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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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Rodriguez-Merchan EC. Hemophilic arthropathy: a teaching approach devoted to hemophilia treaters in under-development countries. Expert Rev Hematol 2021; 14:887-896. [PMID: 34482789 DOI: 10.1080/17474086.2021.1977118] [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] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Arthropathy is the characteristic injury of hemophilia, primarily occurring in the elbows, knees, and ankles. The aim of this review is a teaching approach devoted to hemophilia treaters in under-development countries. AREAS COVERED Current major challenges include the absence of the following therapeutic tools for all people with hemophilia (PWH) worldwide: hematological prophylaxis; well-coordinated multidisciplinary teams in specialized centers; joint aspiration of acute hemarthrosis; point-of-care ultrasonography (POC-US); exercise; treatment of synovitis by means of radiosynovectomy; treatment of mild hemophilic arthropathy with analgesics, anti-inflammatory agents, and rehabilitation medicine; intra-articular injections of corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells; and treatment of severe hemophilic arthropathy by surgical treatment. The future scenario in under-development countries should include all the aforementioned treatment tools plus the possibility of performing total joint arthroplasty in PWH with inhibitors; concomitant use of bypassing agents with emicizumab for PWH with inhibitors undergoing orthopedic surgery; and telemedicine. EXPERT OPINION Primary hematological prophylaxis is now the gold standard for the management of hemophilia. Acute hemarthrosis needs intense hematological management and articular aspiration; the articular situation should be scrutinized by POC-US. Synovitis can be controlled by radiosynovectomy. In cases of severe articular degeneration, surgical procedures might be required.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, La Paz University Hospital Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Xiao R, Cirino C, Williams C, Hausman M. Arthroscopy of the Pediatric Elbow: Review of the Current Concepts. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2021. [DOI: 10.1055/s-0041-1730394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractAs surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.
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Affiliation(s)
- Ryan Xiao
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Carl Cirino
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Christine Williams
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Michael Hausman
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
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Chon HN, Cho JH, Park YS. Perioperative Management and Outcomes in Children with Hereditary Bleeding Disorder: a Retrospective Review at a Singl e Hemophilia Treatment Center. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2020. [DOI: 10.15264/cpho.2020.27.2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ha Nuel Chon
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Ja Hyang Cho
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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Badulescu OV, Filip N, Sirbu PD, Bararu-Bojan I, Vladeanu M, Bojan A, Ciocoiu M. Current practices in haemophilic patients undergoing orthopedic surgery - a systematic review. Exp Ther Med 2020; 20:207. [PMID: 33123236 DOI: 10.3892/etm.2020.9337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Haemophilia is an inherited disease that requires a different approach in order to evaluate, monitor and treat patients. Despite the great advances in therapeutic agents that have emerged, reports on the impact of monitoring outcomes on treatment decisions are rarely presented. Haemophilia A and haemophilia B are inherited bleeding disorders caused by deficiencies in blood clotting factor proteins. A systematic review was performed to identify literature reports on the current practices in haemophilic patients undergoing orthopedic surgery. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications. Besides the primary prophylaxis, thromboprophylaxis is used to prevent venous thrombosis in patients with hemophilia who undergo surgical orthopedic procedures. Further research is needed to better manage the pharmacologic approaches in haemophilic patients undergoing orthopedic surgery. Although patients with haemophilia present low risk for thromboembolic complications, such events have been reported in surgical procedures. The recommendations in patients with haemophilia are considerably variable in the current guidelines and clinical practice. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications.
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Affiliation(s)
- Oana Viola Badulescu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Nina Filip
- Department of Biochemistry, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Paul Dan Sirbu
- Department of Orthopedics and Traumatology Surgical Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iris Bararu-Bojan
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria Vladeanu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Andrei Bojan
- Department of Surgical Sciences, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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van Vulpen LFD, Thomas S, Keny SA, Mohanty SS. Synovitis and synovectomy in haemophilia. Haemophilia 2020; 27 Suppl 3:96-102. [PMID: 32490595 PMCID: PMC7984224 DOI: 10.1111/hae.14025] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/17/2020] [Indexed: 12/25/2022]
Abstract
Joint bleeds cause major morbidity in haemophilia patients. The synovial tissue is responsible for removal of blood remnants from the joint cavity. But blood components, especially iron, lead to a series of changes in the synovial tissue: inflammation, proliferation and neovascularization. These changes make the synovium vulnerable to subsequent bleeding and as such a vicious cycle of bleeding-synovitis-bleeding may develop leading to chronic synovitis. The initial step in the treatment is adequate clotting factor supplementation and immediate physiotherapeutic involvement. If these measures fail, synovectomy may be indicated. Non-surgical options are chemical and radioactive synovectomy. This is a relatively non-invasive procedure to do synovectomy, leading to a reduction in pain and joint bleeds. Radioactive synovectomy seems more effective than chemical synovectomy in larger joints. Surgical options are open and arthroscopic synovectomy. Open synovectomy has been found to decrease the incidence of breakthrough bleeds but at the cost of loss of joint motion. Use of arthroscopic synovectomy has been advocated to reduce bleeding episodes with less morbidity to extra-articular tissue and preservation of joint motion. Use of a continuous passive motion (CPM) machine and early mobilization can decrease the postoperative stiffness and promote early recovery. This review addresses the current understanding of synovitis and its treatment options with specific emphasis on chemical and radioactive synovectomy and surgical options.
