Nonunion: general principles and experimental data

Nonunions of long bone fractures can be treated successfully with one operative procedure in more than 90% of patients. In fact, 80% of patients can have good to excellent final restoration of mechanical axis alignment and proper length. Patients with infected nonunions may require more than one procedure to eliminate infection and heal the nonunion. Treatment must be tailored to the individual patient to address all components of the problem. We reviewed the main experimental data regarding the knowledge of nonunions and the basic methods that may be applied to the treatment of nonunions.

Joint protection in haemophilia

Haemarthroses (intra-articular haemorrhages) are a frequent finding typically observed in patients with haemophilia. Diagnosis and treatment of these bleeding episodes must be delivered as early as possible. Additionally, treatment should ideally be administered intensively (enhanced on-demand treatment) until the resolution of symptoms. Joint aspiration plays an important role in acute and profuse haemarthroses as the presence of blood in the joint leads to chondrocyte apoptosis and chronic synovitis, which will eventually result in joint degeneration (haemophilic arthropathy). Ultrasonography (US) is an appropriate diagnostic technique to assess the evolution of acute haemarthrosis in haemophilia, although magnetic resonance imaging remains the gold standard as far as imaging techniques are concerned. Some patients experience subclinical haemarthroses, which eventually tend to result in some degree of arthropathy, especially in the ankles. Nowadays, the most effective way of protecting these patients is primary prophylaxis, which in practice changes severe haemophilia into moderate haemophilia, preventing or at least minimizing the occurrence of haemarthrosis. If primary prophylaxis is, for whatever reason not an option, secondary prophylaxis and enhanced on demand treatment should be considered. Two alternatives are available for inhibitor patients: (i) control of haemostasis using by-passing agents (rFVIIa or aPCCs) either as enhanced on demand treatment or secondary prophylaxis, as appropriate, following the same basic principles used for non-inhibitor patients and (ii) immune tolerance induction (ITI) to eradicate the inhibitor.

Total knee replacement in haemophilic arthropathy

The results of primary total knee replacement performed on a group of haemophiliac patients in a single institution by the same surgeon using the same surgical technique and prosthesis are reported. A total of 35 primary replacements in 30 patients were carried out between 1996 and 2005 and were reviewed retrospectively. The mean age of the patients was 31 years (24 to 42) and the mean follow-up was for 7.5 years (1 to 10). There were 25 patients with haemophilia A and five with haemophilia B. The HIV status and CD4 count were recorded, and Knee Society scores determined. Two patients had inhibitors to the deficient coagulation factor. There were no early wound infections and only one late deep infection which required a two-stage revision arthroplasty, with a good final result. The incidence of infection in HIV-positive and negative patients was thus similar. One knee in a patient with inhibitor had excessive bleeding due to a pseudoaneurysm which required embolisation. The results were excellent in 27 knees (77%), good in six (17%) and fair in two (6%). The survival rate at 7.5 years taking removal of the prosthesis for loosening or infection as the end-point was 97%. The mechanical survival of total knee replacements in haemophiliacs is very good. Our results confirm that this is a reproducible procedure in haemophilia, even in HIV-positive patients with a CD4 count > 200 mm(3) and those with inhibitors. Our rate of infection was lower than previously reported. This could be due to better control of the HIV status with highly active anti-retroviral therapy and the use of antibiotic-loaded cement.

Musculoskeletal complications of hemophilia

The most important clinical strategy for management of patients with hemophilia is the avoidance of recurrent hemarthroses by means of continuous, intravenous hematological prophylaxis. When only intravenous on-demand hematological treatment is available, frequent evaluations are necessary for the early diagnosis and treatment of episodes of intra-articular bleeding. The natural history of the disease in patients with poorly controlled intra-articular bleeding is the development of chronic synovitis and, later, multi-articular hemophilic arthropathy. Once arthropathy develops, the functional prognosis is poor. Treatment of these patients should be conducted through a comprehensive program by a multidisciplinary hemophilia unit. Although continuous prophylaxis can avoid the development of the orthopedic complications of hemophilia still seen in the twenty-first century, such a goal has not, so far, been achieved even in developed countries. Therefore, many different surgical procedures such as arthrocentesis, radiosynoviorthesis (radiosynovectomy) (yttrium-90, rhenium-186), tendon lengthenings, alignment osteotomies, joint arthroplasties, removal of pseudotumours, and fixation of fractures are still frequently needed in the care of these patients.

