Aspects of current management: orthopaedic surgery in haemophilia

Incidence and treatment-related risk factors of inhibitor development after intensive FVIII replacement for major orthopaedic surgery in previous treated haemophilia A

INTRODUCTION

Haemophilia A (HA) is an X-linked recessive bleeding disorder caused by lack or deficiency of coagulation factor VIII.

AIM

The aim of this study is to determine the incidence and treatment-related risk factors of inhibitor development after intensive FVIII replacement for major orthopaedic surgery in previous treated persons with HA.

METHODS

A total of 151 HA who underwent 221 major orthopaedic surgical procedures after intensive FVIII treatment were reviewed. The results of inhibitor tests were collected. Potential clinical risk factors for inhibitor development were analyzed.

RESULTS

111 people were diagnosed with severe HA. Thirty-seven persons (24.5%) had history of previous intensive FVIII treatment for surgical procedure. They received a mean perioperative cumulative FVIII of 498 iu/kg within first week after surgery. Seven cases (4.6%) developed an inhibitor post-operatively in our study. Surgical procedure for pseudotumor and the group of persons who experienced postoperative complications had the higher incidence of inhibitor development (9.5%, 13.3% respectively). Only previous history for intensive FVIII exposure was considered as a significant predictor for postoperative inhibitor development after multivariate logistic regression analysis (OR: 29.5, P = 0.002).

CONCLUSION

The incidence of inhibitor development in previously treated persons with HA undergoing major orthopaedic surgery was 4.6% and the history of previous intensive FVIII treatment for surgery was associated with higher risk of inhibitor development.

The effect of HIV prevalence, CD4 counts and disease severity on the outcome of total knee arthroplasty for haemophilic arthropathy: a systematic review and meta-analysis

PURPOSE

End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count.

METHODS

A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan-Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV.

RESULTS

Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94%, 86%, and 76% respectively. NJR-reported survivorship for males < 55 years was 94%, 90%, and 86%. Survivorship improved over time (1973-2018), and correlated inversely with HIV prevalence. Infection rate was 5%, compared to 0.5-1% in the NJR. Infection was not significantly increased with higher HIV prevalence, and CD4 + count had no effect. Complications were inconsistently reported.

CONCLUSION

Survivorship was similar at 5 years but declined thereafter, and infection rate was six-fold higher. HIV was related to worse survivorship, but not increased infection. Meta-analysis was limited by inconsistent reporting, and standardised reporting is required in future studies.

Surgical treatment of a distal radius and ipsilateral metacarpal hemophilic pseudotumor without recurrence or functional deficit: a case report

Background

Distal hemophilic pseudotumor (HP) occurring distal to the wrist appear to be secondary to intraosseous hemorrhage, which develops rapidly and should be treated primarily with long-term replacement therapy and cast immobilization. Surgical removal or even amputation is indicated when conservative management fails to prevent progression. Here, a practical strategy was described for those patients who cannot afford the cost of routine coagulation factor replacement therapy, namely immediate surgical curettage and bone grafting as well as continuous follow-up.

Case description

A 7-year-old boy with a history of mild hemophilia A was admitted to our medical center because of a 2-year history of progressive swelling and pain around right forearm and hand. Coagulation factor VIII level was 11.1% of normal with no inhibitor. Radiographs revealed expansile swelling, bone destruction, and deformity of the distal right radius and the second metacarpal bone. He was diagnosed with distal HP. Surgical procedure of curettage and bone grafting was performed. The function and appearance of the right wrist were almost normal without discomfort at the 101-month follow-up. Significantly, the same patient was hospitalized again because of a year-long progressive swelling and pain around the left hand when he was 14 years old. X-ray showed multiple bone destruction of the left proximal phalanges of left thumb, middle finger and little finger with local pathological fractures. Surgical procedure of HPs including curettage and bone grafting was performed. Postoperative recovery was good, and the last clinical follow-up at 18 months after the operation displayed a satisfactory shape and functional outcomes.

Conclusions

Curettage and bone grafting prove to be safe and feasible for patients with distal HP and continuous follow-up of patients with distal HP is very vital for timely finding and then treating successive HP in developing countries.

The Ilizarov technique in the management of haemophilic knee flexion contracture

INTRODUCTION

The Ilizarov technique has the potential to be an attractive option for severe knee flexion contracture (KFC) patients with a high risk of bleeding. However, studies on this technique in the management of haemophilic KFC are scarce.

AIM

The purpose of this study was to review and analyse the results of the Ilizarov technique in correcting haemophilic KFC and to evaluate the safety and efficacy of this technique.

METHODS

Twelve male haemophilia patients with severe KFC who underwent distraction treatment using the Ilizarov technique from June 2013 to April 2019 were included in this study. The hospital day, flexion contracture, range of motion (ROM) of the knees, complications and functional outcomes were recorded and analysed. Functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) knee scores of the preoperation, end of distraction and last follow-up.

RESULTS

The average preoperative flexion contracture and range of motion (ROM) of the knees were 55 ± 15° and 66 ± 18°, respectively. The average preoperative HSS knee score was 47 ± 5. The average duration of follow-up was 75.5 ± 30.1 months. All flexion contractures achieved full correction (≤5°) at the end of distraction, and the flexion contracture significantly decreased to 6 ± 5° at the last follow-up (p < .0001). The ROM of the knees was significantly increased at the last follow-up compared with that before distraction treatment (p < .0001). The HSS knee scores at the end of distraction and at the last follow-up were both significantly higher than the preoperative HSS knee score (p < .0001). No major complications were encountered.

CONCLUSIONS

This study provided evidence for the safety and effectiveness of Ilizarov technique plus physical therapy in the management of haemophilic KFC and accumulated clinical experience for the proper application of this technology.

A Novel Surgical Classification for Extremity and Pelvic Hemophilic Pseudotumors: The PUMCH Classification

BACKGROUND

A hemophilic pseudotumor (HPT) is a rare and challenging complication of hemophilia for which there is no classification system that provides uniformity of descriptions or that can be used to guide management. We have developed such a classification based on anatomical site, HPT severity, and corresponding surgical treatment.

METHODS

The PUMCH (Peking Union Medical College Hospital) classification was developed on the basis of clinical manifestations and imaging features. Extremity and pelvic HPTs were divided into 4 types and 6 subtypes according to anatomical site and whether or not there was destruction of adjacent bone. Associations between the PUMCH classification and surgical treatment, preoperative comorbidities, operative time, intraoperative bleeding, and postoperative complication rates were analyzed.