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Affiliation(s)
- Lize F D van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sylvia Thomas
- Nuclear Medicine Department, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Swapnil A Keny
- Department of Orthopaedics, King Edward Memorial Hospital, Mumbai, India
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Yoo MC, Jeong BO, Ahn J. Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy. Haemophilia 2019; 25:e159-e164. [PMID: 30866148 DOI: 10.1111/hae.13719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Haemophilic ankle arthropathy may cause joint bleeding, pain, stiffness, erosion and progressive motion limitations, including a decreased range of motion (ROM) secondary to anterior osteophyte impingement. AIM The purpose of this study was to investigate changes in the ROM and symptoms after synovectomy and anterior osteophyte resection for haemophilic ankle arthropathy. METHODS We retrospectively reviewed 41 ankles in 35 patients with haemophilic arthropathy who underwent arthroscopic and/or open synovectomy. The mean follow-up period was 59.5 months. Indications for the procedure included a lack of improvement with conservative management, and the presence of haemarthrosis and arthralgia. We assessed radiographic images, ankle joint range of motion, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and patients' subjective satisfaction preoperatively and at the last follow-up. RESULTS Arthroscopic synovectomy was performed in 32 ankles, open synovectomy in 6, and arthroscopic synovectomy with additional mini-open debridement in 3. Ankle dorsiflexion improved from a mean of 2.7° preoperatively to a mean of 7.5° at the final follow-up (P = 0.003), whereas plantar flexion improved from a mean of 30.7° preoperatively to a mean of 32.7° at the final follow-up (P = 0.276). The AOFAS score improved from 62.2 preoperatively to 79.1 at the final follow-up (P < 0.001). Patient satisfaction was "excellent" in 11 ankles, "good" in 22, "fair" in 3 and "poor" in 5. CONCLUSION Arthroscopic and/or open synovectomy with anterior osteophyte resection and early rehabilitation in adolescents and adults with haemophilic ankle arthropathy showed improved ankle dorsiflexion and AOFAS scores.
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Affiliation(s)
- Myung Chul Yoo
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Bi O Jeong
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Jungtae Ahn
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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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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Zhang T, Huang S, Xu S, Li H, He X, Zhang F. Clinical outcomes of arthroscopic synovectomy for adolescent or young adult patients with advanced haemophilic arthropathy. Exp Ther Med 2018; 16:3883-3888. [PMID: 30344665 PMCID: PMC6176150 DOI: 10.3892/etm.2018.6709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/09/2018] [Indexed: 11/10/2022] Open
Abstract
The aim of the present study was to assess the clinical outcomes of arthroscopic synovectomy in adolescent or young adult patients with advanced haemophilic arthropathy. From January 2009-January 2012, clinical data from 11 adolescent or young adult patients with advanced haemophilic arthropathy who were treated with arthroscopic synovectomy were retrospectively collected. The mean follow-up period was 71.91±5.28 months. The evaluated indicators included frequency of joint bleeding, range of motion (ROM), X-ray staging, hospital for special surgery (HSS) knee score and HSS pain scores. Joint bleeding frequency, pain degree and HSS scores significantly improved following arthroscopic synovectomy at the end of the follow up period. The ROM did not significantly improve. Among the 11 patients, radiographic stage remained unchanged in 9 cases whereas the remaining 2 cases progressed from stage IV to stage V. No patients required total knee arthroplasty through the end of the follow-up period. These findings suggested that arthroscopic synovectomy appears to an effective treatment option to decrease the frequency of bleeding and knee pain, improve knee function and delay knee joint arthroplasty to a certain extent for adolescent or young adult patients with advanced haemophilic knee arthropathy.
