Knee flexion contracture treated with botulinum toxin type A in patients with haemophilia (PWH)

INTRODUCTION

Knee flexion contracture (KFC) remains a common complication of haemoarthrosis in children and young adults with haemophilia. If the KFC is not treated properly it produces disability, postural and gait abnormalities.

OBJECTIVE

Evaluate the effectiveness of conservative treatment of KFC with Botulinum toxin type A (BTX-A) in PWH.

METHODS

Seventeen patients were treated, with 21 affected knees. Mean age was 26 years. The mean follow up was 12 months. We evaluated flexion and KFC pretreatment BTX-A and up to 12 months posttreatment. BTX-A application was in hamstring and calf muscles. To evaluate the function, a questionnaire about different activities was made, and it was checked 3, 6 and 12 months after BTX-A. According to the degree of KFC, knees were divided into 3 groups: Group 1: -10° to -30° (n = 10), Group 2: -31° to -45° (n = 6) Group 3: -46° or more (n = 5).

RESULTS

The average KFC improved from -38° to -24°. The improvement was 14° (P < 0.001). The average KFC improvement was 9° in group 1, 17° in group 2, and 23° in group 3. There was a high correlation between the improvement in KFC and the total score of the questionnaire R = 0.77.

CONCLUSIONS

Treatment of KFC with BTX-A improves knee-related functional activities, with the advantage of being a low-cost procedure and easy to apply.

Epidemiology of fractures in patients with haemophilia

INTRODUCTION

Haemophilia is an X-chromosome linked inherited bleeding disorder characterised by an anomaly synthesis of coagulation factor VIII (Haemophilia A) or factor IX (Haemophilia B). There is very little information on the magnitude and management of fractures in PWH in the literature regards the advance on replacement therapy. The purpose of this paper is to present our 28 years experience treating PWH who suffered fractures and evaluate the impact of access to treatment.

MATERIALS AND METHODS

In the period 1986-2013, 151 fractures in 141 PWH were treated, 125 patients type A (88.7%), 12 type B (8.5%) and 4 (2.8%) with von Willebrand's disease. For the sake of analysis we divided the fractures in five groups: 1986-1990: 25, 1991-1995: 35, 1996-2001: 33, 2002-2007: 31, and 2008-2013: 27; and classified the fractures in lower limb (LL) and upper limb (UL). We also considered the age at which the fractures occurred.

RESULTS

However the incidence of presentation of the fractures of the upper limb and lower limb changed through the years, being more frequent in the LL in the first period analysed (76% LL vs. 24% UL) and in the UL in the latter one (63% UL vs. 37% LL), the difference was statically significant (p=0.0168). In the relation with the age, the 1986-1990 cohort vs. 2008-2013 cohort reached statistical significance (p: 0.035). Regarding treatment, 121 fractures were treated in a non invasive way, the others 30 fractures, were treated with internal fixation. The patient treated with internal fixation had less mal-alignment, and delay consolidation.

DISCUSSION

This is the largest series of fractures in PWH published. We show a higher incidence of LL fractures in the first period analysed (1986-1990), over time, the ratio LL/UL changed as UL fractures became more frequent. This change is due to the access of the treatment and specifically to the prophylaxis.

CONCLUSION

Fractures in PWH have changed their pattern, becoming more common in the UL than in the LL, lowering the age at which they occur and being less frequent. We believe that the advent of new and accessibly treatments, decreased the development of orthopaedic complications and favours the improvement in quality of life of PWH.

Is it possible to use autologous adipose graft for wound repair in patients with coagulation disorders?

INTRODUCTION

Wound healing is an intricate process whereby the skin repairs itself after injury according to a specific sequence: haemostasis, inflammation, proliferation and remodelling. Cell therapy has the potential to improve wound healing conditions and can be applied in both acute and chronic wounds. Normal healing requires adequate haemostatic function. Patients with coagulation disorders whose haemostatic function is altered may not heal naturally.

AIM

The aim of this study was to show a simple, safe and inexpensive minimally invasive technique for wound repair in patients with coagulation disorders which involves the use of concentrated autologous adipose cells.

PATIENTS AND METHOD

Six patients were enrolled in this study at the Foundation of Haemophilia, in Buenos Aires, Argentina. Five patients had severe haemophilia type A and one had severe von Willebrand diseases. The average age was 37.5 years old. One patient had a retractile scar (RS) and five patients had cutaneous fistulas (CF). Suction was used to obtain autologous adipose graft from subcutaneous abdominal tissue. The graft was centrifuged and, the adipose cell concentrate was transferred to a syringe and injected in the edge of the lesion.

RESULTS

One adipose suction in each patient was performed. There were no intraoperative or postoperative complications in any of the six patients.