RESULTS

Forty-five patients with 53 HPTs that were treated at PUMCH between December 2005 and October 2021 were included. The mean age at the time of surgery was 35.4 ± 11.9 years, and the median follow-up duration was 60.3 months. Twenty-eight HPTs were classified as type I (13 IA, 7 IB, 8 IC); 3, as type II; 6, as type III; and 16, as type IV. All 20 type-IA and IB HPTs were treated with excision, and the 3 type-II HPTs were treated with curettage and bone grafting. Fourteen type-IV pelvic HPTs underwent excision, 2 of which needed concomitant pelvic reconstruction. Six type-IC HPTs and 1 type-III HPT underwent excision and osseous reconstruction. Amputation was required for 1 type-IC and 3 type-III HPTs. Type-IC HPTs had the longest mean operative time (194.3 ± 28.2 minutes) and the greatest intraoperative bleeding (2,000 mL [interquartile range, 1,100 to 3,000 mL]). Postoperative infection was more common in patients with type-III (50.0%) and type-IC (28.6%) HPTs, but not significantly so.

CONCLUSIONS

The PUMCH classification is based on the anatomic pathology and surgical strategy for HPTs. The classification of HPTs corresponds to surgical outcomes, and may be helpful for decision-making regarding their surgical treatment.

LEVEL OF EVIDENCE

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

Three-stage total knee arthroplasty combined with deformity correction and leg lengthening using Taylor spatial frames and conversion to internal fixation for severe intra- and extra-articular deformities and hypoplasia in a patient with hemophilic knee arthropathy: A case report

BACKGROUND

Hemophilic arthropathy is a cause of severe knee deformity, because chronic synovitis due to repeated hemarthrosis affects the area of the epiphyseal plates in juvenile cases. Total knee arthroplasty (TKA) is the standard treatment for end-stage knee arthropathy. However, it is difficult to perform one-stage TKA in patients with severe intra- and extra-articular deformities.

CASE PRESENTATION

We reported a case of hemophilic arthropathy in a 55-year-old male with leg length discrepancy of 4 cm, limited range of knee motion (-40° extension and 85° flexion), intra-articular deformity (medial proximal tibial angle: 69°; mechanical lateral distal femoral angle: 79°), extra-articular deformity at the distal femoral metaphyseal (30° valgus and 45° flexion deformity), and varus malalignment (% mechanical axis: 33%). We planned a three-stage TKA. Firstly, we performed gradual correction and lengthening of the distal femur using Taylor spatial flame. Six months after surgery, we performed conversion surgery from external fixation to internal fixation. Finally, we performed TKA with rotating hinged type implant. Two years after surgery, physical examination showed a normal gait, leg length discrepancy of 2 cm (the right leg was shorter), improvement in the range of knee motion (0° extension and 100° flexion).

CONCLUSION

To the best of our knowledge, this presents the first combination of three-stage TKA with correction of femoral deformity and leg lengthening using a Taylor spatial frame and conversion to internal fixation in a patient with hemophilic knee arthropathy and severe intra- and extra-articular deformities.

Perioperative Outcomes of Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center

Persons with bleeding disorders (PwBD) are at high risk for bleeding with invasive procedures. However, the risk of bleeding in PwBD undergoing major surgery and outcomes of patients managed perioperatively at a hemophilia treatment center (HTC) are not well described. We performed a retrospective review of surgical outcomes among PwBD undergoing major surgery between January 1st, 2017 and December 31st, 2019 at the Cardeza Foundation Hemophilia and Thrombosis Center in Philadelphia, PA. The primary outcome was postoperative bleeding, assessed according to the ISTH-SSC's 2010 definition. Secondary outcomes included use of unplanned postoperative hemostatic therapy, LOS, and 30-day readmission rate. Results were compared to non-PwBD population from a surgical database, matched for surgery, age, and sex. During the study period, 50 PwBD underwent 63 major surgeries. The most common diagnoses were VWD (64%) and hemophilia A (20.0%). The most common surgical procedure category was orthopedic (33.3%), predominantly arthroplasties. Postoperatively,4.8% of procedures were complicated by major bleeding and 1.6% by non-major bleeding. The mean LOS was 1.65 days, and 30-day readmission rate was 1.6%. In comparison to matched, non-PwBD patients in a national surgical database undergoing the same procedures, study patients had a similar rate of bleeding complications per procedure (5.0% vs 1.04% P = .071, Fisher's exact test). PwBD undergoing major surgeries have low rates of major bleeding when receiving comprehensive care at an HTC. Bleeding and hospital readmission rates were similar to non-PwBD baseline in a large database.

Septic Arthritis in Pediatric Hemophilia A: A Case Report and Review of Literature

Hemophilia A is a hereditary bleeding disorder due to coagulation factor VIII deficiency. Septic arthritis is in itself a dreaded infective condition of the joint. It is much more common in hemophilia patients than the general population and is associated with considerably higher morbidity. It presents as a difficult clinical and therapeutic problem, necessitating prompt diagnosis and intensive therapy. There was under-diagnosis of blood coagulation disorders in developing countries like India which has improved in the present time. But there is still considerable uncertainty about proper management guidelines, protocols and resources settings for treating this complication in hemophilia patients. Hereby we present a case of a 9-year-old hemophilia A patient with septic arthritis of knee joint treated at a tertiary hospital centre with available present recommended guidelines in literature, and stress upon the necessity of further formulating and improvising management guidelines for treatment and prevention of this complication in Hemophilia.

Orthopedic surgery in hemophilic patients with musculoskeletal disorders: A systematic review

Hemophilia is a hereditary coagulopathy caused by factor VIII (hemophilia type A) or by coagulation factor IX (hemophilia type B) dysfunction, characterized by an increased bleeding predisposition, which is either spontaneous or secondary to minimal trauma. Currently, hemophilia may also be considered an 'orthopedic' condition, due to the fact that it affects the musculoskeletal system of most hemophilic patients. In recent years, constant prophylaxis using coagulation factors has led to a significant improvement in the hemophilic patient's quality of life, by reducing both life-threatening hemorrhagic phenomena, as well as the occurrence of chronic complications. Nevertheless, progressive joint bleeding remains unavoidable in this category of patients, and the onset of chronic arthropathy with secondary motor deficiency remains the main complication with an invalidating character. In such cases, orthopedic management is imperative; osteoarticular complications being managed most often with the help of conservative or surgical techniques. The purpose of this review is to provide an overview of modern orthopedic practices which are useful in the management of hemophilic patients suffering from osteoarticular disorders.