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Affiliation(s)
- Ting Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Sihua Huang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Siyue Xu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Haopeng Li
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Xijing He
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Feng Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
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Tobase P, Lane H, Siddiqi AEA, Soucie JM, Ingram-Rich R, Ward S, Gill JC. Risk factors associated with invasive orthopaedic interventions in males with haemophilia enrolled in the Universal Data Collection program from 2000 to 2010. Haemophilia 2018; 24:964-970. [PMID: 29957840 DOI: 10.1111/hae.13511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Invasive orthopaedic interventions (IOI) are often used to control recurrent haemarthrosis, pain and loss of joint function, in males with haemophilia (Factor VIII and Factor IX deficiency). AIM Identify risk factors associated with IOIs in males with haemophilia enrolled in the Universal Data Collection (UDC) surveillance program from 2000 until 2010. METHODS Data were collected on IOIs performed on patients receiving care in 130 haemophilia treatment centers in the United States annually by health care providers using standardized forms. IOIs included in this study are as follows: 1) synovectomy and 2) arthrodesis or arthroplasty (A/A). Information about potential risk factors was obtained from the preceding UDC visit if available, or from the same visit if not. Patients with no reported IOI at any of their UDC visits were the reference group for the analysis. Multivariate analyses were conducted to identify independent risk factors for synovectomies and arthrodesis/arthroplasty. RESULTS Risk factors significantly associated with the two IOI categories were age, student status, haemophilia severity, number of joint bleeds within the last 6 months, HIV or hepatitis C (HCV) status. Multivariate analyses showed patients on continuous prophylaxis were 50% less likely to have had a synovectomy and were 40% less likely to have an A/A. CONCLUSIONS This study shows modifiable risk factors, including management of bleeding episodes with a continuous prophylactic treatment schedule are associated with a decreased likelihood of IOIs in males with haemophilia.
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Affiliation(s)
- P Tobase
- Hemophilia Treatment Center, University of California, San Francisco, CA, USA
| | - H Lane
- Intermountain Hemophilia and Thrombosis Center Primary Children's Medical Center, Salt Lake City, UT, USA
| | - A-E-A Siddiqi
- Division of Blood Disorders, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - J M Soucie
- Division of Blood Disorders, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | - S Ward
- Department of Physical Therapy, University of Utah College of Health, Salt Lake City, UT, USA
| | - J C Gill
- Medical College of Wisconsin and Comprehensive Center for Bleeding Disorders, Blood Center of Wisconsin, Milwaukee, WI, USA
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Strauss AC, Goldmann G, Ezziddin S, Placzek R, Müller MC, Pflugmacher R, Oldenburg J, Pennekamp PH. Treatment options for haemophilic arthropathy of the elbow after failed conservative therapy. Hamostaseologie 2017; 34 Suppl 1:S17-22. [DOI: 10.5482/hamo-14-01-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/17/2014] [Indexed: 11/05/2022] Open
Abstract
SummaryAfter ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. objective: The objective of this retrospective single centre study is to evaluate the results of treatment of elbow arthropathy after failed conservative therapy. Patients, methods: In 21 consecutive patients, 11 radiosyn-oviortheses (RSO), four arthroscopic and six open synovectomies were performed, among them four with additional resection of the radial head. The mean duration of follow-up was 4.8 (RSO) and 5.3 years (surgery), respectively. Pain status (visual analogue scale, VAS), bleeding frequency, range of motion (ROM) as well as patient satisfaction were evaluated. Results: Both, RSO and surgical synovectomy, achieved a significant reduction of pain and bleeding frequency (p < 0.05). Surgical synovectomies were associated with a marked yet not statistically significant increase of postoperative ROM. Radial head resection improved forearm rotation in all cases. No complications occurred. 20 out of 21 patients were satisfied or highly satisfied with the result of the treatment and would undergo the respective procedure again. Conclusion: Due to the effectiveness and safety RSO is considered to be the primary treatment option in haemophilic arthropathy of the elbow after failed conservative therapy. Arthroscopic synovectomy should be considered if RSO shows inadequate effect or in the presence of contraindications. Open synovectomy with resection of the radial head yields good results in the case of advanced arthropathy with radial head impingement.
