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Rodriguez-Merchan EC, De la Corte-Rodriguez H, Gomez-Cardero P, Alvarez-Roman MT, Jimenez-Yuste V. Arthroscopic ankle surgery in people with haemophilia. Haemophilia 2024; 30:286-294. [PMID: 38379188 DOI: 10.1111/hae.14967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION People with haemophilia (PWH) not administered primary haematological prophylaxis since childhood, that is, those treated haematologically on demand or not treated at all, often experience the degeneration of the ankles, leading to pain and functional impairment. AIM To analyse the outcomes and complications of arthroscopic ankle surgery performed on PWH. METHODS For this narrative review of the literature, a search was conducted in PubMed on 2, December 2023, using the keywords "haemophilia", "ankle" and "arthroscopy". Of the 29 articles identified, 15 specifically related to ankle arthroscopy in PWH were selected (inclusion criterion). The remaining articles did not meet this requirement (exclusion criterion) and were therefore eliminated. RESULTS Arthroscopic procedures (arthroscopic synovectomy, debridement and arthrodesis of the ankle) are increasingly used in the surgical treatment of haemophilic ankle arthropathy. Although arthroscopic ankle surgery offers good outcomes in patients with haemophilia, the procedure is not free of complications, which range from 7.9% for arthroscopic ankle debridement to 13.1% in arthroscopic ankle synovectomy and 17.8% in arthroscopic ankle arthrodesis, respectively. The non-union rate of arthroscopic ankle arthrodesis is 7.1% (2/28). CONCLUSION Although arthroscopic interventions in the haemophilic ankle (synovectomy, debridement, arthrodesis) offer good functional outcomes, they are associated with a non-negligible rate of complications. Arthroscopic ankle surgery in PWH is major surgery and should be treated as such.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain
- Osteoarticular Surgery Research, La Paz Hospital Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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2
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Rodriguez-Merchan EC. Ankle arthrodesis and total ankle replacement in patients with congenital bleeding disorders suffering from severe ankle arthropathy. Expert Rev Hematol 2024; 17:1-8. [PMID: 38131332 DOI: 10.1080/17474086.2023.2299301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/21/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION In patients with congenital bleeding disorders suffering from severe ankle arthropathy, when conservative treatment and joint-preserving surgical techniques fail, there are two possible non-joint-preserving options: ankle arthrodesis (AA) and total ankle replacement (TAR). AREAS COVERED The scope and aim of this article was to analyze the current role of AA and TAR in patients with congenital bleeding disorders suffering from severe ankle arthropathy. EXPERT OPINION In patients with congenital bleeding disorders, both TAR and AA provide good results, mainly in terms of pain relief, although they are not exempt from complications (between 0% and 33% in TAR and between 5% and 23.5% in AA). The current controversy about which of the two surgical techniques, TAR or AA, gives better results, the current literature is not able to resolve it in patients with congenital bleeding disorders. While this question is being answered, my opinion regarding patients with congenital bleeding disorders is that the age of the patient must be taken into account. Given known prosthetic survival rates, the older the patient, the more we might be inclined to indicate TAR. Conversely, AA may be more appropriate for relatively young patients.
