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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Gomez-Cardero P, Jimenez-Yuste V. Ultrasound-guided joint procedures in hemophilia: technique, indications and tips. Expert Rev Hematol 2024; 17:419-430. [PMID: 39008070 DOI: 10.1080/17474086.2024.2380477] [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: 03/21/2024] [Accepted: 07/11/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION The therapeutic approach to pain in hemophilia should be multimodal. Intra-articular injections are a good option when joint lesions do not respond to hematological treatment or rehabilitation and orthopedic surgery is not yet indicated. Performing these procedures under ultrasound guidance has been shown to improve their accuracy and efficacy. AREAS COVERED This article provides a practical overview of the most frequently employed ultrasound-guided intra-articular procedures on the joints of people with hemophilia. The article describes the key elements for performing the technique on the elbow, knee and ankle as the most affected joints. The particularities of the most frequent indications, arthrocentesis, synoviorthesis and analgesic injections with various products are detailed. EXPERT OPINION Current hematological treatments have made it possible to incorporate new therapeutic tools for pain relief for people with hemophilia, including ultrasound-guided joint procedures, which offer excellent results.
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Martins SCM, DE Andrade E, Silva MBE, Ozelo MC, Campos GCDE, Pagnano RG. EFFECTIVENESS OF VISCOSUPPLEMENTATION IN THE TREATMENT OF HEMOPHILIC ARTHROPATHY: A SYSTEMATIC REVIEW. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e271857. [PMID: 38115879 PMCID: PMC10726718 DOI: 10.1590/1413-785220233105e271857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/28/2023] [Indexed: 12/21/2023]
Abstract
Objective To describe the efficacy of using viscosupplementation in patients with hemophilic arthropathy (HA), on pain, limb functionality, and quality of life. Methods A systematic review of the literature was performed following the PRISMA guidelines without limitations of language or year of publication. The search was performed on the following medical databases: PubMed, Cochrane Library, EMBASE, BVS/BIREME, Scopus, Web of Science, EBSCOhost, and PROQUEST in April 2020. The search used the following word: (hemophilia AND joint diseases) OR (haemophilic arthropathy OR hemophilic arthropathy) AND viscosupplementation. Results The systematic review identified 127 articles, 10 of which were selected for data extraction and qualitative analysis. The 10 selected articles included 297 joints with HA in 177 hemophilic subjects. Our review showed positive results in alleviating pain and improving functional capacity, and quality of life. No major adverse effects were observed. Conclusion There is a lack of scientific evidence regarding viscosupplementation with hyaluronic acid, but the results presented in this research suggest that it is an effective and safe therapeutic option to alleviate pain and improve functional capacity in patients with HA. Level of Evidence II, Systematic Review.
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Affiliation(s)
- Samilly Conceição Maia Martins
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Ortopedia e Traumatologia, Campinas, SP, Brazil
| | - Erion DE Andrade
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Neurologia e Neurocirurgia, Campinas, SP, Brazil
| | - Mayara Branco E Silva
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Ortopedia e Traumatologia, Campinas, SP, Brazil
| | - Margareth Castro Ozelo
- Universidade Estadual de Campinas, Centro de Hematologia e Hemoterapia, Unidade de Hemofilia "Claudio Luiz Pizzigatti Correa", Campinas, SP, Brazil
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Gustavo Constantino DE Campos
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Ortopedia e Traumatologia, Campinas, SP, Brazil
| | - Rodrigo Gonçalves Pagnano
- Universidade Estadual de Campinas, Faculdade de Ciencias Medicas, Departamento de Ortopedia e Traumatologia, Campinas, SP, Brazil
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Poenaru D, Sandulescu MI, Cinteza D. Intraarticular management of chronic haemophilic arthropathy (Review). Biomed Rep 2023; 19:59. [PMID: 37614987 PMCID: PMC10442758 DOI: 10.3892/br.2023.1641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/19/2023] [Indexed: 08/25/2023] Open
Abstract
Hemophilia is an inherited X-linked bleeding condition with predominant joint involvement due to intra-articular bleeding, hemosiderin deposition and the synovial hypertrophy that is responsible for cartilage destruction, joint deformity and malalignment, pain and functional restriction. Management of chronic arthropathy includes conservative and surgical approaches. Conservative therapies consist of pain modulation, oral drugs, physiotherapy and intra-articular agents. For the present review, the literature was searched for intra-articular agents and 20 papers on the use of corticosteroids (CS), hyaluronic acid (HA) and platelet-rich plasma (PRP), with different regimes of administration, were included. CS had a longer record of injection, with statistically significant pain reduction and functional improvement in the short-term and moderate persistence in the long-term. HA was able to improve the clinical and functional status of joints with moderate or severe hemophilia. PRP was relatively recently introduced to joint management and the results remain controversial. Different associations between the above-mentioned agents were proposed by studies including a small number of patients, producing comparable results. It was concluded that there is a need for extensive research on intra-articular agents, with stratification according to the severity of joint involvement. The lack of a blinded or placebo-controlled arm due to ethical aspects makes the task challenging.
