Surgical procedures in patients with haemophilic arthropathy of the ankle

A single-centre experience of 29 total ankle replacement in haemophiliac patients: Therapeutic management, factor consumption and cost

INTRODUCTION

In patients with haemophilia, repeated bleeding in large joints leads to chronic haemophilic arthropathy, a rare disease that can be managed surgically with ankle arthrodesis or with total ankle replacement (TAR). TAR has been reported to provide good surgical results in the medium/long-term and allow preservation of joint mobility but the medical therapeutic management of the patients has not been described.

AIM

To describe the medical therapeutic management of TAR.

METHODS

All patients with haemophilia A/B, with haemophilic ankle arthropathy, and who underwent TAR between April 2006 and October 2019 were retrospectively included. Factor consumption, perioperative and early complications, volume of blood lost, and orthopaedic data were collected.

RESULTS

A total of 25 patients underwent 29 TAR (mean age was 44.7 years [range: 26-65]). In the 17 patients with HA without history of anti-FVIII inhibitor, the mean ± SD consumption the day of surgery was 116 ± 16 UI/kg when clotting factors were administered by continuous infusion, 106 ± 13 UI/kg when SHL factors were administered by bolus infusion, and 75 ± 22 UI/kg when EHL factors were administered by bolus infusion. During hospitalisation, the mean factor cost was €38,073 (83.7% of the total cost of surgery). Mean blood loss was significantly lower in patients treated with tranexamic acid (164 mL, range: 40-300) than in those not (300 mL, range: 70-800; p = .01). Six patients had haematoma. The 10-year survival free of any prosthesis removal/arthrodesis was estimated to be 92.2% (95% CI [83; 100]).

CONCLUSION

The medical therapeutic management of TAR is complex, carried out by a multidisciplinary team but effective in avoiding the occurrence of complications.

Surgery for chronic arthropathy in people with haemophilia

BACKGROUND

Chronic arthropathy is a potentially debilitating complication for people with haemophilia - a genetic, X-linked, recessive bleeding disorder, characterised by the absence or deficiency of a clotting factor protein. Staging classifications, such as the Arnold-Hilgartner classification for haemophilic arthropathy of the knee, radiologically reflect the extent of knee joint destruction with underlying chronic synovitis. Management of this highly morbid disease process involves intensive prophylactic measures, and chemical or radioisotope synovectomy in its early stages. However, failure of non-surgical therapy in people with progression of chronic arthropathy often prompts surgical management, including synovectomy, joint debridement, arthrodesis, and arthroplasty, depending on the type of joint and extent of the damage. To date, management of people with mild to moderate chronic arthropathy from haemophilia remains controversial; there is no agreed standard treatment. Thus, the benefits and disadvantages of non-surgical and surgical management of mild to moderate chronic arthropathy in people with haemophilia needs to be systematically reviewed.  OBJECTIVES: To assess the efficacy and safety of surgery for mild to moderate chronic arthropathy in people with haemophilia A or B.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, and two trial registers to August 2022. We also handsearched relevant journals and conference abstract books.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing surgery and non-surgical interventions, for any joint with chronic arthropathy, in people with haemophilia, who were at least 12 years old.

DATA COLLECTION AND ANALYSIS

The review authors did not identify any trials to include in this review.

MAIN RESULTS

The review authors did not identify any trials to include in this review.

AUTHORS' CONCLUSIONS

The review authors did not identify any trials to include in this review. Due to a lack of research in this particular area, we plan to update the literature search every two years, and will update review if any new evidence is reported. There is a need for a well-designed RCT that assesses the safety and efficacy of surgical versus non-surgical interventions for chronic arthropathy in people with haemophilia.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle

BACKGROUND

Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder.

METHODS

From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed.

RESULTS

Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010).

CONCLUSION

Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Total Ankle Replacement in Hemophilia

Introduction

Severe ankle hemophilic arthropathy can be a calamitous sign of severe hemophilia with important inferences for activities of daily living.

Aims

To summarize the contemporary, accessible information on Total Ankle Replacement (TAR) for ankle hemophilic arthropathy.

Methods

A search of Cochrane Library and PubMed (MEDLINE) regarding the role of TAR in ankle hemophilic arthropathy.

Results

The insufficient information regarding the results of TAR for hemophilic arthropathy is confined to scanty case series and case reports. An evaluation of the accessible literature reveals encouraging but inconstant outcomes. The reported rate of adverse events is 33%. The reported anticipated survival of TAR is 94% at 5 years, 85% at 10 years and 70% at 15 years.

Conclusion

Whereas people with advanced hemophilic arthropathy of the ankle are prone to ameliorate pain and range of motion following TAR, there is deficient knowledge to regularly recommend its use. Adverse events and infection percentages are disturbing. Moreover, the lack of survival analysis knowledge makes it difficult to assess the benefit to people with hemophilia. TAR is a demanding surgical procedure and its survival is not comparable to that after hip or knee replacement.