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3
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Rodriguez-Merchan EC. Management of musculoskeletal complications in patients with hemophilia: literature review and expert recommendations. Cardiovasc Hematol Disord Drug Targets 2021; 21:162-166. [PMID: 33906595 DOI: 10.2174/1871529x21666210427134232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/02/2021] [Accepted: 03/01/2021] [Indexed: 11/22/2022]
Abstract
In people with hemophilia, hematological prophylaxis during childhood and adolescence could elude the occurrence of musculoskeletal complications (in joints and muscles) if the concentration of the defective factor is averted from decreasing under 1% of normal. Prompt management is of capital significance as the juvenile skeleton is hypersensitive to the adverse events of the disease; intense structural defects might appear rapidly. Important articular bleeds and inveterate hypertrophy of the articular synovial membrane must be treated vigorously to preclude joint degeneration (hemophilic arthropathy). At the moment that extreme joint disease is in place with intense affliction, the goal must be to reestablish activity whilst at the same time reducing the peril to the patient. Articular debridement is an efficacious surgical technique to accomplish this goal, particularly around the knee or ankle, and may be contemplated to be a backup to ankle arthrodesis or ankle or knee replacement in patients of younger age. Eventually joint replacement can commonly reestablish both articular mobility and function in an unhealthy articulation.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid. Spain
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Visweshwar N, Zhang Y, Joseph H, Jaglal M, Ayala I. Chronic pain in patients with hemophilia: is it preventable? Blood Coagul Fibrinolysis 2020; 31:346-352. [PMID: 32815911 DOI: 10.1097/mbc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
: Current management of chronic pain in patients with hemophilia (PWH) focuses on pain relief with analgesics and symptom control. The clinical practice of managing chronic pain in PWH varies considerably across hemophilia treatment centers. Here, we aim to study the appropriate intervention of hemophilic arthropathy for prevention and treatment of chronic pain in PWH. Medline, Embase, Cochrane databases were searched for randomized controlled trials, and the European Hemophilia Therapy Standardization Board, The World Federation of Hemophilia, Nordic Hemophilia Guidelines, American Society of the International Pain Physicians and the Medical and Scientific Advisory Council guidelines were studied through November 2019 for chronic pain in PWH for a narrative review. We found no standardized approach for the prevention and management of chronic pain in PWH. Evidence suggests that prophylactic factor concentrate therapy, programmed exercise and educational intervention may help PWH manage their chronic pain.
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Affiliation(s)
| | - Yumeng Zhang
- Department Internal Medicine, University of South Florida
| | | | | | - Irmel Ayala
- Hemophilia Treatment Center, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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Yontar NS, Can A, Ögüt T. Surgical Treatment of Neglected Bilateral Hemophilic Equinus Contracture With External Fixation: A Case Report. J Foot Ankle Surg 2018; 57:605-609. [PMID: 29472170 DOI: 10.1053/j.jfas.2017.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Indexed: 02/03/2023]
Abstract
Hemophilia is a disorder of blood coagulation with X-linked recessive inheritance. It is characterized by uncontrollable hemorrhage, and 80% of these occur intraarticularly. With recurrent hemarthrosis, recurrent synovitis occurs, which eventually leads to the formation of articular contractures. The key to the prevention of hemophilic joint complications is successful prevention of bleeding and management of the initial hemarthrosis. However, after the development of a rigid contracture, surgical correction remains the only method to correct the deformity. Achilles tendon lengthening, synovectomy, anterior osteophyte resection, corrective osteotomies, external fixators, or arthrodesis should be considered as surgical options. In the present report, we describe our experience using hybrid-type external fixators to manage bilateral neglected rigid equinus contractures in a hemophilic patient, with 78 months of follow-up data.
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Affiliation(s)
| | - Ata Can
- Orthopedist, Nisantasi Ortopedi Merkezi, Unimed Center, Fulya, Turkey
| | - Tahir Ögüt