Aspects of current management: orthopaedic surgery in haemophilia

If continuous prophylaxis is not feasible due to expense or lack of venous access, we must aggressively treat major haemarthroses (including arthrocentesis) to prevent progression to synovitis, recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy). For the treatment of chronic haemophilic synovitis, radiosynovectomy should always be indicated as the first procedure. If, after three procedures with 6-month interval, radiosynovectomy fails, an arthroscopic synovectomy must be indicated. Between the second and fourth decades, many haemophilic patients develop joint destruction (arthropathy). At this stage possible treatments include alignment osteotomy, arthroscopic joint debridement, arthrodesis (joint fusion) and total joint arthroplasty. For the hip press-fit uncemented components (hemispherical acetabulum, flanged femoral stem, metal-to-polyethylene) are recommended whilst for the knee a posterior-stabilized (PS) cemented design is advised. Muscular problems must not be underestimated in haemophilia due to their risk of developing compartment syndromes (which will require surgical decompression) and pseudotumours (which will require surgical removal or percutaneous treatment). Regarding patients with inhibitors, the advent of APCCs and rFVIIa has made major orthopaedic surgery possible, leading to an improved quality of life for haemophilia patients. Concerning local fibrin seal, it is not always necessary to achieve haemostasis in all surgical procedures performed in persons with haemophilia. However, it could be a good adjunct therapy, mainly when a surgical field potentially will bleed more than expected (i.e. patients with inhibitors), and also in some orthopaedic procedures (mainly the surgical removal of pseudotumours).

Elective orthopaedic surgery for inhibitor patients

We report on a series of 108 elective orthopaedic surgical procedures. It includes 88 radiosynoviortheses and 20 major orthopaedic procedures, performed on 51 patients at nine centres worldwide. The average age of patients was 28.5 years (range 5-40 years), and the average follow-up time was 2 years (range 1-5 years). There were 82 good results, 15 fair and 11 poor. In the synoviorthesis group (41 patients, 88 synoviortheses) the average age was 14.3 years (range 5-40 years) and the average follow-up was 6.5 years (range 1-10 years). There were 66 good results, 14 fair and eight poor. There were no complications. In the group of major orthopaedic procedures, the average age of the 10 patients was 32.5 years (range 27-40 years), and the average follow-up was 2.3 years (range 1-5 years). There were 16 good results, one fair and three poor. Postoperative bleeding complications occurred in three of the 20 major orthopaedic procedures performed (15% complications rate). They occurred in three patients treated with insufficient doses of recombinant activated factor VII. Despite such complications, the study has shown that haemophilic patients with inhibitors requiring elective orthopaedic surgery (EOS) can undergo such procedures with a high expectation of success. In other words, EOS is now possible in haemophilic patients with inhibitors, leading to an improved quality of life for these patients. Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Instability following total knee arthroplasty

