Hemophilic arthropathy. Current concepts of pathogenesis and management

Managing Surgical Risks in Hemophilic Elbow Arthropathy: An In-Depth Case Study and Literature Review

This study presents a detailed case analysis of a 40-year-old male patient with hemophilia A and severe chronic elbow arthropathy, exploring the surgical challenges and outcomes within the context of the current literature. The patient, with a history of multiple comorbidities including Hodgkin's lymphoma and cardiomyopathy, exhibited significant joint damage and functional impairment. A comprehensive approach was employed, collecting all relevant clinical data, including radiographic and MRI findings, to inform treatment decisions. Clinical findings and treatment decisions are presented as they occurred in real time, simulating the clinical reasoning process. Subsequent references to the clinical and instrumental findings as well therapeutic interventions are discussed in light of the current literature to reinforce the decision-making framework. This report underscores the importance of multidisciplinary care in optimizing patient outcomes and contributes to the ongoing discourse on the management of advanced musculoskeletal conditions in hemophilic patients. The findings emphasize the necessity for early intervention and specialized care to mitigate complications and improve long-term prognosis.

Morphological Measurement and Clinical Significance of Abnormal Development of Distal Femur with Hemophilia Knee Arthritis: A Consideration on the Renewal of Total Knee Prosthesis

OBJECTIVE

The knee joint of hemophiliacs may face the result of local morphological changes due to long-term irritation of synovitis. This study aims to elucidate the morphological characteristics of distal femur in hemophilic arthritis (HA) and compare the compatibility of three types of prostheses with the anteroposterior (AP) and mediolateral (ML) dimensions of the femoral osteotomy surface.

METHODS

This study retrospectively and randomly selected 50 patients with HA registered for treatment at our hospital from June 2016 to August 2022 as the study subjects, with an equal number of male osteoarthritis (OA) patients and healthy male individuals set as the control group. This study used medical digitalization software to simulate osteotomies on the distal femur during total knee arthroplasties (TKA) for 50 patients with HA, OA patients, and the healthy population, respectively, and measure the morphological parameters to compare with three commonly used femoral components of TKA in clinical practice. The differences between the femur resection of anteroposterior and mediolateral (FRAP, FRML) osteotomy surface and the prosthesis's BOX-AP/ML were compared in three prostheses. One-way ANOVA and multiple Kruskal-Wallis H test were used for the normal or non-normal distribution data, and pairwise comparisons between groups were conducted using the Bonferroni method, and the linear correlation analysis was utilized to assess the relationship between section femoral morphological data and prosthesis parameters.

RESULT

In HA patients, the morphological characteristics of the distal femur were shown as shorter than femur AP (FAP), medial and lateral condyle anterior-posterior dimension (FMCAP, FLCAP), notch width (NW), posterolateral condyle height (PLCH), posteromedial condyle width (PMCW), and posterior condylar axis length (PCAL) dimension. They had comparatively smaller femur section aspect ratios (p < 0.005). They showed longer posterolateral condyle width (PLCW), anterior condyle mediolateral dimension (FRACML), anterolateral condyle height (ALCH), and femur resection anterior condylar mediolateral (FRACML) dimension (p < 0.005). They showed larger distal femur aspect ratio and resection aspect ratio (FAR, FRAR, p < 0.005). All selected prostheses showed ML undercoverage under similar AP dimensions, and ML undersizing of Attune systems was more obvious in three femoral prostheses.

CONCLUSION

The distal femur morphological change of HA patient is shown as smaller AP dimension, narrow posterior condyle spacing, lower and shallower trochlear, thinner anterior condyle, wider and lower intercondylar notch and higher posterior-lateral condyle. The selected prostheses showed ML undercoverage under similar AP dimensions. This typical morphological tendency of the distal femur seems to warrant consideration in the process of knee joint prosthesis upgrading.

Clinical Outcomes of Total Knee Arthroplasty in Patients Who Have Hemophilic Arthropathy: A Prospective Study

BACKGROUND

Total knee arthroplasty (TKA) is considered the gold standard treatment for patients who have advanced hemophilic knee arthropathy. However, special considerations are required for these patients. This prospective study reports on the need for soft-tissue procedures, implant types, complication rates, mean 53.3 months implant survivorship, and patient-reported outcome measures of TKA in hemophilic patients.

METHODS

There were twenty primary TKAs that were performed on 15 hemophilic patients from 2012 to 2023. The mean follow-up was 53.3 months (range, 6 to 128). The necessity for additional soft tissue procedures, implant type, complications, and revision rates were recorded. Knee Injury and Osteoarthritis Outcome Score, Knee Society Score, Hemophilia-specific Quality of Life Questionnaire for Adults, Hemophilia Activities List, and range of motion, were compared preoperatively and at the last follow-up.

RESULTS

At the last follow-up, implant survivorship was 90%. There were 2 revisions: one for aseptic loosening and one for periprosthetic joint infection. Additional soft tissue procedures included 2 quadriceps snips (10%). Tibial augments, tibial stubby stems, and both tibial and femoral traditional stems were used in one (5%), 4 (20%), and one (5%) TKAs, respectively. A constrained posterior-stabilized bearing was necessary in one case. Clinically and statistically significant improvements were found between the preoperative and final follow-up values of all patient-reported outcome measures, knee flexion (73 versus 108 °, P < 0.001), and flexion contracture (11 versus 4 °, P = 0.002).

CONCLUSIONS

This study showed that TKA, in patients who have hemophilic knee arthropathy, is a reliable treatment option that improves knee function and patients' quality of life with acceptable implant survival rates at midterm follow-up (mean 53.3 months). Standard implants and approaches can be used in most cases. Despite good outcomes, hemophilic patients carry additional risks for complications that require specific considerations. It is paramount for these patients to be treated in specialized centers by experienced surgeons to achieve good results.

Outcome measures analysis following total knee arthroplasty in patients with severe haemophilic arthropathy of the knee

Total knee arthroplasty (TKA) has been the gold standard for treating severe haemophilic arthropathy of the knee when all conservative measures fail. However, performing a TKA in patients with haemophilic arthropathy is difficult due to severe joint deformity and destruction, and poor bone quality. The aim of the present study was to evaluate the short-term results of TKA in the treatment of knee haemophilic arthropathy in a tertiary referral centre, with an emphasis on health-related quality of life and knee function. A prospective study was conducted that included 19 male patients with end-stage haemophilic knee arthropathy who underwent TKA in a tertiary referral centre. Clinical outcome and health-related quality of life were assessed by the Western Ontario and McMaster Universities Arthritis (WOMAC) index and the Short Form-36 (SF-36) both pre-operatively and at 1-year post-operatively. The mean age of the patients was 50.37±7.63 years (range, 40-65 years). Pre-operative health-related quality of life was impaired in all patients in all SF-36 domains but was markedly improved after TKA. Knee function in all dimensions (pain, stiffness and physical function), as measured by the WOMAC questionnaire, significantly improved after TKA. Pre-operative pain, stiffness and function, along with total WOMAC score, were strongly and negatively correlated with pre-operative SF-36. Overall, the present study indicated a significant improvement in quality of life and clinical outcome after TKA in patients with advanced haemophilic arthropathy. More studies with longer follow-up periods in a larger population are needed to fully elucidate the mid- and long-term values of TKA in haemophilic patients.

