Management of haemophilic pseudotumours with special emphasis on radiotherapy and arterial embolization

Spontaneous resolution and bone regeneration in hemophilic pseudotumor: A rare case report and literature review

AIM

Hemophilic pseudotumor (HP) is a very rare complication of hemophilia seen in only 1-2% of the cases. Although it is much more common in long bones, pelvis and small bones of hands and feet and very rarely involving jaw bones.

METHOD AND RESULT

In the present case, the presence of a rare hemophilic pseudotumor of the mandible with the positive history of Hemophilia B justifies that the history, clinical and radiological examinations were sufficient to arrive at conclusive diagnosis precluding invasive diagnostic procedures such as biopsy hence avoiding the risk of hemorrhage, infection, or fistula. This case also highlights that patient was conservatively managed with Factor IX replacement alone with a very good clinical outcome.

CONCLUSION

HP should be considered as a differential diagnosis of any progressive swelling of hard and soft tissues occurring in a patient with severe haemophilia.

Surgical treatment for pelvic haemophilic pseudotumour: a retrospective analysis of 21 cases

Background

Due to the rarity of pelvic haemophilic pseudotumour (PHPT) and demanding surgical technique for PHPT excision, no study reports the mid-term follow-up outcomes of surgical treatment of PHPT in a relatively large cohort. PHPT with varying degrees of bony pelvic involvement and infection status necessitates different operative procedures, yet there is currently no classification system for PHPT based on surgical practice.

Methods

The study was conducted between June 25, 2004 and July 18, 2023, in Peking Union Medical College Hospital and Nanfang Hospital in China. We performed a retrospective analysis involving 21 patients with 24 PHPTs with a mean follow-up period of 7.1 years. The demographic information, PHPT characteristics, surgical data, and perioperative complications were analysed.

Findings

21 consecutive male patients with 24 PHPTs (21 primary PHPTs and three recurrent PHPTs) that underwent surgical treatment were involved in the study. A classification system including four subtypes was introduced as (I) PHPT confined to soft tissue; (II) PHPT involving bony pelvic without pelvic discontinuity; (III) PHPT causing pelvic discontinuity; (IV) Infectious PHPT. Of the 24 PHPTs, 11 (45.8%) were identified as Type I, five (20.8%) as Type II, three (12.5%) as Type III, and five (20.8%) as Type IV. At the time of surgery, the patients had a mean age of 37.0 ± 9.5 years (Range, 24-52 years). The mean maximum diameter of PHPTs upon surgery was 17.0 ± 7.7 cm (Range, 4.3-40.0 cm). The mean surgical duration was 192 ± 77 min (Range, 60-330 min) and the median intraoperative blood loss was 400 mL (IQR, 225-950 mL, Range, 100-3000 mL). One patient (4.8%) underwent intraoperative cardiopulmonary arrest and expired the following week. Four PHPTs (16.7%) presented postoperative wound infections and poor wound healing. During the follow-up period, five PHPTs (20.8%) experienced pseudotumour recurrence.

Interpretation

Our findings suggest that surgical treatment for PHPTs is feasible and relatively safe. Symptomatic and progressive PHPTs should undergo surgical intervention as early as possible to minimise the surgical risks. Intraoperative use of abundant gelatin sponges in PHPT excision draws attention to severe embolism complications.

Funding

There are no sources of funding for this manuscript.

Surgical treatment of a distal radius and ipsilateral metacarpal hemophilic pseudotumor without recurrence or functional deficit: a case report

Background

Distal hemophilic pseudotumor (HP) occurring distal to the wrist appear to be secondary to intraosseous hemorrhage, which develops rapidly and should be treated primarily with long-term replacement therapy and cast immobilization. Surgical removal or even amputation is indicated when conservative management fails to prevent progression. Here, a practical strategy was described for those patients who cannot afford the cost of routine coagulation factor replacement therapy, namely immediate surgical curettage and bone grafting as well as continuous follow-up.

