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Gao ZZ, Yang H, Liu WB, Xu C, Xiang SC, Wang LC, Mao YJ. Physical therapy for end-stage hemophilic arthropathy: a case report. BMC Musculoskelet Disord 2023; 24:916. [PMID: 38012586 PMCID: PMC10680260 DOI: 10.1186/s12891-023-07056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023] Open
Abstract
This report introduces a young adult who has been in bed for more than ten years with end-stage hemophilic arthropathy. He didn't have access to factor VIII (FVIII) in the early stage of hemophilia due to the high costs of clotting replacement therapy. As a result, he is experiencing some difficulties, such as joint contracture, muscular atrophy, severe pain, and poor function of cardiopulmonary. He came to visit us for a comprehensive rehabilitation program, and, finally, he achieved the basic goal of self-care in daily life.
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Affiliation(s)
- Zhen-Zhen Gao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Hang Yang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Wen-Bin Liu
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Cui Xu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Shou-Chang Xiang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Ling-Cong Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China
| | - Ya-Jun Mao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, 310006, China.
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Rodriguez-Merchan EC. Hemophilic arthropathy: how to diagnose subclinical bleeding early and how to orthopedically treat a damaged joint. Expert Rev Hematol 2023; 16:651-658. [PMID: 37392151 DOI: 10.1080/17474086.2023.2232547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION It is important to know the current status of hemophilic arthropathy diagnoses, treatments, complications, and outcomes in developed countries. AREAS COVERED A bibliographic search in PubMed for articles published from 1 January 2019 through 12 June 2023 was performed. EXPERT OPINION In developed countries with specialized hemophilia treatment centers, primary hematological prophylaxis (started before the age of 2 years and after no more than one joint bleed) has almost completely eliminated the joint-related problems of the disease. The ideal goal of zero hemarthroses can be achieved only with intense and well-dosed prophylaxis: intravenous infusion of coagulation factor - standard half-life or extended half-life; periodic or subcutaneous injections of nonfactor products (emicizumab or fitusiran). However, hemophilic arthropathy continues to occur due to subclinical joint hemorrhages. In one study, 16% of the joints without reported hemarthroses showed signs of previous subclinical bleeding (hemosiderin deposits with/without synovial hypertrophy on magnetic resonance imaging were deemed signs of previous subclinical bleeding), rendering evidence for subclinical bleeding in people with severe hemophilia with lifelong prophylaxis treatment. Subclinical joint hemorrhages can be averted only by employing accurate and tailored prophylaxis.
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Cai G, Song L, Chen G, Yuan S, Cai L, Ning X, Wang J, Jiang W. Short‐term Effectiveness of a Modified Osteotomy for Total Elbow Joint Replacement in Patients of Hemophilic Elbow Arthritis with Severe Flexion Contracture Deformity: A Three‐Cases Series Report. Orthop Surg 2022; 14:2741-2749. [PMID: 36053811 PMCID: PMC9531090 DOI: 10.1111/os.13457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To report the modified osteotomy and the short‐term effectiveness of the total elbow joint replacement in patients of hemophilic elbow arthritis with severe flexion contracture deformity. Methods This study introduced the therapeutic approach of the total elbow joint replacement in patients of hemophilic elbow arthritis with severe flexion contracture deformity, and assessed the short‐term effectiveness in three cases (three elbows) of end‐stage hemophilic elbow arthritis admitted from October 2020 to December 2020. The included patients were all diagnosed with hemophilia A (factor VII deficiency), accompanied by severe bilateral elbow joint flexion contracture, which seriously affects daily life and requires surgical intervention. Clinical data and follow‐up results were analyzed before total elbow arthroplasty and 1, 3, and 6 months postoperatively. Pre‐ and postoperative range of motion, pain score, and function score were compared, and intraoperative and postoperative complications are reported. Results All three patients were male, with an average age of 31 years. The main clinical manifestations were bilateral elbow arthritis with flexion contracture. Two of the patients underwent right elbow replacement, and one patient underwent left elbow replacement. All cases were followed up for 6 months postoperatively. No incision infection or ulnar nerve injury occurred. Postoperative triceps brachii muscle strength was slightly weakened compared with preoperative muscle strength. Average elbow flexion and extension range of motion was 60° (30°–100°) preoperatively and increased to 127° (110°–140°) postoperatively; rotational range of motion of the affected forearm was 47° (10°–85°) preoperatively and increased to 117° postoperatively. The mean visual analogue scale (VAS) was 6 (5–8) preoperatively and decreased to 3 (2–4) postoperatively. The mean MEPS score was 62 (55–75) and increased to 87 (80–95) postoperatively. During the follow‐up, anteroposterior and lateral radiographs showed no signs of prosthesis loosening in the elbow. Conclusions For severe hemophilic elbow arthritis patients, the short‐term treatment effect of total elbow replacement is good, following the strict adherence to the surgical indications and proper preparation for the perioperative period. The modified osteotomy can fully expose the visual field and reduce complications of ulnar nerve injury. The long‐term effects need to be study future.