Force-sensing treadmill gait analysis system can detect gait abnormalities in haemophilia patients without arthropathy

BACKGROUND

Joint damage in patients with haemophilia (PwH) is commonly assessed by imaging, but few reports have described how structural changes in joints, for example, haemophilic arthropathy (HA)-affect gait ability.

OBJECTIVES

We evaluated gait function among PwH with HA, PwH without HA, and people without haemophilia (non-PwH) using a Zebris FDM-T treadmill (FDM-T), an easy-to-use gait assessment instrument with a force sensor matrix.

METHODS

The following gait parameters were collected: centre of pressure trajectory intersection (COPi) anterior/posterior variability, COPi lateral variability, COPi anterior/posterior symmetry, COPi lateral symmetry, single-limb support line (SLSL) length, and SLSL variability. Participants walked at their typical gait speed. The physical function of the PwH was assessed by the Hemophilia Joint Health Score (HJHS). Parameters were compared among the three groups.

RESULTS

Twelve PwH with HA, 28 PwH without HA, and 12 non-PwH were enrolled. Gait speed significantly differed between groups (non-PwH, 3.1 ± 0.7; PwH without HA, 2.0 ± 0.7; PwH with HA; 1.5 ± 0.4). The COPi anterior/posterior variability, COPi lateral variability, SLSL length, and SLSL variability were greater in the PwH groups than in the non-PwH group. The COPi lateral symmetry differed between PwH with HA and the other groups. The HJHS was not correlated with gait parameters among PwH with HA.

CONCLUSIONS

Gait parameters and speed were abnormal in both PwH with HA and PwH without HA. The FDM-T can be used to identify early stages of physical dysfunction that cannot be detected by conventional functional assessments such as the HJHS.

Safety and efficacy of myofascial release therapy in the treatment of patients with hemophilic ankle arthropathy. Single-blind randomized clinical trial

BACKGROUND

Hemophilia is characterized by degenerative joint damage. Patients with hemophilic arthropathy present joint damage, reduced range of motion, and decreased strength and functional capacity. Myofascial release therapy aims to decrease pain and improve tissue mobility and functionality.

OBJECTIVES

To evaluate the safety and efficacy of myofascial release therapy in patients with hemophilic ankle arthropathy.

METHOD

Single-blind randomized controlled trial. Fifty-eight adult patients with hemophilia were randomly allocated to the experimental group (myofascial release therapy with foam roller) or the control group (no intervention whatsoever). The daily home protocol of myofascial release therapy for the lower limbs using a foam roller lasted eight consecutive weeks. The primary variable was the safety of myofascial release therapy (weekly telephone follow-up). The secondary variables were pain intensity (visual analog scale), range of motion (goniometer), functional capacity (2-Minute Walk Test) and muscle strength (dynamometer), at baseline and at 8 and 10 weeks.

RESULTS

During the experimental phase, none of the patients in the experimental group developed ankle hemarthrosis. There were statistically significant changes in time*group interaction in ankle dorsal flexion (F[1.75] = 10.72; p < .001), functional capacity (F[1.16] = 5.24; p = .009) and gastrocnemius strength (F[2] = 26.01; p < .001). The effect size of the changes after the intervention was medium-large in pain intensity (d = -1.77), functional capacity (d = 1.34) and gastrocnemius strength (d = 0.76).

CONCLUSION

Myofascial release therapy is a safe form of physical therapy for patients with hemophilia. Myofascial release therapy can effectively complement prophylactic pharmacological treatment in patients with hemophilic arthropathy, improving range of motion in dorsal flexion, functional capacity and gastrocnemius strength.

Effects of Plyometric-Based Hydro-Kinesiotherapy on Pain, Muscle Strength, Postural Stability, and Functional Performance in Children with Hemophilic Knee Arthropathy: A Randomized Trial

AIM

To explore how plyometric-based hydro-kinesiotherapy (Plyo-HKT) would affect pain, muscle strength, postural stability, and functional performance in a convenience sample of children with hemophilic knee arthropathy (HKA).

METHODS

Forty-eight children with HKA (age: 8-16 years) were randomly allocated to the Plyo-HKT group (n = 24; underwent the Plyo-HKT for 45 min, twice/week over 12 wk in succession) or the comparison group (n = 24; performed the standard exercise rehabilitation at an equivalent frequency and duration). Pain, peak concentric torque of quadriceps and hamstring (produced at two angular velocities: 120 and 180 o/sec), dynamic limits of postural stability (DLPS), and functional performance [Functional Independence Score in Hemophilia (FISH) and 6-Minute Walk Test (6-MWT)] were assessed pre- and post-intervention.

RESULTS

In contrast with the comparison group, the Plyo-HKT group achieved more favorable pre-to-post changes in pain (p = .028, η2p = 0.10), peak torque of quadriceps [120°/sec (p = .007, η2P = 0.15); 180°/sec (p = .011, η2P = 0.13)] and hamstring [120°/sec (p = .024, η2P = 0.11); 180°/sec (p = .036, η2P = 0.09)], DLPSdirectional [forward (p = .007, η2P = 0.15); backward (p = .013, η2P = 0.12); affected side (p = .008, η2P = 0.14); non-affected side (p = .002, η2P = 0.20)], DLPSoverall (p < .001, η2P = 0.32), and functional performance [FISH (p < .001, η2p = 0.26); 6-MWT (p = .002, η2p = 0.19)].

CONCLUSION

Plyo-HKT is likely helpful for reducing pain, improving strength, enhancing postural stability, and boosting functional capabilities in children with HKA. Physical rehabilitation practitioners should, therefore, consider this intervention strategy.

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.

The hidden joint in children with haemophilia on prophylaxis

Prophylaxis is the gold standard treatment for children with haemophilia (CWH). MRI studies revealed joint damage, even with this treatment; this suggests the presence of subclinical bleeding. In the case of children with haemophilia, it is relevant to detect early signs of joint damage, as this allows the medical team to provide the appropriate treatment and follow-up, in order to avoid arthropathy development and its consequences. The aim of this study is to detect the hidden joint in children with haemophilia on prophylaxis (CWHP) and analyse, by age group, which joint is the most affected. We define the hidden joint in CWH on prophylaxis as the joint that presents joint damage secondary to repetitive bleeding episodes and is detected in the joint evaluation, despite being asymptomatic or with mild symptoms. It is most commonly caused by repetitive subclinical bleeding.

