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Bakeer N, Saied W, Gavrilovski A, Bailey C. Haemophilic arthropathy: Diagnosis, management, and aging patient considerations. Haemophilia 2024; 30 Suppl 3:120-127. [PMID: 38578694 DOI: 10.1111/hae.15004] [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: 01/12/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/07/2024]
Abstract
Gene therapy and universal use of safer, more effective, and personalised prophylactic regimens (factor, and nonfactor) are expected to prevent joint bleeding and promote joint health in persons with haemophilia (PwH). Growing evidence suggests that subclinical bleeding, with active and inactive synovial proliferation, continues and haemophilic arthropathy remains a major morbidity in PwH despite early institution of joint prophylaxis. Joint health assessment is evolving with physical examination scores complementing imaging scores. Point-of-care ultrasound is emerging as a safe, cost-effective, and readily available tool for acute determination of musculoskeletal abnormalities, serial evaluation of joints for sonographic markers of haemophilic arthropathy, and in providing objective insight into the efficacy of new therapies. In acute haemarthrosis, arthrocentesis expedites recovery and prevent the vicious cycle of bleed-synovitis-rebleed. When synovial proliferation develops, a multidisciplinary team approach is critical with haematology, orthopaedics, and physiotherapy involvement. Synovectomy is considered for patients with chronic synovitis that fail conservative management. Non-surgical and minimally invasive procedures should always be offered and considered first. Careful patient selection, screening and early intervention increase the success of these interventions in reducing bleeding, pain, and improving joint function and quality of life. Chemical synovectomy is practical in developing countries, but radioactive synovectomy appears to be more effective. When surgical synovectomy is considered, arthroscopic/minimally invasive approach should be attempted first. In advanced haemophilic arthropathy, joint replacement and arthrodesis can be considered. While excited about the future of haemophilia management, navigating musculoskeletal challenges in the aging haemophilia population is equally important.
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Affiliation(s)
- Nihal Bakeer
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
- Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Walid Saied
- Department of Paediatric Orthopaedic Surgery, Children's Hospital "Bechir HAMZA", Medical School of Tunis, University Tunis-El Manar, Tunis, Tunisia
| | - Antonio Gavrilovski
- University Clinic for Orthopaedic Surgery-TOARILUC, Clinical Centre Mother Theresa Skopje, Skopje, North Macedonia
| | - Cindy Bailey
- Orthopaedic Haemophilia Treatment Centre at Orthopaedic Institute for Children Los Angeles, Los Angeles, California, USA
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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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Beckers G, Manon J, Cornu O, VAN Cauter M. Unilateral versus simultaneous bilateral total hip arthroplasty. The Belgian experience. Acta Orthop Belg 2023; 89:575-579. [PMID: 38205744 DOI: 10.52628/89.4.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Bilateral hip osteoarthritis is frequent. The safety and patient selection for simultaneous bilateral total hip arthroplasty (SBTHA) are still debated. The purpose of this article is to share our experience and assess if performing SBTHA carries more risk than unilateral total hip arthroplasty (UTHA). METHODS A retrospective data analysis was performed on 468 patients who underwent either UTHA (418 patients) or SBTHA (50 patients) using a direct anterior approach between June 2016 and December 2020. Apart from SBTHA patients being significantly younger, there was no significant preoperative difference in demographics, comorbidities, surgical variables and biological values between the two groups. Primary outcomes were 90-days emergency room (ER) visit and readmission, as well as 90-days minor and major complications. Secondary outcomes were length of stay (LOS), operative time and blood loss. RESULTS 90-days ER visit (p=0.244), 90- days readmission (p=0.091), overall complications rate (p=0.376), minor complications (p=0.952) and major complications (p=0.258) were not statistically different between the two groups. Operative time and average LOS were significantly longer in the SBTHA group (p<0.001). Blood loss was significantly higher (p<0.001) in the SBTHA group. However, no difference in the transfusion rate between the two groups was observed (p=0.724). CONCLUSION Complication rate, 90- days hospital readmission and 90-days ER visit were similar between the two groups. This study shows that performing SBTHA is a safe, effective, and doesn't carry additional risks for patients with bilateral symptomatic osteoarthritis.
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de Klerk HH, Verweij LPE, Sierevelt IN, Priester-Vink S, Hilgersom NFJ, Eygendaal D, van den Bekerom MPJ. Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review. Arthroscopy 2023; 39:2363-2387. [PMID: 37146664 DOI: 10.1016/j.arthro.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To perform a systematic review of complications associated with elbow arthroscopy in adults and children. METHODS A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. RESULT A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication. CONCLUSIONS Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates. LEVEL OF EVIDENCE Level IV; systematic review of Level I-IV studies.
