them on treatment options.

Periprosthetic joint infections at a teaching hospital in 1990-2007

BACKGROUND

Periprosthetic joint infections (PJIs) are major complications associated with high costs and substantial morbidity. We sought to evaluate hip and knee arthroplasty infection rates at our hospital, compare them in periods before and after implementation of measures to reduce PJIs (1990-2002 and 2003-2007) and identify associated risk factors.

METHODS

We retrospectively reviewed records of patients who received primary hip or knee total joint prostheses at our centre between Jan. 1, 1990, and Dec. 31, 2007, and were readmitted for the treatment of infection related to their surgery. We also reviewed data from a prospective surveillance protocol of total hip (THA) and knee arthroplasty (TKA) infections that started in November 2005. We ascertained the annual rates of deep, superficial and hematogenous infections.

RESULTS

During the periods studied, 2403 THAs and 1220 TKAs were performed. For THA, the average rates of deep, superficial and hematogenous infections were 2.0%, 0.8% and 0.3%, respectively. For TKA, the rates were 1.6%, 0.7% and 0.2%, respectively. Of 106 infected joints, 84 (79.2%) presented risk factors for infection. Efforts to reduce the infection rate at our institution began in 2003. We achieved a 44% decrease in the deep infection rate for THA (2.5% v. 1.4%; p = 0.06) and a 45% decrease for TKA (2.0% v. 1.1%, p = 0.20) between the periods studied.

CONCLUSION

Knowing the actual infection rate associated with different procedures in specific settings is essential to identify unexpected problems and seek solutions to improve patient care. Although we do not know what specific improvements were successful, we were able to decrease our infection rates to levels comparable to those reported by similar care centres.

Revision Arthroplasty in the Haemophiliac Patient

Arthroplasty in the haemophiliac patient is associated with higher rates of infection and is traditionally performed in a younger age group. Despite this there is little evidence in the literature regarding revision arthroplasty in this cohort of patients. We describe the case of a periprosthetic fracture in a haemophiliac patient requiring revision arthroplasty, who did not consent to receiving blood products due to religious beliefs, with a successful outcome.

The need for guidelines in asplenic patients undergoing total joint arthroplasty: a case report

There are currently no guidelines for splenectomy patient undergoing total joint arthroplasty. We present a case history of a 63-year-old man with a history of splenectomy that underwent a total knee arthroplasty with standard intravenous antibiotic prophylaxis. Two weeks postoperatively, he developed a prosthetic joint infection and followed the standard antimicrobial management with intravenous and oral antibiotics prior to having revision surgery. We propose that there are guidelines to properly manage these patients in the pre- and perioperative setting following an orthopaedic procedure.

Total knee arthroplasty in severe haemophilic patients under continuous infusion of clotting factors

PURPOSE

Haemophilic arthropathy is painful, invalidating and destructive. Authors report a prospective study of total knee arthroplasties in patients with severe haemophilia under continuous infusion of clotting factors. The purpose is to evaluate the benefits of continuous infusion of clotting factors regarding long-term functional improvement and radio-clinical results.

METHODS

From 1998 to 2009, 20 total knee arthroplasties were implanted in 14 patients with a mean age of 36.5 years (24-56). A continuous infusion of anti-haemophilic factors was used and supervised by the physician of the Regional Haemophilia Treatment Centre (CRTH). Evaluation was clinical using the HSS and Oxford scores and radiological.

RESULTS

One patient was lost to follow-up. Median follow-up is 66.5 months (6-134). Oxford score at latest follow-up is 42 (37-46). On revision, HSS score is 91 (84-96). Median flexion gain is 32.5° (-20; 75°). There is a median flexion contracture of 5° (0-15°) and a median extension improvement of 22.5°. We report 2 secondary infectious complications, concerning the same operated knee of a single patient. No post-operative haematoma was reported in our study.

CONCLUSION

Total knee arthroplasty in haemophilic arthropathy improves both the function and quality of life of this group of patients. Continuous infusion of clotting factors contributes significantly to these results, by allowing early and intensive rehabilitation, and offers security regarding haemorrhagic complications commonly described in the literature and that we have not encountered in our study.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Is there an increased risk of post-operative surgical site infection after orthopaedic surgery in HIV patients? A systematic review and meta-analysis

Background

There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk of post-operative SSI and sought to determine if this risk is altered by antibiotic use beyond 24 hours.