Case description

A 7-year-old boy with a history of mild hemophilia A was admitted to our medical center because of a 2-year history of progressive swelling and pain around right forearm and hand. Coagulation factor VIII level was 11.1% of normal with no inhibitor. Radiographs revealed expansile swelling, bone destruction, and deformity of the distal right radius and the second metacarpal bone. He was diagnosed with distal HP. Surgical procedure of curettage and bone grafting was performed. The function and appearance of the right wrist were almost normal without discomfort at the 101-month follow-up. Significantly, the same patient was hospitalized again because of a year-long progressive swelling and pain around the left hand when he was 14 years old. X-ray showed multiple bone destruction of the left proximal phalanges of left thumb, middle finger and little finger with local pathological fractures. Surgical procedure of HPs including curettage and bone grafting was performed. Postoperative recovery was good, and the last clinical follow-up at 18 months after the operation displayed a satisfactory shape and functional outcomes.

Conclusions

Curettage and bone grafting prove to be safe and feasible for patients with distal HP and continuous follow-up of patients with distal HP is very vital for timely finding and then treating successive HP in developing countries.

Outcome of Surgical Management of Hemophilic Pseudotumor: Review of 10 Cases from Single-Center

Objective

To evaluate the operative methods and clinical results of surgical treatment in a case series of 10 patients with hemophilic pseudotumors.

Methods

Ten patients with hemophilic pseudotumors who received surgical resection treatment in our hospital from October 2017 to June 2020 were retrospectively reviewed. All patients were hemophilia A (factor VIII deficiency).The age range was 20–51 years. Preoperative imaging examination revealed the size of irregular mass from 8.2 cm× 3.3 cm× 2.3 cm to 22.3 cm× 15.5 cm× 17.0 cm. With the supplementary of recombinant coagulation factor VIII, five cases received complete resection; one received resection and skin grafting; one received cytoreduction surgery as the pseudotumor closing to iliac vessel and nerve; three cases received complete resection and construction as bone destruction. The perioperative variables were recorded and all the patients were followed in the outpatient clinic. Clinical and radiological assessments were conducted.

Results

In these patients, the average intraoperative blood loss volume was 783.1 mL (range, 240–2100 mL). Six patients received blood transfusion during perioperative period. The average duration of surgery was 140.7 min (range, 110–240 min). All wounds healed smoothly and there was no infection or chronic sinus formation. The average length of hospital stay was 16.3 days (range, 12–25 days). There is no iatrogenic vascular nerve injury in our series. Complete follow‐up was performed in all patients. Mean follow‐up duration was 14.2 months (range, 6–26 months). One patient with pseudotumor in the thigh had a recurrence 1 year after operation, then secondary operation was performed. In three cases who received complete resection and construction, patient 8 obtained bone graft and late fixation. X‐ray examination showed bone formation in the lesion at the 2‐year follow‐ups after operation. Patient 9 underwent knee replacement, his left knee showed flexion deformity in preoparation. At the last follow‐up, range of motion was improved from 0° to 40° compared with preoperative status. Patient 10 had pseudotumor in the distal femur, received long bone graft and intramedullary nail fixation.

Conclusions

Surgical resection for hemophilic pseudotumors is an effective and safe method. The choice of surgical procedure must be individualized according to the localization and progress of pseudotumor.

Haemophilic Pelvic Pseudotumour: A New Surgical Option

Background: Haemophilia is an inherited coagulopathy caused by the absence or dysfunction of clotting factor VIII or IX. Clinical manifestations are generally secondary to recurrent bleeding episodes mainly in the musculoskeletal system. Bleeding symptoms appear early in life and, when the disease is severe (when plasma factor VIII or IX activity is <1% of normal), joint and muscle bleeding may occur spontaneously. A pseudotumour is a recurrent, chronic, encapsulated, slowly expanding, muscle hematoma. Haemophilic pseudotumour is a rare complication of haemophilia which occurs, as a condition either from repeated spontaneous bleeding or coming from a traumatic origin, in 1–2% of haemophilic patients. Case report: A 32-year-old man with severe haemophilia A referred to our Clinic with a massive right iliac wing pseudotumour complicated by Staphylococcus aureus superinfection and skin fistulisation. In this report we describe the medical management and surgical treatment by the adoption of a novel surgical technique which involves the use of a pedicle-screw and rod system (PSRS), a polyglycolic acid MESH and bone cement in order to build up an artificial ilium-like bony mass. This case report highlights the importance of interdisciplinary approach and the efficacy of eradicating surgery as treatment, especially in the case of large and long-lasting lesions.