- Professor, Department of Orthopaedics and Traumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Kaya Bicer E, Kayaokay K, Alsina A, Gunay H, Kavakli K, Aydoğdu S. Role of Arthroscopic Debridement of Hemophilic Ankles. Foot Ankle Int 2018; 39:1199-1204. [PMID: 29860878 DOI: 10.1177/1071100718779079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthroscopic debridement has been used in the treatment of early stages of hemophilic ankle arthropathy. The aim of this procedure is to alleviate pain, improve function, and diminish bleeding episodes. Evaluation of patient-reported outcomes of arthroscopic debridement for hemophilic ankle arthropathies was evaluated in this study. METHODS Fifteen patients with hemophilia who had undergone arthroscopic debridement between 2008 and 2017 were included in this study. Preoperative American Orthopaedic Foot & Ankle Society Score (AOFAS) and Foot Function Index (FFI) with its subscales were obtained. Patient-reported outcome was measured using FFI at the latest follow-up. Radiologic severity of hemophilic arthropathy was assessed with the Pettersson score. Preoperative and postoperative intraarticular bleeding frequencies of the hemophilic patients were compared. RESULTS Patients experienced statistically significant improvements of FFI and its subscales. Median preoperative FFI scores dropped from 42.2% to 22.2% postoperatively. Median value for the Pettersson score was 3. Annual median bleeding frequency of the study group was 18 preoperatively and 1.5 postoperatively ( P = .002). CONCLUSION By assessing patient-reported outcomes, pain and functional restrictions associated with hemophilic ankle arthropathy were improved following arthroscopic debridement. By means of subjective measures, this procedure was effective. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Elcil Kaya Bicer
- 1 Department of Orthopaedics and Traumatology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kemal Kayaokay
- 1 Department of Orthopaedics and Traumatology, Ege University Faculty of Medicine, Izmir, Turkey.,2 Siverek Public Hospital, Sanliurfa, Turkey
| | - Andac Alsina
- 1 Department of Orthopaedics and Traumatology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Huseyin Gunay
- 1 Department of Orthopaedics and Traumatology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kaan Kavakli
- 3 Department of Pediatric Hematology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Semih Aydoğdu
- 1 Department of Orthopaedics and Traumatology, Ege University Faculty of Medicine, Izmir, Turkey
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Donoso-Úbeda E, Meroño-Gallut J, López-Pina JA, Cuesta-Barriuso R. Safety of fascial therapy in adult patients with hemophilic arthropathy of ankle. A cohort study. Musculoskelet Sci Pract 2018; 35:90-94. [PMID: 29550698 DOI: 10.1016/j.msksp.2018.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/22/2018] [Accepted: 03/09/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hemophilic arthropathy is characterized by loss of function and chronic pain. Fascial therapy mobilizes the connective tissue, intervening in the state of the injured fascial complex and the surrounding tissues. OBJECTIVES The aim of this study is to evaluate the safety of a physiotherapy program through fascial therapy in adult patients with hemophilic ankle arthropathy. DESIGN Prospective cohort study. METHODS Twenty-three adult patients with hemophilia from 26 to 65 years of age were recruited. The intervention consisted of three sessions of 45-minute fascial therapy for three consecutive weeks. An evaluation was carried out before as well as after treatment. The study variables were joint status (assessed with Hemophilia Joint Health Score), joint pain (using visual analogue scale), ankle range of motion (with a universal goniometer) and bleeding frequency (administering self-registration of bleeding). The mean difference was calculated using the Student's t-test for paired samples and using the Cohen formula we calculated the effect size of the dependent variables. RESULTS None of the patients developed muscular or articular bleeding during the treatment period. After treatment, significant improvements (p < 0.05) in plantar flexion, ankle pain under load and joint condition were observed in both ankles. Similarly, we found improvement in left ankle dorsiflexion. CONCLUSIONS The application of physiotherapy through fascial therapy does not appear to produce muscle or joint hemorrhages. A treatment through three sessions of fascial therapy may improve joint pain, mobility and joint ankle condition in patients with hemophilic arthropathy.
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Affiliation(s)
| | | | | | - Rubén Cuesta-Barriuso
- Department of Physiotherapy, European University of Madrid, Spain; Royal Victoria Eugenia Foundation, Madrid, Spain; Fishemo CEE, Spanish Federation of Hemophilia, Madrid, Spain.