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Affiliation(s)
- Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, the Netherlands.
| | - Lukas P E Verweij
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, the Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Inger N Sierevelt
- Specialized Centre for Orthopedic Research and Education (SCORE), Xpert Clinics, Orthopedic Department, Amsterdam, the Netherlands; Department of Orthopaedics, Spaarne Gasthuis Academie, Hoofddorp, the Netherlands
| | - Simone Priester-Vink
- Medical Library, Department of Research and Epidemiology, OLVG, Amsterdam, the Netherlands
| | - Nick F J Hilgersom
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
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Mancuso ME, Holstein K, O'Donnell JS, Lobet S, Klamroth R. Synovitis and joint health in patients with haemophilia: Statements from a European e-Delphi consensus study. Haemophilia 2023; 29:619-628. [PMID: 36622258 DOI: 10.1111/hae.14734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Synovitis, a common feature in haemophilia, is triggered by the presence of blood in joints, and represents the first step towards the development of chronic arthropathy. Synovitis may be detected early by means of ultrasound or magnetic resonance imaging scan; clinical joint scores are less sensitive in this setting. Regular long-term prophylaxis with clotting factor concentrates, as primary prophylaxis and tailored to individual needs, has high efficacy in preventing synovitis. In general, higher factor levels lower bleeding risk, but no direct correlation between factor levels and synovitis incidence has been demonstrated. AIM This study aimed to develop an expert consensus relating to the definition, pathophysiology, diagnosis, prevention, follow-up and treatment of synovitis, recognising its relevance for joint health and taking into account existing knowledge gaps. METHODS A Delphi consensus study was designed and performed. An expert group prepared 22 statements based on existing literature; a wider expert panel subsequently voted on these. RESULTS Retention of panellists was high. Four statements required amending and consensus on all statements was achieved after three rounds of voting. CONCLUSION This e-Delphi consensus study addressed the importance of synovitis in joint health of people with haemophilia and highlighted knowledge gaps in this field. Studies on the natural course of synovitis are lacking and the biological mechanisms underlying this process are not yet fully elucidated. While basic and clinical research proceeds in this field, expert consensus can help guide clinicians in their routine clinical practice, and Delphi methodology is often used to produce best-practice guidelines.
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Affiliation(s)
- Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
| | - Katharina Holstein
- Department of Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - James S O'Donnell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland
| | - Sébastien Lobet
- Hematology department, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Institute for Experimental and Clinical, Catholic University of Louvain, Avenue Hippocrate, Woluwe-Saint-Lambert, Belgium.,Physical Medicine and Rehabilitation Service, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium
| | - Robert Klamroth
- Vivantes Hospital, Friedrichshain, Berlin, Germany.,Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
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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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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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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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14
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Yasui T, Hirose J, Ono K, Takedani H. Arthroscopic debridement for advanced haemophilic ankle arthropathy. Haemophilia 2017; 23:e479-e481. [PMID: 28782247 DOI: 10.1111/hae.13309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 12/13/2022]
Affiliation(s)
- T Yasui
- Department of Orthopedic Surgery, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan.,Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - J Hirose
- Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - K Ono
- Department of Joint Surgery, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - H Takedani
- Department of Joint Surgery, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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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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17
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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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Valentino LA, Pipe SW, Collins PW, Blanchette VS, Berntorp E, Fischer K, Ewenstein BM, Oh M, Spotts G. Association of peak factor
VIII
levels and area under the curve with bleeding in patients with haemophilia A on every third day pharmacokinetic‐guided prophylaxis. Haemophilia 2016; 22:514-20. [DOI: 10.1111/hae.12905] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | - E. Berntorp
- Lund University Skane University Hospital Malmö Sweden
| | - K. Fischer
- Van Creveldkliniek University Medical Center Utrecht Utrecht the Netherlands
| | | | - M. Oh
- Baxter Healthcare Corporation Westlake Village CA USA
| | - G. Spotts
- Baxter Healthcare Corporation Westlake Village CA USA
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Hemophilic arthropathy of the elbow: prophylaxis, imaging, and the role of invasive management. J Shoulder Elbow Surg 2015; 24:1669-78. [PMID: 26385390 DOI: 10.1016/j.jse.2015.06.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/14/2015] [Accepted: 06/22/2015] [Indexed: 02/01/2023]
Abstract
Hemophilia is an X-linked recessive deficiency of clotting factor VIII (hemophilia A) or IX (hemophilia B) that can result in hemarthrosis of various joints, including the elbow. Left unchecked, this can lead to progressive joint destruction and significant morbidity. Appropriate management of the elbow joint through prophylactic measures, accurate imaging, and timely intervention is essential. Replacing or supplementing deficient factor with a plasma-derived or recombinant factor concentrate can minimize bleeding episodes. Joints should be routinely monitored for damage. Plain films offer an inexpensive window into bone disease and joint space changes but lack soft tissue detail and may not detect early changes. Magnetic resonance imaging provides a high level of detail but may be limited by its cost and need for sedation in younger patients. Ultrasound may not achieve the same level of resolution as magnetic resonance imaging, but it is increasingly used as a convenient, effective, and relatively inexpensive alternative. Patients who experience hemarthrosis of the elbow with joint damage often require more invasive treatment. Radiosynovectomy and arthroscopic synovectomy are effective at minimizing pain and preventing future bleeding episodes, whereas extensive joint damage may necessitate total elbow replacement.