Perioperative Management of Orthopaedic Patients with Hematologic Disorders: A Critical Analysis Review

Perioperative management of orthopaedic patients with a hematologic disorder is a complex endeavor that requires a multidisciplinary team-based approach. A team composed of an experienced orthopaedic surgeon, an anesthesiologist, and a hematologist is necessary to achieve optimal outcomes. Patients with hemophilia and other complex hematologic disorders should be managed at, or in consultation with a hematologist at, a comprehensive hemophilia center. Bleeding disorders and inherited thrombophilia present unique challenges for the perioperative management of orthopaedic surgery. Comprehensive preoperative planning and familiarity with treatment guidelines can help to minimize these risks. Knowledge of the disease processes outlined in this article will provide orthopaedic surgeons with the requisite background knowledge that is needed to initiate safe and effective treatment strategies involving this high-risk patient population.

Inflammation, angiogenesis and sensory nerve sprouting in the synovium of bony ankylosed and not bony ankylosed knees with end-stage haemophilic arthropathy

INTRODUCTION

Clinical practice showed that patients with haemophilia (PwH) with bony ankylosed end-stage haemophilic arthropathy knees reported milder pain than those with not bony ankylosed knees.

AIM

To compare the differences in pain sensation and the histopathological differences in synovial samples of affected knee joints between PwH with bony ankylosed end-stage haemophilic arthropathy knees and those with not bony ankylosed knees.

METHODS

From January 2011 to December 2019, the synovial samples of knee joints were collected during total knee arthroplasty (TKA) surgery for end-stage haemophilic arthropathy. The visual analogue scale (VAS, 0-10) pain score was reviewed from the chart data of the patients. The thickness of the inner layer of the synovium in haematoxylin and eosin (H&E) staining sections was measured. The expression levels of Ki67, IL-1β, TNF-α, CD31, VEGF, NGF and PGP9.5 in the synovium were detected by immunohistochemistry (IHC) method.

RESULTS

Fifty-two end-stage haemophilic arthropathy knee synovial samples from 36 male PwH (34 type A and 2 type B) were collected. Fifteen knees had bony ankylosed (BA-group), and 37 were not bony ankylosed (Not-BA-group). The mean age of patients at TKA surgery of BA-group and Not-BA-group was 32 years (15) and 32 years (10), respectively (p = 0.824). Before TKA surgery, the mean VAS pain scores of patients in the Not-BA-group were significantly higher than those in the BA-group (p < 0.001). The mean thickness of the inner layer of the synovium, the mean rate of Ki67+ cells, the mean density of CD31+ vascular endothelial cells and the expression levels of IL-1β, TNF-α, VEGF and NGF in samples in the Not-BA-group was significantly higher than those in samples in the BA-group (p < 0.001, p = 0.02, p = 0.001, p = 0.117, p < 0.001, p = 0.003 and p = 0.008), respectively. The mean density of PGP9.5+ sensory neural fibres in the Not-BA-group was slightly higher than in the BA-group (p = 0.131). Linear regression analysis showed a significant positive correlation between the VAS pain score and indicators including the synovial thickness, the rate of Ki67+ cells, the expression level of IL-1β, TNF-α, VEGF, NGF and the densities of CD31+ vascular endothelial cells and PGP9.5+ nerve fibres (p < 0.05).

CONCLUSIONS

Worsened hypertrophic synovitis, angiogenesis and sensory nerve sprouting in the synovium may play a critical role in causing worse pain sensation in PwH with not bony ankylosed haemophilic arthropathy knees than in those with bony ankylosed knees.

Rehabilitation management of a triceps surae muscle injury in a young male with haemophilia A and high-titre inhibitors

Haemophilia A is a rare inherited hematologic disorder characterized by a deficit of coagulation factor VIII. It is associated with frequent episodes of musculoskeletal bleedings that occur mainly inside joints and secondly inside muscles. The majority of intramuscular hematomas respond well to conservative protocols, based on rehabilitation techniques and appropriate haemostatic coverage; surgery is limited to refractory cases. This manuscript describes the management of an intramuscular bleeding in a young patient with severe haemophilia A and high-titre inhibitors. A multidisciplinary approach directed by a physiatrist and combining surgical intervention, use of bypassing agents and rehabilitation treatment allowed to successfully managing this case, leading to a complete functional recovery. Given the lack of consensus on the treatment of intramuscular bleedings in haemophiliac patients, this case report provides an example of successful management for such conditions, which require a multidisciplinary approach in which the physiatrist plays a key role.

Developing clinical practice guidelines for physiotherapists working with people with inherited bleeding disorders

INTRODUCTION

Several bleeding disorders are characterized by haemorrhage into joints and muscles. These conditions are best managed by interdisciplinary teams that include physiotherapists. In 1997, physiotherapists from haemophilia treatment centres in Canada formed the Canadian Physiotherapists in Hemophilia Care (CPHC). The guiding principles of the CPHC reflect a commitment to evidence-based practice, education and collaboration.

AIM

To describe the process used by CPHC to develop evidence-based clinical practice guidelines to inform best practice, guide decision-making and help educate physiotherapists, students, and other team members about the physiotherapy management of people with bleeding disorders.

METHODS

We followed the procedures outlined in the American Physical Therapy Association's Clinical Practice Guideline Process Manual (2018). Namely, we selected a working group, determined the scope of the guidelines, performed a literature search, selected and appraised the evidence, drafted the guidelines as practice statements, assigned a strength of recommendation to each practice statement and disseminated the guidelines.

RESULTS

Thirty-nine practice statements were developed in nine practice areas. Strength of evidence was strong for two statements, moderate for one and weak for three. The remainder were graded as theoretical or best practice.

CONCLUSION

To our knowledge, these are the first evidence-based clinical practice guidelines that cover all aspects of physiotherapy management of people with bleeding disorders. Some areas, such as exercise and manual therapy, have been well investigated. However, the overall low levels of evidence and low strengths of recommendations highlight the need for more rigorous research with this population.

[Orthopedic treatment of musculoskeletal disorders in hemophilic patients]

Objective: To study the orthopedic treatment strategy for hemophilia complicated with musculoskeletal disorders as well as the peri-operative consumption of clotting factor. Methods: Total 338 orthopedic surgeries were performed for 261 patients, average age of 30.6 y (6-65 y) , with hemophilia between January 1996 and December 2019 at our institute. Two hundred and twenty-six patients presented with bleeds within the joints. Sixty-one patients presented with intramuscular bleeds, 45 presented with hemophilic pseudotumors, and six presented with miscellaneous complaints. Strategy of clotting factor replacement therapy was designed as per differences in the level of the operation procedure. Information regarding clinical manifestation, operative strategy, clotting factor consumption, and re-operation for complications was retrospectively recorded. The costs for multiple joint procedure and single joint procedure were studied. Results: We found that 270 of the 338 surgical procedures were major surgical procedures (79.9%) . There were 203 procedures of joint arthroplasty (60%) . Fourteen patients underwent reoperations for local recurrence (4.2%) . The average factor Ⅷ consumption before the surgery was 44.4 ± 8.1 IU/kg. The average FⅧ consumption within postoperative 2 weeks was 40 962 IU (647±177 IU/kg) . Seven type A hemophilic patients developed F Ⅷ inhibitor following the surgical procedure, with an average level of 13.7±11.2 BU/mL. Sixty-eight patients underwent multiple joint procedures under one anesthesia session (26%) . There was no significant difference in the factor consumption between the multiple joint procedure and single joint procedure. Conclusions: Surgical treatment was found to be effective for hemophilic arthropathy and lesion of the musculoskeletal apparatus, with the clotting factor replacement therapy. Multiple joint procedures under one anesthesia were more cost effective for patients with hemophilia, with less factor consumption than staged single joint procedure.