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Affiliation(s)
- Gaorui Cai
- Department of Orthopedics The Third People's Hospital of Shenzhen Shenzhen Guangdong Province China
| | - Lixia Song
- Department of Orthopedics The Third People's Hospital of Shenzhen Shenzhen Guangdong Province China
| | - Guoneng Chen
- Department of Orthopedics The Third People's Hospital of Shenzhen Shenzhen Guangdong Province China
| | - Shanyou Yuan
- Department of Orthopedics The Third People's Hospital of Shenzhen Shenzhen Guangdong Province China
| | - Lisheng Cai
- Department of Hematology The Second People's Hospital of Shenzhen Shenzhen Guangdong Province China
| | - Xianjia Ning
- Center of Clinical Epidemiology The Third People's Hospital of Shenzhen Shenzhen Guangdong China
| | - Jinghua Wang
- Center of Clinical Epidemiology The Third People's Hospital of Shenzhen Shenzhen Guangdong China
| | - Wenxue Jiang
- Department of Orthopedics The Third People's Hospital of Shenzhen Shenzhen Guangdong Province China
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Rodriguez-Merchan EC. Past, present and future of orthopedic surgery in hemophilia: looking to a world without bleeding and arthropathy in the near future. Expert Rev Hematol 2022; 15:821-831. [PMID: 35930399 DOI: 10.1080/17474086.2022.2110063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article is to review the literature on orthopedic surgery in people with hemophilia (PWH), to better understand its past and present and attempt to predict the future. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to orthopedic surgery in PWH was analyzed. A downward trend in orthopedic surgery in PWH has been observed. Patients on continuous prophylaxis are less likely to require orthopedic surgery. In patients with hemophilia, the risk of major bleeding remains high after total joint arthroplasty, even with factor replacement. Cases of acute compartment syndrome, pseudotumors and even limb amputations are still observed in PWH. EXPERT OPINION Orthopedic surgery for PWH should always be performed in specialized centers with multidisciplinary expertise in the correct management of hemophilia. It is paramount to perform an accurate preoperative coagulation screening before surgery. The availability of prophylaxis through replacement and the recent non-replacement therapy in the well-developed countries will diminish substantially or hopefully abolish completely the need for surgery in the treatment of PWH. Therefore, we are looking to a world without bleeding and arthropathy in the next future. Unfortunately, this is not true for the under-development countries.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Chowdary P, Holmström M, Mahlangu J, Ozelo MC, Pabinger I, Pasi KJ, Ragni M, Shapiro A, Barnowski C, Lethagen S. Managing surgery in hemophilia with recombinant factor VIII Fc and factor IX Fc: Data on safety and effectiveness from phase 3 pivotal studies. Res Pract Thromb Haemost 2022; 6:e12760. [PMID: 35910942 PMCID: PMC9326287 DOI: 10.1002/rth2.12760] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/09/2022] [Accepted: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Background Surgical procedures impose hemostatic risk to people with hemophilia, which may be minimized by optimal factor (F) replacement therapy. Methods This analysis evaluates the efficacy and safety of extended half-life factor replacement recombinant FVIII and FIX Fc fusion proteins (rFVIIIFc and rFIXFc) during surgery in phase 3 pivotal (A-LONG/Kids A-LONG and B-LONG/Kids B-LONG) and extension (ASPIRE and B-YOND) studies. Dosing regimens were determined by investigators. Injection frequency, dosing, blood loss, transfusions, and hemostatic response were assessed. Results Forty-five major (n = 31 subjects) and 90 minor (n = 70 subjects) procedures were performed in hemophilia A; 35 major (n = 22) and 62 minor (n = 37) procedures were performed in hemophilia B. Unilateral knee arthroplasty was the most common major orthopedic procedure (hemophilia A: n = 15/34; hemophilia B: n = 8/24). On the day of surgery, median total dose in adults/adolescents was 