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Brunel T, Lobet S, Deschamps K, Hermans C, Peerlinck K, Vandesande J, Pialat JB. Reliability and clinical features associated with the IPSG MRI tibiotalar and subtalar joint scores in children, adolescents and young adults with haemophilia. Haemophilia 2017; 24:141-148. [DOI: 10.1111/hae.13368] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2017] [Indexed: 11/29/2022]
Affiliation(s)
- T. Brunel
- Department of Radiology; Hôpital de la Croix-rousse; Hospices Civils de Lyon; Lyon France
| | - S. Lobet
- Secteur des Sciences de la Santé; Institut de Recherche Expérimentale et Clinique; Neuromusculoskeletal Lab (NMSK); Université Catholique de Louvain; Brussels Belgium
- Cliniques Universitaires Saint-Luc; Service d'hématologie; Brussels Belgium
- Cliniques Universitaires Saint-Luc; Service de médecine physique et réadaptation; Brussels Belgium
| | - K. Deschamps
- Department of Rehabilitation Sciences; Musculoskeletal Rehabilitation Research Group; KU Leuven; Leuven Belgium
- Laboratory for Clinical Motion Analysis; University Hospital Pellenberg; UZ Leuven; Leuve Belgium
- Department of Podiatry; Parnasse-ISEI; Brussels Belgium
- Department of Podiatry; Artevelde University College Ghent; Ghent Belgium
| | - C. Hermans
- Cliniques Universitaires Saint-Luc; Service d'hématologie; Brussels Belgium
| | - K. Peerlinck
- Department of Cardiovascular sciences; KULeuven; Leuven Belgium
- Haemophilia Center; University Hospitals Leuven; Leuven Belgium
| | - J. Vandesande
- Haemophilia Center; University Hospitals Leuven; Leuven Belgium
| | - J.-B. Pialat
- Department of Radiology; Centre Hospitalier Lyon-Sud; Hospices Civils de Lyon; Pierre-Bénite France
- Université Claude Bernard Lyon 1; Université de Lyon; Lyon France
- INSERM; UMR 1033 LYOS; Lyon France
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9
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Solimeno LP, Pasta G. Knee and Ankle Arthroplasty in Hemophilia. J Clin Med 2017; 6:E107. [PMID: 29165342 PMCID: PMC5704124 DOI: 10.3390/jcm6110107] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 10/30/2017] [Accepted: 11/01/2017] [Indexed: 12/15/2022] Open
Abstract
Today, major surgical procedures can be safely performed in hemophilic patients with chronic arthropathy, using available factor concentrates. In this setting, total knee replacement is considered the "gold standard", while the use of total ankle replacement is still debated. Indeed, the unsatisfactory results obtained with the previous available design of implants did not raise enthusiasm as knee or hip replacement. Recently, the introduction of new implant designs and better reported outcomes have renewed the interest in total ankle replacement in people with hemophilia. In this review, the role of replacement surgery in the treatment of chronic hemophilic arthropathy will be described.
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Affiliation(s)
- Luigi Piero Solimeno
- Division of Orthopaedic Surgery and Traumatology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza, 28, 20122 Milan, Italy.
| | - Gianluigi Pasta
- Division of Orthopaedic Surgery and Traumatology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza, 28, 20122 Milan, Italy.
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10
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Lobet S, McCarthy A, Hermans C, Peerlinck K, Matricali GA, Staes F, Deschamps K. Biomechanical markers and theoretical concepts related to haemophilic ankle and subtalar joint arthropathy: introducing the term ‘haemophilic tarsal pan-arthropathy’. Haemophilia 2017; 23:e250-e258. [DOI: 10.1111/hae.13202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2017] [Indexed: 12/22/2022]
Affiliation(s)
- S. Lobet
- Secteur des Sciences de la Santé; Institut de Recherche Expérimentale et Clinique; Computer Assisted Robotic Surgery (CARS); Université catholique de Louvain; Brussels Belgium
- Cliniques universitaires Saint-Luc; Service d'hématologie; Brussels Belgium
- Cliniques universitaires Saint-Luc; Service de médecine physique et réadaptation; Brussels Belgium
| | - A. McCarthy
- Katharine Dormandy Haemophilia & Thrombosis Centre; Royal Free Hospital; London UK
| | - C. Hermans