Complications of Muscle Hematomas in Hemophilia

Prevention is essential for avoiding the complications of muscle hematomas (compartment syndrome, pseudotumors and peripheral nerve lesions) in hemophilic patients. This is achieved through early diagnosis of muscle hematomas and proper long-term hematological treatment until they have resolved (confirmed by image studies). Ultrasound-guided percutaneous drainage could be beneficial in terms of achieving better and faster symptom relief. Acute compartment syndrome (ACS) requires emergency surgical treatment (decompression fasciotomy). As for pseudotumors, the biopsy will help us confirm the diagnosis and rule out true tumors (chondrosarcoma, liposarcoma, synovial sarcoma) that sometimes mimic hemophilic pseudotumors. Surgical removal of hemophilic pseudotumors is the best solution. As alternatives, there are curettage and filling with cancellous bone and radiotherapy (when surgery is contraindicated). Preoperative arterial embolization (ideally 2 weeks before surgery) helps control intraoperative bleeding during surgery for giant pelvic pseudotumors. Peripheral nerve injuries, which are rare, almost always occur due to compression of hematomas in the vicinity. In most cases, they usually resolve with hematological treatment only. If such treatment fails, surgery would be indicated.

Surgical treatment of haemophilic pseudotumor with severe bone destruction: a case report

Haemophilia is an X-linked congenital bleeding disorder caused by a deficiency of factor VIII/IX. Patients with haemophilia (PWH) experience spontaneous bleeding into joints and muscles. Recurrent joint bleeds result in painful and disabling haemophilic multi-arthropathy characteristic of elbows, knees and ankles. The standard of care for PWH is replacement of factor concentrate. Haemophilic pseudotumor (HPT) is one of the complications which can occur in PWH due to repeated bleeding. The occurrence of HPT is not uniform, so treatment needs to be tailored to the individual. We report the case of right distal femur HPT with multi haemophilic end-staged arthropathies (bilateral elbows, knees and ankles). He suffered from walking disability and right thigh pain. He showed functional limitations in those arthropathies, so he could not use crutches. To reduce excess loads on affected joints, we performed left total knee arthroplasty before excision of HPT of the right femur. This is the first case report of a 37-year-old man with haemophilia whose treatment combined en bloc excision of the HPT and reconstruction of distal femur using a tumour prosthesis with severe bone destruction after excision of HPT. At the 24-month postoperative follow-up, the patient was able to walk without any support. When the patients suffer from multi-joint haemophilic arthropathy and HPT, comprehensive and well-planned surgical treatment strategy under adequate factor VIII replacement therapy is necessary.

Pain assessment and management in Italian Haemophilia Centres

BACKGROUND

Although the widespread use of factor VIII/IX replacement therapy has significantly reduced the severity of arthropathy in persons with haemophilia (PWH), some develop degenerative joint changes, associated with significant pain. The aim of this survey was to investigate the management and perception of pain among Italian physicians who treat PWH.

MATERIALS AND METHODS

Between September and October 2017, a questionnaire was distributed to 35 Italian haemophilia treatment centres (60 physicians).