Background Knee prosthesis instability (KPI) is a frequent cause of failure of total knee arthroplasty. Moreover, the degree of constraint required to achieve immediate and long-term stability in total knee arthroplasty (TKA) is frequently debated. Questions This review aims to define the problem, analyze risk factors, and review strategies for prevention and treatment of KPI. Methods A PubMed (MEDLINE) search of the years 2000 to 2010 was performed using two key words: TKA and instability. One hundred and sixty-five initial articles were identified. The most important (17) articles as judged by the author were selected for this review. The main criteria for selection were that the articles addressed and provided solutions to the diagnosis and treatment of KPI. Results Patient-related risk factors predisposing to post-operative instability include deformity requiring a large surgical correction and aggressive ligament release, general or regional neuromuscular pathology, and hip or foot deformities. KPI can be prevented in most cases with appropriate selection of implants and good surgical technique. When ligament instability is anticipated post-operatively, the need for implants with a greater degree of constraint should be anticipated. In patients without significant varus or valgus malalignment and without significant flexion contracture, the posterior cruciate ligament (PCL) can be retained. However, the PCL should be sacrificed when deformity exists particularly in patients with rheumatoid arthritis, previous patellectomy, previous high tibial osteotomy or distal femoral osteotomy, and posttraumatic osteoarthritis with disruption of the PCL. In most cases, KPI requires revision surgery. Successful outcomes can only be obtained if the cause of KPI is identified and addressed. Conclusions Instability following TKA is a common cause of the need for revision. Typically, knees with deformity, rheumatoid arthritis, previous patellectomy or high tibial osteotomy, and posttraumatic arthritis carry higher risks of post-operative instability and are indications for more constrained TKA designs. Instability following TKA usually requires revision surgery which must address the cause of the instability for success.

Haemophilic cysts (pseudotumours)

It is very likely that with the advent of widespread maintenance therapy, pseudotumours will be less common in the future. It is important that they are diagnosed early, and prevention of muscular haematomas is the key to reducing their incidence. There are a number of therapeutic alternatives for this dangerous condition: surgical removal, percutaneous management, exeresis and filling of the dead cavity, irradiation, and embolization. The management of a patient with a haemophilic pseudotumour is complex, with a high rate of potential complications. Surgical excision is the treatment of choice but should only be carried out in major haemophilia centres by a multidisciplinary surgical team. The main postoperative complications are death, infection, fistulization, and pathological fractures (even requiring amputations of affected limbs). Pelvic pseudotumours can even become complicated by fistulization to the large bowel and by obstruction of the ureters. Untreated, proximal pseudotumours will ultimately destroy soft tissues, erode bone, and may produce neurovascular complications.

Radiosynovectomy in haemophilia: long-term results of 500 procedures performed in a 38-year period

BACKGROUND

Radiosynovectomy (RS) can reduce the number of haemarthroses in chronic haemophilic synovitis. The purpose of this study was to assess the effectiveness of RS in terms of the objective improvement of five parameters (number haemarthroses, articular pain, degree of clinical synovitis, clinical score of the World Federation of Haemophilia (WFH), and radiological score of the WFH.

METHODS

In a 38-year period (1976-2013), five hundred radiosynovectomies were performed in 443 joints of 345 patients with haemophilia diagnosed with chronic synovitis. The mean patient age was 23.7 years (range, 6-53). The mean follow-up was 18.5 years (range: 6 months-38 years). The RS was carried out with either yttrium-90 or rhenium-186. We performed 1 to 3 injections (RS-1, RS-2, RS-3), with a 6-month interval between them.

RESULTS

RS resulted in significant improvement in all the parameters studied, except in the WFH radiologic score that showed no improvement. On average, the number of haemarthroses decreased by 64.1% and articular pain decreased by 69.4%. The degree of synovitis showed a reduction of 31.3%. The WFH clinical score revealed an improvement of 19%. The WFH radiological score showed no improvement. There were four complications (0.9%) of RS. Twenty-eight (6.3%) joints eventually had to be subjected to arthroscopic synovectomy or total knee replacement (TKR). No cancer was observed in this group of patients during the 38-year period.

CONCLUSIONS

Radiosynovectomy (RS) is an effective, safe, minimally invasive, well tolerated procedure in the long-term for the treatment of chronic haemophilic synovitis. Moreover, it is very easy to perform. The knee required more injections than the elbow or the ankle and more severe synoviums required a higher number of RS procedures.