CONCLUSIONS

The application of autologous adipose graft is a simple and safe treatment for complicated wound repair in patients with coagulation disorders.

Elective orthopaedic surgery for haemophilia patients with inhibitors: single centre experience of 40 procedures and review of the literature

With the introduction of safe and effective factor VIII/IX-bypassing agents--recombinant activated factor VII (rFVIIa) and plasma-derived activated prothrombin complex concentrates (pd-APCC)--elective orthopaedic surgery (EOS) is a viable option for haemophilia patients with inhibitors. We report a series of patients with haemophilia and inhibitors undergoing EOS between 1997 and 2008 using bypassing agents to provide haemostatic cover. All inhibitor patients undergoing EOS and receiving rFVIIa, plasma-derived prothrombin complex concentrates (pd-PCC) or pd-APCC as haemostatic cover were included. Patients were operated on by the same surgeon and were managed by the same haemophilia treatment centre. Forty procedures (25 minor and 15 major) were conducted in 18 patients. Twenty-one minor cases were covered using rFVIIa, three with pd-PCC, and one with pd-APCC; all major cases were covered using rFVIIa. Bleeding was no greater than expected compared with a non-haemophilic population in all 25 minor procedures. In the major procedure group, there was no excessive bleeding in 40% of cases (6/15) and bleeding completely stopped in response to rFVIIa. For the remaining nine cases, bleeding response to rFVIIa was described as 'markedly decreased' or 'decreased' in 4/15 cases and 'unchanged' in 5/15 cases. Overall, efficacy of rFVIIa, based on final patient outcome, was 85%. One death occurred as a result of sepsis secondary to necrotizing fasciitis. Good control of haemostasis can be achieved with bypassing agents in haemophilia patients with inhibitors undergoing minor EOS; rFVIIa was used as an effective bypassing agent, enabling EOS in patients undergoing minor and major procedures.

Chemical synoviorthesis with rifampicin in haemophilia

Rifampicin is an antibiotic that has been currently used for the treatment of noninfectious articular lesions with satisfactory results. The first experience was performed with patients who presented rheumatoid arthritis, and later with haemophilic patients. The clinical experience of three haemophilia centres which used rifampicin for the treatment of chronic haemophilic synovitis is presented here. The protocols were different. It was observed that rifampicin is more effective when it is used in small joints (elbows and ankles), than when used in bigger ones (knees), and that a high number of injections predicts failure. Mention is also made of experimental studies in animals where it was shown that the healing pattern of rifampicin is similar to that of NSAIDs.

Extensor supracondylar femoral osteotomy as treatment for flexed haemophilic knee

The experience with extensor supracondylar femoral osteotomy as treatment for the flexed haemophilic knee is presented with the description of 19 patients treated during a 30-year period (1968-98). The average age of the patients was 16 (8-35 years), and the average age follow-up was 13 years (3-30 years). Six patients had flexion fixed deformity while the rest presented 40 degrees average range of motion (10-75 degrees). In 13 patients a single osteotomy without internal fixation was performed, in one an osteosynthesis with a condylar plate and in five stabilization was achieved by means of Blount staples. Previous surgery was performed in two patients with patello-femoral ankylosis. The osteotomy site was consolidated in every patient and the deformity was corrected. Two bleeding complications were observed: one haemarthrosis and one psoas haematoma. Flexion relapsed in one patient who underwent another procedure after 12 years. One patient presented with a peroneal nerve paralysis; another one a genu recurvartum; which required flexor osteotomy. The extensor supracondylar femoral osteotomy is a procedure that aligns the limb with scarce modification of articular mobility.

Haemophilic synovitis: is rifampicin an alternative?

Rifampicin synoviorthesis has been empirically used for the treatment of haemophilic synovitis for some time. This paper reports on the experience of three Latin American centers with this treatment and compares it with radioactive synoviorthesis results. Chemical synoviorthesis with rifampicin is best indicated in younger patients (< 15 years) and small joint (ankles and elbows).

Chemical synoviorthesis for hemophilic synovitis

For many years, Rifampicin has been used empirically for the treatment of hemophilic chronic synovitis with encouraging results. A study was performed in which Rifampicin was shown to reduce the inflammation of joints affected by hemophilic synovitis. A clinical study was performed on 48 hemophilic patients (48 joints). Seventeen elbows, eight knees, and 23 ankles were treated. The mean age of the patients was 6 years (range, 4-23 years) and the mean followup was 29 months (range, 24-53 months). Overall, 40 excellent results and eight good results were obtained. The average number of weekly injections of Rifampicin was 3.06 (range, 1-10 injections). Eight patients experienced pain on the first injection, which subsided gradually with the subsequent procedures. Synoviorthesis with Rifampicin seems to be a good method for the treatment of hemophilic synovitis, especially in small joints (elbows and ankles) and in younger children.