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Affiliation(s)
- Daniela Poenaru
- Rehabilitation Department, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Miruna Ioana Sandulescu
- Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Delia Cinteza
- Rehabilitation Department, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
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Rodriguez-Merchan EC. The role of intraarticular injections of hyaluronic acid in joint pain relief in hemophilic arthropathy. Expert Rev Hematol 2023; 16:811-817. [PMID: 37837349 DOI: 10.1080/17474086.2023.2271660] [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: 07/19/2023] [Accepted: 10/12/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Chronic pain in hemophilic patients is due to joint degeneration associated with hemophilic arthropathy. In addition to appropriate hematological treatment (primary prophylaxis), pharmacologic management and Physical Medicine and Rehabilitation should be indicated. When such measures are not sufficient, intraarticular injections (IAIs) of hyaluronic acid (HyA) may be considered. AREAS COVERED In order to determine whether IAIs of HyA are effective in terms of pain relief in individuals with painful moderate hemophilic arthropathy, a PubMed and Cochrane Library search using 'hemophilia hyaluronic acid' as keywords was performed on 18 July 2023. EXPERT OPINION In a study of individuals with hemophilic arthropathy (elbows, knees and ankles), 91% of them improved pain after a mean follow-up of 6 years. In another study of individuals with knee arthropathy, after a 7-year follow-up 82% reported an improvement in pain. As for hemophilic ankle arthropathy, in a study 67% of patients showed relief of joint pain at 6-month follow-up. Although the literature on the subject is very heterogeneous and difficult to interpret, it appears that IAIs of HyA can relieve the joint pain of painful moderate hemophilic arthropathy for months. Moreover, the IAIs can be repeated every 6-12 months.
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Taylor S, David J, Partington K, Pemberton S, Mangles S, Wells A, Curry N. A single centre, open label, pilot study evaluating the effect of intra-articular hyaluronic acid injection on pain and functionality when injected into the ankle (tibio-talar and sub-talar) joint in patients with haemophilic arthropathy. Haemophilia 2022; 28:e181-e188. [PMID: 35905300 DOI: 10.1111/hae.14639] [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: 04/20/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/29/2022]
Abstract
AIMS Ankle arthropathy commonly affects persons with haemophilia (PWH). Joint damage causes loss of movement, pain and reduced function. Current treatments are limited. Viscosupplementation has been used to treat other patient groups with joint damage. Viscosupplements serve to augment or act as a substitute for synovial fluid and may ameliorate the effects of cartilage loss by cushioning joints and reducing pain. This study evaluated intra-articular Ostenil Plus™ (HA) for ankle arthropathy in PWH. Reduction in pain was the primary outcome. METHODS A single centre open label pilot study. PWH and significant ankle arthropathy, according to MRI scores, were recruited. Participants received intra-articular HA injections at baseline and 6 months. Follow up assessments were completed three-monthly for 1 year. Pain was assessed by the Visual Analogue Scale (VAS). Participant perceptions of overall changes to pain, function and quality of life were sought. RESULTS Twenty-four participants were recruited, three withdrew. Twenty-six joints were injected. Twenty participants had severe haemophilia. Mean age 35 years. Participants reported significant reduction in pain over the study. VAS baseline: 5.62; 6 month 3.92; 12-month 3.42, P < .0001. Joint function improved together with ankle HJHS. No change was seen for EQ-5D-5L. Sixteen participants reported reductions in ankle pain and stiffness and greater confidence in undertaking physical activities. No significant adverse reactions were reported. CONCLUSION Ostenil Plus™ treatment improves pain, function and patient perception of functional ability in PWH and ankle arthropathy. This study supports the use of HA as a safe treatment in PWH.
