Prophylaxis with factor concentrates in preventing hemophilic arthropathy

Seven children with severe hemophilia A on prophylactic substitution therapy since a mean age of 5 years (group I) were investigated in 1978 (at ages 6-12 years) and in 1988 (at ages 16-22 years). The results were compared with those of seven children aged 5-12 for whom such treatment was started at a mean age of 3 years (group II). In group I, four had each had more than 20 ankle hemarthroses at the first investigation, while in group II, only one boy had experienced such a high bleeding frequency. Radiological changes in ankles were found in one of seven in group II compared with five of seven in group I. Progression of these changes was shown in eight of 10 ankles of group I at reinvestigation. Regular prophylactic therapy must start early, at ages 1-2 years, to prevent changes in ankle joints, and parents and children must learn to recognize ankle bleeding. Modern Factor VIII concentrates must be administered to children two or three times per week in dosages of 3,000 U/kg/year in order to reduce hemarthroses to a minimum. The dosages can probably be lowered if the intervals are shortened. Children on prophylactic treatment can engage in regular sports activities.

Posterior cruciate ligament injuries in trauma patients

The purpose of this article is to evaluate the incidence of posterior cruciate ligament (PCL) injuries in trauma patients with acute hemarthrosis of the knee. Sixty-one acute knee injuries underwent examination under anesthesia and diagnostic arthroscopy at a tertiary care trauma center over an 11-month period. PCL injuries occurred in 44% (27 of 61) acute knee injuries; 81.5% (22 of 27) were trauma patients and 18.5% (five of 27) were sports related. Higher energy mechanisms of injury may account for the difference. Isolated PCL injuries were rare [7.5% (two of 27)], whereas 92.5% (25 of 27) of PCL injuries occurred in combination with other ligament injuries. Trauma patients have a higher incidence of PCL injuries than does the athletic population. Acute knee hemarthrosis in trauma patients should elevate suspicion for PCL injuries. Arthroscopy is a valuable tool for PCL evaluation and surgical planning.

Factor X deficiency: clinical manifestation of 102 subjects from Europe and Latin America with mutations in the factor 10 gene

Inherited factor X deficiency (FXD) is a rare (1:1,000,000) recessive bleeding disorder. The clinical and laboratory phenotypes of FXD are poorly correlated and few regional studies on the genotype and the clinical manifestations of FXD are known. To understand the association between clinical manifestations and causative genotype, detailed evaluation of bleeding pattern in a high number of patients is needed. This international study analysed the phenotype and genotype of 102 subjects from Central Europe (Germany, Poland and Slovakia) and Latin America (Costa Rica and Venezuela) with causative mutations in the F10 gene, via sequencing. Twenty-eight homozygous, seven compound-heterozygous and 67 heterozygous FXD subjects were characterized. Twenty-nine different causative mutations, including 15 novel mutations, were analysed. Spontaneous bleeding symptoms in 42 symptomatic individuals (26 homozygous, seven compound heterozygous and nine heterozygous) comprised easy bruising (55%), haematoma (43%), epistaxis (36%), haemarthrosis (33%), intracranial haemorrhage (ICH; 21%), and gastrointestinal (GI) haemorrhage (12%). The manifestation of bleeding symptoms in 9 of 67 (13%) symptomatic heterozygous subjects is described. The bleeding patterns of the enrolled patients showed differences that are associated with the types of F10 mutation, and the corresponding genotypes. The homozygous patients were evaluated for genotype-phenotype correlation. The results suggested that ICH seems to be associated with the F10 mutation Gly380Arg, and possibly with the mutations IVS7-1G>A and Tyr163delAT. A tentative association of other mutations to severe symptoms such as haemarthrosis and GI haemorrhage is reported. The severity of FXD, the genotype-phenotype association, and the results of regional studies are discussed.