81 IU/kg for rFVIIIFc and 144 IU/kg for rFIXFc; most major procedures required ≤2 injections (including loading dose). Through days 1-14, most major procedures had ≤1 injection/day. Hemostasis was rated excellent (rFVIIIFc: n = 39/42; rFIXFc: n = 29/33) or good (n = 3/42; n = 4/33) in evaluable major surgeries, with blood loss comparable with subjects without hemophilia. Most minor procedures in adults/adolescents required one injection on the day of surgery, including median loading dose of 51 IU/kg (rFVIIIFc) and 80 IU/kg (rFIXFc). No major treatment-related safety concerns were identified. No subjects developed inhibitors or serious vascular thromboembolic events. Conclusions rFVIIIFc and rFIXFc were efficacious and well tolerated for the management of perioperative hemostasis across a wide spectrum of major and minor surgeries in hemophilia.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Margareta Holmström
- Coagulation Unit, Department of Hematology, Department of Medicine, Karolinska Institute SolnaKarolinska University HospitalStockholmSweden
- Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Johnny N. Mahlangu
- Hemophilia Comprehensive Care Centre, Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
| | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine IMedical University of ViennaViennaAustria
| | - K. John Pasi
- Royal London Hospital Haemophilia CentreBarts and The London School of Medicine and DentistryLondonUK
| | - Margaret V. Ragni
- Division of Hematology/Oncology, and Hemophilia Center of Western PA, Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis CenterIndianapolisIndianaUSA
| | | | - Stefan Lethagen
- Swedish Orphan Biovitrum ABStockholmSweden
- Copenhagen UniversityCopenhagenDenmark
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Rodriguez-Merchan EC, De la Corte-Rodriguez H, Alvarez-Roman T, Gomez-Cardero P, Encinas-Ullan CA, Jimenez-Yuste V. Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health. Expert Rev Hematol 2022; 15:65-82. [PMID: 35041571 DOI: 10.1080/17474086.2022.2030218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article has been to review the literature on total knee arthroplasty (TKA) in people with hemophilia (PWH), to mention the lessons we have learned from our own experience and to try to find out what the future of this type of surgery will be. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to TKA PWH was analyzed. In PWH, the complication rate after TKA can be up to 31.5%. These include infection (7.1%) and bleeding in the form of hematoma, hemarthrosis or popliteal artery injury (8.9%). In a meta-analysis the revision arthroplasty rate was 6.3%. One-stage or two-stage revision arthroplasty due to infection (septic loosening) is not always successful despite providing correct treatment (both hematological and surgical). In fact, the risk of prosthetic re-infection is about 10%. It is necessary to perform a re-revision arthroplasty, which is a high-risk and technically difficult surgery that can sometimes end in knee arthrodesis or above-the-knee amputation of the limb. EXPERT OPINION TKA (both primary and revision) should be performed in centers specialized in orthopedic surgery and rehabilitation (knee) and hematology (hemophilia), and with optimal coordination between the medical team.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Current and Emerging Approaches for Pain Management in Hemophilic Arthropathy. Pain Ther 2022; 11:1-15. [PMID: 35020184 PMCID: PMC8861243 DOI: 10.1007/s40122-021-00345-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction Hemophilia is an inherited bleeding hematological disorder characterized by the partial or complete deficiency of clotting factor VIII or IX. Hemophilic arthropathy is the consequence of repeated joint bleeding (hemarthrosis) and its management is based on the prevention of acute bleeding through the administration of the deficient clotting factor concentrate or non-factor therapies. In addition, the management of acute and chronic pain is pivotal in hemophilic arthropathy in order to restore function and allow rehabilitation of the joint.