- Cliniques universitaires Saint-Luc; Service d'hématologie; Brussels Belgium
| | - K. Peerlinck
- Centre for Molecular and Vascular Biology; KU Leuven; Leuven Belgium
| | - G. A. Matricali
- Department of Development & Regeneration; KU Leuven; Leuven Belgium
- Department of Orthopaedics; Foot & Ankle Unit; University Hospitals Leuven; KU Leuven; Leuven Belgium
- Institute of Orthopaedic Research & Training; KU Leuven; Leuven Belgium
| | - F. Staes
- Department of Rehabilitation Sciences; Musculoskeletal Rehabilitation Research Group; KU Leuven; Leuven Belgium
| | - K. Deschamps
- Department of Rehabilitation Sciences; Musculoskeletal Rehabilitation Research Group; KU Leuven; Leuven Belgium
- Department of Podiatry; Artevelde University College; Ghent Belgium
- Department of Podiatry; Parnasse-ISEI; Haute Ecole Leonard de Vinci; Bruxelles Belgium
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11
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Brkljac M, Shah S, Hay C, Rodriguez-Merchan EC. Hindfoot fusion in haemophilic arthropathy: 6-year mean follow-up of 41 procedures performed in 28 adult patients. Haemophilia 2016; 22:e87-e98. [DOI: 10.1111/hae.12863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- M. Brkljac
- Manchester Royal Infirmary; University of Manchester; Manchester UK
| | - S. Shah
- Department of Orthopaedic Surgery; Manchester Royal Infirmary; Manchester UK
| | - C. Hay
- Department of Haematology; Manchester Royal Infirmary; Manchester UK
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12
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Bluth BE, Fong YJ, Houman JJ, Silva M, Luck JV. Ankle fusion in patients with haemophilia. Haemophilia 2013; 19:432-7. [DOI: 10.1111/hae.12114] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2013] [Indexed: 11/26/2022]
Affiliation(s)
- B. E. Bluth
- UCLA/Orthopaedic Hospital Department of Orthopaedics; David Geffen School of Medicine at UCLA; Los Angeles; CA; USA
| | - Y. J. Fong
- Hemophilia Treatment Center at Orthopaedic Hospital; Los Angeles; CA; USA
| | - J. J. Houman
- University of Rochester; School of Medicine; Rochester; NY; USA
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13
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Van MEEGEREN MER, Van VEGHEL K, De KLEIJN P, Van ROERMUND PM, BIESMA DH, LAFEBER FPJG, ROOSENDAAL G. Joint distraction results in clinical and structural improvement of haemophilic ankle arthropathy: a series of three cases. Haemophilia 2012; 18:810-7. [DOI: 10.1111/j.1365-2516.2012.02805.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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14
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TSAILAS PG, WIEDEL JD. Arthrodesis of the ankle and subtalar joints in patients with haemophilic arthropathy. Haemophilia 2010; 16:822-31. [DOI: 10.1111/j.1365-2516.2010.02248.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pasta G, Mancuso ME, Perfetto OS, Solimeno LP. Synoviorthesis in haemophilia patients with inhibitors. Haemophilia 2009; 14 Suppl 6:52-5. [PMID: 19134034 DOI: 10.1111/j.1365-2516.2008.01890.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recurrent bleeding into joints represents the clinical hallmark of haemophilia and, if not adequately treated, it may cause chronic synovitis and degenerative arthropathy. In haemophilia patients with inhibitors, a more severe degree of synovitis is often observed owing to the fact that treatment is more problematic in this setting. The first treatment option of recurrent haemarthroses and/or chronic synovitis is represented by synoviorthesis, both chemical and radioisotopic, with a success rate of approximately 80% for both. However, radioisotopic synoviorthesis should be preferred in inhibitor patients because it makes it possible to obtain complete synovial fibrosis usually in one session, without the need for repeated injections, thus reducing the risk of bleeding complications and concentrate consumption. For all these reasons this procedure should be implemented and supported, particularly in developing countries.
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Affiliation(s)
- G Pasta
- Traumatology Department and Angelo Bianchi Bonomi Haemophilia Centre, IRCCS Maggiore Hospital Foundation, Milan, Italy.