Methods

We searched electronic databases, manually searched citations from relevant articles, and reviewed conference proceedings. The risk of postoperative SSI was pooled using Mantel-Haenszel method.

Results

We identified 18 cohort studies with 16 mainly small studies, addressing the subject. The pooled risk ratio of infection in the HIV patients when compared to non-HIV patients was 1.8 (95% Confidence Interval [CI] 1.3–2.4), in studies in Africa this was 2.3 (95% CI 1.5–3.5). In a sensitivity analysis the risk ratio was reduced to 1.4 (95% CI 0.5–3.8). The risk ratio of infection in patients receiving prolonged antibiotics compared to patients receiving antibiotics for up to 24 hours was 0.7 (95% CI 0.1–4.2).

Conclusions

The results may indicate an increased risk in HIV infected patients but these results are not robust and inconclusive after conducting the sensitivity analysis removing poor quality studies. There is need for larger good quality studies to provide conclusive evidence. To better develop surgical protocols, further studies should determine the effect of reduced CD4 counts, viral load suppression and prolonged antibiotics on the risk for infection.

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.

Outcomes in total elbow arthroplasty in patients with haemophilia at the University of California, San Francisco: a retrospective review

Severe haemophilic arthropathy of the elbow is a significant cause of morbidity among adults with haemophilia. However, previous reports of total elbow arthroplasty (TEA) in the haemophilic population have been based on small numbers of patients with relatively short-term follow-up. The records of seven total elbow arthroplasties in six adult men with haemophilia at the University of California, San Francisco who underwent TEA over a period of 25 years were retrospectively reviewed. Type of haemophilia, age at time of TEA, HIV infection status, pre- and postoperative range-of-motion (ROM) scores, complications (including infections), need for subsequent surgical revision and functional outcomes were recorded. Four patients had severe factor VIII deficiency and two patients had severe factor IX deficiency. None of the patients had an inhibitor. The mean age at the time of surgery was 34 years (range, 22-46 years) and the mean follow-up period was 118 months (range, 37-176 months). One of the six patients had TEA in both elbows. Five of the six patients were infected with HIV. There were no immediate perioperative complications. At a mean of 19.2 months postoperatively, ROM had improved in five of seven TEAs: mean flexion had increased from 110.7° (SD = 15.0) to 120.1° (SD = 14.5), whereas mean preoperative extension increased from -44.3° (SD = 21.5) to -36.9° (SD = 27.0). One patient required a revision at 30 months because of ulnar component loosening. This same patient sustained a staph epidermidis infection and ultimate removal of the prosthesis 15 years postoperatively. At a mean of 118 months postoperatively, five of six patients continued to report reduced pain and preserved functionality, with ability to perform normal daily activities. TEA resulted in favourable results in six of seven procedures. Our findings support the viability of TEA for individuals with severe haemophilic arthropathy of the elbow, especially to reduce pain and preserve or restore functionality.

Total knee replacement in patients with end-stage haemophilic arthropathy

Haemophilia is an x-linked inherited bleeding disorder which can cause severe arthropathy. We have reviewed the results of 70 primary total knee replacements (TKR) performed in 57 haemophilic patients between 1983 and 2007. The functional results were assessed using the Hospital for Special Surgery (HSS) knee scoring system and Kaplan-Meier survivorship analysis. Six patients died. HSS scores were available for 60 TKRs at a mean follow-up of 9.2 years (2 to 23); 57 (95%) had good or excellent results. Deep infection was recorded in one patient. Kaplan-Meier analysis using infection and aseptic loosening as endpoints showed the survival rate at 20 years to be 94.0%.

A reduction in infection, spontaneous haemarthrosis and improvement in the quality of life were noted to justify surgery in our series of patients with a mean age of 43 (25 to 70). We have found that using the latest techniques of continuous infusion of clotting Factor have significantly helped to reduce the complication rates and have achieved results which match those of the non-haemophilic population undergoing TKR.

Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty

BACKGROUND

Development of a postoperative hematoma is a reported complication after primary total knee arthroplasty. However, little is known about the clinical outcomes in patients who require surgical evacuation of an acute hematoma. The purpose of this study was to determine the incidence, risk factors, and long-term sequelae of postoperative hematomas requiring surgical evacuation.