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Buda R, Cavallo M, Castagnini F, Cenacchi A, Natali S, Vannini F, Giannini S. Treatment of Hemophilic Ankle Arthropathy with One-Step Arthroscopic Bone Marrow-Derived Cells Transplantation. Cartilage 2015; 6:150-5. [PMID: 26175860 PMCID: PMC4481389 DOI: 10.1177/1947603515574286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Ankle arthropathy is a frequent and invalidating manifestation of hemophilia. Arthrodesis is the gold standard surgical procedure in end-stage disease, with many drawbacks in young patients. Recent literature has shown increase interest in regenerative procedures in hemophilic arthropathy, which may be desirable to delay or even avoid arthrodesis. The aim of this article is to present five cases of osteochondral lesions in ankle hemophilic arthropathy treated with a regenerative procedure: bone marrow-derived cells transplantation (BMDCT). DESIGN We report five hemophilic patients (four cases with hemophilia type A; one case with hemophilia type B) who have undergone BMDCT treatment, synovectomy, and arthroscopic debridement, with the use of autologous platelet-rich fibrin, to treat osteochondral lesions in hemophilic ankle arthropathy. The patients, included within this retrospective study, were clinically and radiologically evaluated with serial follow-ups, using the American Orthopaedic Foot and Ankle Society (AOFAS) scores, radiographs, and magnetic resonance imaging (MRI). RESULTS The mean preoperative AOFAS score was 35. After a mean follow-up of 2 years, the mean postoperative AOFAS score was 81, which included three patients returning back to sporting activities. The MRI Mocart score demonstrated signs of regeneration of chondral and bony tissue. No progression of joint degeneration was shown radiographically. CONCLUSION BMDCT is a promising regenerative treatment for osteochondral lesions in mild ankle hemophilic arthropathy, which may be useful to delay or even avoid ankle arthrodesis. Nevertheless, longer follow-ups and a larger case series are required.
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Affiliation(s)
- Roberto Buda
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Marco Cavallo
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Francesco Castagnini
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Annarita Cenacchi
- Service of Immunohematology and Transfusional Medicine, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Simone Natali
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Francesca Vannini
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Sandro Giannini
- I Clinic of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
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21
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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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Abstract
Elbow arthroscopy is a tool useful for the treatment of a variety of pathologies about the elbow. The major indications for elbow arthroscopy include débridement for septic elbow arthritis, synovectomy for inflammatory arthritis, débridement for osteoarthritis, loose body extraction, contracture release, treatment of osteochondral defects and selected fractures or instability, and tennis elbow release. Contraindications, technical considerations, and favorable outcomes following treatment with elbow arthroscopy require careful patient evaluation, a thorough understanding of anatomic principles, and proper patient positioning and portal selection to guide preoperative planning and overall patient care. Elbow arthroscopy is an effective procedure for the treatment of inflammatory arthritis, osteoarthritis, and lateral epicondylitis.
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23
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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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24
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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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25
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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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26
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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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28
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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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29
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DE KLEIJN P, ODENT T, BERNTORP E, HILLIARD P, PASTA G, SRIVASTAVA A, ILIESCU A, MOHANTY S. Differences between developed and developing countries in paediatric care in haemophilia. Haemophilia 2012; 18 Suppl 4:94-100. [DOI: 10.1111/j.1365-2516.2012.02875.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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30
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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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31
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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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32
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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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Abstract
In this issue of Blood, Acharya and colleagues provide evidence for the role of angiogenesis in the pathophysiology of hemophilic joint disease. Is this the linchpin that unravels this important clinical condition or merely a cog in a not so stepwise process?