METHODS

This was an observational, analytical, cross-sectional study of 106 CWH on prophylaxis treated in our centre. Patients were divided according to age and type of treatment. Joint damage was defined as a HEAD-US score ≥ 1.

RESULTS

Patients' median age was 12 years. All had severe haemophilia. The median age of onset of prophylaxis was 2.7. Forty-seven (44.3 %) patients received primary prophylaxis (PP) and 59 (55.7 %), secondary prophylaxis. Six hundred and thirty-six joints were analysed. Type of prophylaxis and joint involvement showed statistically significant differences (p < 0.001). However, patients on PP had a greater number of damaged joints at older ages. Twenty-two % (140) of the joints scored ≥1 on HEAD-US. Cartilage was most frequently involved, followed by synovitis, and bone damage. We observed a greater frequency and degree of arthropathy in subjects aged 11 and above. Sixty (12.7 %) joints showed a HEAD-US score ≥ 1, with no history of bleeding. The ankle was the most affected joint, representing the hidden joint according to our definition.

CONCLUSION

Prophylaxis is the best treatment for CWH. However, symptomatic or subclinical joint bleeding may occur. The routine evaluation of joint health is relevant, particularly, of the ankle. In our study, early signs of arthropathy according to age and type of prophylaxis were detected by HEAD-US.

Hemophilic Arthropathy: Barriers to Early Diagnosis and Management

Hemophilia is a congenital coagulopathy characterized by a deficiency of one of the clotting factors. It is characterized by the development of hematomas and hemarthrosis, either spontaneously or after minor trauma. The recurrence of hemarthroses leads to progressive and degenerative joint damage from childhood (hemophilic arthropathy). This arthropathy is characterized by disabling physical effects that limit the functionality and quality of life of these patients. Medical progress achieved over the last decade in the drug treatment of hemophilia has improved the medium and long-term prospects of patients with more effective and long-lasting drugs. The universal use of safer, more effective and prolonged prophylactic treatments may promote the prevention of bleeding, and also therefore, of the development of hemarthrosis and joint damage. A number of imaging instruments have been developed for the assessment of hemarthrosis and hemophilic arthropathy, using ultrasound, magnetic resonance imaging and simple radiology. Different physical examination scores and questionnaires allow the assessment of joint health, self-perceived activity and functionality of patients with hemophilia. The approach to these patients should be interdisciplinary. Assessment of the processes that affect pain in these patients and the development of pain education models should be implemented. Expert advice and information to patients with hemophilia should be based on individual functional prevention diagnoses, advice on available therapies and sports practice, as well as health recommendations.

Total Hip Replacement in Severe Haemophilia A: Challenges and Feasibility

The management of haemophilic patients is complicated due to multiple comorbidities. A dedicated haemophilia treatment centre with a multidisciplinary team can plan and execute elective orthopaedic surgery in such haemophilic individuals. A cementless total hip arthroplasty (THA) was performed in a 26-year-old male patient with haemophilic arthropathy of the right hip under factor VIII replacement therapy based on activated partial thromboplastin time levels. The patient received a preoperative dose of recombinant anti-haemophilic factor. Venous thromboembolic event prophylaxis was not given. Postoperative radiographs demonstrated successful prosthesis placement. The patient could bear weight and walk unassisted two weeks after surgery. THA in patients with haemophilia leads to significant improvement in joint function with a relatively low incidence of complications with modern techniques and haematological management.

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

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.

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

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

Anatomical bone structure differences in patients with hemophilic arthropathy of the knee

Objectives:

The anatomical differences of the bony structure of the knee joint in patients with hemophilia were evaluated, and the results were compared with the knees of patients with primary gonarthrosis and no arthrosis.

Material and Methods:

This study reviewed 41 knees in 21 patients (with an Arnold-Hilgartner classification of Stages 4 and 5 hemophilic arthropathy) who underwent total knee arthroplasty in single center. Two control groups including 21 asymptomatic patients (42 knees) and 21 primary knee osteoarthritis patients (42 knees) were formed to compare the measurements with hemophiliacs. Femoral mediolateral width, femoral anteroposterior width, femur and tibia diaphysis width, adductor tubercle-joint line distance, tibial plateau width, and medial and lateral tibia plateau width were measured separately.

Results:

Femoral mediolateral width was significantly narrow comparing with healthy individuals and primary knee osteoarthritis group. Tibial plateau was similar to asymptomatic group but significantly narrow compared with primary knee osteoarthritis group. With the correlation, the tibial plateau measurements and medial and lateral plateau were significantly narrow at hemophilic arthropathy group (P < 0.05). The slope was less in hemophilic patients as compared with asymptomatic individuals (P: 0.001). Hemophilic patients had larger femoral aspect ratios than asymptomatic group but there were no observable differences with the primary osteoarthritis group. For the tibial aspect ratios, hemophilic had a smaller ratio than the primary osteoarthritis group but there were no significant differences with the asymptomatic group.

Conclusion:

Hemophilic knee has a mismatch between femoral and tibial side while comparing with the other groups.

Level of Evidence:

Level IV, cross-sectional study.

Perioperative blood loss during joint replacement: comparison between patients with and without hemophilia

Background

Although arthroplasty provides satisfactory pain relief, functional improvement, and reduced flexion contracture in patients with hemophilia arthropathy, bleeding remains the primary problem associated with hemophilic arthropathy joint replacement. We aimed to explore the differences in perioperative blood loss (PBL) associated with joint replacement surgery in patients with and without hemophilia.

Methods

This study retrospectively analyzed 61 cases of PBL in patients undergoing joint replacement surgery, including 37 patients with hemophilia and 24 patients without hemophilia. All patients demonstrated severe joint flexion contractures that seriously affected their daily lives and required surgical intervention. PBL was compared between the two groups.

Results

In univariate analysis, the overall (p < 0.001) and hidden (p < 0.001) blood losses were significantly higher for patients with hemophilia than those for patients without hemophilia. However, after adjustment for multiple factors, there was no significant difference in overall blood loss between the two groups (p = 0.731). In addition, sex, age group, and surgical site did not affect blood loss in patients with hemophilia.

Conclusion

Overt bleeding did not increase significantly in patients with hemophilia, compared with that in patients without hemophilia. In terms of blood loss, joint replacement surgery for patients with hemophilia is relatively safe. The results of this study must be verified by a prospective follow-up study with larger sample size.

Trial registration Retrospectively registered.

Study on the morphological characteristics and rotational alignment axis of placement plane of the tibial component in total knee arthroplasty for hemophilia-related knee arthritis

Background

Abnormal epiphyseal growth plate development of the proximal tibia in hemophilia patients leads to notable morphological changes in the mature knee joint. This study aimed to compare the morphological characteristics of tibial component placement cut surface in patients with hemophilic arthritis (HA) and osteoarthritis (OA) and to determine the tibial component rotational alignment axis’ best position for HA patients.