Methods We conducted a qualitative review of the literature regarding current and emerging strategies for pain treatment in hemophilic arthropathy. This review considers systemic and local pharmacological and non-pharmacological interventions for acute and chronic pain management.
Results In hemophilic arthropathy, pain management is based on analgesics such as paracetamol, which represents the first choice for acute and chronic pain in adults and children, in association with opioids for adults. Non-steroidal anti-inflammatory drugs inhibit platelet function, so that the currently preferred drugs are short courses of cyclooxygenase 2 inhibitors. Local treatment with intra-articular injections of corticosteroids is an option for refractory cases and physiotherapy has an important role after hemarthrosis and for the long-term management of chronic pain for both pediatric and adult patients.
Conclusions The management of pain in hemophilia requires more standardization. Meanwhile, the safest drugs should be used at the lowest effective dosage and for periods as short as possible. For the non-pharmacological management of pain in these patients, a multidisciplinary team including hematologists, orthopedic surgeons, rheumatologists, and physiotherapists is warranted.
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Abou-Ismail MY, Connell NT. How to manage bleeding disorders in aging patients needing surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:529-535. [PMID: 34889441 PMCID: PMC8791143 DOI: 10.1182/hematology.2021000288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
With improvements in medical care, the life expectancy of patients with bleeding disorders is approaching that of the general population. A growing population of older adult patients with bleeding disorders is at risk of age-related comorbidities and in need of various elective and emergent age-related procedures. The increased risk of thrombosis and volume overload in older adults complicates perioperative hemostatic management. Furthermore, antithrombotic treatment such as antiplatelet or anticoagulant therapy, which is frequently required for various cardiovascular interventions, requires a meticulous individualized approach. Evidence-based guidelines for the management of aging patients with bleeding disorders are lacking, largely due to the underrepresentation of older adult patients in clinical trials as well as the rarity of many such bleeding disorders. We discuss the current guidelines and recommendations in the perioperative hemostatic management of older adult patients with hemophilia and von Willebrand disease as well as other rare bleeding disorders. The optimal management of these patients is often complex and requires a thorough multidisciplinary and individualized approach involving hematologists, surgeons, anesthesiologists, and the specialists treating the underlying disorder.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Mohan K, Broderick JM, Raftery N, McAuley NF, McCarthy T, Hogan N. Perioperative haematological outcomes following total knee arthroplasty in haemophiliacs. J Orthop Surg (Hong Kong) 2021; 29:23094990211033999. [PMID: 34583559 DOI: 10.1177/23094990211033999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Patients with haemophilia suffer from recurrent joint haemarthrosis. This can progress to symptomatic arthropathy commonly affecting the knee. While modern coagulation strategies have reduced those proceeding to end-stage arthropathy, total knee arthroplasty (TKA) remains the optimal treatment for some patients. Despite innovation in perioperative haematological management, concerns about the potential for excessive haemorrhage still exist. The aim of this study is to quantify immediate postoperative blood loss and haematological complications in haemophiliacs following TKA. METHODS A retrospective study of patients with haemophilia types A or B who underwent a TKA over a 12-year period at a single institution was conducted. These patients were compared to both a non-haemophiliac control group and to published standards in non-haemophiliacs undergoing TKA. RESULTS Twenty-one TKA procedures in 18 patients (72% haemophilia A, 28% haemophilia B) were suitable for inclusion with a mean age of 44 years. The mean haemoglobin drops at 24 and 48 h postoperatively were 2.7 g/dl and 3.8 g/dl respectively. There was no significant difference in haemoglobin drop at 48 h postoperatively when compared to the non-haemophiliac control group (P = 0.2644). There were no immediate perioperative complications and two patients (9.6%) required postoperative transfusion. CONCLUSION Haemophiliacs undergoing a unilateral primary TKA in a specialised tertiary referral centre appear to have comparable rates of perioperative blood loss when compared to both a non-haemophiliac control group as and published haemostatic standards in non-haemophiliac patients following TKA. Perioperative management with expert orthopaedic and haematological input is recommended to optimise outcomes in this complex patient group.