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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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35
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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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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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Accadbled F. Arthroscopic surgery in children. Orthop Traumatol Surg Res 2010; 96:447-55. [PMID: 20472522 DOI: 10.1016/j.otsr.2010.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 03/15/2010] [Indexed: 02/02/2023]
Abstract
Arthroscopic surgery for children and adolescents is developing fast, thanks to technical progress in adult arthroscopy, improved knowledge of child joint disorders, and instrument miniaturization. The specificity of arthroscopy in children lies, on the one hand, in the small joint size and, on the other, in the presence of neighboring growth plates. There also exist specific pathologies as well as differences in indications in pathologies common to children and adults. These specificities need to be known, and adapted techniques and equipment require to be used, given which arthroscopy is feasible even in infants. Growth plate must be respected, and the residual growth of the operated segment (e.g., in knee ligament reconstruction) needs to be known. Joint decoaptation often does not require traction, and any stress maneuvers (valgus/varus) need to be gentle. The knee is by far the most frequently implicated joint in child arthroscopy, partly due to a rise in sports injuries. There is a variety of traumatic pathologies (osteochondral or meniscal/ligament tears, etc.) and of indications. Arthroscopy in children is safe, given awareness of these indications and respect of certain precautions. The advantages over conventional open surgery are the same as in adults: simpler postoperative course, faster functional recovery and better esthetic result. Arthroscopy will continue to develop in pediatrics in coming years.
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Affiliation(s)
- F Accadbled
- Orthopedic and Traumatologic Surgery Department, Children's Hospital, Toulouse, France.
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38
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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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Rampal V, Odent T, Torchet MF, Rothschild C, Elie C, Glorion C, Padovani JP. Surgical synovectomy of the knee in young haemophiliacs: long-term results of a monocentric series of 23 patients. J Child Orthop 2010; 4:33-7. [PMID: 21286256 PMCID: PMC2811685 DOI: 10.1007/s11832-009-0229-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 12/08/2009] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In haemophiliacs, synovectomy is indicated for recurrent joint bleedings, despite medical treatment. METHOD We report a series of 23 surgical synovectomies of the knee with a median follow-up of 8.8 years. The median age of patients at surgery was 13.5 years. Clinical and radiological evaluations were made according to the Petrini and the Pettersson scores, at 1 and 5 years after surgery, and at the last follow-up. Wilcoxon and Spearman's tests were used for the statistical analysis. RESULT The Petrini score improved at 1 and 5 years (P < 0.001). Nine patients have 20 years of follow-up and a stable result. In more than half of the knees, no episode of recurrent bleeding occurred. The effect of surgery on the range of motion (ROM) was moderate and mobilisation under anaesthesia did not improve it significantly. There was a progressive worsening of the radiological score, but no correlation between clinical and radiological score was noticed (ρ = 0.08, P = 0.77). CONCLUSION Complete synovectomy gives good long-term results in term of bleeding recurrence and overall function.
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Affiliation(s)
- Virginie Rampal
- />Service d’Orthopédie Pédiatrique, Hôpital de l’Archet, Université Nice Sophia Antipolis, 151 Rte de Saint Antoine de Ginestière, 06202 Nice, France
| | - T. Odent
- />Service d’Orthopédie Pédiatrique, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
| | - M. F. Torchet
- />Centre d’Hémophilie, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
| | - C. Rothschild
- />Centre d’Hémophilie, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
| | - C. Elie
- />Service de Santé Publique et Médecine Sociale, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
| | - C. Glorion
- />Service d’Orthopédie Pédiatrique, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
| | - J. P. Padovani
- />Service d’Orthopédie Pédiatrique, Hôpital Necker, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France
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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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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: 46] [Impact Index Per Article: 2.9] [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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43