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16
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Pasta G, Forsyth A, Merchan CR, Mortazavi SMJ, Silva M, Mulder K, Mancuso E, Perfetto O, Heim M, Caviglia H, Solimeno L. Orthopaedic management of haemophilia arthropathy of the ankle. Haemophilia 2008; 14 Suppl 3:170-6. [PMID: 18510538 DOI: 10.1111/j.1365-2516.2008.01720.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Joint bleeding, or haemarthrosis, is the most common type of bleeding episode experienced by individuals with haemophilia A and B. This leads to changes within the joints, including synovial proliferation, which results in further bleeding and chronic synovitis. Blood in the joint can also directly damage the cartilage, and with repeated bleeding, there is progressive destruction of both cartilage and bone. The end result is known as haemophilic arthropathy. The joints most commonly affected are the knees, elbows and ankles, although any synovial joint may be involved. In the ankle, both the tibiotalar and subtalar joints may be affected and joint bleeding and arthropathy can lead to a number of deformities. Haemophilic arthropathy can be prevented through regular factor replacement prophylaxis and implementing physiotherapy. However, when necessary, there are multiple surgical and non-surgical options available. In early ankle arthropathy with absent or minimal joint changes, both radioisotopic and chemical synoviorthesis can be used to reduce the hypertrophied synovium. These procedures can decrease the frequency of bleeding episodes, minimizing the risk of articular cartilage damage. Achilles tendon lengthening can be performed, in isolation or in combination with other surgical measures, to correct Achilles tendon contractures. Both arthroscopic and open synovectomies are available as a means to remove the friable villous layer of the synovium and are often indicated when bleeding episodes cannot be properly controlled by factor replacement therapy or synoviorthesis. In the later stages of ankle arthropathy, other surgical options may be considered. Debridement may be indicated when there are loose pieces of cartilage or anterior osteophytes, and can help to improve the joint function, even in the presence of articular cartilage damage. Supramalleolar tibial osteotomy may be indicated in patients with a valgus deformity of the hindfoot without degenerative radiographic findings. Joint fusion, or arthrodesis, is the treatment of choice in the advanced stages of ankle arthropathy although total ankle replacement is currently available. Early ankle replacement components were associated with a poor outcome, but as implant designs have improved, there have been successful outcomes achieved. As the ankle is a commonly affected joint in many individuals with haemophilia, it is important to add to the knowledge base to validate indications and timing of surgical and non-surgical interventions in ankle arthropathy.
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Affiliation(s)
- G Pasta
- Traumatology Department and Angelo Bianchi Bonomi Hemophilia Center, IRCCS, Maggiore Hospital Foundation, Milan, Italy.
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17
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Choudhury MZB, Mann HA, Goddard NJ, Lee CA. An outline of the current orthopaedic management of haemophilic disease of the upper limb. Haemophilia 2007; 13:599-605. [PMID: 17880450 DOI: 10.1111/j.1365-2516.2007.01493.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There remains a relative paucity in the literature regarding upper limb manifestations of haemophilic arthropathy. Haemophilia has a wide range of clinical manifestations, often presenting with orthopaedic complications. These arise from multiple haemarthroses which exact a cumulative toll on the fabric of the joints. Although the lower limbs are predominantly affected due to their load-bearing nature, upper limb disease is common. This arises from the mechanical demands on the upper limb as the elbow and shoulder become partially weight bearing on use of walking aids such as elbow crutches.
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18
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Wallny T, Brackmann H, Kraft C, Nicolay C, Pennekamp P. Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1-24 years. Acta Orthop 2006; 77:164-8. [PMID: 16534718 DOI: 10.1080/17453670610045867] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Bleeding in the calf or ankle joint may lead to ankle equinus deformity, particularly in childhood and during adolescence. We assessed the long-term functional and radiographic results after Achilles tendon lengthening for ankle equinus deformity in hemophiliacs. PATIENTS AND METHODS Between 1975 and 1986, 30 hemophilic patients with pes equinus were surgically managed by Achilles tendon lengthening. Of these, 23 were followed up prospectively twice a year for an average of 13 (1-24) years. The mean age at operation was 29 (12-46) years. The clinical results were documented according to the score of the Advisory Committee of the World Federation of Hemophilia (WFH), while radio-graphs were evaluated using the Pettersson score. On average, preoperative ankle equinus deformity was 21 (5-55) degrees. Mean range of motion was 21 (5-42) degrees prior to surgery. RESULTS At the first postoperative examination 1 year after surgery, 21/23 cases were improved, and 9/21 reached dorsiflexion to at least neutral position. At the last follow-up, ankle equinus deformity was 10 (4-20) degrees on average. 20/23 patients still showed significant improvement compared to their condition before surgery. 7 patients still had complete correction of the equinus deformity, while mean range of motion decreased constantly over the observation period. The clinical score was significantly improved 1 year after surgery and diminished only slightly afterwards. Radio-graphic outcome deteriorated, with scores rising from 4.3 (1-10) points preoperatively to 7.3 (3-12) points at last follow-up. INTERPRETATION Most patients treated for hemophilic pes equinus by Achilles tendon lengthening experienced long-term benefit concerning the equinus deformity, but gradually lost overall movement of the ankle joint. Progression of the ankle arthropathy cannot be hindered.