Development of a Self-Assessment Tool for the Nontechnical Skills of Hemophilia Teams

BACKGROUND AND OBJECTIVES

The treatment of chronic illnesses requires health care professionals (HCPs) to master several nontechnical skills to meet patient care needs. This article aims to describe the rationale and the inductive process through which a self-assessment tool for the nontechnical skills of hemophilia teams was conceived, developed, and tested.

METHODS

Starting from an explorative analysis of hemophilia HCP work experiences, the process followed 3 phases: an in-depth analysis of hemophilia HCP skills; the questionnaire development; and a pilot study.

RESULTS

Using the voice of HCPs as a starting point, the tool proved to be able to identify precise cross-professional and intercultural challenges as well as related required and/or acquired skills in the hemophilia field.

CONCLUSION

The proposed tool may contribute to providing HCPs with strategic knowledge to successfully perform everyday practices, to improve the effectiveness of hemophilia teams and the care model adopted by their centers, and to implement intercultural research in this field. It may be used to propose ad hoc training courses targeted by challenge, in order to fill the major gaps reported by the teams, or targeted by medical specialty or country (and therefore health care system) specificity.

Early wound complications after orthopaedic surgery for haemophilia: What can we do more

BACKGROUND

The characteristics of the haemophilia may endanger the patient with haemophilia (PWH) to higher ratio of wound complication, even lead to the refractory wound problem. The early wound complication in PWH has not been well studied in literature.

METHODS

Between the period from 2002 to 2018, 250 patients underwent 323 elective orthopaedic surgical procedures for the treatment of haemophilic musculoskeletal disorders. The medical records were retrospectively reviewed. The patients were evaluated for postoperative wound complications within 30 days. Risk factors related to wound complications were further analysed. The patients underwent vacuum sealing drainage (VSD) for refractory wound healing problem were further analysed.

RESULTS

Twenty-four patients of 250 patients experienced early wound complication within postoperative 30 days. The incidence of wound complication in the patients without preoperative infection was 6.5%. Positive inhibitor and surgery for pseudotumour were associated with higher rate of wound complication after logistic regression, with the odds ratios (OR) of 5.7 (95% CI, 1.08 to 30.3) and 4.9 (95% CI, 1.3 to 18.5), respectively. Eight patients underwent VSD treatment for refractory wound healing problem and recovered uneventfully. The total VSD treatment cycle was 2.25 (from 2 to 4). The average factor consumption was 26.1 IU kg^-1  d^-1 . The patients complicated with infection had higher, but not statistically significantly, treatment duration, factor consumption and peri-VSD total blood loss than the patients without infection.

CONCLUSIONS

PWH had an incidence of 6.5% of early wound healing problem after elective orthopaedic surgery for musculoskeletal disorder in the present study. The presence of positive inhibitor and surgical procedure for haemophiliac pseudotumour are associated with higher incidence of wound healing problem. The VSD is an effective alternative for the treatment of refractory wound healing problem for PWH, especially for the patients complicated with infection.

Total Knee Arthroplasty in Patients with Hemophilia: What Do We Know?

Total knee arthroplasty is considered as the treatment of choice for those with end stage hemophilic arthropathy. Compared to other patients undergoing TKA, these patients have specific features such as bleeding tendency, younger age, pre-operative restricted range of motion (ROM), altered anatomy, and increased complications. This narrative review of literature is going to investigate several issues regarding the TKA in hemophilic patients including indications, perioperative factor replacement, surgical challenges, postoperative rehabilitation, outcomes, and complications.

Acute Compartment Syndrome After Knee Synovectomy in a Patient with Hemophilia A: A Case Report

CASE

A 19-year-old man with severe hemophilia A underwent open surgical synovectomy to treat recurrent hemarthrosis of the knee. He developed symptoms and signs of acute compartment syndrome (ACS) despite receiving full-dose factor replacement. Arthrotomy was performed twice, and massive hemarthrosis was evacuated. The symptoms subsided after supplementing clotting factor with prednisone.

CONCLUSIONS

ACS may complicate hemophilia. Diagnosis is mainly based on clinical judgment. Proper factor replacement is the mainstay of treatment. Surgery is reserved for patients with no improvement following factor administration.

A novel protocol for accurate and reliable postoperative bolus administration of recombinant factor VIIa using an automated mini-pump system

INTRODUCTION

Recombinant FVIIa (rFVIIa) is widely used to manage bleeding risk during and after surgery in patients with haemophilia complicated by inhibitors. In the postoperative period, rFVIIa must be delivered frequently and regularly to maintain haemostasis, considering its short half-life. Preparation and manual administration of bolus doses of rFVIIa at regular intervals may place a strain on available nursing resources. A programmable mini-pump may offer an approach to facilitate regular administration of bolus doses of rFVIIa at specified intervals.

AIM

To investigate if a mini-pump is a practical and effective way to deliver rFVIIa in the postoperative period.

METHODS

It was first necessary to establish that rFVIIa remains stable and sterile in the mini-pump reservoir for an extended period. Four days after loading the mini-pump under sterile conditions no evidence of bacterial or fungal growth was observed and in vitro procoagulant activity of rFVIIa remained stable. The mini-pump was used to deliver rFVIIa as bolus doses to two patients with inhibitors who had undergone surgery. Nurses were asked to report their satisfaction with the use of the mini-pump using a specific questionnaire.

RESULTS

Haemostasis was evaluated as excellent in both cases; nurses were satisfied with use of the mini-pump.

CONCLUSION

This pilot study shows that intermittent delivery of rFVIIa at fixed intervals using an automated mini-pump offers accurate and reliable administration in the postoperative setting. This approach may reduce burden on nursing staff, potentially minimize the risk of human error and avoid delay in administration of rFVIIa.