The haemophilic pseudotumour

The orthopaedic management of severe haemophilia is mainly concerned with intra-articular and intramuscular bleeding. Pseudotumour is a serious, but very rare, complication; it is a progressive cystic swelling involving muscle, produced by recurrent bleeding and accompanied by radiographic evidence of bone involvement. Ultrasonography, CT scan, MRI and vascular injection studies should be undertaken, but preoperative biopsy is contraindicated. Most pseudotumours are seen in adults and occur near the large bones of the proximal skeleton. However, a number develop distal to the wrist and ankle in younger patients before skeletal maturity. If untreated, proximal pseudotumours will destroy soft tissues, erode bone and produce vascular or neurological lesions. Surgical removal is the treatment of choice when it can be carried out in major haemophilia centres, and has a mortality rate of 20%. Regression, but not a true cure, may occur with long term replacement therapy and immobilisation; this conservative treatment is not recommended except in patients with high-titre inhibitors in whom operation is not a possibility. In these cases, percutaneous evacuation and filling with a fibrin seal or cancellous bone, depending on the size of the cavity, should be carried out. Distal pseudotumours should be treated primarily with long term factor replacement and cast immobilisation because they may respond to many modalities of conservative management. The presence of one or more progressively enlarging masses in the limbs or pelvis of a haemophiliac should raise the suspicion of a pseudotumour, although chondrosarcoma and liposarcoma have occurred in such patients.

Knee instruments and rating scales designed to measure outcomes

In this article, the knee instruments and rating scales that are designed to measure outcomes are revised. Although the International Knee Documentation Committee Subjective Knee Form can be used as a general knee measure, no instrument is currently universally applicable across the spectrum of knee disorders and patient groups. Clinicians and researchers looking to use a patient-based score for measurement of outcomes must consider the specific patient population in which it has been evaluated. The Western Ontario and McMaster Universities Osteoarthritis Index is recommended for the evaluation of treatment effect in persons with osteoarthritis (OA). This is a generic health status questionnaire that contains 36 items, is widely used, and easy to complete. The Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire evaluates the functional status and quality of life (QoL) of patients with any type of knee injury who are at increased risk of developing OA; i.e., patients with anterior cruciate ligament (ACL) injury, meniscus injury, or chondral injury. So far, the KOOS questionnaire has been validated for several orthopedic procedures such as total knee arthroplasty, ACL reconstruction, and meniscectomy. The utilization of QoL questionnaires is crucial to the adequate assessment of a number of orthopedic procedures of the knee. The questionnaires are generally well accepted by the patients and open up new perspectives in the analysis of prognostic factors for optimal QoL of patients undergoing knee surgery.

Consensus perspectives on surgery in haemophilia patients with inhibitors: summary statement

Summary. Participants in an international workshop on surgery in haemophilia patients with inhibitors developed a consensus summary of the findings and conclusions of the meeting. In the consensus, participants agreed upon revised definitions for minor and major surgery, including an intermediate degree of surgery. An evaluation system of intraoperative and postoperative bleeding was developed. Recommended doses of FEIBA((R)) and rFVIIa (both in bolus injections and in continuous infusion) for surgery were agreed. Participants also agreed on the main blood tests to be performed peri-operatively. They also suggested the need of a prospective evaluation in the future. Finally, the approximate number of surgical procedures and costs performed on haemophilia patients with inhibitors were analysed.

The haemophilic ankle

Radiation synoviorthesis is a very effective procedure that decreases both the frequency and the intensity of recurrent ankle bleeds related to ankle synovitis. The procedure should be performed as soon as possible to minimize the degree of articular cartilage damage. It can also be used in patients with inhibitors with minimal risk of complications. On average, the efficacy of the procedure ranges from 76% to 80%, and can be performed at any age. The procedure slows the cartilaginous damage which intra-articular blood tends to produce in the long term. After 30 years of using radiation synovectomy worldwide, no damage has been reported in relation to the radioactive materials. Radiation synovectomy is currently the preferred procedure when radioactive materials are available; however, chemical synoviorthesis is an effective alternative method if radioactive materials are not available. Personal experience and the general recommendation among orthopaedic surgeons and haematologists is that when three early consecutive synoviorthesis (repeated every 3 months) fail to halt synovitis, a surgical synovectomy (open or by arthroscopy) should be immediately considered. For advanced haemophilic arthropathy of the ankle, the best solution is an ankle arthrodesis. Primary prophylaxis and radioactive synoviorthesis are the best ways that we have today of protecting against haemophilic synovitis and arthropathy of the ankle joint.