RESULTS

Fifty-three haemophilia specialists completed the survey. We found that there was good agreement (98.1%) on the need to investigate pain at each clinical visit, but there was heterogeneity in the opinions of haemophilia specialists with regards to the availability of validated guidelines (35.8%) and whether pain specialists should be a part of the comprehensive care team in daily clinical practice (58.5%). Haemophilia specialists also agreed pain should be evaluated using a rating scale validated in PWH (88.7%). Pain was mainly managed by the haemophilia specialists themselves, supported by a physiatrist and physiotherapist, while a pain specialist was only involved in 26.4% of cases. The combination of paracetamol with tramadol or codeine was the most common first-line treatment, while cyclo-oxygenase-2 inhibitors, non-steroidal anti-inflammatory drugs, and opioids were less commonly used.

DISCUSSION

There are some unmet needs in Italy regarding pain management for PWH and the management of pain in these patients by haemophilia specialists. There is a lack of evidence-based guidelines for these specialists to use, as well as a reluctance to involve pain specialists. The lack of spontaneous reporting of pain by PWH, despite using pain relief, highlights the need for clinicians to actively ask patients about any pain they may be experiencing.

Treatment of pelvic haemophilic pseudotumour: A retrospective study

BACKGROUND

The incidence of a pelvic haemophilic pseudotumour is very low and is rarely seen in the clinic. Due to the lack of clear treatment standards, patients often suffer from the condition over a protracted period. The aim of this retrospective study was to present our institutional experience in the treatment of pelvic haemophilic pseudotumours over the past 8 years.

METHODS

We retrospectively analysed patients with a pelvic haemophilic pseudotumour who were treated in the Nanfang hospital between February 2012 and December 2019. The type and severity of haemophilia, the presence of inhibitors, comorbidities, pseudotumour imaging data, treatment and follow-up results were recorded and analysed.

RESULTS

Pelvic pseudotumours were identified in seven patients with haemophilia. Three patients had severe haemophilia, three had moderate haemophilia, one had mild haemophilia and inhibitors were present in two patients. Transfusion-related infectious diseases were noted in three patients. Spontaneous rupture and infection of the pseudotumour occurred in five patients. In addition, five patients underwent surgical treatment, two of whom healed well, two patients suffered recurrence of the pseudotumour, and one patient developed a postoperative haematoma twice. Two patients were treated conservatively, one of whom was unable to walk because of progression of the disease, while the other died from severe bleeding and infection.

CONCLUSIONS

Once a pelvic haemophilic pseudotumour is diagnosed, surgical resection should be performed as soon as possible. A delay in diagnosis and suboptimal treatment may lead to complications of the pelvic haemophilic pseudotumour.

Clinical characteristics and surgical treatment of haemophilic pseudotumor: A retrospective analysis of thirty-four patients

AIMS

Haemophilic pseudotumor (HPT) is a rare but challenging complication of haemophilia. This study was intended to provide our experience about clinical characteristics and surgical treatment of HPT.

METHODS

Clinical medical records were retrieved from the Hemophilia Center, Nanfang Hospital, to identify the patients who had been surgically treated from 1 January 2006 to 31 December 2017 with a definite diagnosis of HPT. Their clinical features, surgical management, outcomes and complications after surgery were analysed.

RESULTS

We identified 34 patients with HPT who had surgical treatment over a 12-year period and five of them had multiple HPTs. The incidence of HPT at this centre was 2.3% over the dozen years. A previous trauma leading to the development of HPT was reported in 18 cases (52.9%). The HPT affected only soft tissue in 7 patients, bone and soft tissue in 25 ones and joint in 2 ones. Preoperative infection and fistula formation happened in ten patients, two of whom were related to abdominal HPTs. Enterococcus faecalis was cultured in five cases with fistula formation. HPT associated with pathological fracture was observed in five cases, two of whom were treated by external fixation and 3 by HPT resection and metallic internal fixation. Amputation was performed for nine patients, 6 of whom had preoperative infection and fistula formation. Their follow-up duration averaged 4.2 ± 2.9 years (range, from 1 to 13.5 years) after surgery. Of all our cases, three suffered from postoperative infection, five from recurrence of HPT and two with external fixation from fracture non-union.