Changes in Muscle Activity Patterns and Joint Kinematics During Gait in Hemophilic Arthropathy

Hemophilic arthropathy is the result of repetitive intra-articular bleeding and synovial inflammation. In people with hemophilic arthropathy (PWHA), very little is known about the neural control of individual muscles during movement. The aim of the present study was to assess if the neural control of individual muscles and coordination between antagonistic muscle pairs and joint kinematics during gait are affected in PWHA. Thirteen control subjects (CG) walked overground at their preferred and slow velocity (1 m/s), and 14 PWHA walked overground at the preferred velocity (1 m/s). Joint kinematics and temporal gait parameters were assessed using four inertial sensors. Surface electromyography (EMG) was collected from gluteus maximus (GMAX), gluteus medius (GMED), vastus medialis (VM), vastus lateralis (VL), rectus femoris (RF), medial gastrocnemius (MG), lateral gastrocnemius (LG), soleus (SOL), tibialis anterior (TA), semitendinosus (ST), and biceps femoris (BF). Waveforms were compared using the time-series analysis through statistical parametric mapping. In PWHA compared to CG, EMG amplitude during the stance phase was higher for LG (for both velocities of the CG), BF (slow velocity only), and ST (preferred velocity only) (p < 0.05). Co-contraction during the stance phase was higher for MG-TA, LG-TA, VL-BF, VM-ST, LG-VL, and MG-VM (both velocities) (p < 0.05). MG and LG were excited earlier (preferred velocity only) (p < 0.05). A later offset during the stance phase was found for VL, BF, and ST (both velocities), and BF and GMAX (preferred velocity only) (p < 0.05). In addition, the range of motion in knee and ankle joints was lower in PWHA (both velocities) and hip joint (preferred velocity only) (p < 0.05). In conclusion, the neural control of individual muscles and coordination between antagonistic muscles during gait in PWHA differs substantially from control subjects.

Health care professionals dealing with hemophilia: insights from the international qualitative study of the HERO initiative

Background: Assessing the viewpoints of health care professionals concerning their work with chronic patients is a relatively new research topic, widely overlooked in the literature. However, understanding their subjective work experience is highly relevant for identifying problems and perceived resources, enhancing health service organisation, improving relationships or communication with patients, and maintaining well-being. Purpose and method: Qualitative data from the "Haemophilia Experience, Results and Opportunities" Initiative - a research program aimed at investigating the psychosocial aspects of hemophilia - were used to evaluate the experiences of 62 professionals from seven countries around the world. Semi-structured interviews were submitted to thematic analysis of elementary contexts with the aid of T-Lab software. Results: Five dominant themes emerged, identifying the main challenges that professionals have to deal with in their everyday work practice: caring for impaired adult patients; handling policies and stakeholders; providing counselling on diagnosis and reproductive choices; considering the role of family dynamics; coping with adolescent patients. Conclusion: The outcomes of the study provide an opportunity to develop the area of the non-technical skills in the core curriculum of those who work with chronic illnesses by focusing on cross-professional competences and by improving a comprehensive care model for hemophilia patients.

Accelerating recovery from acute hemarthrosis in patients with hemophilia: the role of joint aspiration

: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.

Increased serum levels of progranulin (PGRN) in patients with haemophilic arthropathy

Haemophilia A and B are rarely occurring X chromosome-linked congenital coagulation disorders dominated by spontaneous joint bleedings and chronic synovitis, leading to development of haemophilic arthropathy (HA). Progranulin (PGRN) is a growth factor with anti-inflammatory and immunomodulatory properties. PGRN is an important molecule in the pathogenesis of osteoarthritis (OA) and rheumatological disorders. This study was aimed at investigating the potential role of PGRN in the mechanisms underlying the pathogenesis of HA. The serum levels of PGRN were measured by enzyme-linked immunosorbent assay (ELISA) in patients with end-stage knee joint HA (n = 20) and end-stage primary knee joint OA (n = 20) who met the inclusion and exclusion criteria. The clinical and radiological assessment of disease severity was evaluated by the Knee Society Score (KSS) and Kellgren-Lawrence scale. Median PGRN levels in HA patients was 349.1 ng/mL (232.8-415.6 ng/mL) and in OA patients 148.3 ng/mL (112.1-275.3 ng/mL) with statistically significant differences between both groups (P < 0.015). Further analysis revealed no correlation between PGRN levels and any of the patient demographics and clinical parameters. This study demonstrates increased PGRN serum levels in patients with HA and provides new insights into the mechanisms underlying the pathogenesis of HA indicating a new potential target for therapeutic intervention.

Comparison of 90-Day Complication Rates and Cost Between Single and Multiple Joint Procedures for End-Stage Arthropathy in Patients with Hemophilia

Background

Multiple joint procedures during a single anesthetic episode have been proposed for patients with hemophilia as a way to reduce cost. The postoperative 90-day complication rate and the cost distribution between multiple joint procedures and single joint procedures for patients with hemophilia have not been well studied.

Methods

Between January 1996 and December 2016, 124 patients underwent 177 surgical procedures (total knee arthroplasty, total hip arthroplasty, and ankle arthrodesis) for the treatment of hemophilic end-stage arthropathy. Forty-eight patients (39%) underwent multiple joint procedures during 1 hospitalization, and 76 patients (61%) underwent single joint procedures. The medical records were retrospectively reviewed. The patients were evaluated for complications within 90 days postoperatively and the cost during hospitalization. Risk factors related to complications were further analyzed.

Results

Twenty-seven of the 124 patients experienced 29 complications within 90 days postoperatively, representing a complication rate of 16.4% for all procedures. The patients who had undergone multiple joint procedures had a higher rate of surgical complications than those who had undergone a single joint procedure (14.6% vs. 3.9%; p = 0.039). The patients who had had multiple joint procedures had similar rates of hematological complications (8.3% vs. 9.2%; p = 0.867) and total complications (31.3% vs. 18.4%; p = 0.100) compared with those who had had a single joint procedure. There was no difference between the patients who had had multiple joint procedures and those who had had a single joint procedure with regard to the cost of the coagulation factor (p = 0.212).