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Affiliation(s)
- Kunal Mohan
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - James M Broderick
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Nicola Raftery
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Nuala F McAuley
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Tom McCarthy
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Niall Hogan
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
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Rodriguez-Merchan EC. Haemophilic arthropathy: Contemporary management challenges and a future scenario. Haemophilia 2021; 27:e765-e767. [PMID: 34498331 DOI: 10.1111/hae.14411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, La Paz University Hospital Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Rodriguez-Merchan EC. Hemophilic arthropathy: a teaching approach devoted to hemophilia treaters in under-development countries. Expert Rev Hematol 2021; 14:887-896. [PMID: 34482789 DOI: 10.1080/17474086.2021.1977118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Arthropathy is the characteristic injury of hemophilia, primarily occurring in the elbows, knees, and ankles. The aim of this review is a teaching approach devoted to hemophilia treaters in under-development countries. AREAS COVERED Current major challenges include the absence of the following therapeutic tools for all people with hemophilia (PWH) worldwide: hematological prophylaxis; well-coordinated multidisciplinary teams in specialized centers; joint aspiration of acute hemarthrosis; point-of-care ultrasonography (POC-US); exercise; treatment of synovitis by means of radiosynovectomy; treatment of mild hemophilic arthropathy with analgesics, anti-inflammatory agents, and rehabilitation medicine; intra-articular injections of corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells; and treatment of severe hemophilic arthropathy by surgical treatment. The future scenario in under-development countries should include all the aforementioned treatment tools plus the possibility of performing total joint arthroplasty in PWH with inhibitors; concomitant use of bypassing agents with emicizumab for PWH with inhibitors undergoing orthopedic surgery; and telemedicine. EXPERT OPINION Primary hematological prophylaxis is now the gold standard for the management of hemophilia. Acute hemarthrosis needs intense hematological management and articular aspiration; the articular situation should be scrutinized by POC-US. Synovitis can be controlled by radiosynovectomy. In cases of severe articular degeneration, surgical procedures might be required.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, La Paz University Hospital Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Abstract
Haemophilia A and B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of levels of FVIII or FIX, which are determined by the type of the causative mutation in the genes encoding the factors (F8 and F9, respectively). The hallmark clinical characteristic, especially in untreated severe forms, is bleeding (spontaneous or after trauma) into major joints such as ankles, knees and elbows, which can result in the development of arthropathy. Intracranial bleeds and bleeds into internal organs may be life-threatening. The median life expectancy was ~30 years until the 1960s, but improved understanding of the disorder and development of efficacious therapy based on prophylactic replacement of the missing factor has caused a paradigm shift, and today individuals with haemophilia can look forward to a virtually normal life expectancy and quality of life. Nevertheless, the potential development of inhibitory antibodies to infused factor is still a major hurdle to overcome in a substantial proportion of patients. Finally, gene therapy for both types of haemophilia has progressed remarkably and could soon become a reality.