CONCLUSIONS

HPT patients with preoperative infection had worse prognosis than those without. Surgical treatment plus intensive replacement therapy was effective for HPT but with a high rate of complications. HPT resection and metallic internal fixation rather than external fixation should be recommended for HPT patients with pathological fracture.

Musculo-skeletal problems of the hand in haemophilia

Musculo-skeletal complications of the hand in the haemophilia patient are rare, and they include synovitis, arthropathy, pseudotumours, carpal tunnel syndrome and vascular aneurysms and pseudoaneurysms.

The best way to prevent the aforementioned musculo-skeletal complications is early continuous haematological primary prophylaxis (intravenous infusion of the deficient coagulation factor, ideally from cradle to death).

There is a wide range of procedures that a hand surgeon treating these patients should be able to manage, including synovectomy, prosthetic replacement of small joints, removal or curettage of pseudotumours, release of carpal tunnel and, occasionally, vascular reconstruction of aneurysms.

The treatment of these patients should be made at an institution with close collaboration between haematologists and hand surgeons (all surgical procedures must always be performed under cover of the deficient coagulation factor).

Cite this article: EFORT Open Rev 2020;5:328-333. DOI: 10.1302/2058-5241.5.190078

Management of Hemophilic Cysts and Pseudotumors of the Hand in Bleeding Disorders: A Case Series

PURPOSE

Hemophilic cysts and pseudotumors (HCPTs) of the hand are rare and are secondary to bleeding disorders such as hemophilia A and B. This is a report of our experience in the management of this rare condition.

PATIENTS AND METHODS

Seven male patients with hemophilia A presenting with progressive swelling of the hand were treated between 2004 and 2013 at a tertiary referral hospital. All patients had clotting factor replacement based on our previously reported protocol. The age of the patients ranged from 3 to 49 years (median age, 19 years).

RESULTS

Four patients had soft tissue hemophilic cysts and 3 had bony hemophilic pseudotumors. Two patients had traumatic pseudoaneurysm of the ulnar artery in addition to the cysts. The soft tissue cysts required surgical excision in 3 patients under factor cover as per the protocol. The bony lesions were initially managed nonsurgically by factor replacement, but 2 patients failed to respond and required amputation of the fingers. The ulnar artery aneurysm was excised and artery ligated in 1 patient and the artery was vein grafted owing to poor hand perfusion in 1.

CONCLUSIONS

Based on our observations in the management of HCPTs of the hand and the existing literature, we conclude that the soft tissue cysts require surgical excision along with factor replacement and distal bony lesions smaller than 3 cm respond to factor replacement. Larger bony lesions require surgical treatment. Treatment of hemophilic cysts and pseudotumors should be undertaken only in centers with a major hematology backup.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Bone haemophilic pseudotumour of the ulna: A rare complication of haemophilia in a dog

OBJECTIVES

This case report describes for the first time a bone haemophilic pseudotumour in a dog.

CASE DESCRIPTION

A seven-month-old German Shepherd male dog was presented with the complaint of a forelimb weight-bearing lameness with major swelling that expanded dramatically after fine needle aspiration. Radiographs showed a large, well-defined ulnar diaphyseal cystic-like osteolytic lesion. Based on prolonged activated partial thromboplastin time (aPTT) and low factor VIII activity, haemophilia A was diagnosed. Bone scintigraphy, computed tomography, magnetic resonance imaging, and histological findings definitely ruled out malignant neoplasia or inflammation and strongly supported a bone haemophilic pseudotumour over an aneurysmal bone cyst. Segmental ulnar resection  and replacement by a polymethylmethacrylate spacer combined with perioperative bleeding management resulted in a successful outcome.

DISCUSSION

This case provided evidence that a bone haemophilic pseudotumour may be the sole presenting clinical sign of haemophilia A in dogs. Early diagnosis, based on history and magnetic resonance imaging findings, is imperative for prompt treatment leading to successful outcome. It is challenging as fine needle aspiration or biopsy is contraindicated. As described in humans, surgical excision of the lesion combined with management of severe postoperative bleeding was associated with successful outcome in the present case.