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Rodriguez-Merchan EC, Valentino LA. Orthopedic disorders of the knee in hemophilia: A current concept review. World J Orthop 2016; 7:370-375. [PMID: 27335812 PMCID: PMC4911520 DOI: 10.5312/wjo.v7.i6.370] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/10/2016] [Accepted: 04/22/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Wu LT, Lu HT, Chen CH, Ko A, Lee CH. Arthroscopic synovectomy considerably reduces bleeding frequency and improves joint function in hemophilic patients with chronic synovitis. FORMOSAN JOURNAL OF SURGERY 2016. [DOI: 10.1016/j.fjs.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Barg A, Morris SC, Schneider SW, Phisitkul P, Saltzman CL. Surgical procedures in patients with haemophilic arthropathy of the ankle. Haemophilia 2016; 22:e156-76. [DOI: 10.1111/hae.12919] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2016] [Indexed: 12/14/2022]
Affiliation(s)
- A. Barg
- Department of Orthopaedics University of Utah Salt Lake City UT USA
| | - S. C. Morris
- Department of Orthopaedics University of Utah Salt Lake City UT USA
| | - S. W. Schneider
- Department of Dermatology, Venerology, and Allergology University Medical Center and Medical Faculty Mannheim University of Heidelberg Mannheim Germany
| | - P. Phisitkul
- Department of Orthopaedics and Rehabilitation University of Iowa Iowa City IA USA
| | - C. L. Saltzman
- Department of Orthopaedics University of Utah Salt Lake City UT USA
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Mingo-Robinet J, Odent T, Elie C, Torchet MF, Glorion C, Padovani JP, Rothschild C. Open synovectomy of the ankle joint in young haemophiliacs: mid-term to long- term results of a single-centre series of 32 procedures. Haemophilia 2015; 21:e306-11. [DOI: 10.1111/hae.12704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2015] [Indexed: 11/28/2022]
Affiliation(s)
- J. Mingo-Robinet
- Department of Orthopaedics and Traumatology; Complejo Asistencial Universitario de Palencia; Palencia Spain
| | - T. Odent
- Department of Pediatric Orthopedics; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
| | - C. Elie
- Clinical Investigation Unit; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
| | - M.-F. Torchet
- Haemophilia Care Centre; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
| | - C. Glorion
- Department of Pediatric Orthopedics; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
| | - J.-P. Padovani
- Department of Pediatric Orthopedics; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
| | - C. Rothschild
- Haemophilia Care Centre; Hopital Universitaire Necker Enfants Malades; Assistance Publique Hopitaux de Paris; Paris France
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de Almeida AM, de Rezende MU, Cordeiro FG, Villaça PR, D'Amico EA, Hernandez AJ, Camanho GL. Arthroscopic partial anterior synovectomy of the knee on patients with haemophilia. Knee Surg Sports Traumatol Arthrosc 2015; 23:785-91. [PMID: 25839071 DOI: 10.1007/s00167-013-2706-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE This study assessed the results of two-portal knee arthroscopic synovectomy in terms of bleeding recurrence, knee function, quality of life (QOL), and radiographic staging in a prospective case series of patients with haemophilia. METHODS Nine knees from eight patients (median age 16.1 years; range 9.6-25 years) with haemophilia and recurrent knee haemarthrosis were prospectively evaluated. Yearly recurrence of bleeding was evaluated once a year for 5 years postoperatively. Range of motion (ROM) and radiographic staging, as well as results of the short form (SF)-36 and subjective knee form of the International Knee Documentation Committee (IKDC) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires, were evaluated before surgery and at the end of follow-up. RESULTS Mean bleeding recurrence was significantly reduced during the 5-year follow-up period. Questionnaire results showed significant improvements (IKDC P = 0.015, WOMAC P = 0.011, and SF-36 P = 0.023), whereas ROM was not significantly affected. Arthropathy progressed from Arnold-Hilgartner radiographic stage III to stage IV (P = 0.0082). CONCLUSIONS Two-portal knee arthroscopic synovectomy was effective at reducing bleeding recurrence and improving knee function and QOL in patients with haemophilia, but did not interrupt the progression of radiographic changes.
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Rodriguez-Merchan EC. Hemophilic synovitis of the knee: radiosynovectomy or arthroscopic synovectomy? Expert Rev Hematol 2014; 7:507-11. [DOI: 10.1586/17474086.2014.926809] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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18
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Radiosynovectomy: review of the literature and report from two haemophilia treatment centers. Blood Coagul Fibrinolysis 2013; 24:465-70. [PMID: 23492910 DOI: 10.1097/mbc.0b013e3283602a28] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Haemophilic arthropathy occurs due to recurrent bleeding into joints leading to swelling, inflammation, destruction of cartilage and bone, and development of arthritis. Although prophylactic replacement therapy assists in preventing arthropathy, it is not always adequate or affordable. Radiosynovectomy is a minimally invasive intervention for treatment of synovitis in haemophilic joints. The procedure utilises locally injected radioisotopes (Y, P, Rh) to ablate abnormal synovium with the goal of decreasing bleeding, slowing progression of cartilage and bone damage and preventing arthropathy. The objective of this review is to summarize the radiosynovectomy literature and to present patient outcomes associated with radiosynovectomy over the past 17 years from two haemophilia treatment centers (HTCs), one in the United States and one in Spain. Articles from these two centers support the current literature. A retrospective medical records review was performed by the two reporting HTCs on patients who underwent radiosynovectomy prior to 2009. Data review included: site of procedure, isotope utilized, bleeding frequency, and procedure complications. Radiosynovectomy is a cost-effective, minimally invasive, well tolerated procedure. As the paradigm for care in haemophilia shifts towards prevention of joint disease, the number of target joints with synovitis will likely decrease, except in patients who develop inhibitors. We propose early consideration of radiosynovectomy for patients with haemophilic synovitis prior to appearance of articular cartilage damage.