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Pain management in people with hemophilia in childhood and young adulthood. Expert Rev Hematol 2021; 14:525-535. [PMID: 34042011 DOI: 10.1080/17474086.2021.1935852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Rodriguez-Merchan EC, Encinas-Ullan CA, Gomez-Cardero P. Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective. Expert Rev Hematol 2021; 14:517-524. [PMID: 34042014 DOI: 10.1080/17474086.2021.1935850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Rodriguez-Merchan EC. Management of musculoskeletal complications in patients with hemophilia: literature review and expert recommendations. Cardiovasc Hematol Disord Drug Targets 2021; 21:162-166. [PMID: 33906595 DOI: 10.2174/1871529x21666210427134232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/02/2021] [Accepted: 03/01/2021] [Indexed: 11/22/2022]
Abstract
In people with hemophilia, hematological prophylaxis during childhood and adolescence could elude the occurrence of musculoskeletal complications (in joints and muscles) if the concentration of the defective factor is averted from decreasing under 1% of normal. Prompt management is of capital significance as the juvenile skeleton is hypersensitive to the adverse events of the disease; intense structural defects might appear rapidly. Important articular bleeds and inveterate hypertrophy of the articular synovial membrane must be treated vigorously to preclude joint degeneration (hemophilic arthropathy). At the moment that extreme joint disease is in place with intense affliction, the goal must be to reestablish activity whilst at the same time reducing the peril to the patient. Articular debridement is an efficacious surgical technique to accomplish this goal, particularly around the knee or ankle, and may be contemplated to be a backup to ankle arthrodesis or ankle or knee replacement in patients of younger age. Eventually joint replacement can commonly reestablish both articular mobility and function in an unhealthy articulation.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid. Spain
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Rodriguez-Merchan EC. Total Ankle Replacement in Hemophilia. Cardiovasc Hematol Disord Drug Targets 2021; 20:88-92. [PMID: 31820705 PMCID: PMC7360905 DOI: 10.2174/1871529x19666191210110626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022]
Abstract
Introduction
Severe ankle hemophilic arthropathy can be a calamitous sign of severe hemophilia with important inferences for activities of daily living. Aims
To summarize the contemporary, accessible information on Total Ankle Replacement (TAR) for ankle hemophilic arthropathy. Methods
A search of Cochrane Library and PubMed (MEDLINE) regarding the role of TAR in ankle hemophilic arthropathy. Results
The insufficient information regarding the results of TAR for hemophilic arthropathy is confined to scanty case series and case reports. An evaluation of the accessible literature reveals encouraging but inconstant outcomes. The reported rate of adverse events is 33%. The reported anticipated survival of TAR is 94% at 5 years, 85% at 10 years and 70% at 15 years. Conclusion
Whereas people with advanced hemophilic arthropathy of the ankle are prone to ameliorate pain and range of motion following TAR, there is deficient knowledge to regularly recommend its use. Adverse events and infection percentages are disturbing. Moreover, the lack of survival analysis knowledge makes it difficult to assess the benefit to people with hemophilia. TAR is a demanding surgical procedure and its survival is not comparable to that after hip or knee replacement.
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Rodríguez-Merchán EC. Recent advances in surgery and its perioperative treatment in people with hemophilia. Expert Rev Hematol 2021; 14:271-280. [PMID: 33605827 DOI: 10.1080/17474086.2021.1893689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: People with hemophilia (PWH) may require some surgical procedures (orthopedic surgery, cardiac surgery, neurosurgery, et cetera) throughout their lives.Areas covered: Articles on surgery and hemophilia published during the year 2020 were analyzed. The principal inclusion factor was a focal point on surgery in hemophilia. Articles that did not concentrate on this subject were not included.Expert opinion: Turoctocog alfa pegol appears to be efficacious for perioperative hemostatic treatment of all kind of surgical operations (minor and major) in PWH A. Long-acting recombinant coagulation factor IX (FIX) albumin fusion protein (rIX-FP) seems to facilitate perioperative management in PWH B. In people suffering from von Willebrand disease (VWD), the utilization of concentrates of von Willebrand factor (VWF) is commonly used for the decrease of exaggerated bleeding during surgical operations. On-demand management with 30-60 IU/kg may keep hemostasis under control during all kind of surgical operations. Factor concentrates with extended half-life (EHL) are a good option to standard half-life (SHL) products in PWH undergoing surgery, permitting diminished number of infusions and inferior consuming, particularly for EHL factor IX (FIX). Supplementary factor VIII (FVIII) and/or bypassing management have demonstrated to be secure and efficacious in association with emicizumab for major surgical procedures.