Emicizumab: Review of the literature and critical appraisal

INTRODUCTION

Emicizumab-kywh (ACE910) is a recombinant, humanized, asymmetric bispecific antibody that functions to bring activated FIX (FIXa) and zymogen FX into an appropriate steric conformation to medicate the activation of FX to FXa thereby mimicking the cofactor function of FVIIIa.

AIM

The objective of this manuscript was to review the development and potential role for emicizumab in the treatment of patients with haemophilia A with and without inhibitors.

METHODS

A Cochrane Library and PubMed (MEDLINE) search focusing on emicizumab in haemophilia was conducted.

RESULTS

In total, 37 citations were retrieved and serve as the database for the literature reviewed herein. Once-weekly subcutaneous injection of emicizumab at three dose levels has been shown to be effective as prophylaxis to prevent bleeding in a majority haemophilia A patients with inhibitors to FVIII. Likewise, prevention of bleeding was also observed in more than two thirds of patients without inhibitors to FVIII. One antidrug antibody to emicizumab has been reported in over 600 treated patients, two have developed thromboembolic events and three thrombotic microangiopathy. These thrombotic complications have occurred in conjunction with FVIII-bypassing agents, and none have been observed following recommendations from the manufacturer regarding concomitant use of bypassing agents. The median annual treated bleeding rates were decreased in patients with as well as those without an inhibitor to FVIII.

CONCLUSION

The principal advantage of emicizumab is subcutaneous administration and effectiveness irrespective of the presence of inhibitors. Emicizumab could conceivably represent a new epoch in the treatment of people with haemophilia A.

Topical therapies for knee osteoarthritis

BACKGROUND

Symptomatic knee osteoarthritis (OA) involves millions of adults around the world.

PURPOSE

To analyze the effectiveness and tolerability of topical therapies and their contemporary placement in knee OA management criteria.

METHODS

A Cochrane Library and PubMed (MEDLINE) search related to the role of topical therapies in knee OA was carried out.

RESULTS

Many types of local therapy have been reported, including nonsteroidal anti-inflammatory drugs (NSAIDs) like diclofenac and ketoprofen; capsaicin, cream containing glucosamine sulfate, chondroitin sulfate, and camphor; nimesulide; civamide cream 0.075%; menthol; drug-free gel containing ultra-deformable phospholipid vesicles (TDT 064); 4Jointz utilizing Acteev technology; herbal therapies; gel of medical leech (Hirudo medicinalis) saliva extract; and gel prepared using Lake Urmia mud. One systematic review showed that topical diclofenac and topical ketoprofen can alleviate pain. However, another systematic review found that topical diclofenac and ketoprofen had limited efficacy in knee OA at 6 to 12 weeks. Many studies with a low level of evidence have reported some pain mitigation using the rest of aforementioned topical therapies.

CONCLUSIONS

Although some controversy exists on the role of topical NSAIDs, current management guidelines advise topical NSAIDs as an option and even first-line therapy for knee OA treatment, particularly among elderly patients. Topical NSAIDs may be contemplated as similar options to oral NSAIDs and are associated with fewer gastrointestinal complications when compared with oral NSAIDs. Caution should be taken with the use of both topical and oral NSAIDs, including close adherence to dosing regimens and monitoring, especially for patients with previous complications of NSAIDs. The role of other topical therapies needs further research.