Conclusions

The performance of multiple joint procedures during a single anesthetic episode is a safe approach for patients with hemophilia with end-stage arthropathy, with no substantial increase in the 90-day complication rate in comparison with that following a single joint procedure. The performance of multiple joint procedures under a single anesthetic episode can save cost and is more cost-effective when managing patients with hemophilia who have end-stage arthropathy.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous bilateral total knee arthroplasty in patients with end-stage hemophilic arthropathy: a mean follow-up of 6 years

To investigate the safety, cost-effectiveness, and clinical outcomes of simultaneous bilateral total knee arthroplasty (TKA) in hemophilic arthropathy (HA), the requirements for transfusions, complications, costs, hospital stays, Hospital for Special Surgery (HSS) knee scores, knee range of motion (ROM) and revision rates were compared between simultaneous bilateral and unilateral TKA in HA patients. A total of 36 patients and 54 knees were included. Compared to the unilateral group, the bilateral group did not require more transfusions (2.39 ± 3.13 vs 0.83 ± 1.38 units of RBCs, p > 0.05) or consumption of coagulation factors (50091.67 ± 25168.5 vs 46477.78 ± 11348.32 IU, p > 0.05), complications rate (13/36 vs 6/18, p > 0.05), hospital stay (32.39 ± 19.77 vs 29.11 ± 12.67 days, p > 0.05), or costs excluding prostheses (14945.41 ± 6634.35 vs 14742.12 ± 5746.78 US dollars, p > 0.05). Additionally, the two groups exhibited similar medium-term knee HSS scores (83.67 ± 7.11 vs 81.00 ± 10.35, p > 0.05) and ROM (89.39° ± 13.66° vs 88.91° ± 12.90°, p > 0.05). Our data indicate that bilateral TKA is a safe and cost-effective treatment for HA with similar medium-term results compared to unilateral TKA.

Risks and challenges of orthopaedic invasive interventions in haemo -philia in a low-resource country

Haemophilic arthropathy is a defining feature and a debilitating condition of persons with haemophilia (PwH) in low resource countries. Orthopaedic surgery is unavoidable for patients with high occurrence of joint damage. Aims: We aimed to evaluate the spectrum and outcome of invasive orthopaedic therapies in PwH and von Willebrand diseases (VWD). Patients and methods: Our descriptive observational retrospective study included 131 invasive surgical procedures, performed on 76 consecutive patients, most of them (93.4%) with severe disease, treated in Timisoara’s Haemophilia Center over a period of 12 years; 17.1% had pre-operation anti-FVIII inhibitors. Invasive elective procedures were predominant (90.8%) as compared to emergency measures (9.2%); according to their invasiveness, 20.6% of interventions were major, 44.3% intermediate and 35.1% minor. Results: were good in the majority of cases; significantly reduced joint bleed rate and pain score were the most consistent achievements. The greatest proportion of complications occurred after major (66.7%), compared to moderate (25.6%) and minor (7.7%) interventions. The main threatening complication was the development (3.8%) or increase (4.6%) of inhibitor titer. Local bacterial infections and wound dehiscence complicated the evolution in 4.6% and 0.8 % of cases, respectively; we noticed no blood-borne infections or thrombotic accidents. Low dosage (10.7%) and short duration of substitution (21.4%) led to increased post-surgical bleeding and post-haemorrhagic anaemia. Conclusions: Surgery is a highly demanding intervention in haemophilia, which cannot be ignored in a low resource country. It represents a life or limb-saving and quality of life-improving measure.

Long-acting recombinant factor VIII Fc fusion protein (rFVIIIFc) for perioperative haemostatic management in severe haemophilia A

The Phase 3 A-LONG and Kids A-LONG studies demonstrated the prolonged half-life of rFVIIIFc compared with rFVIII, and the safety and efficacy of rFVIIIFc in subjects with severe haemophilia A. Eligible subjects from A-LONG and Kids A-LONG continued rFVIIIFc treatment by enrolling in ASPIRE, an ongoing extension study. Based on combined data from the primary studies and ASPIRE interim data, the safety and efficacy of rFVIIIFc in subjects requiring surgery were evaluated. Perioperative dosing regimens were determined by investigators with guidance based on pharmacokinetic data and recommendations from a clinical dosing committee. In addition to dosing frequency, factor consumption, blood loss, transfusions, bleeding episodes, and haemostatic response were assessed. Across studies, 21 subjects underwent 23 evaluable major surgeries, including 19 orthopaedic surgeries; 41 subjects underwent 52 minor surgeries, including 30 dental procedures. No major and 10 minor surgeries were performed in paediatric subjects. Of the major (n = 22) and minor (n = 32) surgeries assessed for haemostatic response, all were rated as excellent or good by the investigator/surgeon. During most major surgeries (95.7 %), haemostasis was maintained with one rFVIIIFc infusion. Blood loss in major surgeries was consistent with similar surgeries in subjects without haemophilia. Across studies, rFVIIIFc was well tolerated; no subject developed an inhibitor.

Surgical Management of Haemophilic Pseudotumors: Experience in a Developing Country

AIM

Hemophilic pseudotumors result from repeated episodes of bleeding into bone, subperiosteum, and soft tissue. Since clotting factors became available, uncontrolled perioperative bleeding is a less significant problem for surgeons in developed countries. However, they are more difficult to come by in China. Additionally, patients often have to undergo surgery for giant masses and suffer complications. We wanted to present our experience in the surgical management of hemophilic pseudotumors over a 40-year period.

METHODS

We retrospectively reviewed 429 hemorrhagic coagulopathy patients between 1983 and 2015. Diagnosis of hemophilic pseudotumor was confirmed following clinical, radiological, and pathological criteria. The data were recorded and analyzed: type and severity of hemophilia, presence of inhibitor, etiological antecedent, localization of pseudotumors, clinical signs, surgical management and outcomes.

RESULTS

Eighteen pseudotumor patients underwent surgical treatment. All of them were male, with mean age of 34.3 years. Fifteen patients had hemophilia A and three patients had hemophilia B. There were twelve proximal and two distal pseudotumor patients. The mean follow-up was 51.9 months. For pseudotumors in the extremities, complete surgical resection was achieved. For four patients with pelvic or abdominal pseudotumors, complete surgical resection was only achieved in two patients because of preventing potential vital organs injuries. Delayed healing of the incision, allergic reactions, and ureteral injury were the major complications.

CONCLUSION

Surgery is an alternative method with safety and efficacy. Careful and individual treatment is required by the hematologist, orthopedic surgeon and other members of the team who collaborate and participate in hemophilic surgery.

Long-term results of total knee arthroplasty in haemophilic patients: an 18-year follow-up

PURPOSE

Total knee arthroplasty (TKA) for patients with end-stage haemophilic arthropathy is considered to be a successful procedure with satisfying mid- to long-term results. It was the purpose of this study to provide clinical and radiological long-term results of TKAs implanted in a consecutive cohort of haemophilic patients.

METHODS

Primary TKA was performed in 43 consecutive knees in 30 haemophilic patients. After a mean of 18 (SD ± 4) years, 15 patients (21 knees) with a mean age of 58 (SD ± 8) years were available for follow-up. The outcome was assessed using the Knee Society score, WOMAC, SF-36, Kaplan-Meier survivorship analysis as well as radiographic evaluation of radiolucency.