CLINICAL SIGNIFICANCE

A bone haemophilic pseudotumour should be considered in the differential diagnosis of expanding mass associated with osteolysis, especially in young male dogs. Perioperative monitoring of the bleeding disorder and subsequent FVIII replacement therapy was of paramount importance in the present case.

Availability of angiography and therapeutic embolization for the treatment of acute bleeding in patients with hemophilia

Clotting factor replacement therapy alone is often inadequate for acute bleeding in hemophilia patients, and surgery for such patients poses significant clinical challenges. Arterial angiographic intervention is used to control bleeding in local blood vessels. In the present study, we examined the clinical course and prognosis of hemophilia patients with bleeding who had undergone angiography, and evaluated the validity of diagnostic angiography and therapeutic embolization in these patients. Angiography was performed in five hemophilia patients, who experienced bleeding that was difficult to control even after treatment with clotting factor replacement or bypassing agent therapy. Of these patients, four were confirmed to have continued bleeding, and angiographic embolization was performed using clotting factor concentrates or bypassing agents. However, one patient developed uncontrollable bleeding at the puncture site, which eventually led to the patient's death. Thus, angiography and therapeutic embolization may be the preferred procedures for the treatment of hemorrhagic complications, refractory to treatment with clotting factor concentrates or bypassing agents. Further comprehensive, multidisciplinary team studies are needed to develop effective strategies to reduce hemorrhagic complications.

Surgical Treatment for Hemophilic Pseudotumor: Twenty-three Cases with an Average Follow-up of 5 Years

BACKGROUND

Hemophilic pseudotumor (HPT) is a rare disease with many challenges. Only a few reports on surgical treatment for HPT have been published.

METHODS

The cases of 23 patients with HPT who had surgical treatment from July 1996 to December 2014 were retrospectively reviewed. Demographic data, blood loss and transfusion during surgery, outcomes, and complications after surgery were analyzed.

RESULTS

Eleven patients underwent HPT resection; 4 underwent HPT excision, allograft transplantation, and absorbable screw fixation; 3 had HPT resection and metallic internal fixation; 2 had HPT resection, autogenous fibular grafting, and absorbable screw fixation; 2 underwent curettage and bone-grafting; and 1 patient received above-the-knee amputation. The average age (and standard deviation) of the patients at the time of surgery was 31.9 ± 12.8 years (range, 6 to 54 years) with an average follow-up of 5.3 ± 4.7 years (range, 1.1 to 19.6 years). The median duration of the surgery was 157 minutes (range, 90 to 315 minutes). The median amount of blood loss during surgery was 800 mL (range, 100 to 4,000 mL). Three patients (13%) had a postoperative infection, 2 (8.7%) had recurrence of HPT, and another 2 patients had fracture nonunion.

CONCLUSIONS

Surgical treatment of HPT with a modified protocol of coagulation factor replacement is safe and effective. It should be recommended for patients with HPT who have progressive enlargement of the mass, recurrent and massive bleeding, spontaneous perforation, bone erosion, or compression of surrounding tissues or who have had failure of conservative treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hemophilic pseudotumor in a non-hemophilic patient treated with a hybrid procedure of preoperative embolization of the feeding arteries followed by surgical resection-A case report

•

Hemophilic pseudotumor is a rare complication of Hemophilia A and B.

•

Diagnosis requires a high index of suspicion-especially in non-hemophilic patients.

•

Radiographic findings are similar to that of malignant tumors.

•

Surgical intervention remains the mainstay of treatment.

•

Pre-operative embolization has been shown to reduce intra-operative bleeding.

Introduction

Hemophilic pseudotumor is a rare but well documented complication seen in approximately 1–2% of patients with hemophilia. The incidence continues to decrease, likely because of increasingly sophisticated techniques in managing factor deficiency. We present a case of hemophilic pseudotumor in a patient without hemophilia, an exceptionally rare entity, and outline a hybrid approach to treatment.