The treatment of patellar tendinopathy

BACKGROUND

Patellar tendinopathy (PT) presents a challenge to orthopaedic surgeons. The purpose of this review is to revise strategies for treatment of PT MATERIALS AND METHODS: A PubMed (MEDLINE) search of the years 2002-2012 was performed using "patellar tendinopathy" and "treatment" as keywords. The twenty-two articles addressing the treatment of PT with a higher level of evidence were selected.

RESULTS

Conservative treatment includes therapeutic exercises (eccentric training), extracorporeal shock wave therapy (ESWT), and different injection treatments (platelet-rich plasma, sclerosing polidocanol, steroids, aprotinin, autologous skin-derived tendon-like cells, and bone marrow mononuclear cells). Surgical treatment may be indicated in motivated patients if carefully followed conservative treatment is unsuccessful after more than 3-6 months. Open surgical treatment includes longitudinal splitting of the tendon, excision of abnormal tissue (tendonectomy), resection and drilling of the inferior pole of the patella, closure of the paratenon. Postoperative inmobilisation and aggressive postoperative rehabilitation are also paramount. Arthroscopic techniques include shaving of the dorsal side of the proximal tendon, removal of the hypertrophic synovitis around the inferior patellar pole with a bipolar cautery system, and arthroscopic tendon debridement with excision of the distal pole of the patella.

CONCLUSION

Physical training, and particularly eccentric training, appears to be the treatment of choice. The literature does not clarify which surgical technique is more effective in recalcitrant cases. Therefore, both open surgical techniques and arthroscopic techniques can be used.

Internal fixation of nonunions

We review the two major types of internal fixation of nonunions (plating and intramedullary nailing), and analyze nonunions in different locations (upper and lower extremities). Depending on the type and the location of the nonunion, plating or intramedullary nailing may be selected. Both have advantages and disadvantages: plating requires opening the nonunion site, which entails some damage to the soft tissues, and carries with it a risk of secondary infection. With plating, it often is impossible to do a real decortication because the periosteum may be thin and poorly adherent to bone, and the quality of bone may prove insufficient to achieve good fixation with most of the screws. However, plating still is used in metaphyseal nonunions, and angular deformities may be corrected by applying a plate under tension on the convex side of the bone. Nailing can be done percutaneously in numerous cases; it has a smaller risk of infection but, should an infection be present, there is a risk that it may spread over the entire length of the medullary cavity. Nailing stimulates bone formation, but noninterlocking nails may cause shortening and rotational instability of the nonunion site. Plate fixation was popular approximately 20 years ago, but now has been largely superseded by intramedullary nailing except for proximal or distal nonunions. Dynamic locking nails are preferable. Successful treatment of nonunions often requires several consecutive surgical actions and a global strategy must be established from the beginning, taking care not to interfere with the successive steps.

General principles and indications of synoviorthesis (medical synovectomy) in haemophilia

The indication for a synoviorthesis (medical synovectomy) is chronic haemophilic synovitis causing recurrent haemarthroses, unresponsive to haematological treatment. Synoviorthesis is the intra-articular injection of a certain material to diminish the degree of synovial hypertrophy, decreasing the number and frequency of haemarthroses. There are two basic types of synoviorthesis: chemical synoviorthesis and radiation synoviorthesis. On average, the efficacy of the procedure ranges from 76 to 80%, and can be performed at any age. The procedure slows the cartilaginous damage which intra-articular blood tends to produce in the long term. Synoviorthesis can be repeated up to three times with 3-month intervals if radioactive materials are used (Yttrium-90 and Phosphorus-32), or weekly up to 10-15 times if rifampicin (chemical synovectomy) is used. After 30 years of using radiation synovectomy worldwide, no damage has been reported in relation to the radioactive materials. Radiation synovectomy is currently the preferred procedure when radioactive materials are available, however, rifampicin is an effective alternative method if radioactive materials are not available. Several joints can be injected in a single session, although no more than two joints at the same time is probably the best protocol to follow.

Intra-articular Injections of Hyaluronic Acid and Other Drugs in the Knee Joint

BACKGROUND

Degenerative osteoarthritis of the knee (OA) affects 35% of persons older than 65 years. If pain persists after non-invasive treatment, some intra-articular drugs can be tried before surgical treatment.