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Turkmen C, Kilicoglu O, Dikici F, Bezgal F, Kuyumcu S, Gorgun O, Taser O, Zulfikar B. Survival analysis of Y-90 radiosynovectomy in the treatment of haemophilic synovitis of the knee: a 10-year retrospective review. Haemophilia 2013; 20:e45-50. [DOI: 10.1111/hae.12252] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2013] [Indexed: 10/26/2022]
Affiliation(s)
- C. Turkmen
- Department of Nuclear Medicine; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - O. Kilicoglu
- Department of Orthopedics and Traumatology; Istanbul Faculty of Medicine; Istanbul University; Istanbul Turkey
| | - F. Dikici
- Department of Orthopedics and Traumatology; Istanbul Faculty of Medicine; Istanbul University; Istanbul Turkey
| | - F. Bezgal
- Hemophilia Society of Turkey; Istanbul Turkey
| | - S. Kuyumcu
- Department of Nuclear Medicine; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - O. Gorgun
- Department of Pediatric Hematology and Oncology; Institute of Oncology; Istanbul University; Istanbul Turkey
| | - O. Taser
- Hemophilia Society of Turkey; Istanbul Turkey
| | - B. Zulfikar
- Department of Pediatric Hematology and Oncology; Cerrahpasa Medical Faculty; Institute of Oncology; Istanbul University; Istanbul Turkey
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20
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Rodriguez-Merchan EC. Haemophilic synovitis of the elbow: radiosynovectomy, open synovectomy or arthroscopic synovectomy? Thromb Res 2013; 132:15-8. [PMID: 23786892 DOI: 10.1016/j.thromres.2013.05.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 05/21/2013] [Accepted: 05/26/2013] [Indexed: 11/26/2022]
Abstract
Arthroscopic synovectomy (AS) of the elbow, while providing similar pain relief to open synovectomy (OS), may place patients at higher risk for recurrence. The primary predictor of outcome is degree of pre-existing degenerative changes within the joint. Regarding haemophilia patients, radiosynovectomy (RS) is the best choice for patients with persistent synovitis of the elbow. In the elbow we recommend a dose of 30-40 megabecquerels (mBq) in children and a dose of 56-74 mBq in adults. If three consecutive RSs with 6 months intervals are ineffective, an AS or OS must be indicated. Synovectomy (by any method) significantly reduces bleeding episodes. Although the dose of radiation of RS is minimal, 0.32 millisieverts (mSv) in children, 0.54 mSv in adults, and neither articular nor systemic neoplastic changes related to RS have been reported so far, all patients must be given opportunity to consider risk/benefit ratios. Radiation dose due to natural sources is 2 mSv per year and the recommended limit for patients (apart from natural sources is 1 mSv per year). My current recommendation is to use RS in children older than 12 years of age. Therefore, in children younger than 12 years of age an AS should be indicated. OS should be reserved for adults requiring radial head excision (due to a severe limitation of pronation-supination) and synovectomy in the same surgical session.
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21
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Silva M, Luck JV, Leissinger C. Opinions on radiosynovectomy for chronic haemophilic synovitis: point/counterpoint. Haemophilia 2012; 18:836-42. [PMID: 22762742 DOI: 10.1111/j.1365-2516.2012.02908.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2012] [Indexed: 01/17/2023]
Abstract
Joint bleeding is the hallmark of severe haemophilia and the major cause of disability in patients with this coagulopathy. Repeated bleeding into the same joint can lead to chronic synovitis and progressive arthropathy. Radiosynovectomy is one option for the treatment of chronic haemophilic synovitis, but concerns about the risks of exposure to ionizing radiation have divided clinicians as to the safety and appropriate use of the procedure. This article presents two differing viewpoints, one from a pair of orthopaedic surgeons who collectively have performed more than 300 radiosynovectomies in patients with haemophilia. They maintain that radiosynovectomy is a simple, effective, safe and low-cost technique children and adults with chronic haemophilic synovitis. The other perspective is from an experienced haemophilia treater who directs a major US haemophilia treatment centre. She believes that unresolved questions about the safety of radiation exposure in children argue against the use of radiosynovectomy in paediatric patients with haemophilia.