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Affiliation(s)
- E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Tat AM, Can F, Tat NM, Sasmaz HI, Antmen AB. The effects of manual therapy and exercises on pain, muscle strength, joint health, functionality and quality of life in haemophilic arthropathy of the elbow joint: A randomized controlled pilot study. Haemophilia 2021; 27:e376-e384. [PMID: 33626198 DOI: 10.1111/hae.14281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Effective physiotherapy interventions are required for haemophilic arthropathy (HA) of the elbow due to its biomechanical differences and contribution to upper limb functionality. AIM To investigate the effects of manual therapy & exercises on bleeding frequency, pain, range of motion (ROM), strength, joint health, functionality and quality of life (QoL) in HA of the elbow. METHODS Seventeen participants with HA of the elbow were randomized as Manual Therapy & Exercises Group (MTEG = 9) and Home Exercises Group (HEG = 8). Soft tissue mobilization, joint traction (grade I-II) and Mulligan's mobilization with movement as manual therapy, and stretching/strengthening exercises were applied to MTEG, while HEG had only same exercises as home programme. The interventions lasted 3 days/weekly for 5 weeks. Bleeding frequency was evaluated with patients' records; pain with Numeric Pain Scale; ROM with goniometer; strength with digital dynamometer; joint health with HJHS; functionality with Quick-Disability of Arm, Shoulder and Hand questionnaire; and QoL with Oxford Elbow Score. RESULTS Bleeding frequency and activity pain were decreased, while elbow ROMs and flexor strength were increased in MTEG (P ˂ 0.05). Also significantly improvements were seen in joint health, functionality and QoL in MTEG. HEG showed improvements in activity pain, QoL and some ROMs. MTEG had better results in ROMs, joint health and functionality (P ˂ 0.05). CONCLUSION Manual therapy & exercises may be used without causing bleeding and pain to increase the functionality, joint health and QoL, and is superior to home exercise for joint health and functionality. Home exercises may be ameliorated in pain, QoL and some ROMs.
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Affiliation(s)
- Ayse Merve Tat
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Necmettin Erbakan University, Konya, Turkey
| | - Filiz Can
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Necati Muhammed Tat
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Necmettin Erbakan University, Konya, Turkey
| | - Hatice Ilgen Sasmaz
- Faculty of Medicine, Department of Pediatric Hematology and Oncology, Cukurova University, Adana, Turkey
| | - Ali Bulent Antmen
- Department of Pediatric Hematology and Oncology, Acıbadem Hospital, Adana, Turkey
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Badulescu OV, Filip N, Sirbu PD, Bararu-Bojan I, Vladeanu M, Bojan A, Ciocoiu M. Current practices in haemophilic patients undergoing orthopedic surgery - a systematic review. Exp Ther Med 2020; 20:207. [PMID: 33123236 DOI: 10.3892/etm.2020.9337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Haemophilia is an inherited disease that requires a different approach in order to evaluate, monitor and treat patients. Despite the great advances in therapeutic agents that have emerged, reports on the impact of monitoring outcomes on treatment decisions are rarely presented. Haemophilia A and haemophilia B are inherited bleeding disorders caused by deficiencies in blood clotting factor proteins. A systematic review was performed to identify literature reports on the current practices in haemophilic patients undergoing orthopedic surgery. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications. Besides the primary prophylaxis, thromboprophylaxis is used to prevent venous thrombosis in patients with hemophilia who undergo surgical orthopedic procedures. Further research is needed to better manage the pharmacologic approaches in haemophilic patients undergoing orthopedic surgery. Although patients with haemophilia present low risk for thromboembolic complications, such events have been reported in surgical procedures. The recommendations in patients with haemophilia are considerably variable in the current guidelines and clinical practice. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications.
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Affiliation(s)
- Oana Viola Badulescu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Nina Filip
- Department of Biochemistry, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Paul Dan Sirbu
- Department of Orthopedics and Traumatology Surgical Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iris Bararu-Bojan
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria Vladeanu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Andrei Bojan
- Department of Surgical Sciences, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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Mortazavi SJ, Bagheri N, Farhoud A, Hadi Kalantar S, Ghadimi E. Total Knee Arthroplasty in Patients with Hemophilia: What Do We Know? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:470-478. [PMID: 32884968 DOI: 10.22038/abjs.2019.42247.2149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Total knee arthroplasty is considered as the treatment of choice for those with end stage hemophilic arthropathy. Compared to other patients undergoing TKA, these patients have specific features such as bleeding tendency, younger age, pre-operative restricted range of motion (ROM), altered anatomy, and increased complications. This narrative review of literature is going to investigate several issues regarding the TKA in hemophilic patients including indications, perioperative factor replacement, surgical challenges, postoperative rehabilitation, outcomes, and complications.