Methods

Preoperative computed tomography scans of 40 OA and 40 HA patients who underwent total knee arthroplasty were evaluated using a three-dimensional (3D) software. The tibial component’s placement morphological parameters were measured. The tibial component’s rotational mismatch angles were evaluated, and the most appropriate 0°AP axis position for HA patients was investigated.

Results

In the two groups, the morphology was significantly different in some of the parameters (p < 0.05). The tibial component rotational mismatch angles were significantly different between both groups (p < 0.05). The medial 9.26° of the medial 1/3 of the patellar tendon was the point through which 0°AP axis passed for the HA patients. Similarly, the medial 13.02° of the medial 1/3 of the tibial tubercle was also the point through which the 0°AP axis passed.

Conclusions

The ratio of the anteroposterior length to the geometric transverse length of the placement section of the tibial component in HA patients was smaller than that in OA patients. The medial 9.26° of the medial 1/3 of the patellar tendon or the medial 13.02° of the medial 1/3 of the tibial tubercle seem to be an ideal reference position of the rotational alignment axis of the tibial component for HA patients.

Bilateral Pseudoarthrodesis: A Case Report of Complex Bilateral Total Knee Replacement for a Severe Hemophilia A Patient with Inhibitors

CASE

We present a severe hemophilia A patient with high titers of inhibitors presenting stage IV knee arthropathy with functional bilateral arthrodesis. On presentation, his mode of ambulation was to project himself forward without the benefit of any significant ankle motion. Total knee arthroplasty was performed on both knees and allowed significant improvement in the range of motion of both knees from 5° to 100°.

CONCLUSION

Although hemophilic patients with inhibitors can represent complex cases, successful outcomes can be achieved in a multidisciplinary team setting. However, we would recommend performing this type of surgery at an earlier stage when less extensive muscle and tendon release is required.

Pathological changes and expression of lysine oxidases and matrix metalloproteinases -1, -2, and -3 in ligaments of patients with haemophilic arthritis

INTRODUCTION

Studying the pathological changes of ligaments in patients with haemophilic arthritis (HA) has important significance for guiding the release of ligaments during total knee arthroplasty (TKA) and exploring interventions to prevent ligament lesions.

AIM

This study was conducted to show the pathological changes and investigate the lysine oxidase (LOX) and matrix metalloproteinase (MMP)-1, -2, and -3 levels in the ligaments of patients with HA compared with those of patients with osteoarthritis (OA).

METHODS

Ligaments obtained during the TKA were stained with Masson trichrome, Verhoeff-Van Gieson and haematoxylin and eosin to show the basic pathological changes. Collagen I, elastin, LOXs and MMP-1, -2, and -3 expression levels were detected via western blot. LOX and MMP-1, -2, and -3 mRNA expression levels were analysed via quantitative real-time PCR.

RESULTS

Compared with OA ligaments, HA ligaments were constructed more loosely with wider gaps, more breaks, haemocytodeposition and local hypertrophy among the fibres. LOXs and MMP mRNA expression levels were upregulated in the HA tissues, which was consistent with the western blot results. Collagen I and elastin levels were also higher in patients with HA.

CONCLUSIONS

The metabolism of the ligaments in patients with HA is more complex than in those with OA, and the ligaments of patients with HA have stronger healing and destruction processes. This pathology is related to iron overload and imbalanced inflammatory factors due to repeated intra-articular bleeding.

Hemophilic arthropathy: Current knowledge and future perspectives

Hemophilia A and B are rare X-linked inherited bleeding disorders caused by complete or partial deficiency in or the absence of coagulation factors VIII and IX. Recurrent joint bleeding (hemarthrosis) is the most frequent clinical manifestation of severe hemophilia. Unless appropriately managed, even subclinical hemarthrosis can lead to the development of hemophilic arthropathy, a disabling condition characterized by joint remodelling, chronic pain, and a reduced quality of life, and eventually requires joint replacement. Given the lack of specific treatments to reduce blood-induced synovitis, the prevention of bleeding is pivotal to the maintenance of joint health. Prophylactic coagulation factor replacement therapy using extended half-life recombinant drugs has significantly improved patients' quality of life by reducing the burden of intravenous injections, and the more recent introduction of nonreplacement therapies such as subcutaneous emicizumab injections has improved treatment adherence and led to the greater protection of patients with hemophilia A. However, despite these advances, chronic arthropathy is still a significant problem. The introduction of point-of-care ultrasound imaging has improved the diagnosis of acute hemarthrosis and early hemophilic arthropathy, and allowed the better monitoring of progressive joint damage, but further research into the underlying mechanisms of the disease is required to allow the development of more targeted treatment. In the meantime, patient management should be based on the risk factors for the onset and progression of arthropathy of each individual patient, and all patients should be collaboratively cared for by multidisciplinary teams of hematologists, rheumatologists, orthopedic surgeons, and physiotherapists at comprehensive hemophilia treatment centers.

Clinical and ultrasound evaluation of patients with haemophilia on prophylaxis

INTRODUCTION

Primary prophylaxis is the current gold standard in haemophilia care for the prevention of bleeding and ensuing joint damage. Early detection of joint bleeding, whether symptomatic or subclinical, preferably during childhood, helps prevent joint deterioration and subsequent disability. The aim of this study is to evaluate the level of agreement between the Haemophilia Joint Health Score and the Haemophilia Early Arthropathy Detection with Ultrasound tools in children with severe haemophilia on primary and secondary prophylaxis.

MATERIALS AND METHODS

All patients were followed up regularly at our centre. Elbows, knees and ankles were evaluated by physical examination using the Haemophilia Joint Health Score 2.1 (HJHS 2.1), and by ultrasound with HEAD-US score.

RESULTS

A total of 80 children with haemophilia on prophylaxis were included in this study. Mean age was 10.8 years (range 4-18). We evaluated 480 joints, of which 423 (88.1%) were concordant with both tools, whereas 57 (11.9%) were discordant; 377 (78.5%) joints scored 0 on HJHS, 370 (77%) on HEAD-US and 345 (72%) on both tools. The overall Kappa concordance coefficient was .656. For elbows, knees and ankles the respective values were .783, .522 and .589. For HJHS scores greater than 3, all joints scored ≥1 on HEAD-US.

CONCLUSION

HJHS and HEAD-US are used to assess joint health in children with haemophilia on prophylaxis. In this study, the level of agreement between both tools was consistent with literature values only for the elbow joint.

Cementless total hip arthroplasty in haemophilia patients through direct anterior approach

INTRODUCTION

Total hip arthroplasty (THA) has become the treatment of choice for patients with severe haemophilic arthropathy of the hip. However, the intraoperative and postoperative complications, including blood loss and infection, are significant concerns. Direct Anterior Approach (DAA) might be beneficial in THA of patients with haemophilia.