Changes in treatment strategies for severe haemophilia over the last 3 decades: effects on clotting factor consumption and arthropathy

A cohort study was performed among 214 patients with severe haemophilia, born 1944-1994, to describe changes in treatment over the last 3 decades and its effects on clotting factor consumption and haemophilic arthropathy. Data on treatment strategy, clotting factor consumption, and outcome were collected for 3567 patient years (from 1972 to 1998), and 493 Pettersson scores were analysed. Median follow up was 17 years (range 6-27 years), and median age in 1998 was 27.6 years. Since 1965, replacement therapy, prophylaxis, and home treatment have been used and treatment intensified. Over the last 3 decades, annual clotting factor consumption increased by 260%, for both prophylactic and on-demand treatment. Annual clotting factor consumption kg-1 increased during childhood and appeared to stabilize in early adulthood for patients born 1965-79, who were treated with early replacement therapy or early prophylaxis. In contrast, clotting factor consumption increased continuously for patients born before 1965, who had had no access to replacement therapy during the early years of their life. The annual number of joint bleeds decreased over the years. Arthropathy as measured by the Pettersson score generally became apparent around the age of 15 years and was lowest in patients treated with primary prophylaxis. In conclusion, clotting factor consumption has increased and haemophilic arthropathy has decreased due to the intensification of treatment for severe haemophilia over the last 3 decades. Annual clotting factor consumption stabilizes in adulthood for patients who receive early intensive treatment.

Continuous passive motion after total knee arthroplasty

Sixty-two patients undergoing primary total knee arthroplasty were studied prospectively. There were 42 patients in whom continuous passive motion (CPM) was used after surgery and 20 controls. The two groups were comparable with respect to age, diagnosis, sex, weight, and preoperative deformity and motion. The mean length of time required for CPM patients to achieve 90 degrees of flexion (9.1 days) was shorter than that for the control group (13.8 days). At the time of discharge from the hospital, however, there was no significant difference between the groups in amount of either flexion or extension. All patients had venograms performed after arthroplasty; the incidence of positive studies indicating thrombophlebitis was 45% in CPM patients and 75% in controls. These data demonstrate that CPM after knee arthroplasty enables patients to recover motion more quickly and affords some protection against deep vein thrombosis.

Lateral retinacular release of the patella

From October 1977 through January 1984, 2,330 arthroscopic procedures of the knee were performed by one of the authors (G.J.S.). Among these procedures, 35 lateral retinacular releases were performed through minimal, lateral incisions. Twenty-two knees in 22 patients were available for follow-up evaluation, and these cases were reviewed retrospectively. The average age of the patients at the time of surgery was 22.6 years. The average follow-up period was 48 months. The patients were divided into three subgroups on the basis of their preoperative diagnosis. Group I (eight knees) had a history of patellar dislocations; group II (seven knees) had recurrent patellar subluxation, identified by history and physical and radiographic examinations; and group III (seven knees) had patellar pain without a history of dislocations or subluxation and with no symptoms of instability. All of these patients underwent diagnostic arthroscopy and lateral retinacular release, as well as arthroscopic treatment of associated pathology. Postoperatively and at the time of followup, all patients were evaluated for pain, function and patellar instability. In 15 patients with a history of patellar dislocation or subluxation, 67% were found to have had significant improvement in their symptoms, which was borne out by the findings during physical examination. None was worse following treatment. Among the seven patients with no history of patellar dislocation or subluxation, only one of the seven had a satisfactory result. Based upon the findings of this study, it was concluded that arthroscopic lateral retinacular release is a reasonable, initial step in the surgical treatment of patellar dislocation or subluxation, resistant to conservative treatment. Its efficacy in cases of recalcitrant patellar pain without a history of instability is doubtful.

Short-term evaluation of synovectomy in haemophilia

Twenty-three operations of synovectomy (15 on the knee, 5 on the ankle, and 3 on the elbow) were carried out over a three-year period in 19 patients with severe haemophilia A and B who were followed for an average period of 15 months postoperatively. Short-term evaluation of the results was mainly based on the postoperative incidence of haemarthrosis and on the range of joint motion, which were compared with the preoperative findings. Synovectomy reduced, but did not abolish, the occurrence of haemarthrosis; however, after the operation bleeding episodes were usually less severe and incapacitating. Joint mobility was often reduced despite an intensive and prolonged programme of physiotherapy. Nevertheless, most of the patients were pleased with the results of the operation as they could lead a more active life because of the decreased risk of joint bleeding.In the light of these findings we conclude that synovectomy is not the elective treatment of choice for haemophilic arthropathy. It may be indicated in a few selected cases when conservative treatment has failed to control repeated haemarthrosis and synovitis. Controlled clinical trials and long-term evaluation are needed to establish its effect on the final outcome of haemophilic arthropathy.