QUESTIONS/PURPOSES

The purpose of this article is to review the literature after 2006 with the aim of answering two questions: (1) Are intra-articular injections of corticosteroids (CS), hyaluronic acid (HA) and platelet-rich plasma (PRP) effective in painful knee OA? and (2) Which of these drugs is more effective?

METHODS

The search engines were MedLine and the Cochrane Library. The keywords used were: knee, osteoarthritis, and intra-articular injections. Eight hundred and forty-four articles were found but only 142 had been published after 2006. Of those, only 14 were selected and reviewed because they were strictly focused on the topic and the questions of this article.

RESULTS

The clinical efficacy of intra-articular injections of HA and CS in patients with knee OA has been demonstrated. Pain reduction after three to five weekly injections of HA lasts between 5 to13 weeks (sometimes up to 1 year). Pain reduction is less durable after CS injections (2 to 3 weeks). Recent reports indicate that PRP could have a better performance than HA in younger patients.

CONCLUSIONS

Three to five weekly intra-articular injections of HA are recommendable in patients with knee OA before surgical treatment. CS injections have a very short effect. The efficacy and duration of PRP injections require further studies.

Percutaneous reduction of displaced radial neck fractures in children

Twenty-three children with displaced radial neck fractures were treated by percutaneous reduction with a Steinmann pin after closed reduction failed. Reduction was successfully accomplished in 20 patients. The average age at treatment was 10.5 years (range, 7-13 years). The average length of follow-up was 2.5 years (range, 1-6 years). According to the criteria of Steinberg et al., 14 children (70%) had a good result, three (15%) had a fair result, and three (15%) had a poor result. Percutaneous pin reduction of angulated and displaced radial neck fractures is a simple, safe alternative to open reduction. It appears that when radial head fractures are associated with severe displacement, a moderate rate of fair and poor results (30%) can be expected, despite treatment by percutaneous reduction with a Steinmann pin.

Orthopaedic surgery for inhibitor patients: a series of 27 procedures (25 patients)

We report on a series of 27 orthopaedic surgical procedures. It includes 20 radiosynoviortheses and seven major orthopaedic procedures, performed on 26 patients. The average age of patients was 36 years (range: 8-53) and the average follow-up time was 2.5 years (range:1-5). There were 23 good results and four fair. In the synoviorthesis group (20 patients, 20 synoviortheses) the average age was 13.5 years (range: 9-26) and the average follow-up was 4.5 years (range: 1-7). There were 19 good results and one fair. All synoviortheses were done with activated prothrombin complex concentrates (FEIBA), all the responses being good except in one case (which had the final fair result). The total dose of FEIBA used was 600 IU kg(-1,) except in a patient that had a haemorrhagic complication. In fact, he required a prolongation of treatment up to a total dose of 2000 IU kg(-1). In the group of major orthopaedic procedures, the average age of the six patients was 30.5 years (range: 11-53) and the average follow-up was 2.5 years (range: 1-5). There were six good results and one fair. Postoperative bleeding complications occurred in one of the seven major orthopaedic procedures performed (arterial pseudoaneurym after a total knee arthroplasty). Despite such complication, which had the final fair result, our study has shown that haemophilic patients with high inhibitor titres requiring orthopaedic surgery can undergo such procedures with a high expectation of success. In other words, orthopaedic surgery is now possible in haemophilia patients with high-titre inhibitors, leading to an improved quality of life for these patients.

The haemophilic pseudotumour

The management of the patient with a haemophilic pseudotumour is complex and carries a high rate of potential complications. There are a number of therapeutic alternatives for this dangerous condition: embolization, radiation, percutaneous management, surgical removal and exeresis, and filling of the dead cavity. It is hoped that with the advent of widespread maintenance therapy, pseudotumours will be less common in the future. It is important that they are diagnosed early, and prevention of muscular haematomas is key to reducing their incidence. Untreated, proximal pseudotumours will ultimately destroy soft tissues, erode bone and may produce neurovascular complications. Surgical excision is the treatment of choice but should only be carried out in major haemophilia centres by a multidisciplinary surgical team.