AIM

The present study was conducted to assess outcomes of THA using DAA in patients with haemophilia.

METHODS

We retrospectively reviewed our joint replacement database. From January 2010 to December 2015, we had 12 patients with haemophilia who underwent 14 THAs by DAA and followed for an average of 69 months.

RESULTS

All patients were male with a mean age of 36 ± 7 years at the time of THA. The mean Harris Hip Score improved from 46 preoperatively to 89 at the final follow-up visit. One dislocation and one infection occurred. Only one patient with simultaneous bilateral THA needed a transfusion. All components were radiologically well fixed at the final follow-up visit except one acetabular loosening that needed revision. All patients were satisfied with the outcome of the surgery at the final follow-up visit.

CONCLUSION

In this study, it was observed that complications of cementless THA using DAA in haemophilia patients with hip arthropathy are comparable to other surgical approaches. However, the complication of bleeding in this approach might be less.

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.

Outcome measures in Haemophilia: Beyond ABR (Annualized Bleeding Rate)

Options for management of haemophilia are increasing rapidly with completely novel therapeutic approaches that cannot be compared using traditional factor assays. In addition, as prophylaxis regimens have improved, bleeding rates have decreased, and consequently, it is difficult to show an impact of novel therapies on rates of spontaneous bleeding. There is currently an urgent need for a panel of outcome measures to compare therapies that are dissimilar in many essential ways. Conventional objective outcome measures including joint physical examination and joint imaging continue to hold a central importance. Factor assays are essential for evaluation of products derived from native factor genes, but are not applicable to some extended half-life factors or non-factor bypassing agents. Global assays including thrombin generation and chromogenic assays of factor X activation are under investigation for their usefulness in haemophilia assessment. Bleeding rate is a conventional subjective patient-reported outcome that, while decreasing in frequency, is indispensable as an outcome given that the primary manifestation of haemophilia is bleeding. Other patient-reported outcomes such as pain intensity and interference, health-related quality of life and activities and participation are increasingly important to distinguish superior outcomes in comparative trials. This review of outcome measures for haemophilia presents examples of existing outcome measures with an emphasis on their strengths and limitations.

Knee radiosynovectomy with 153Sm-hydroxyapatite compared to 90Y-hydroxyapatite: initial results of a prospective trial

INTRODUCTION

Radiosynovectomy (RS) with ⁹⁰Y-hydroxyapatite (⁹⁰Y-HyA) aims to control knee hemarthrosis in hemophiliac patients to prevent secondary arthropathy. However, knee RS using ¹⁵³Sm-hydroxyapatite (¹⁵³Sm-HyA) is considered less suitable due to the lower average soft tissue range and energy of ¹⁵³Sm for large joints, such as the knees.

PURPOSE

The objective of this investigation was to assess the efficacy and safety of knee RS with ¹⁵³Sm-HyA, compared to ⁹⁰Y-HyA.

METHODS

Forty patients were prospectively assigned to undergo knee RS with ¹⁵³Sm-HyA (n = 19) or with ⁹⁰Y-HyA (n = 21). The frequency of hemarthrosis episodes before and after treatment were compared.

RESULTS

After six months of knee RS, ¹⁵³Sm-HyA and ⁹⁰Y-HyA promoted a similar reduction of hemarthrosis episodes (50% and 66.7%, respectively). However, after 12 months of knee RS, the reduction of hemarthrosis episodes was significantly (p = 0.037) higher using ¹⁵³Sm-HyA (87.5%) compared to ⁹⁰Y-HyA (50.0%). This discrepancy was more pronounced (p = 0.002) for ¹⁵³Sm-HyA compared to ⁹⁰Y-HyA in adults/adolescents.

CONCLUSION

Knee radiosynovectomy with ¹⁵³Sm-HyA is safe, reduces hemarthrosis episodes after 12 months of treatments, especially in adults/adolescents and even with grades III/IV arthropathy, similar to ⁹⁰Y-HyA. ⁹⁰Y-HyA seems to promote better hemarthrosis control in small children.

Mid-to Long-Term Survival of Total Knee Arthroplasty in Hemophilic Arthropathy

While satisfactory results have been reported during short-to mid-term follow-up assessments of hemophilic patients who have undergone total knee arthroplasty (TKA), limited literature focusing on long-term survival following TKA exists to date. As part of this investigation, a consecutive series of 78 TKAs in 56 patients with hemophilic arthropathy was reviewed. The mean patient age at the time of operation was 38.7 years old and the mean length of follow up was 10.2 years. Clinical and radiologic outcomes, quality of life, complications, and long-term survivorship of TKA were evaluated. At the latest point of follow up, the average American Knee Society (AKS) knee and function scores had improved from 32.1 to 85.7 points and 41.5 to 83.3 points, respectively. Moreover, the average range of motion (ROM) was significantly increased from 64.2° preoperatively to 84.2° postoperatively. The physical and mental Short Form-36 results were also significantly improved at the latest point of follow up. Postoperative complications appeared in 12 knees (15.4%). The readmission rate in the 30 days after discharge was 6.4%. Revision TKA was performed in three knees for periprosthetic joint infection (n = 2 knees) and tibial component loosening (n = 1 knee). The Kaplan-Meier 10- and 13-year prosthesis survival rates were 97.1% and 93.2%, respectively. The current study suggests that the mid-to long-term results of TKA in patients with hemophilic arthropathy are favorable, with successful long-term prosthesis survival achievable in most cases.

Acupuncture as a therapeutic resource for treatment of chronic pain in people with haemophilia

INTRODUCTION

Chronic pain is common in individuals with severe and moderate haemophilia who did not receive prophylaxis during childhood.

OBJECTIVE

To verify the effectiveness of acupuncture in reducing intensity in chronic pain, changes in quality of life, joint function and impact on treatment satisfaction of haemophilia patients.

METHODS

Single-blinded randomized clinical trial with 28 participants divided into two groups: Acupuncture (G1) treated with traditional unilateral acupuncture (side of greatest referred pain) and Control (G2) treated with transcutaneous electrical nerve stimulation (TENS), with electrodes on the joint of most intense pain. Both groups had a 20-minute session per week, total of 05 consecutive sessions. Before starting treatment, participants underwent sociodemographic assessment, physical assessment (HJHS), quality of life questionnaire (Haem-a-Qol) and treatment expectation (Likert scale). After the end of the fifth session, Haem-a-Qol, HJHS and degree of satisfaction (Likert) were performed. The assessment of pain intensity using the visual analogue scale (VAS) was performed before the beginning and after the end of all sessions in both groups. Statistical analysis was performed using ANOVA, Bonferroni, t test and chi-square test (P < .05).