RESULTS

In 13 (30%) of the 43 consecutive knees, revision surgery was necessary due to infection or aseptic loosening, among which eight (19%) due to aseptic loosening and five (12%) due to haematogenous infection. The calculated 20-year survival rates with revision for any reason or infection as the end points were 59 and 82%, respectively. All patients with the primary TKA in situ observed progressive radiolucent lines around the implants at the final follow-up. The Knee Society clinical and functional score significantly improved from pre- (36 points; SD ± 16 and 62 points; SD ± 19) to post-operatively (73 points; SD ± 15 and 78 points; SD ± 18; p < 0.001). Eighty-six per cent rated their result as either good or excellent. Whereas flexion did not improve, flexion contracture could be reduced significantly from 18° (SD ± 12) to 6° (SD ± 5; p < 0.001) post-operatively.

CONCLUSION

Total knee arthroplasty in haemophilic patients is associated with high revision, loosening and infection rates after 18 years. However, if revision can be avoided, joint replacement in haemophilic patients helps to relieve pain, achieve higher subjective satisfaction and to restore knee function. Level of evidence IV.

Orthopaedic procedures in haemophilia

Haemophilia may nowadays be considered an "ortho paedic" disease given due to the involvement of musculoskeletal system in almost all haemophilic subjects. The modern haematological prophylaxis has dramatically improved the quality of life reducing bleedings and life-threatening complications; however, joint bleedings, progressive and irreversible arthropathy and osteoporosis are still now common challenging issues to be faced. One of the tissues involved by Haemophilia is the bone, particularly in the periarticular zone: poor bone quality and decrease of bone stock are typical patterns, and the worse is the arthropathy, the greater the bone loss. The orthopaedic management of such condition is now mandatory and characterized by several surgical techniques. The purpose of this work is to provide an overview of these options derived from our experience in managing haemophilic patients.

Hip Arthropathy in Haemophilia

Hip arthropathy in haemophilic patients is disabling for hip and other common target joints. Even if bleedings in the hip are not frequent, femoroacetabular alterations may affect the functional ability of patients at a very young age. A haematologic prophylaxis combined with an adequate lifestyle and regular and low-traumatic physical activity are the keys to preventing such arthropathy. In the early stages of arthropathy, anti-inflammatory drugs and physical therapy may be sufficient to limit its progression. In cases of recurrent symptoms, viscosupplementation with hyaluronic acid, and chemical synoviorthesis are useful options. In more advanced stages, hip arthroscopy may be treated by synovectomy or loose body removal. For late stages, total hip arthroplasty (THA) is mandatory. Until a few decades ago, the clinical outcomes after hip arthroplasty were variable, due to the different management of patients and the use of old generation implants and couplings. In the last decade, the introduction of the multidisciplinary management and the use of modern cementless implants with high performing materials and less invasive surgical techniques have dramatically improved the functional results. Nowadays, as is the case for other target joints, the purpose of the management in haemophilia centers is the early detection of any hip alterations—by clinical and ultrasound (US) evaluations of patients in childhood—to reveal any early articular damage and to provide adequate treatment in case of symptoms. The present paper represents an updated review of the several approaches to hip arthropathy in haemophilia.

Supracondylar femoral osteotomy and knee joint replacement during the same surgical procedure in a type A haemophiliac patient with knee flexion deformity and ankylosis

BACKGROUND

Haemophilia A is the cause of diverse musculoskeletal disorders such as ankylosis, arthritis and associated angular deformity. There are few reported cases in patients with haemophilia A in which simultaneous supracondylar femoral osteotomy and knee joint replacement has been performed to treat knee angular deformity and ankylosis. Here we present the case of an 18year old male patient, with an evolution of two years, who was unable to walk due to the presence of an untreated supracondylar fracture in the left femur and ipsilateral haemophilic arthropathy which led him to develop an ankylosis in flexion close to 70°.

METHODS AND RESULTS

Supracondylar osteotomy of the femur and of the left knee joint was performed in the same surgical procedure. Bleeding control was achieved with a protocol of factor VIII supply. The patient was followed up for eight years, and recovered a 0 to 90° range of motion and regained his gait pattern.

CONCLUSIONS

This case potentially provides a new alternative approach for haemophilia patients presenting with angular deformities and complex ankylosis. We suggest that mixed lesions of intra- and extra-articular deformity in haemophiliac patients can be corrected during the same surgical intervention. In addition, interdisciplinary management including haematology for operative and immediately postoperative control of intra-bleeding using factor VIII supply and control, combined with a controlled rehabilitation plan, can yield good functional outcomes in patients with haemophilic arthropathy.

Perioperative Physiotherapy for Total Ankle Replacement in Patients with Inherited Bleeding Disorders: Outline of an Algorithm

The treatment of end-stage hemophilic arthropathy of the ankle joint remains a controversial problem, and total ankle replacement (TAR) is considered to be a valuable management option. Physiotherapy continues to be an extremely important part of TAR and has a tremendous impact on the outcomes of this procedure. Given the lack of data on the latter, this study details a protocol of perioperative physiotherapy in TAR in patients with inherited bleeding disorders (IBD). The protocol outlined in this paper was devised via consultations within an interdisciplinary group, the authors' own experiences with TAR in hemophilic and non-hemophilic patients, previous reports on this issue in the literature, and patient opinions. Our working group followed the criteria of the International Classification of Functioning, Disability and Health. The algorithm includes 4 physiotherapy phases with specified time frames, aims, interventions, and examples of exercises for each phase. We emphasize the importance of preoperative rehabilitation, and recommend introducing intensive physiotherapy immediately after the surgery, with regard to the wound protection and avoiding full weight-bearing in the first weeks. The intensity of physiotherapy should be adjusted individually depending on individual patient progress. This study details a rehabilitation protocol for TAR in patients with IBDs, which can be equally applicable to clinicians and researchers. Further scientific studies are required to investigate the beneficial effect of different protocols as well as to clarify the effectiveness of various frequencies, durations, and intensities of selected interventions.

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

Background

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

Material/Methods

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

Results

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

Conclusions

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

Thromboprophylaxis and Outcomes for Total Joint Arthroplasty in Congenital Bleeding Disorders

Total joint arthroplasty (TJA) improves the quality of life for patients with end-stage osteoarthritis but is associated with an increased risk of venous thromboembolism (VTE), thus pharmacologic thromboprophylaxis is recommended for most patients. Patients with congenital bleeding disorders may develop severe arthropathies due to repeated hemarthroses and derive similar benefit from TJA as the general population. No guidelines for pharmacologic thromboprophylaxis in this population exist, however, as the risks and benefits are not well defined. We undertook the current study to assess the safety and efficacy of pharmacologic VTE prophylaxis in patients with congenital bleeding disorders undergoing TJA. We retrospectively reviewed the medical records of patients with bleeding disorders who underwent TJA at our academic institution between 1987 and 2012. We identified 28 patients who underwent 38 TJA procedures. Low-molecular-weight heparin (LMWH) was administered in 29 procedures (76%) and was discontinued early in 3 procedures (2 patients) due to nonjoint bleeding. No symptomatic VTE was identified, and no joint or deep wound infections were seen. Twenty-two patients accounting for 31 procedures were contacted to discuss their experience with TJA. All reported decreased pain, and 97% reported improved function after the surgery. Impressively, 97% stated that they would choose to have the surgery again. These results confirm the benefit of TJA in patients with congenital bleeding disorders and end-stage arthropathies and suggest that LMWH thromboprophylaxis is safe. No patient in our cohort developed symptomatic VTE, whether or not thromboprophylaxis was administered, thus necessity of thromboprophylaxis remains an unanswered question.