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

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

Dental management of patients with haemophilia in the era of recombinant treatments: increased efficacy and decreased clinical risk

Haemophilia is a hereditary X-linked recessive disorder caused by a deficiency of either clotting factor VIII (haemophilia A) or IX (haemophilia B). Conventional treatment is currently based on the use of either plasma derived or recombinant coagulation factors. This paper reports on the case of a patient with severe haemophilia who presented with mesial decay and interproximal tartar build-up, for which extraction and scaling to remove tartar deposits were indicated. Following extraction, the usual haemostasis techniques were applied, and postoperative prophylactic antihaemophilic treatment was indicated for 2 or 3 days. The patient presented with moderate bleeding for a few minutes immediately after the procedure. Administration of factor VIII before surgery as well as the patient’s favourable pharmacokinetic response allowed for an optimal result. This treatment has afforded patients with haemophilia a better quality of life, and safe and efficient access to invasive surgical procedures.

Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy

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.

Role of Arthroscopic Debridement of Hemophilic Ankles

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.

Orthotropic live transplantation for cirrhosis from hepatitis C virus leads to correction of factor IX deficiency allowing for ankle arthroplasty without factor replacement in a patient with moderate haemophilia B

: Liver transplantation is one of the treatments for haemophilic patients having severe liver cirrhosis who are infected with the hepatitis C virus. Patients with haemophilia can develop arthroplasty requiring surgical intervention, and the surgical outcomes of patients undergoing such procedures after liver transplant has not been reported. Treatment for arthropathy is important for improving the quality of life for patients who survive after liver transplantation. We report the first case of ankle arthroscopic arthrodesis in a patient with haemophilia B after undergoing living donor liver transplantation. We carefully monitored the patient's factor IX (FIX) plasma levels during his perioperative period, and we successfully performed his arthroscopic ankle arthrodesis without administration of any additional FIX concentrates. Our case has demonstrated the feasibility of joint surgery after liver transplantation without administration of additional clotting factors while monitoring FIX activity.

Can a Three-Component Prosthesis be Used for Conversion of Painful Ankle Arthrodesis to Total Ankle Replacement?

BACKGROUND

In patients with painful ankle arthrodesis, the surgical treatment is challenging, and may include takedown of ankle arthrodesis and conversion to a total ankle replacement (TAR). This procedure is technically demanding given the altered anatomy after arthrodesis. Few studies have evaluated TAR in the setting of prior arthrodesis.

QUESTIONS/PURPOSES

(1) What intraoperative and perioperative complications were observed in patients who underwent conversion of an ankle arthrodesis to a TAR? (2) Was durable fixation achieved at short term, and what was the alignment of the components? (3) What subsequent surgical procedures were performed, including revisions? (4) What improvements were observed in pain, tibiotalar range of motion (ROM), and quality of life?

METHODS

Between January 2007 and December 2014, 18 patients with a painful ankle arthrodesis underwent conversion to TAR at our tertiary referral center. During this period, the indications for conversion of ankle arthrodesis to TAR were tibiotalar nonunion or malunion after attempted arthrodesis in patients who declined revision ankle arthrodesis. The goal of revision surgery was to help patients regain hindfoot mobility and to decrease pain. During the study period, all patients who met indications were treated with a conversion procedure. Of the 18 patients included, 14 were men and four were women. The mean age of the patients was 51 ± 7 years. The mean followup was 54 ± 27 months, with no loss to follow up observed. The initial ankle arthrodesis was performed 6 ± 3.5 years before conversion to TAR. In all patients, the conversion to TAR was performed using a nonconstrained cementless three-component prosthesis. Intraoperative and postoperative complications, revision procedures, and prosthesis component loosening were evaluated. Weightbearing radiographs were used to determine the angular alignment of the tibial and talar components using α/β/γ angles and to analyze the bone-implant interface. Osseointegration was defined as visible trabecular structures at the bone-implant interface without radiolucent lines. The criteria for radiographic loosening was defined as subsidence or migration of prosthesis components and/or a cystic lesion with a diameter at least 2 mm. Clinical assessment included pain evaluation, measurement of ankle ROM, and quality of life.

RESULTS

Two of the 18 patients sustained an intraoperative medial malleolar fracture. In three patients, delayed wound healing was observed. At latest followup, four patients had incomplete osseointegration (posterior quarter of the bone-prosthesis interface on the tibial side). None of the 18 patients had prosthesis loosening. In all patients, both components were neutrally aligned. Two patients had painful arthrofibrosis with reduced ROM, which we treated with an open arthrolysis and exchange of mobile-bearing inlay; one other patient is considering a revision for substantial tibial component medial tilt with collapse of the medial arch. At the latest followup, the mean dorsiflexion and plantar flexion were 8.5° ± 3° and 15° ± 5°, respectively. The mean visual analog scale (VAS) score decreased from 9 ± 0.8 to 1.7 ± 1.6 (p < 0.001). The Short Form Health Survey questionnaire (SF-36) physical and mental outcome scores improved from 34 ± 5 to 74 ± 11 (p < 0.001) and from 49 ± 4 to 75.5 ± 7 (p < 0.001).

CONCLUSIONS

Conversion of an ankle arthrodesis to a TAR is a technically challenging procedure. In this small series, it was associated with frequent complications including arthrofibrosis, and functional outcomes including postoperative ROM were lower than reported for primary TAR. However, pain and function did improve. Further studies are necessary to address long-term clinical and radiographic outcomes in this patient cohort.

LEVEL OF EVIDENCE

Level IV, therapeutic study.