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Affiliation(s)
- Stephanie Taylor
- Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - Joel David
- Rheumatology Department, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - Sam Pemberton
- Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - Sarah Mangles
- Haemophilia, Haemostasis & Thrombosis Centre, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Anna Wells
- Haemophilia, Haemostasis & Thrombosis Centre, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford, UK
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Current and Emerging Approaches for Pain Management in Hemophilic Arthropathy. Pain Ther 2022; 11:1-15. [PMID: 35020184 PMCID: PMC8861243 DOI: 10.1007/s40122-021-00345-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction Hemophilia is an inherited bleeding hematological disorder characterized by the partial or complete deficiency of clotting factor VIII or IX. Hemophilic arthropathy is the consequence of repeated joint bleeding (hemarthrosis) and its management is based on the prevention of acute bleeding through the administration of the deficient clotting factor concentrate or non-factor therapies. In addition, the management of acute and chronic pain is pivotal in hemophilic arthropathy in order to restore function and allow rehabilitation of the joint.
Methods We conducted a qualitative review of the literature regarding current and emerging strategies for pain treatment in hemophilic arthropathy. This review considers systemic and local pharmacological and non-pharmacological interventions for acute and chronic pain management.
Results In hemophilic arthropathy, pain management is based on analgesics such as paracetamol, which represents the first choice for acute and chronic pain in adults and children, in association with opioids for adults. Non-steroidal anti-inflammatory drugs inhibit platelet function, so that the currently preferred drugs are short courses of cyclooxygenase 2 inhibitors. Local treatment with intra-articular injections of corticosteroids is an option for refractory cases and physiotherapy has an important role after hemarthrosis and for the long-term management of chronic pain for both pediatric and adult patients.
Conclusions The management of pain in hemophilia requires more standardization. Meanwhile, the safest drugs should be used at the lowest effective dosage and for periods as short as possible. For the non-pharmacological management of pain in these patients, a multidisciplinary team including hematologists, orthopedic surgeons, rheumatologists, and physiotherapists is warranted.
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Pain management in people with hemophilia in childhood and young adulthood. Expert Rev Hematol 2021; 14:525-535. [PMID: 34042011 DOI: 10.1080/17474086.2021.1935852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Buccheri E, Avola M, Vitale N, Pavone P, Vecchio M. Haemophilic arthropathy: A narrative review on the use of intra-articular drugs for arthritis. Haemophilia 2019; 25:919-927. [PMID: 31639263 DOI: 10.1111/hae.13857] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/16/2019] [Accepted: 09/18/2019] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Intra-articular injections of various drugs are commonly used in patients with degenerative osteoarthritis and also in haemophilic patients. Haemophilic arthropathy is a particular type of secondary osteoarthritis (OA), but the degeneration of strong synovial, cartilaginous and subchondral constituents is provoked by the direct action of iron and blood in the joint. AIM OF THE STUDY The aim of this study is to review the literature regarding the use of various intra-articular drugs in joints affected by haemophilic arthropathy. METHODS We reviewed the data from the literature; the search was performed on three medical electronic databases (PubMed, Cochrane Library and Scopus Web of Science) by three authors (B. E., A. M. and V. N.) from 3 December 2018 till 15 December 2018. The search string was as follows: (hyaluronic acid OR viscosupplementation OR platelet-rich plasma OR corticosteroid OR mesenchymal stem cells) AND (haemophilia OR haemophilic arthropathy OR haemophilic arthritis). RESULTS Once the research was performed, a total of 300 articles were identified. 47 selected articles were analysed by the reviewers, and the eligibility of the study inclusion was assessed independently. Twelve papers were included based on clear fulfilment of the inclusion criteria. Thirty-five articles were excluded for the following reasons: no full text or accessible data for 14 of them, 15 involved surgery or rehabilitation therapy as the primary topic and 6 were systematic reviews (the main topics were beyond the haemophilic arthropathy). CONCLUSION Although the degree of scientific evidence of the publications on intra-articular injections of various drugs (hyaluronic acid, corticosteriods, PRP and MSCs) in haemophilia is very low, it seems that intra-articular injections of hyaluronic acid can relieve joint pain for months and can be repeated every 6-12 months, which is why they can be recommended. Corticosteroid injections seem to relieve joint pain for a few weeks, but their routine use is not recommended in haemophilia. The efficacy of PRP and MSCs in haemophilic arthropathy is pending confirmation, which is why they are not currently recommended.