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

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

Perioperative Period of a Hemophilia-related Osteoarthropathy Therapeutic Regimen and Analysis of Complications

OBJECTIVE

To investigate the effectiveness of our department's therapeutic regimen and treatment of complications during the perioperative period of hemophilia-related osteoarthropathy.

METHODS

In this retrospective study, data on 101 patients with hemophilia who had undergone operative treatment in our hospital from January 2000 to August 2014 were assessed. Ninety-one of the patients had hemophilia A and 10 hemophilia B. All patients were male. Changes in Hospital for Special Surgery (HSS), Harris and American Orthopedic Foot and Ankle Society (AOFAS) scores, occurrence of complications during the perioperative period and the clinical treatment and prognosis pre- and postoperatively and during follow-up were analyzed. Relevant clinical data were obtained through telephone calls, outpatient follow-up, and medical clinical record searches.

RESULTS

The 101 patients who were followed up (for an average of 96 months) had 147 orthopedic operations, including joint replacement, hemophilia-related false tumor resections, and tendo-achillis lengthening. The HSS scores for knee surgeries increased from 52 points preoperatively to 86 postoperatively, Harris scores for hip joint surgery from 26 to 87 points, respectively, and AOFAS scores for foot and ankle surgeries from 39 to 81 points, respectively. Eight patients had wound complications, four intra-articular hematomas, two peroneal nerve injuries, one a proximal femur splitting fracture and one deep venous thrombosis.

CONCLUSIONS

Surgical treatment is a safe and reliable choice for addressing complications including hemophilia-related osteoarthropathy given the implementation of effective measures for treatment during the perioperative period.

Declining trends in invasive orthopedic interventions for people with hemophilia enrolled in the Universal Data Collection program (2000-2010)

INTRODUCTION

Recurrent joint hemarthroses due to hemophilia (Factor VIII and Factor IX deficiency) often lead to invasive orthopedic interventions to decrease frequency of bleeding and/or to alleviate pain associated with end-stage hemophilic arthropathy.

AIM

Identify trends in invasive orthopedic interventions among people with hemophilia who were enrolled in the Universal Data Collection (UDC) program during the period 2000-2010.

METHODS

Data were collected from 130 hemophilia treatment centers in the United States annually during the period 2000-2010, in collaboration with the Centers for Disease Control and Prevention (CDC). The number of visits in which an invasive orthopedic intervention was reported was expressed as a proportion of the total visits in each year of the program. Invasive orthopedic interventions consisted of arthroplasty, arthrodesis, and synovectomy. Joints included in this study were the shoulder, elbow, hip, knee, and ankle.

RESULTS

A 5.6% decrease in all invasive orthopedic interventions in all joints of people with hemophilia enrolled in the UDC program over the 11-year study period was observed.

CONCLUSIONS

These data reflect a declining trend in invasive orthopedic interventions in people with hemophilia. Further research is needed to understand the characteristics that may influence invasive orthopedic interventions.

Patient dissatisfaction after total knee arthroplasty for hemophilic arthropathy and osteoarthritis (non-hemophilia patients)

In advanced painful hemophilic arthropathy of the knee (APHAK) and advanced painful osteoarthritis of the knee (APOAK) the last resort is total knee arthroplasty (TKA). However, some patients with APOAK are not satisfied despite a good clinical result. A review the literature on APHAK and APOAK was performed to know their rates of dissatisfaction and their main causes. In APOAK the rate of dissatisfaction ranges between 3 and 28.3%. Causes of dissatisfaction in APOAK are high preoperative body mass index, lack of fulfillment of patient expectations, a low 1-year WOMAC, preoperative pain at rest, a postoperative complication requiring hospital readmission, and a poor preoperative psychological state. Very limited information exists on APAHAK in the literature, but it also shows an increase in patient satisfaction after TKA. However, the results do not reach the same level as in patients with APOAK, due to residual symptoms and impairment of other joints.

Advances and challenges in hemophilic arthropathy

Hemophilic arthropathy is a form of joint disease that develops secondary to joint bleeding and presents with synovial hypertrophy, cartilage and bony destruction. The arthropathy can develop despite clotting factor replacement and is especially disabling in the aging population. Pathobiological tissue changes are triggered by release of hemoglobin and iron deposition in the joint, but the sequence of events and the molecular mechanisms resulting in joint deterioration are incompletely understood. Treatment options other than clotting factor replacement are limited. Improvements in the treatment of hemophilia necessitate a better understanding of the processes that lead to this disabling condition and better diagnostic tools. Towards that end, studies of the molecular mechanisms leading to the arthropathy, as well as the development of sensitive imaging techniques and biomarkers are needed. These will pave the way to identify the cause of acute pain such as joint bleeding or synovitis, detect early, potentially reversible structural changes, and predict progression of disease. This review describes current imaging techniques and the development of high resolution musculoskeletal ultrasound with power Doppler to afford point-of-care diagnosis and management, the potential utility of diagnostic biomarkers, and summarizes our current knowledge of the pathobiology of hemophilic arthropathy.

Elective total knee arthroplasty in haemophilic patients. Proposal for a clinical pathway

Total knee arthroplasty (TKA) provides significant pain relief and better function in patients with end-stage haemophilic knee arthropathy. Peri- and postoperative care tends to be more complex than in non-haemophilic patients undergoing TKA and requires a multidisciplinary team approach.

AIM

The implementation of standardized clinical pathways in non-haemophilic patients undergoing TKA has been shown to increase quality of care and to reduce postoperative complication rates. Consequently, the use of clinical pathways in haemophilic patients undergoing TKA may be beneficial to this particular subpopulation of patients.

METHODS

A clinical pathway for TKA for haemophilic patients was designed in a consensus process involving all participating departments.

RESULTS

We propose a specifically adjusted clinical pathway for TKA for haemophilic patients to show that standardization of elective orthopaedic surgery in haemophilia is feasible.

CONCLUSION

The authors emphasize that there are limitations on categorizing haemophilic patients and stress that individual interdisciplinary treatment should take precedence over a standardized approach.