METHODS

From 1981 to 2004, 17,784 primary total knee arthroplasties were performed at our institution. Forty-two patients (forty-two knees) returned to the operating room within thirty days of the index arthroplasty for evacuation of a postoperative hematoma. A case-control study, with forty-two patients matched one-to-one with forty-two control subjects, was performed to attempt to identify risk factors for the development of postoperative hematoma requiring surgical evacuation.

RESULTS

The rate of return to surgery within thirty days for evacuation of a postoperative hematoma was 0.24% (95% confidence interval, 0.17% to 0.32%). For patients undergoing postoperative hematoma evacuation, the two-year cumulative probabilities of undergoing subsequent major surgery (component resection, muscle flap coverage, or amputation) or having a deep infection develop were 12.3% (95% confidence interval, 1.6% to 22.4%) and 10.5% (95% confidence interval, 0.2% to 20.2%), respectively. In contrast, for knees without early hematoma evacuation, the two-year cumulative probabilities were 0.6% (95% confidence interval, 0.5% to 0.7%) and 0.8% (95% confidence interval, 0.6% to 0.9%), respectively (p < 0.001 for both outcomes). A history of a bleeding disorder was identified as having a significant association with the development of a hematoma requiring surgical evacuation (p = 0.046).

CONCLUSIONS

Patients who return to the operating room within thirty days after the index total knee arthroplasty for evacuation of a postoperative hematoma are at significantly increased risk for the development of deep infection and/or undergoing subsequent major surgery. These results support all efforts to minimize the risk of postoperative hematoma formation.

A modular total knee arthroplasty in haemophilic arthropathy

The results of 24 modular Genesis II (Smith & Nephew, Memphis, TN, USA) total knee arthroplasties, performed in 20 patients with haemophilia were prospectively reviewed. The hypothesis that the use of a new-generation implant and advanced, more aggressive hematological care, will result in a decrease rate of complications and better functional results for the haemophilic patients with TKA was tested. The mean age at the time of surgery was 36 years (25 to 44). All the patients were reviewed clinically and radiologically with an average follow-up of 4.4 years (2 to 7 years). At the final follow-up the knee score improved from an average of 23 points (11 to 45) to 86 points (62 to 100; p<0.001). The mean knee flexion contracture improved from 22 degrees (0 degrees to 45 degrees ) to 3 degrees (0 degrees to 10 degrees ; p<0.0001). The mean total flexion arc improved from 69 degrees (5 degrees to 130 degrees ) to 92 degrees (80 degrees to 145 degrees p<0.001). The results of our study confirm that the introduction of modular design may improve the functional results of TKA in haemophilic arthropathy which results in a better range of motion and lower flexion contracture.

Modern management of haemophilic arthropathy

Currently available factor concentrates for treatment of patients with haemophilia are virally inactivated or are made by recombinant technology and their broad use in developed nations has resulted in the dramatic elimination of the treatment-related viral illnesses that decimated the haemophilia community in the late 20th century. The major morbidity experienced by patients with haemophilia today is joint disease, a result of repeated bleeding episodes into joint spaces. Although administration of factor concentrates to prevent bleeding has been demonstrated to prevent haemophilic joint disease when applied assiduously, repeated bleeding episodes induce synovitis that is irreversible and may progress despite subsequent prophylaxis. Surgical and nuclear medicine interventions are available to reduce the pain of haemophilic arthropathy and to reduce further bleeding episodes. Patients with high titre inhibitors are at great risk for the development of joint disease and present the greatest therapeutic challenges when joint surgery is needed.

Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement

Use of antibiotic-loaded bone cement for prophylaxis against infection is not indicated for patients not at high risk for infection who are undergoing routine primary or revision joint replacement with cement. The mechanical and elution properties of commercially available premixed antibiotic-loaded bone-cement products are superior to those of hand-mixed preparations. Use of commercially available antibiotic-loaded bone-cement products has been cleared by the United States Food and Drug Administration only for use in the second stage of a two-stage total joint revision following removal of the original prosthesis and elimination of active periprosthetic infection. Use of antibiotic-loaded bone cement for prophylaxis against infection in the second stage of a two-stage total joint revision involves low doses of antibiotics. Active infection cannot be treated with commercially available antibiotic-loaded bone cement as such treatment requires higher doses of antibiotics.