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Affiliation(s)
- M Silva
- Los Angeles Orthopaedic Hospital, UCLA/Orthopaedic Hospital, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90007, USA.
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22
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Konkle BA. The aging patient with hemophilia. Am J Hematol 2012; 87 Suppl 1:S27-32. [PMID: 22430948 DOI: 10.1002/ajh.23161] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 02/06/2012] [Accepted: 02/08/2012] [Indexed: 12/23/2022]
Abstract
The prospects for many boys born with hemophilia today include a normal life expectancy and minimal to no joint disease. However, despite the availability of safe replacement clotting factor concentrates and effective antiviral treatment, the aging patient with hemophilia today faces many challenges. These include management of their hemophilia as well as the same age-related health issues as experienced in the general population. While increasing, data on the prevalence of comorbidities and their management in the hemophilia population remain limited. This review will focus on issues related to management of hemophilia and complications of cardiovascular, musculoskeletal, hepatic, and renal disease. Available research is summarized and potential approaches to management are discussed.
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Affiliation(s)
- Barbara A Konkle
- Puget Sound Blood Center, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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Affiliation(s)
- Rolf C. R. Ljung
- Lund University, Departments of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö; Sweden
| | - Karin Knobe
- Lund University, Departments of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö; Sweden
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Acharya SS. Exploration of the pathogenesis of haemophilic joint arthropathy: understanding implications for optimal clinical management. Br J Haematol 2011; 156:13-23. [DOI: 10.1111/j.1365-2141.2011.08919.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Abstract
Hemophilia is a hereditary disease in which circulating levels of coagulation factors are lacking, resulting in a propensity toward bleeding. Intra-articular hemorrhages are a hallmark of hemophilia and may lead a cascade of cytokine elaboration and inflammatory-mediated changes, which ultimately result in cartilage loss and arthropathy. Diarthrodial joints, such as the knee, elbow, and ankle, are most commonly affected. This article highlights issues surrounding hemophilic arthropathy of the elbow and focuses on preventive measures, management strategies of the hemophilic elbow, and treatment options for established arthropathy.
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Affiliation(s)
- Julie E Adams
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, R200, Minneapolis, MN 55454, USA.
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26
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Abstract
If continuous prophylaxis is not feasible due to expense or lack of venous access, we must aggressively treat major haemarthroses (including arthrocentesis) to prevent progression to synovitis, recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy). For the treatment of chronic haemophilic synovitis, radiosynovectomy should always be indicated as the first procedure. If, after three procedures with 6-month interval, radiosynovectomy fails, an arthroscopic synovectomy must be indicated. Between the second and fourth decades, many haemophilic patients develop joint destruction (arthropathy). At this stage possible treatments include alignment osteotomy, arthroscopic joint debridement, arthrodesis (joint fusion) and total joint arthroplasty. For the hip press-fit uncemented components (hemispherical acetabulum, flanged femoral stem, metal-to-polyethylene) are recommended whilst for the knee a posterior-stabilized (PS) cemented design is advised. Muscular problems must not be underestimated in haemophilia due to their risk of developing compartment syndromes (which will require surgical decompression) and pseudotumours (which will require surgical removal or percutaneous treatment). Regarding patients with inhibitors, the advent of APCCs and rFVIIa has made major orthopaedic surgery possible, leading to an improved quality of life for haemophilia patients. Concerning local fibrin seal, it is not always necessary to achieve haemostasis in all surgical procedures performed in persons with haemophilia. However, it could be a good adjunct therapy, mainly when a surgical field potentially will bleed more than expected (i.e. patients with inhibitors), and also in some orthopaedic procedures (mainly the surgical removal of pseudotumours).
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Affiliation(s)
- E C Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid and Autónoma University, Madrid, Spain.
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27
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DUNN AL. Pathophysiology, diagnosis and prevention of arthropathy in patients with haemophilia. Haemophilia 2011; 17:571-8. [DOI: 10.1111/j.1365-2516.2010.02472.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Valentino LA. Controversies regarding the prophylactic management of adults with severe haemophilia A. Haemophilia 2010; 15 Suppl 2:5-18, quiz 19-22. [PMID: 20041959 DOI: 10.1111/j.1365-2516.2009.02159.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L A Valentino
- Department of Pediatrics and Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3833, USA.