Ankle surgery in haemophilia with special emphasis on arthroscopic debridement

Various conservative options are available to treat ankle problems in haemophilia, which achieve a high rate of satisfactory results in the majority of cases. They are usually employed in combination and include the use of patellar tendon bearing (PTB) orthoses and radiosynoviorthesis. The effect of the PTB orthoses is that it allows the patient to walk without weight bearing of the ankle. Radiosynoviorthesis can be performed in cases of haemophilic arthropathy of the ankle, provided there is at least a minimal degree of synovitis within the joint, with a 75% of satisfactory results. If the conservative options fail, surgical intervention can be indicated. Alternatives to total ankle arthroplasty or arthrodesis include arthroscopic debridement, removal of osteophytes of the anterior aspect of the distal tibia and peri-articular osteotomies to correct angular, rotational or translational malalignment. Ankle arthrodesis is the standard technique for end-stage ankle arthropathy. Arthroscopic debridement of the ankle with haemophilic arthropathy can offer temporary relief; however, it is important to stress to patients that the degree of improvement is limited. The complication rate in ankle arthroscopy is high compared with other joints, which is especially true for neurological complications and postoperative infections. Orthopaedic procedures are not very frequent in the haemophilic ankle, because the majority of problems can be solved satisfactorily by conservative means (radiosynoviorthesis and PTB orthosis).

Therapeutic options in the management of articular contractures in haemophiliacs

Haemophilic contracture is seen most commonly as an equinus deformity of the ankle, or at the knee or elbow in the form of a flexion deformity. Treatment options are varied, and decision-making is based on the degree of the contracture, its chronicity, the presence of articular subluxation, the patient's ability to participate in treatment, and the available medical facilities. The treatments available fall into four categories: physiotherapy, orthotics, corrective devices, and surgical procedures. Treatment should be primarily by physiotherapy, splintage, and corrective devices. The late or severe case may require surgical correction in the form of soft-tissue procedures. Soft-tissue correction of muscle shorthening may be performed such as lengthening of the Achilles tendon for equinus deformity of the ankle, or hamstring release of the flexor muscles of the knee. Lower femoral osteotomy has been used for correction of flexion deformity at the knee joint. Mechanical distraction using external fixators for treatment of severe knee flexion contractures has been recently reported with satisfactory results. The main principle underlying the treatment of haemophilic contracture is the restoration of the patient's lifestyle and mobility, rather than anatomic or radiographic normality.

Surgical wound healing in bleeding disorders

Animal experiments have shown that a number of bleeding disorders may affect wound healing (WH), including haemophilia B, deficiency of factor XIII and abnormalities of fibrinogen. Therefore, normal healing requires adequate haemostatic function for the appropriate time frame (up to 4 weeks in the clean and uncontaminated wound). Many factors may affect WH, including impaired haemostasis, diabetes, poor nutrition, insufficient oxygenation, infection, smoking, alcoholism, old age, stress and obesity. The gold standard for the correct care of surgical wounds in patients with bleeding disorders includes wound dressing and comprehensive standard care (haemostasis, nutritional support, treatment of co-morbidities, offloading, reperfusion therapy and compression). Although complications of surgical wounds healing in patients with bleeding disorders are uncommon, a low level of the deficient factor for an insufficient period of time could cause WH complications such as haematomas, infection, and skin necrosis and dehiscence. Clinical experience and animal experiments appear to indicate that, to get a satisfactory healing of surgical wounds and avoid potential complications of WH, a good level of haemostasis is necessary for 2-3 weeks after surgery. However, many treaters would regard this recommendation at odds with (i.e. more aggressive than) current standards. Unfortunately no additional clinical evidence for this recommendation can be provided.