Presentation of case

The patient presented with a left sided iliopsoas mass and associated radiculopathy, with a history of a poorly characterized bleeding diathesis and Noonan’s syndrome. He had no history of trauma and was not being treated with anti-coagulation. Of note, factors VIII, IX and XI were normal. An open biopsy was consistent with hemophilic pseudotumor. The patient underwent a hybrid procedure of preoperative embolization of the left internal iliac and left deep circumflex arteries followed by surgical debridement and resection, with an excellent outcome.

Discussion

Hemophilic pseudotumor is rarely seen in patients with hemophilia, and even less frequently in patients without. Trauma is often the inciting event. A high index of clinical suspicion is required in order to secure the diagnosis, as the radiographic appearance is non-specific. Our patient had no history of trauma, although we question whether his underlying bleeding diathesis may have predisposed him to developing the pseudotumor. Surgery remains the cornerstone of management in these cases.

Conclusion

Within the literature, there are only two other cases of hemophilic pseudotumor occurring in a non-hemophiliac patient, highlighting the rarity of this case and the associated diagnostic dilemma.

Perioperative Period of a Hemophilia-related Osteoarthropathy Therapeutic Regimen and Analysis of Complications

OBJECTIVE

To investigate the effectiveness of our department's therapeutic regimen and treatment of complications during the perioperative period of hemophilia-related osteoarthropathy.

METHODS

In this retrospective study, data on 101 patients with hemophilia who had undergone operative treatment in our hospital from January 2000 to August 2014 were assessed. Ninety-one of the patients had hemophilia A and 10 hemophilia B. All patients were male. Changes in Hospital for Special Surgery (HSS), Harris and American Orthopedic Foot and Ankle Society (AOFAS) scores, occurrence of complications during the perioperative period and the clinical treatment and prognosis pre- and postoperatively and during follow-up were analyzed. Relevant clinical data were obtained through telephone calls, outpatient follow-up, and medical clinical record searches.

RESULTS

The 101 patients who were followed up (for an average of 96 months) had 147 orthopedic operations, including joint replacement, hemophilia-related false tumor resections, and tendo-achillis lengthening. The HSS scores for knee surgeries increased from 52 points preoperatively to 86 postoperatively, Harris scores for hip joint surgery from 26 to 87 points, respectively, and AOFAS scores for foot and ankle surgeries from 39 to 81 points, respectively. Eight patients had wound complications, four intra-articular hematomas, two peroneal nerve injuries, one a proximal femur splitting fracture and one deep venous thrombosis.

CONCLUSIONS

Surgical treatment is a safe and reliable choice for addressing complications including hemophilia-related osteoarthropathy given the implementation of effective measures for treatment during the perioperative period.

Nonhemophiliac musculoskeletal pseudotumor

A 24-year-old man presented with impending ulceration of a large thigh swelling which appeared after minor trauma. Imaging revealed a large well-encapsulated lesion with no vascularity. He was diagnosed to have a pseudotumor and underwent successful excision of the mass under blood and cryoprecipitate cover. The unusual presentation was suspected to be secondary to a transient drug-induced factor XIII deficiency because the result of the final coagulation study was normal.

Surgical management of hemophilic pseudotumor complicated by destructive osteoarthropathy

Hemophilic pseudotumor gradually erodes bone and induces fracture or deformity, causing joint dysfunction or destructive osteoarthropathy. Reports about surgery for hemophilic pseudotumor complicated by destructive osteoarthropathy are scarce. The object of this study was to evaluate the results and complications of surgical management for patients of pseudotumor complicated by destructive osteoarthropathy. We retrospectively reviewed records from July 1996 to July 2013, and found eight patients with pseudotumor complicated by destructive osteoarthropathy. We recorded their demographic data, time of surgery, amount of blood loss and transfusion, bone union, and complications. Seven patients were diagnosed with hemophilia A and one with hemophilia B. The mean age at surgery was 31.9 ± 8.3 years. Two of the eight underwent excision of the pseudotumor and metallic fixation, one had amputation, and five underwent autogenous or exogenous bone grafting and fixation with an absorbable screw. The median operating time was 170 min (135-315 min). The median amount of intraoperative blood loss was 1350 ml (100-4000 ml). The amount of red blood cells, plasma, and whole blood transfusion after surgery were 0-24 units, 0-2000 ml, and 0-4600 ml, respectively. After a median follow-up of 75 months, the numbers of pseudotumor recurrence, fracture nonunion, coagulation factor inhibitor formation, and wound complications were one, one, two, and four, respectively. Surgery is an effective treatment for hemophilic pseudotumor complicated by destructive osteoarthropathy. However, the incidences of wound infection, coagulation factor inhibitor formation, hemophilic pseudotumor recurrence, and fracture nonunion are high.