RESULTS

There was a statistical difference within and between groups G1 and G2 in reduction of VAS. In Haem-a-Qol, the groups showed similarity in quality of life. Both groups had high expectations for treatment. G1 presented a better degree of treatment satisfaction than G2. Total HJHS showed no difference within and between groups.

CONCLUSION

Acupuncture was effective in reducing pain intensity in haemophilia patients with chronic joint disease when compared to TENS.

Comparison of Total Ankle Arthroplasty and Ankle Arthrodesis in End-Stage Hemophilic Arthropathy

BACKGROUND

Total ankle arthroplasty (TAA) can result in excellent outcomes in patients with end-stage arthritis, but most patients with end-stage hemophilic ankle arthropathy (ESHAA) still undergo ankle arthrodesis (AA). The purpose of this study was to analyze clinical and radiological results of TAA and AA for ESHAA.

METHODS

A total of 29 cases (16 TAAs and 13 AAs) of painful ESHAA were included. For clinical outcome evaluation, visual analog scale (VAS) for pain, Foot Function Index (FFI), and range of motion (ROM) were analyzed. Postoperative clinical and radiological complications were also analyzed. The mean duration of follow-up was 6.8 ± 3.0 years. The mean age was 44.1 ± 9.9 years.

RESULTS

The VAS for pain was significantly improved from 5.5 ± 2.3 to 0.9 ± 1.2 (P < .001). The FFI scale was significantly improved from 61.6% ± 15.5% to 16.6% ± 15.4% (P < .001). In FFI disability and activity subscales, the TAA group exhibited meaningful outcomes relative to those of the AA group (P = .012 and .036, respectively). The total ROM in the TAA group changed from 30.8 ± 12.6 degrees to 37.3 ± 12.8 degrees at final follow-up (P = .090). Three cases of osteolysis and 1 case of heterotopic ossification were noted in the TAA group. No cases of nonunion were noted in the AA group. Progressive arthrosis of adjacent joints after AA was observed in 1 case.

CONCLUSION

Both TAA and AA in ESHAA exhibited significant improvement in pain based on VAS and FFI scales. Compared to AA, TAA resulted in superior outcomes in FFI disability and activity subscales, suggesting that TAA may be considered as a surgical option alongside AA for ESHAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Pulsed Nd:YAG laser: effects on pain, postural stability, and weight-bearing pattern in children with hemophilic ankle arthropathy

Hemophilic ankle arthropathy features joint pain, impaired postural control, and abnormal weight-bearing pattern. This study was designed to investigate the effects of pulsed Nd:YAG laser on pain, postural stability, and weight-bearing pattern in children with hemophilic ankle arthropathy. Forty children diagnosed with hemophilia type A (age, 8-16 years) were randomly allocated to either the treatment group (n = 20) who received a three-phase active therapy with pulsed Nd:YAG laser thrice/week (total energy was 1500 J) plus a physical exercise program for four consecutive weeks, or the placebo group (n = 20) who received placebo laser plus the physical exercise program. Pain, postural control (i.e., directional control [DC], endpoint excursion [EE], center-of-gravity movement velocity [CoG-MV], and maximum excursion [MXE]), and weight-bearing pattern (i.e., pressure peaks of the hindfoot [PP-HF] and forefoot [PP-FF], and the foot contact area [FCA]) were assessed pre- and post-treatment. The treatment group showed greater improvement in pain (P = .004), DC (P = .02), EE (P = .003), and CoG-MV (P = .003) compared to the placebo group. However, there was no statistically significant difference between both groups regarding the MXE (P = .15). In addition, the treatment group achieved favorable improvements in PP-HF (P = .003), PP-FF (P = .027), and FCA (P = .002) relative to the placebo group. Pulsed Nd:YAG laser is a potentially effective therapy for pain relief, postural control enhancement, and weight-bearing pattern adjustment in children with hemophilic ankle arthropathy.

Pathophysiological Role of Synovitis in Hemophilic Arthropathy Development: A Two-Hit Hypothesis

Despite an increasing access to prophylaxis with clotting factor concentrates, arthropathy still represents the main chronic complication of hemophilia. Whereas previous studies described hemophilic arthropathy (HA) as a degenerative arthropathy, somehow resembling osteoarthritis (OA), most recent evidence suggests that complex inflammatory and immunologic mechanisms are also involved in the pathophysiology of HA. In the present review, we described available data on major mechanisms leading to arthropathic changes in patients with hemophilia, with a specific focus on the role of synovium. The presence of hemosiderin in the joint space induces synovium proliferation, thus leading to formation of several lytic enzymes determining chondrocytes apoptosis and proteoglycans levels reduction. This leads to a direct joint “chemical” damage representing early damages in the pathogenesis of HA (first hit). In parallel, synovial membrane and synovial endothelial cells become a dynamic reservoir of inflammatory cells and mediators, and propagate the inflammatory response (second hit), switching the process from a chemical damage to an inflammatory damage. Overall, consistent data pointed out synovitis as the keystone in HA pathophysiology. This opens novel potential therapeutic targets in this clinical setting.

Prophylaxis for hemophilia A without inhibitors: treatment options and considerations

INTRODUCTION

Hemophilia A is a bleeding disorder traditionally managed with standard half-life (SHL) factor (F) VIII concentrates. Extended half-life (EHL) FVIII products and emicizumab-kywh, a nonfactor therapy, are newer treatment options. Additional nonfactor agents and gene therapy are expected to reach the market in the near future.

AREAS COVERED

A PubMed (MEDLINE) search from 1962 to April 2020 related to hemophilia A, its management, and the products currently available for prophylaxis was performed to comprehensively review these topics and analyze the benefits and drawbacks of each therapeutic.

EXPERT OPINION

Prophylaxis with SHL FVIII concentrates remains the standard of care for patients with severe hemophilia A and may also be considered for selected individuals with moderate disease. Several years of real-world experience with EHL FVIII, emicizumab-kywh, and other agents in development will be necessary to determine their ultimate roles in the prevention of bleeding and its complications. Gene therapy may not provide a permanent cure for hemophilia A.

Chromic phosphate-32 colloid radiosynovectomy for the treatment of haemophilic synovitis: A long-term follow-up study

AIM

We previously reported the outcome of chromic phosphate-32(³² P) colloid synoviorthesis in 53 haemophilic patients with an average follow-up of 31 months. The purpose of the present study was the long-term follow-up of the same cohort on both clinical and radiographic features.

MATERIALS

Nine patients failed to attend the recall appointment. The mean follow-up for the remaining 44 patients (52 procedures) was 15 years (range, 14.6-15.5). The mean age at the time of reassessment was 31 years (range, 18-43).