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Affiliation(s)
| | - Marianna Avola
- Graduate School of Physical Medicine and Rehabilitation, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Nicolò Vitale
- Graduate School of Physical Medicine and Rehabilitation, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Piero Pavone
- University-Hospital "Policlinico-Vittorio Emanuele, " University of Catania, Catania, Italy
| | - Michele Vecchio
- Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Catania, Italy
- Rehabilitation Unit, "AOU Policlinico Vittorio Emanuele", Catania, Italy
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Liu S, Zhou R, Jin Z, Wu M, Zhang P. Age‐related severity and distribution of haemophilic arthropathy of the knee, ankle and elbow among Chinese patients with haemophilia. Haemophilia 2019; 26:129-135. [DOI: 10.1111/hae.13858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/12/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Sha Liu
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Rong‐fu Zhou
- Department of Hematology Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Zhi‐bin Jin
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Min Wu
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Ping‐yang Zhang
- Department of Ultrasound Medicine Nanjing First Hospital Nanjing Medical University Nanjing China
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Ong KL, Runa M, Lau E, Altman R. Is Intra-Articular Injection of Synvisc Associated with a Delay to Knee Arthroplasty in Patients with Knee Osteoarthritis? Cartilage 2019; 10:423-431. [PMID: 29779404 PMCID: PMC6755870 DOI: 10.1177/1947603518775792] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE There is debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We asked the following questions: (1) What is the epidemiology of IA HA use in knee arthroplasty (KA) patients? (2) Is Synvisc associated with a delay to KA? (3) Is there a difference in the delay to KA with the number of HA courses? DESIGN The Optum Clinformatics data set (2006-June 2016) was used to identify patients with knee osteoarthritis (OA). Patients who did not receive IA HA were identified, along with those who received Synvisc or non-Synvisc HA. The median duration from knee OA to KA was compared using quantile regression modeling with propensity score weighting. The trend in time to KA with each HA course was evaluated. RESULTS Of 4,027,848 knee OA patients, 141,305 patients underwent KA. Overall median time from knee OA diagnosis to KA was 1.2 years (average: 1.9 ± 1.9 years; interquartile range of 0.4-2.8 years). HA patients had significantly longer adjusted median time to KA by at least 7 months (P < 0.001). After adjusting for the time to HA and number of injections, Synvisc patients had 1.7 months longer time to KA than non-Synvisc HA patients (P < 0.001). There was a trend toward longer time to KA with more HA courses. CONCLUSIONS Most KA patients did not use HA (73.7%) and when received, it was associated with a longer median time to KA by at least 7 months, though the cause and effect could not be examined. The delay to KA increased with more HA courses.