Hemophilic Pseudotumor: An Important Differential Diagnosis of an Intracranial Mass

Hemophilic pseudotumor is a rare complication of hemophilia. We present the case of a male toddler with moderate hemophilia A and cranial hemophilic pseudotumor managed with factor VIII infusions. We also provide a review of the literature. Recognition of this rare manifestation of this complication of hemophilia is important to provide correct treatment and avoid unnecessary investigations, particularly biopsy, which is contraindicated in this condition.

Management of the hemophilic pseudotumor of the abdomen: A rare pathological entity

INTRODUCTION

Hemophilic pseudotumor is a rare complication that occurs in patients with severe hemophilia. Results from multiple episodes of bleeding into the bones and soft tissues.

PRESENTATION OF CASE

A 31 years old male patient, with severe hemophilia A. Diagnosed with an abdominal tumor 10 years ago during routine screening, that progressively grew to encompass the entire abdominal area, with symptoms of intestinal obstruction.

DISCUSSION

Hemophilic pseudotumor appears as a painless tumor of slow growth that can compress vital organs producing bone destruction, muscle and skin necrosis. The tumor may have fistulas or break spontaneously.

CONCLUSION

The abdominal hemophilic pseudotumor is a rare pathological entity, with few reports worldwide, but must be considered in hemophilic patients with a well documented abdominal tumor.

Hemophilic pseudotumor of the temporal bone with conductive hearing loss--case report

A 46-year-old man with factor VIII deficiency presented with a rare case of hemophilic pseudotumor in the temporal bone manifesting as severe conductive hearing loss and external ear bleeding. The pseudotumor expanded and destroyed the temporal bone and skin of the external ear over the course of 8 years. The pseudotumor was surgically excised, and the patient's symptoms improved. Histological examination of a specimen collected from inside the pseudotumor demonstrated blood products in various stages of evolution and showed that the outer membrane consisted of a collagen layer. Hemophilic pseudotumors are rare complications occurring in 1-2% of patients with mild or severe hemophilia. Pseudotumors are chronic, slowly expanding, encapsulated cystic masses, and most are located in the long bones and pelvis. The present case suggests that cranial pseudotumor should be considered in the differential diagnosis of cranial lesion in a patient with hemophilia.

Surgical treatment of the haemophilic pseudotumour: a single centre experience

PURPOSE

Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.

METHODS

We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.

RESULTS

The mean age at surgery was 45.9 (range, 40-61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4-24) years, normal healing with no recurrence was observed.

CONCLUSIONS

The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.

Aspects of current management: orthopaedic surgery in haemophilia

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).

Pelvic pseudotumor and pseudoaneurysm in a pediatric patient with moderate hemophilia B: successful management with arterial embolization and surgical excision

Development of pseudotumors is an unusual complication of hemophilia. Treatment is controversial, especially in patients with large proximal lesions. Surgery, while curative, can be associated with massive intra-operative bleeding, infection and amputation. Arterial embolization of blood vessels supplying the pseudotumor may reduce these complications. Herein, we report a 14-year-old patient with moderate hemophilia B with a pelvic pseudotumor and pseudoaneurysm that failed conservative management with factor replacement alone. He was successfully treated with Bead Block and coil embolization followed by surgical extirpation of the lesion 24 hr later.