RESULTS

The haemarthrosis frequency was not statistically significant at the latest follow-up years compared with 31 months (0.8 vs 0.4 per week, P = .3). There was no significant change in the clinical severity of haemophilic arthropathy (P = .5). Most of the treated joints still are in stage III of Fernandez-Palazzi and Caviglia classification. There was a trend towards the radiologic deterioration of arthritis with nearly 50% of patients at Arnold-Hilgartner Stage V. 13% of patients underwent a total knee arthroplasty (TKA). The age at which the initial radiosynovectomy was performed was significantly higher in patients who had a TKA than those who had not (22 vs 15 years, P < .002).

CONCLUSION

The bleeding control effect of 32P on the target joint remains over time; however, it did not appear to halt the progression of radiographic changes in haemophiliacs. It could delay the need for TKA if it performs at the right time.

Musculoskeletal treatment in haemophilia

Haemophilia is a group of coagulation disorders inherited in an X-linked recessive pattern.

Nearly three-quarters of all haemorrhages in haemophilia occur in the musculoskeletal system, usually in the large muscles and joints of the lower extremity.

While prevention of bleeding with active prophylaxis is the recommended optimal therapy for severe haemophilia, there are many patients suffering from musculoskeletal system complications subsequent to uncontrolled bleeding.

Recombinant clotting factor concentrates led to home treatment of acute bleeding episodes as well as allowing for minor and major surgical interventions.

Avoiding of further complications by radiosynoviorthesis is the first-line recommendation, and arthroplasty is regarded as the effective salvage procedure for patients presenting with severe disability.

Physiotherapy and rehabilitation in haemophilia patients are important to return the normal status of joint motion, to regain the muscle strength, to obtain the optimal functional levels and to improve patients’ quality of life.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180068

Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy

INTRODUCTION

Haemophilic ankle arthropathy may cause joint bleeding, pain, stiffness, erosion and progressive motion limitations, including a decreased range of motion (ROM) secondary to anterior osteophyte impingement.

AIM

The purpose of this study was to investigate changes in the ROM and symptoms after synovectomy and anterior osteophyte resection for haemophilic ankle arthropathy.

METHODS

We retrospectively reviewed 41 ankles in 35 patients with haemophilic arthropathy who underwent arthroscopic and/or open synovectomy. The mean follow-up period was 59.5 months. Indications for the procedure included a lack of improvement with conservative management, and the presence of haemarthrosis and arthralgia. We assessed radiographic images, ankle joint range of motion, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and patients' subjective satisfaction preoperatively and at the last follow-up.

RESULTS

Arthroscopic synovectomy was performed in 32 ankles, open synovectomy in 6, and arthroscopic synovectomy with additional mini-open debridement in 3. Ankle dorsiflexion improved from a mean of 2.7° preoperatively to a mean of 7.5° at the final follow-up (P = 0.003), whereas plantar flexion improved from a mean of 30.7° preoperatively to a mean of 32.7° at the final follow-up (P = 0.276). The AOFAS score improved from 62.2 preoperatively to 79.1 at the final follow-up (P < 0.001). Patient satisfaction was "excellent" in 11 ankles, "good" in 22, "fair" in 3 and "poor" in 5.

CONCLUSION

Arthroscopic and/or open synovectomy with anterior osteophyte resection and early rehabilitation in adolescents and adults with haemophilic ankle arthropathy showed improved ankle dorsiflexion and AOFAS scores.

Management of knee flexion contracture in haemophilia with the Ilizarov technique

BACKGROUND

There are limited reports about management of Knee flexion contracture (KFC) in haemophiliacs with Ilizarov technique. The aim of this study was to retrospectively analyzed the results of Ilizarov technique to treat KFC.

METHODS

Six patients with haemophilia A and one with haemophilia B were included in this study, with an average age of 17 years old. The mean preoperative KFC and flexion angle of the knee were 58 ± 21° (mean ± standard deviation) and 127 ± 12°, respectively. Preoperative HSS score (hospital for special surgery knee score) was 51 ± 4. The average time of follow-up was 39.3 ± 23.3 months.

RESULTS

All the patients achieved full correction of flexion contracture at the end of distraction and maintained at the last follow-up. The mean flexion angle at the end of distraction and at the last follow-up were 41 ± 35° and 38 ± 19° respectively, which were significantly lower than preoperative flexion angle. The mean HSS score at the end of distraction and at the last follow-up were 65 ± 4 and 64 ± 2 respectively, which were significantly higher than the preoperative HSS score. One patient suffered from transient numbness of left leg, and all the patients had loss of range of knee flexion at last follow-up.

CONCLUSIONS

Ilizarov is an effective and safe procedure to treat KFC in haemophiliacs. However, loss of knee flexion was the most common complication.

Impact of intermediate-dose prophylaxis on progression of haemarthropathy in patients with severe haemophilia A: A 10-year, single-centre experience in Korea

AIM

To determine the impact of 10-year intermediate-dose prophylaxis on haemarthropathy progression in patients with severe haemophilia A (SHA).

METHODS

Prophylactic treatment with intermediate dose was given maximally for 10 years to 42 patients with SHA in a haemophilia treatment centre in Korea. Patients were divided into three groups based on prophylactic treatment started age: 1-10 (group A'), 11-20 (group B'), and ≥21 (group C'). Average annual increase of Pettersson score (P-score) was compared between the treatment groups.

RESULTS

Average ages and P-scores at initiation of prophylaxis were 4.65±3.43 years and 2.09±3.25, 16.13±1.73 years and 7.37±4.38, and 28.33±7.25 years and 12.33±6.50 for groups A', B', and C'. Average annual increase of P-score in groups A', B', and C' was 0.039±0.11, 0.063±0.123, and 0.078±0.124. Assuming that intermediate-dose prophylaxis started at the average age, P-score and annual increase of P-score would be the average values of each group; it would thus take 210 and 46.5 years to reach -2SD of the average critical level of haemarthropathy (The level of haemarthropathy (P-score 13.0 ± 2.7) above which there is a significant impact on quality of life in Korean) in groups A' and B'. However, it would take 55 and 15.75 years if the annual P-score increase were +2SD of the average value in groups A' and B'.

CONCLUSION

Intermediate-dose prophylaxis for patients with SHA in Korea would maintain arthropathy below the critical level for most of the patients' lifetime when started before adolescence. However, this would not be achieved in some adolescent patients with rapid progression of arthropathy and in most adult patients.

Clinical outcomes of arthroscopic synovectomy for adolescent or young adult patients with advanced haemophilic arthropathy

The aim of the present study was to assess the clinical outcomes of arthroscopic synovectomy in adolescent or young adult patients with advanced haemophilic arthropathy. From January 2009-January 2012, clinical data from 11 adolescent or young adult patients with advanced haemophilic arthropathy who were treated with arthroscopic synovectomy were retrospectively collected. The mean follow-up period was 71.91±5.28 months. The evaluated indicators included frequency of joint bleeding, range of motion (ROM), X-ray staging, hospital for special surgery (HSS) knee score and HSS pain scores. Joint bleeding frequency, pain degree and HSS scores significantly improved following arthroscopic synovectomy at the end of the follow up period. The ROM did not significantly improve. Among the 11 patients, radiographic stage remained unchanged in 9 cases whereas the remaining 2 cases progressed from stage IV to stage V. No patients required total knee arthroplasty through the end of the follow-up period. These findings suggested that arthroscopic synovectomy appears to an effective treatment option to decrease the frequency of bleeding and knee pain, improve knee function and delay knee joint arthroplasty to a certain extent for adolescent or young adult patients with advanced haemophilic knee arthropathy.