Results of an orthopaedic survey in young patients with severe haemophilia in Spain

This paper outlines the results obtained in a cross-sectional study of a group of young patients with severe haemophilia A and B. The primary aim of the study was to ascertain the level of orthopaedic complications in the group, the effects that these complications have on quality of life, and the medical resources used on these patients. The secondary aim was to relate their current orthopaedic state to the type of treatment received before the study. The study was carried out in 11 hospitals in Spain, where 70 severe haemophilia patients (factor VIII [FVIII] < 2%), with an average age of 21.6 and a median age of 22, and no inhibitors, were monitored. The percentage of patients suffering from articular complaints was 84.3% and 85.7% according to the Gilbert and Petterson scales, respectively. Furthermore, pain was reported in 16.1% of joints, most frequently in ankles. Using the SF-36 Health Survey, patients were observed to have a poorer quality of life relative to healthy controls. Despite high levels of both the coagulant factor given to patients and the financial resources dedicated to their treatment, the type of treatment (on demand and/or as secondary prophylaxis) provided to the young adults was found to be incapable of preventing haemophilic arthropathy and subsequent negative quality of life consequences.

Haemophilia in Poland

The primary aim of this study was to analyse the data on 2269 haemophilic patients in the Polish National Register of Inherited Bleeding Disorders -- 1953 haemophilia A patients and 316 haemophilia B patients. Haemophilia A occurred in 1512 families, haemophilia B in 240 families. In the majority of haemophilia A and B cases severe haemophilia prevailed (59.7% and 56.6% respectively). In about 50% of haemophilic patients, no family history of bleeding diathesis was reported. For haemophilia A patients the mean age was 30.9 years and for haemophilia B patients, 29.2 years. Prevalence of haemophilia in Poland is approximately 1:12 300 inhabitants (1:5600 males). The second aim was to describe the orthopaedic status of severe haemophilia patients and to relate this status to the type of replacement therapy they received prior to the study. Ninety-two severe haemophilia patients (median age 26.0 years) were enrolled in the study. Right and left knee, elbow and ankle joints were evaluated clinically using the Gilbert scale. X-ray examinations were evaluated according to the Pettersson scale. Knee joints proved to be most affected. Eighty-four patients (91.3%) reported pain. Only one scored 0 on the Gilbert scale, another on the Pettersson scale. Thirty-seven per cent of patients used orthopaedic equipment, either occasionally or constantly. Twenty-five per cent had a history of orthopaedic surgery. Thirty-eight per cent were unemployed with some form of social subvention. On-demand treatment was applied. None of the patients received primary prophylaxis. The mean consumption of clotting factor concentrates was 68 054 IU per patient during the 12 months prior to the current study. These results indicate that in Poland all severe haemophilia patients above 20 years are affected by haemophilic arthropathy.

Survival analysis of patients with haemophilia at the International Haemophilia Training Centre, Bangkok, Thailand

Haemophiliac treatment in less developed countries is limited to locally prepared fresh frozen plasma, cryoprecipitate, cryo-removed plasma and lyophilized products as replacement therapy. Factor concentrate is seldom used because of the high price. The present study reports the survival analysis of 164 patients comprising 138 haemophilia A and 26 haemophilia B cases from 134 families registered at the International Haemophilia Training Centre-Bangkok, Faculty of Medicine, Ramathibodi Hospital, Mahidol University from 1971 to 2000. The duration of follow-up ranged from 1 to 27 years and 8 months with a median of 9 years and 1 month. They received treatment on demand of bleedings, and 85 patients received additional home treatment for early bleedings. The proportion of death was 15.2%. The Kaplan-Meier survival curves revealed the median (95% CI) survival time of patients with severe and moderate degrees of 35 years and 6 months (21.4-49.7), and 38 years and 1 month (28.8-47.3), respectively. To compare the progressive achievement of haemophilia care services, the treatment period was divided into three decades: 1971-1980, 1981-1990 and 1991-2000. The patients with unaided proper walking increased from 62.8% in the first decade to 84.5% in the third decade. However, one-third of the patients developed one to four chronic haemarthrosis determined by clinical evaluation, especially patients with severe degree. Moreover, the estimated probability of a survival time beyond 13 years of age among patients with severe degree increased from 0.85 in the first decade to 0.94 and 1 in the second and third decades, respectively. Thus, established haemophilia care, even with limited resources, has significantly decreased the risk of death and increased the survival time among patients with haemophilia.