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29
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Cho YJ, Kim KI, Chun YS, Rhyu KH, Kwon BK, Kim DY, Yoo MC. Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy. Haemophilia 2010; 16:640-6. [PMID: 20148979 DOI: 10.1111/j.1365-2516.2009.02192.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiosynoviorthesis is a safe and easy method for synovectomy in haemophilic arthropathy. Various agents have been used in radiosynoviorthesis, especially newly developed agent Holmium-166-chitosan complex has good clinical outcome. This study analysed clinical results and radiologic evaluation of radioisotope synoviorthesis using Holmium-166-chitosan complex in haemophilic arthropathy. From March 2001 to December 2003, 58 radiosynoviorthesis were performed in 53 haemophiliacs. The average age at procedure was 13.8 years. The Arnold and Hilgartner stage of the patients was from I to IV. Holmium-166-chitosan complex was injected in 31 ankle joints, 19 elbow joints and 8 knee joints. Average follow-up was 33 months since primary procedure. The range of motion of each joint, frequency of intra-articular bleeding and factor dose used were analysed for clinical assessment. There was no significant improvement of range of motion in affected joints. After procedure, the average frequency of bleeding of the elbow joint has decreased from 3.76 to 0.47 times per month, the knee joint from 5.87 to 1.12 times per month, and the ankle joint from 3.62 to 0.73 times per month respectively (P < 0.05). After treatment, the average coagulation factor dose injected was significantly decreased to 779.3 units per month from 2814.8 units per month before treatment (P < 0.001). Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy is a very safe and simple procedure with the expectation of a satisfactory outcome without serious complication. It has excellent bleeding control effect on target joint and the need for substitution of coagulation factor concentrate can be reduced.
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Affiliation(s)
- Y J Cho
- Department of Orthopaedic Surgery, Kyung Hee Medical Center, School of Medicine, Kyung Hee University, Seoul, South Korea
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30
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KONKLE BA, KESSLER C, ALEDORT L, ANDERSEN J, FOGARTY P, KOUIDES P, QUON D, RAGNI M, ZAKARIJA A, EWENSTEIN B. Emerging clinical concerns in the ageing haemophilia patient. Haemophilia 2009; 15:1197-209. [DOI: 10.1111/j.1365-2516.2009.02066.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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31
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TANAKA Y, SHINOHARA Y, NARIKAWA K, KUMAI T, TAKAKURA Y, SAKURAI Y, TANAKA I, SHIMA M, YOSHIOKA A. Arthroscopic synovectomies combined with reduced weight-bearing using patella tendon-bearing braces were very effective for progressed haemophilic ankle arthropathy in three paediatric patients. Haemophilia 2009; 15:833-6. [DOI: 10.1111/j.1365-2516.2009.01982.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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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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RODRIGUEZ-MERCHAN EC. Ankle surgery in haemophilia with special emphasis on arthroscopic debridement. Haemophilia 2008; 14:913-9. [DOI: 10.1111/j.1365-2516.2008.01820.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Verma N, Valentino LA, Chawla A. Arthroscopic synovectomy in haemophilia: indications, technique and results. Haemophilia 2008; 13 Suppl 3:38-44. [PMID: 17822520 DOI: 10.1111/j.1365-2516.2007.01539.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Recurrent spontaneous haemarthrosis are commonly seen in patients affected by haemophilia. The knee and the elbow are most commonly affected and both are amenable to arthroscopic treatment. Arthroscopic synovectomy is indicated after failure of appropriate medical management with recurrent bleeding. Many patients also demonstrate motion loss and functional deterioration. The benefits of arthroscopic synovectomy include the ability to perform adequate synovial debridement, but also concomitant lysis of adhesion and capsular release to regain range of motion. Results of arthroscopic synovectomy demonstrate a significant decrease in episodes of haemarthrosis, and significant improvement in pain, range of motion and function. The primary predictor of outcome is degree of pre-existing degenerative changes within the joint. In more severe cases, the results of arthroscopic synovectomy are unpredictable and serious consideration should be given to primary arthroplasty.
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Affiliation(s)
- N Verma
- Section of Sports Medicine and Division of Hematology, Rush University Medical Center, Rush-Presbyterian - St Luke's Medical Center, Chicago, IL 60612, USA.