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Affiliation(s)
- Thomas Wallny
- Department of Orthopedic Surgery, University of Bonn, Germany.
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Panotopoulos J, Hanslik-Schnabel B, Wanivenhaus A, Trieb K. Outcome of surgical concepts in haemophilic arthropathy of the hindfoot. Haemophilia 2005; 11:468-71. [PMID: 16128890 DOI: 10.1111/j.1365-2516.2005.01133.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The ankle is one of the most frequent joint affected by haemophilia, in the second decade of life it can be considered as the most common site for haemophilic arthropathy. The aim of this study is to evaluate the results of 15 surgical interventions of the hindfoot performed on 11 patients. Twenty-seven of 70 male patients suffering from haemophilia were treated for haemophilic arthropathy of the hindfoot. We performed 15 operations on 11 patients with a mean age of 33.5 (range: 10-53) years. The surgical treatment consisted of 15 operations, 12 of which concerned the talocrural joint (six synovectomies, three radiosynoviorthesis, four arthrodeses, one achilles tendon lengthening) and one the talocalcaneonavicular joint (one triplearthrodesis). The arthrodeses of the talocrural joint were undertaken by screw, the triplearthrodesis by clamp fixation. The synovectomies were all late synovectomies and performed by open means. The mean follow-up period was 32.0 (range: 12-84) months. The mean age at surgery was 29.6 (range: 8-51) years. No perioperative complications were registered when adequate replacement therapy was carried out. The consolidation of the arthrodeses was accomplished within 8-12 weeks. All synovectomies stopped or reduced significantly recurrent joint bleeding. With both procedures we achieved pain relief and walking ability improvement. The aim of synovectomy is to reduce bleeding episodes. If synovectomy can halt the progression of the haemophilic arthropathy is controversially discussed, especially when surgery was carried out in the presence of an established arthropathy. If synovectomy fails, the arthrodesis proves to be a good treatment option.
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Affiliation(s)
- J Panotopoulos
- Department of Orthopaedics, Medical University of Vienna, Vienna, Austria.
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Journeycake JM, Miller KL, Anderson AM, Buchanan GR, Finnegan M. Arthroscopic synovectomy in children and adolescents with hemophilia. J Pediatr Hematol Oncol 2003; 25:726-31. [PMID: 12972809 DOI: 10.1097/00043426-200309000-00010] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE To retrospectively review the authors' institutional experience with arthroscopic synovectomy in young patients with hemophilia. PATIENTS AND METHODS Patients with moderate or severe hemophilia seen in the authors' center were eligible to undergo synovectomy if they developed subacute or chronic synovitis that did not improve with prophylactic factor replacement. A single orthopedic surgeon performed all procedures. Each patient received aggressive physical rehabilitation and regular factor replacement for 6 weeks following surgery. Outcome data regarding the frequency of bleeding and range of motion were evaluated. RESULTS Twenty-eight arthroscopic synovectomies (11 knees, 12 ankles, 5 elbows) were performed on 26 joints in 20 hemophilia patients between November 1992 and May 2002. There were no intraoperative complications. One patient developed hemarthrosis 1 week postoperatively and another had a soft tissue hematoma at the incision site. Two patients required a second procedure on the same joint because of trauma that occurred 2 months following surgery. Follow-up data were available on 26 joints during the first year after the procedure. The frequency of hemarthrosis diminished significantly in that first year and was maintained for up to 5 years in all but three joints. Seventy-six percent of evaluable patients (19/25) had stable or improved joint function at their most recent comprehensive clinic visit. Patients whose range of motion worsened were older and required more than one procedure. CONCLUSIONS Arthroscopic synovectomy significantly reduces hemorrhage into the index joint and allows for stabilization of joint range of motion. This procedure should be considered in young hemophilia patients with chronic synovitis.
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Affiliation(s)
- Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 75390, USA.