Evaluation of early musculoskeletal disease in patients with haemophilia: results from an expert consensus

: Early joint damage in patients with haemarthrosis often escapes diagnosis because of insufficient investigation of biomechanical changes. Arthropathy in haemophilia requires complex assessment with several tools. Considering the increased emphasis on an integrated approach to musculoskeletal (MSK) outcomes, re-evaluation of MSK assessment to address individual patient needs is warranted. To advise on the optimal use of current assessment tools and strategies for tailored MSK evaluation in patients with haemophilia. A panel of experts in haemophilic arthropathy evaluated internationally recognized assessment tools through published literature and personal expertise. Each tool was considered, scored and ranked for their utility in the clinical assessment of MSK damage. Subsequently, a patient evaluation table detailing advice on type and frequency of assessments for different patient populations was constructed. To obtain a complete MSK assessment, multiple tools must be used to ensure each criterion is evaluated. For patients with haemophilia, clinical examination of the joint, disease-specific structure/function scores, and activity/participation scores including quality of life are important, and should be performed on a regular basis according to age and clinical condition. Joint imaging is recommended in the prevention, diagnosis and follow-up of haemophilic arthropathy and should be used in conjunction with joint structure and function scores. An integrated approach to MSK assessment using combinations of tools will allow earlier management of dysfunction and may improve long-term outcomes. This approach could be used in long-term follow-up of all patients independent of age and disease stage, especially in children to prevent arthropathy.

Clinical and Radiological Evaluation After Chemical Synovectomy With Rifampicin in Hemophilic Arthropathy: Korean Experience With a 2-Week Interval Protocol

Objective

To assess the clinical outcome of chemical synovectomy with rifampicin in hemophilic arthropathy by using the World Federation of Hemophilia (WFH) scoring system and plain radiograph.

Methods

We performed rifampicin synovectomy (RS) on 30 joints of 28 hemophilic patients diagnosed as hemophilic arthropathy stage I–III (based on Fernandez-Palazzi clinical classification). Clinical status (bleeding frequency, pain, joint physical status) and radiological staging were evaluated as parts of the WFH scoring system before and 1 year after RS. The patients were divided into two groups by the Arnold-Hilgartner scale of the initial X-ray as stage 3 or less for the low-stage group (n=17) and over 3 for the high-stage group (n=13).

Results

Total WFH joint physical scores were reduced after injection, and the number of bleeding episodes and pain showed especially significant improvement. For other subscores of the WFH joint physical score, only swelling, range of motion, and crepitus showed statistically significant improvement. According to the severity of the radiologic finding, the WFH joint physical score of both the low-stage and high-stage groups showed significant improvement. In the radiological aspect, the low-stage group, without joint space narrowing at the initial plain radiograph, showed no further aggravation after injection. However, in the high-stage group, radiology found aggravation regardless of the procedure.

Conclusion

It is suggested that chemical synovectomy with rifampicin may prevent hemarthrosis and improve clinical symptoms. Especially in the early stage of arthropathy without joint-space narrowing, it seems to have an additional benefit that delays radiological aggravation and preserves joint status.

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.

Long-term results of total elbow arthroplasty in patients with hemophilia

HYPOTHESIS

It was hypothesized that the long-term survivorship and clinical outcome are reasonable, justifying total elbow arthroplasty (TEA) in patients with end-stage hemophilic arthropathy.

METHODS

From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. Type A hemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

RESULTS

After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

CONCLUSIONS

TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Treatment options for haemophilic arthropathy of the elbow after failed conservative therapy

After ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. objective: The objective of this retrospective single centre study is to evaluate the results of treatment of elbow arthropathy after failed conservative therapy. Patients, methods: In 21 consecutive patients, 11 radiosyn-oviortheses (RSO), four arthroscopic and six open synovectomies were performed, among them four with additional resection of the radial head. The mean duration of follow-up was 4.8 (RSO) and 5.3 years (surgery), respectively. Pain status (visual analogue scale, VAS), bleeding frequency, range of motion (ROM) as well as patient satisfaction were evaluated. Results: Both, RSO and surgical synovectomy, achieved a significant reduction of pain and bleeding frequency (p < 0.05). Surgical synovectomies were associated with a marked yet not statistically significant increase of postoperative ROM. Radial head resection improved forearm rotation in all cases. No complications occurred. 20 out of 21 patients were satisfied or highly satisfied with the result of the treatment and would undergo the respective procedure again. Conclusion: Due to the effectiveness and safety RSO is considered to be the primary treatment option in haemophilic arthropathy of the elbow after failed conservative therapy. Arthroscopic synovectomy should be considered if RSO shows inadequate effect or in the presence of contraindications. Open synovectomy with resection of the radial head yields good results in the case of advanced arthropathy with radial head impingement.

Mid-term outcomes and complications of total knee arthroplasty in haemophilic arthropathy: A review of consecutive 131 knees between 2006 and 2015 in a single institute

INTRODUCTION

Although total knee arthroplasty (TKA) in haemophilic arthropathy can reduce severe joint pain and improve functional disability, it is technically demanding.

AIM

To evaluate mid-term outcomes and complications of TKA in haemophilic arthropathy.

METHODS

This study retrospectively reviewed 131 consecutive primary TKAs in a single institute. The mean age was 41.0 years old, and the mean follow-up period was 6.8 years. Clinical and radiographic results were evaluated. Complications were categorized according to the classification system of the Knee Society for TKA complications.

RESULTS

The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre- and postoperative maximum flexion did not differ (80.9° vs 85.6°, respectively). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal positions of the femoral and tibial components and the sagittal positions of these components were within ±3° in 83.2%, 89.3%, 63.4% and 73.3% of cases, respectively. Complications occurred in 17 knees (13.0%): hemarthrosis (n = 7), medial collateral ligament injury (n = 1), stiffness (n = 2), deep periprosthetic joint infection (PJI) (n = 3) and periprosthetic fracture (n = 4).

CONCLUSIONS

The mid-term results of TKA in haemophilic arthropathy were satisfactory in pain relief, improved function and decreased flexion contracture. Bleeding and PJI continue to be major concerns for TKA in haemophilic arthropathy, and risk of periprosthetic fracture must be taken into account for patient education and appropriate prevention.