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35
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Acharya SS. Hemophilic joint disease – current perspective and potential future strategies. Transfus Apher Sci 2008; 38:49-55. [DOI: 10.1016/j.transci.2007.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Van den Berg HM, Dunn A, Fischer K, Blanchette VS. Prevention and treatment of musculoskeletal disease in the haemophilia population: role of prophylaxis and synovectomy. Haemophilia 2006; 12 Suppl 3:159-68. [PMID: 16684012 DOI: 10.1111/j.1365-2516.2006.01281.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prophylaxis is defined as primary (started before the onset of joint damage) or secondary (started after the onset of joint damage). The aim of primary prophylaxis is to prevent recurrent bleeding into joints and the development of chronic arthropathy in later life. When started early, and at most after two joint bleeds, the result is predictably excellent if there is compliance with the primary prophylaxis regimen. In order to decrease the need for central venous access devices to assure reliable venous access, a number of centres start primary prophylaxis with once weekly infusions with dose-escalation based on frequency of joint bleeding. A major unanswered question is whether primary prophylaxis can be safely discontinued in adolescents/young adults and if so, when. A promising predictor for the milder bleeding phenotype in persons with severe haemophilia is a later onset of joint bleeding. Once joint damage has occurred as a result of recurrent bleeding, secondary prophylaxis can only retard, but not prevent, ongoing joint damage. Other strategies to decrease recurrent bleeding from target joints include surgical synovectomy (ideally performed using an arthroscopic technique), radionuclide synovectomy and chemical synovectomy. These interventions have very good outcomes when performed by an experienced team. Given the very high cost of factor concentrates required for programmes of prophylaxis prospective studies that document benefits to the child and family, e.g. quality of life are to be encouraged.
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Affiliation(s)
- H M Van den Berg
- Van Creveldkliniek, Dutch National Hemophilia Center, Department of Internal Medicine, University Medical Center, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW Degenerative arthropathy resulting from recurrent hemarthrosis remains the largest source of noninfectious morbidity for persons with hemophilia. Optimal treatment to prevent or reduce joint destruction remains controversial. RECENT FINDINGS The most exciting developments in the past year have contributed to our understanding of the pathophysiology behind this destructive process. Particularly interesting is the possible role of protooncogenes and angiogenic factors in the development of hypertrophic synovitis. Arthroscopic synovectomy effectively controls the hypertrophic synovium and resultant bleeding, and can be used safely even in very young patients. Prophylactic factor replacement remains the mainstay to reduce or prevent joint damage. New approaches, chiefly dose escalation strategies, have shown promise instead of standard prophylactic regimens. Additionally aggressive on-demand approaches may be feasible. These techniques allow for fewer indwelling venous access devices in small children, as rates of complications with these devices are shown to be increasingly high. Whether prophylactic therapy can be safely stopped in certain patients is an evolving area of interest. Outcome measures are being validated to assess the impact of interventions on patient quality of life. SUMMARY As hemophilia care evolves, current on-demand and prophylactic regimens will be optimized. Synovectomy will likely play a larger role in the control of synovitis, and validated quality-of-life scores will allow more consistent communication of outcomes. New understanding of the molecular mechanisms of joint destruction will pave the way for new therapeutic options for persons with hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, GA 30322, USA.
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Abstract
Joint haemorrhage and subsequent haemophilic arthropathy are significant complications in haemophilia. The pathophysiology involves inflammation and angiogenesis. Cyclooxygenase-2 (COX-2) inhibitors are anti-inflammatory agents, which have potent anti-inflammatory, anti-angiogenic and analgesic properties yet do not affect platelet function in the manner of traditional non-steroidal anti-inflammatory drugs. These properties make such agents potentially useful as adjunctive therapy in haemophilia. There is only one prior report describing rofecoxib treatment in a single haemophilia patient. Our objectives were to determine the safety and efficacy of rofecoxib in treating acute haemarthrosis, chronic synovitis, target joints and pain. We conducted a retrospective medical record review of patients treated with rofecoxib for acute haemarthrosis, chronic synovitis, target joint or pain. The safety and efficacy of rofecoxib treatment were determined based on subjective patient reports and physical examinations during follow-up clinic visits. A total of 28 patients between 3 and 37 years of age were treated for a total of 42 courses of rofecoxib treatment. All courses were evaluated for safety and 31 for efficacy. Rofecoxib was used for eight acute haemarthrosis, four target joints, seven cases of synovitis and 12 episodes of pain. Efficacy was demonstrated particularly for chronic synovitis and pain and no serious adverse events occurred. This is the largest study to date evaluating COX-2 inhibitors as adjunctive therapy in haemophilia and suggests that these agents may be an important adjunctive therapy in the management of haemophilia.
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Affiliation(s)
- B Rattray
- Division of Hematology, Children's Hospital of Orange County, Orange, CA 92868, USA
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39
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Dunn AL, Abshire TC. Recent advances in the management of the child who has hemophilia. Hematol Oncol Clin North Am 2004; 18:1249-76, viii. [PMID: 15511615 DOI: 10.1016/j.hoc.2004.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article discusses recent advances in the management of the child who has hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2040 Ridgewood Drive NE, Suite 100, Atlanta, GA 30322, USA.
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