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MACNICOL MF, LUDLAM CA. Does avascular necrosis cause collapse of the dome of the talus in severe haemophilia? Haemophilia 2002. [DOI: 10.1046/j.1365-2516.1999.t01-1-00291.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- M. F. MACNICOL
- Princess Margaret Rose Orthopaedic Hospital, Edinburgh UK,
| | - C. A. LUDLAM
- Department of Haematology, Royal Infirmary, Edinburgh, UK
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Klukowska A, Czyrny Z, Laguna P, Brzewski M, Serafin-Krol MA, Rokicka-Milewska R. Correlation between clinical, radiological and ultrasonographical image of knee joints in children with haemophilia. Haemophilia 2001; 7:286-92. [PMID: 11380633 DOI: 10.1046/j.1365-2516.2001.00509.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The aims of the study were to evaluate the clinical, radiological and ultrasonographical images of knee joints in children with severe haemophilia and von Willebrand's disease, to determine the correlation between these images and to assess the usefulness of ultrasonography (USG) in evaluating the intensity of haemophilic arthropathy. Thirty-nine boys were included in the study, all of them with a past history of knee bleeds. The average age of the children was 10.02 +/- 3.01 years. In patients with slight (1-3 points) and moderate (4-7 points) radiological changes in knee joint bones, an increase in synovial fluid, considerable hypertrophy and inflammation of the synovium were observed in USG. In haemophilic patients with severe (8-13 points) bone changes, the amount of fluid was usually normal and there was slight inflammation but considerable hypertrophy of the synovium. Radiological evaluation of haemophilic arthropathy was made according to the Pettersson classification. A good correlation between the degree of cartilage damage in USG and the progression of bone changes in radiographs was found. Cartilage and bone damage progressed with the increase in the number of intra-articular haemorrhages into the knee joint. In our opinion USG is useful in evaluating the fluid, synovium and cartilage of joints in haemophiliacs.
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Affiliation(s)
- A Klukowska
- Departments of Paediatrics, Haematology and Oncology, Medical Academy, Warsaw, Poland
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Abstract
The idea of prevention and preventative care is not new. History and culture have given us many examples of the importance of physical well-being and the prvention of illness and disease. The ancient societies of China focused on the balance of Yin and Yang in promoting health; Greece and Rome valued the importance of health and physical culture; the earliest Hebrew societies documented the importance of diet and dietary restrictions as a means towards good health. Through this century health professionals have advocated the importance of preventive care as an integral element of the quality of health. Haemophilia is a life-long condition with a high potential towards disability, handicap and impairment if not adequately treated. It is therefore essential that those with haemophilia are taught the importance of physical fitness at an early age as a means of preventing articular contractures. Physiotherapy is of great importance in this field, especially in third-world countries where the supply of replacement products are scarce or non-existent.
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Affiliation(s)
- B M Buzzard
- Haemophilia Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Lal P, Biswal BM, Thulkar S, Patel AK, Venkatesh R, Julka PK. Radiation therapy in pseudotumour haemarthrosis. AUSTRALASIAN RADIOLOGY 1998; 42:344-6. [PMID: 9833373 DOI: 10.1111/j.1440-1673.1998.tb00535.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Total or partial deficiency of factor VIII and IX in the coagulation cascade leads to haemophilia. Haemophilia affecting weight-bearing joints gives a 'pseudotumour' or haemarthrosis-like condition. Surgery and cryoprecipitate infusions have been the treatment for this condition. Radiocolloids and radiation therapy have been used with some benefit. One case of ankle pseudotumour which was treated by low-dose external beam radiation is presented here.
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Affiliation(s)
- P Lal
- Department of Radiation Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Abstract
Musculoskeletal dysfunction is a common manifestation of haemophilia. This dysfunction may be associated with imbalances between muscle groups. Evidence emerging from the literature suggests that the rehabilitation of this dysfunction is very relevant for the patient with musculoskeletal problems. Treatment of muscle imbalance may be linked with a reduction in recurrence of symptoms. Further research is needed to establish the relevance of this area in patients with haemophilia but the clinical evidence supports the developing work in this field.
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Affiliation(s)
- K Beeton
- Department of Physiotherapy, University of Hertfordshire, UK.
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