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Affiliation(s)
| | - Maria Runa
- Exponent, Inc., Philadelphia, PA, USA,Maria Runa, Exponent, Inc., 3440 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | | | - Roy Altman
- Academic Speakers of America, Agua Dulce, CA, USA
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Rodriguez-Merchan EC, Valentino LA. Joint lavage followed by intra-articular injection of hyaluronic acid and/or corticosteroids in patients with severe hemophilic arthropathy of the knee: Is this intervention really effective? Expert Rev Hematol 2018; 11:449-454. [DOI: 10.1080/17474086.2018.1472568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Serban M, Poenaru D, Patrascu J, Ursu E, Savescu D, Ionita H, Jinca C, Pop L, Talpos-Niculescu S, Ritli L, Arghirescu S, Schramm W, Mihailov D. Risks and challenges of orthopaedic invasive interventions in haemo -philia in a low-resource country. Hamostaseologie 2017; 34 Suppl 1:S30-5. [DOI: 10.5482/hamo-14-01-0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 09/17/2014] [Indexed: 11/05/2022] Open
Abstract
SummaryHaemophilic arthropathy is a defining feature and a debilitating condition of persons with haemophilia (PwH) in low resource countries. Orthopaedic surgery is unavoidable for patients with high occurrence of joint damage. Aims: We aimed to evaluate the spectrum and outcome of invasive orthopaedic therapies in PwH and von Willebrand diseases (VWD). Patients and methods: Our descriptive observational retrospective study included 131 invasive surgical procedures, performed on 76 consecutive patients, most of them (93.4%) with severe disease, treated in Timisoara’s Haemophilia Center over a period of 12 years; 17.1% had pre-operation anti-FVIII inhibitors. Invasive elective procedures were predominant (90.8%) as compared to emergency measures (9.2%); according to their invasiveness, 20.6% of interventions were major, 44.3% intermediate and 35.1% minor. Results: were good in the majority of cases; significantly reduced joint bleed rate and pain score were the most consistent achievements. The greatest proportion of complications occurred after major (66.7%), compared to moderate (25.6%) and minor (7.7%) interventions. The main threatening complication was the development (3.8%) or increase (4.6%) of inhibitor titer. Local bacterial infections and wound dehiscence complicated the evolution in 4.6% and 0.8 % of cases, respectively; we noticed no blood-borne infections or thrombotic accidents. Low dosage (10.7%) and short duration of substitution (21.4%) led to increased post-surgical bleeding and post-haemorrhagic anaemia. Conclusions: Surgery is a highly demanding intervention in haemophilia, which cannot be ignored in a low resource country. It represents a life or limb-saving and quality of life-improving measure.
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Rodriguez-Merchan EC. Treatment of musculo-skeletal pain in haemophilia. Blood Rev 2017; 32:116-121. [PMID: 28943040 DOI: 10.1016/j.blre.2017.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/01/2017] [Accepted: 09/15/2017] [Indexed: 12/25/2022]
Abstract
Musculo-skeletal pain treatment is inadequate in many haemophilic patients. Analgesics are used only by 36% of adult patients. FVIII/FIX intravenous infusion is mainly used to lessen pain, followed in frequency by usage of NSAIDS (primarily COX-2 inhibitors). In about 30% of patients, pain continues after infusion of F VIII/IX. In acute haemarthroses pain treatment must continue until total disappearance (checked by ultrasonography) and include haematologic treatment, short-term rest of the involved joint, cryotherapy, joint aspiration and analgesic medication (paracetamol in mild pain, metamizole for more intense pain, and in a few precise patients, soft opioids such as codeine or tramadol). In the circumstance of intolerable pain we should use morphine hydrochloride either by continual infusion or a patient-controlled analgesia (PCA) pump, determined by the age, mental condition and grade of observance of the patient. Epidural blocks utilizing bupivacaine and fentanyl may be very efficacious as well. Three main strategies to alleviate chronic musculo-skeletal pain secondary to haemophilic arthropathy (joint degeneration) exist: pharmacologic management, physical medicine and rehabilitation, and intra-articular injections. As for pharmacologic management, NSAIDs (ibuprofen, diclofenac, celecoxib, robecoxib) are better than paracetamol. The advantages of tramadol or tramadol/paracetamol and non-tramadol opioids are scanty. With respect to physical medicine and rehabilitation, there is insufficient confirmation that a brace has supplementary favourable effect compared with isolated pharmacologic management. Land-based curative exercise and watery exercise have at the minimum a tiny short-run benefit. Curative ultrasound can be helpful (poor quality of evidence). The efficacy of transcutaneous electrostimulation (TENS) for pain mitigation has not been proved. Electrical stimulation treatment can procure notable ameliorations. With respect to intra-articular injections, viscosupplementation appears to be a useful method for pain alleviation in the short-run (months). The short-run (weeks) advantage of intra-articular corticosteroids in the treatment of joint pain has been shown.