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Affiliation(s)
- Sm Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Bagheri
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirreza Farhoud
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeid Hadi Kalantar
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
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21
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Complications of hemophilia in the elbow: current management. Expert Rev Hematol 2020; 13:991-1001. [PMID: 32723183 DOI: 10.1080/17474086.2020.1803061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION After the ankle and knee, the elbow is the most commonly impaired joint in patients with hemophilia. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search related to elbow problems in hemophilia was conducted. Early and continuous primary hematological prophylaxis (ideally starting in infancy) is essential, given that the juvenile elbow is highly prone to the musculoskeletal complications of hemophilia. If primary hematological prophylaxis is not administered (due either to lack of affordability or lack of venous access), persistent hemarthrosis can occur in the elbow. Hemarthroses will then require aggressive treatment (through arthrocentesis under factor factor coverage) to prevent progression to synovitis (requiring prompt radiosynovectomy or arthroscopic synovectomy) and ultimately hemophilic arthropathy (requiring rehabilitation and orthopedic surgery). Between the second and fourth decade of life, many patients with hemophilia present elbow joint destruction. EXPERT OPINION In the initial stage of joint destruction, rehabilitation and intraarticular injections of hyaluronic acid can relieve the symptoms. In the advanced stage of hemophilic arthropathy, however, surgery is necessary. The main surgical procedures currently available are arthroscopic debridement, radial head resection, and total elbow arthroplasty. Transposition of the ulnar nerve and removal of heterotopic ossifications might also be necessary.
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Abstract
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
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Affiliation(s)
- Elena Bravo
- Plastic Surgery Department, Hospital Universitario La Paz, Madrid, Spain
| | - Raul Barco
- Upper Limb Unit, Orthopedic Surgery Department, Hospital Universitario La Paz, Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Haemophilia Orthopedic Unit, Orthopedic Surgery Department, Hospital Universitario La Paz, Madrid, Spain
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23
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Malhotra U, Hasday M, Romanos GE, Javed F. Assessment of routine diet (garlic consumption) as a pre- and postoperative protocol in oral and maxillofacial surgical interventions: An evidence-based literature review. Nutr Health 2020; 26:135-139. [PMID: 32241225 DOI: 10.1177/0260106020912940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It was hypothesized that pathological bleeding (PB) during and/or after oral surgical procedures is higher in systemically healthy patients who have a history of garlic intake compared to controls (patients without a history of garlic consumption). AIM The aim of the present review article was to identify studies in which garlic consumption was included as a patient management protocol before and after oral and maxillofacial surgery (OMFS). METHODS A review of pertinent indexed literature was performed. The focused question that was addressed was "Has diet (garlic consumption) been considered as a patient management protocol before and after OMFS?" The inclusion criteria were: (a) studies published in indexed databases, (b) original studies, (c) studies on OMFS, and (d) studies that considered diet (garlic consumption) as a patient management protocol before and after OMFS. Literature review, commentaries, letters to the editor, and studies published in non-indexed resources were excluded. The pattern of the present review was customized to summarize the pertinent information. RESULTS The initial search using the terms "oral," maxillofacial," "protocol," and "surgery" yielded 1478 studies. The addition of the term "diet" to this search strategy reduced the number of studies to five. Further filtration of these studies using the terms "garlic" and/or "Allium sativum" showed no studies. CONCLUSIONS Garlic intake predisposes patients to PB. However, there are no studies in the indexed literature that have considered the inclusion of garlic consumption in patient management protocols before and after OMFS.
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Affiliation(s)
- Upasna Malhotra
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Matthew Hasday
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Georgios E Romanos
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA.,Department of Oral Surgery and Implant Dentistry, Dental School, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Fawad Javed
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA.,Division of Orthodontics and Dentofacial Orthopedics, Eastman Institute for Oral Health, University of Rochester, NY, USA
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