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BOSSARD D, CARRILLON Y, STIELTJES N, LARBRE JP, LAURIAN Y, MOLINA V, DIRAT G. Management of haemophilic arthropathy. Haemophilia 2008; 14 Suppl 4:11-9. [DOI: 10.1111/j.1365-2516.2008.01734.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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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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Hausman MR, Qureshi S, Goldstein R, Langford J, Klug RA, Radomisli TE, Parsons BO. Arthroscopically-assisted treatment of pediatric lateral humeral condyle fractures. J Pediatr Orthop 2008; 27:739-42. [PMID: 17878776 DOI: 10.1097/bpo.0b013e3181558ac5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric lateral humeral condyle fractures are common injuries. Current treatment recommendations include nonoperative treatment for nondisplaced Milch type 1 fractures; however, truly nondisplaced fractures may be rare. Although closed reduction and percutaneous pinning under arthrographic visualization are most commonly used, anatomical reconstitution of the articular surface may require a lateral Kocher approach. This approach may compromise the vascularity of the distal fragment. To avoid this catastrophic complication while still obtaining anatomical articular surface reduction, we have investigated a new technique in which the lateral condyle fracture is reduced arthroscopically, allowing visualization of the articular surface without the soft tissue dissection required with open approaches. The fracture is then percutaneously pinned and immobilized as previously recommended. METHODS Six skeletally immature patients with lateral humeral condyle fractures underwent arthroscopic reduction and percutaneous pinning. The mean age of the patients was 48 months (range, 21-69 months). There were 2 girls and 4 boys. Surgery was performed on 4 left and 2 right elbows. The mean follow-up was 32 weeks (range, 21-44 weeks). Postoperatively, all patients were placed in a long arm cast for 4 weeks. Pins and casts were removed at 4 weeks, and motion was begun. Elbow radiographs were evaluated for fracture healing, articular congruity, malunion, growth disturbance, and presence of avascular necrosis. Range of motion, function, pain, and cosmetic deformity were recorded. RESULTS All patients had full active and passive range of motion. There was no difference in range of motion compared with the contralateral side (P < 0.05). All fractures healed radiographically by 4 weeks. There were no cases of nonunion or malunion. No patients developed cubitus varus. One patient developed radiolucency of the capitellum. There were no other complications. CONCLUSIONS Arthroscopic reduction and percutaneous fixation of pediatric lateral humeral condyle fractures may offer a safe and effective alternative to open treatment with decreased soft tissue stripping and a possibly decreased risk of malunion or avascular necrosis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Michael R Hausman
- Department of Orthopaedics, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
Currently available factor concentrates for treatment of patients with haemophilia are virally inactivated or are made by recombinant technology and their broad use in developed nations has resulted in the dramatic elimination of the treatment-related viral illnesses that decimated the haemophilia community in the late 20th century. The major morbidity experienced by patients with haemophilia today is joint disease, a result of repeated bleeding episodes into joint spaces. Although administration of factor concentrates to prevent bleeding has been demonstrated to prevent haemophilic joint disease when applied assiduously, repeated bleeding episodes induce synovitis that is irreversible and may progress despite subsequent prophylaxis. Surgical and nuclear medicine interventions are available to reduce the pain of haemophilic arthropathy and to reduce further bleeding episodes. Patients with high titre inhibitors are at great risk for the development of joint disease and present the greatest therapeutic challenges when joint surgery is needed.
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Affiliation(s)
- Leslie Raffini
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4399, USA
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Ota S, Mclimont M, Carcao MD, Blanchette VS, Graham N, Paradis E, Feldman BM. Definitions for haemophilia prophylaxis and its outcomes: The Canadian Consensus Study. Haemophilia 2007; 13:12-20. [PMID: 17212719 DOI: 10.1111/j.1365-2516.2006.01409.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The creation of acceptable standard definitions for terms used in the care and assessment of haemophilia patients has become increasingly important, as a growing number of international clinical studies have been initiated. The Delphi approach has been used in health research to reach consensus in large groups and can be used to develop definitions by using several iterations of surveys eliciting opinions from specialists in the field. Three consecutive surveys were designed based on the Delphi approach and distributed to specialist physicians, nurses and physiotherapists in order to develop definitions for seven haemophilia terms: 'primary prophylaxis', 'secondary prophylaxis', 'target joint', 'joint bleed', 'significant soft-tissue bleed', 'superficial soft-tissue bleed' and 'mucosal bleed'. Suggestions were solicited, compiled into a subsequent survey and fed back to the group to rank-order the importance of each suggested component of the definition. Final definitions were created using the top-ranked suggestions and sent back to the experts for approval. Five of the seven terms were highly endorsed with greater than 90% agreement. Some differences in agreement were found when analysed by profession. Haemophilia terms were successfully defined using the Delphi approach. Further refinement from members of the international haemophilia community will ensure that comprehensive standard definitions can be used in multicentre studies in the future.
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Affiliation(s)
- S Ota
- Research program in Child Health Evaluation Sicenses, The Hospital for Sick Children, Toronto, Canada
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49
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Ellenbogenarthroskopie bei Kindern. ARTHROSKOPIE 2006. [DOI: 10.1007/s00142-006-0368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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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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