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Rezende MU, Andrusaitis FR, Silva RT, Okazaki E, Carneiro JDA, Campos GC, Pailo AF, Frucchi R, Pasqualin T, Villaça PR. Joint lavage followed by viscosupplementation and triamcinolone in patients with severe haemophilic arthropathy: objective functional results. Haemophilia 2016; 23:e105-e115. [DOI: 10.1111/hae.13115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
Affiliation(s)
- M. U. Rezende
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - F. R. Andrusaitis
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - R. T. Silva
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - E. Okazaki
- Hematology Clinic; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - J. D. A. Carneiro
- Hematology Clinic; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - G. C. Campos
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - A. F. Pailo
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - R. Frucchi
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - T. Pasqualin
- Orthopedics and Traumatology Institute; Medical School University of Sao Paulo; Sao Paulo Brazil
| | - P. R. Villaça
- Hematology Clinic; Medical School University of Sao Paulo; Sao Paulo Brazil
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Ong KL, Anderson AF, Niazi F, Fierlinger AL, Kurtz SM, Altman RD. Hyaluronic Acid Injections in Medicare Knee Osteoarthritis Patients Are Associated With Longer Time to Knee Arthroplasty. J Arthroplasty 2016; 31:1667-73. [PMID: 26895820 DOI: 10.1016/j.arth.2016.01.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Few nonoperative treatment options for knee osteoarthritis (OA) are available, but there is ongoing debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We investigated whether the formulation of IA HA, or its combined use with IA corticosteroid (CS), may be contributing to some of the reported variation in clinical outcomes. METHODS The 5% Part B Medicare data (2005-2012) were used to identify knee OA patients who underwent knee arthroplasty (KA). The time from diagnosis of OA to KA was compared between patients with (HA) and without (no HA) IA HA use, using quantile regression with propensity score adjustment. These were further stratified by type of IA HA. Patient factors associated with time to KA were also assessed using Cox regression. RESULTS The "HA" cohort was associated with a longer time to KA of 8.7 months (95% confidence interval: 8.3-9.1 months; P < .001) compared with the "no HA" cohort, with extended time to KA in the bioengineered Euflexxa IA HA cohort. Patient factors associated with longer time to KA included women, younger patients, minority patients, patients with fewer comorbidities, and IA CS injection use. Patients with both IA HA and IA CS had an additional 6.3 months (95% confidence interval: 5.5-7.0 months; P < .001) to KA over those with only IA HA. CONCLUSION In a large cohort of elderly patients undergoing KA, there was a significant longer time from diagnosis of OA to KA in those receiving IA HA. It is unclear if the extended time may lead to less KA utilization.
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Affiliation(s)
| | | | - Faizan Niazi
- Ferring Pharmaceuticals, Inc, Parsippany, New Jersey
| | | | | | - Roy D Altman
- Ronald Reagan UCLA Medical Center, Los Angeles, California
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Migliore A, Bizzi E, De Lucia O, Delle Sedie A, Bentivegna M, Mahmoud A, Foti C. Differences among Branded Hyaluronic Acids in Italy, Part 1: Data from In Vitro and Animal Studies and Instructions for Use. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2016; 9:89-101. [PMID: 27257398 PMCID: PMC4881871 DOI: 10.4137/cmamd.s38857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The use of hyaluronic acid (HA) for intra-articular (IA) injection is widespread around the world for patients affected by osteoarthritis. AIM The aim of this study is to identify scientific evidence from in vitro and in vivo studies supporting the use of IA HAs marketed in Italy. We also evaluated the accuracy of indications and contraindications reported in the leaflets of such HAs compared with the available scientific evidence. MATERIALS AND METHODS An extensive literature search was performed to identify all in vitro and in vivo model studies reporting on the effects of various HAs marketed in Italy for IA use. Data reported in the leaflets of different HA-based products for IA use were extracted and analyzed alongside evidence from in vitro and in vivo model studies. RESULTS Nine in vitro studies and 11 studies on animal models were examined. Comparing results with what is reported in the leaflets of HAs marketed in Italy, it was observed that many branded formulations are introduced in the market without any reporting of basic scientific evidence. Only 12.82% and 17.95% of branded products had been shown to be effective with scientific evidence from in vitro and in vivo studies, respectively. The rationale of use of these products is based on their nature, as if a class effect existed such that all HAs would yield similar effects. CONCLUSIONS Data on HAs deriving from in vitro and in vivo studies are scarce and relate to only a small percentage of products marketed in Italy. Many indications and contraindications are arbitrarily reported in Italian HA leaflets without the support of scientific evidence. Larger and brand-specific studies are necessary and should be reported in the leaflets to guide clinicians in making an appropriate choice regarding HA-based IA therapy.
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Affiliation(s)
- A Migliore
- Operative Unit of Rheumatology, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - E Bizzi
- Operative Unit of Rheumatology, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - O De Lucia
- Division and Chair of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | | - M Bentivegna
- Rheumatology Provincial Network Coordinator, ASP 7, Scicli Hospital, Ragusa, Italy
| | - Asmaa Mahmoud
- Physical Medicine, Rheumatology and Rehabilitation Department, Ain Shams University, Cairo, Egypt.; Physical and Rehabilitation Medicine, Tor Vergata University, Rome, Italy
| | - C Foti
- Physical and Rehabilitation Medicine, Clinical Sciences and Translational Medicine Department, Tor Vergata University, Rome, Italy
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Rodriguez-Merchan EC. Musculo-skeletal manifestations of haemophilia. Blood Rev 2016; 30:401-9. [PMID: 27166435 DOI: 10.1016/j.blre.2016.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/24/2016] [Accepted: 04/26/2016] [Indexed: 01/15/2023]
Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain.
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The knee in severe haemophilia with special emphasis on surgical/invasive procedures. Thromb Res 2014; 134:545-51. [DOI: 10.1016/j.thromres.2014.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/23/2014] [Accepted: 05/26/2014] [Indexed: 12/17/2022]
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Young G, Tachdjian R, Baumann K, Panopoulos G. Comprehensive management of chronic pain in haemophilia. Haemophilia 2013; 20:e113-20. [DOI: 10.1111/hae.12349] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2013] [Indexed: 12/13/2022]
Affiliation(s)
- G. Young
- Hemostasis and Thrombosis Center; Children's Hospital Los Angeles; Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - R. Tachdjian
- Division of Clinical Immunology and Allergy; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - K. Baumann
- Center for Bleeding and Clotting Disorders; University of Minnesota; Fairview Medical Center; Minneapolis MN USA
| | - G. Panopoulos
- Fairview Pain Management Center; University of Minnesota; Minneapolis MN USA
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Abstract
Physical medicine and rehabilitation aim to evaluate, diagnose and treat disability in haemophiliac patients, while preventing injury or deterioration. They also aim to maintain the greatest degree of functional capacity and independence in patients with haemophilia, or to return them to that state. Rehabilitation, together with clotting factor replacement therapy, has revolutionized the management of these patients in developed countries and reduced their morbidity/mortality rates. A knowledge of the musculoskeletal signs and symptoms of haemophilia is essential for providing a treatment which is suitable and customized. Physical medicine and rehabilitation techniques, which are based on physical means, are intended to reduce the impact which these injuries and their consequences or sequelae can have on the quality of life of patients with haemophilia. Under ideal haemostatic control conditions (primary prophylaxis), people with haemophilia could achieve good physical condition which will allow them to enjoy both physical activity and a daily life without limitations. Currently, children undergoing primary prophylaxis are quite close to this ideal situation. For these physical activities to be carried out, the safest possible situations must be sought.
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