Twelve-month prevalence of haemarthrosis and joint disease using the Haemophilia Joint Health score: evaluation of the UK National Haemophilia Database and Haemtrack patient reported data: an observational study

OBJECTIVES

To report the 12-month prevalence of joint bleeds from the National Haemophilia Database (NHD) and Haemtrack, a patient-reported online treatment diary and concurrent joint disease status using the haemophilia joint health score (HJHS) at individual joint level, in children and adults with severe haemophilia A and B (HA/HB) without a current inhibitor.

DESIGN

A 2018 retrospective database study of NHD from which 2238 cases were identified, 463 patients had fully itemised HJHS of whom 273 were compliant in recording treatment using Haemtrack.

SETTING

England, Wales and Scotland, UK.

PARTICIPANTS

Children (<18 years) and adults (≥18 years) with severe HA and HB (factor VIII/factor IX, <0.01 iu/mL) without a current inhibitor.

PRIMARY AND SECONDARY OUTCOMES

Prevalence of joint haemarthrosis and concurrent joint health measured using the HJHS.

RESULTS

The median (IQR) age of children was 10 (6-13) and adults 40 (29-50) years. Haemarthrosis prevalence in HA/HB children was 33% and 47%, respectively, and 60% and 42%, respectively, in adults. The most common site of haemarthrosis in children was the knee in HA and ankle in HB. In adults, the incidence of haemarthrosis at the ankles and elbows was equal. The median total HJHS in HA/HB children was 0 and in adults with HA/HB, were 18 and 11, respectively. In adults with HA/HB, the median ankle HJHS of 4.0 was higher than the median HJHS of 1.0 for both the knee and elbow.

CONCLUSION

Despite therapeutic advances, only two-thirds of children and one-third of adults were bleed-free, even in a UK cohort selected for high compliance with prophylaxis. The median HJHS of zero in children suggests joint health is relatively unaffected during childhood. In adults, bleed rates were highest in ankles and elbows, but the ankles led to substantially worse joint health scores.

The efficacy of functional foot orthoses in the control of pain in ankle joint disintegration in hemophilia

Sixteen subjects with hemophilia A of levels 1-5 stage of joint damage were tested over a 6-week period to evaluate the efficacy of functional foot orthoses. The level of ankle bleeds (hemarthrosis) before and after the intervention with functional foot orthoses was determined by evaluating pain, disability, and activity levels. All subjects reported a significant reduction of ankle bleeds coinciding with the intervention of functional foot orthoses. The use of a foot-pain disability measure clearly showed significant reduction in the level of pain experienced by the subjects and in their overall index score. However, the disability and activity index scores showed no significant improvement after the intervention with orthoses. This finding would support the use of functional foot orthoses to treat patients with hemophilia A, as significant reduction in pain levels appears to greatly improve the lives of the patients.

Outcome in moderate haemophilia

BACKGROUND

Moderate haemophilia is the rarest form of haemophilia. This study aims to assess short- and long-term outcome, including its association with treatment, in patients with moderate haemophilia.

MATERIAL AND METHODS

Seventy-five patients with moderate haemophilia (1-5% factor VIII/ factor IX activity), without a history of inhibitors, treated at the van Creveldkliniek, Utrecht (NL) were included in the study. Life-long data on bleeding and treatment were collected. Joints were evaluated using the Haemophilia Joint Health Score. Adults completed questionnaires on activity (HAL) and quality of life (SF-36, EQ5D).

RESULTS

The median age of the patients was 37 years (IQR 23-52 years) and haemophilia A was diagnosed in 89%. Bleeding frequency was low: the median annual bleeding rate was 2.0 bleeds/ year (IQR 0.8-3.7 bleeds/year), including a median of 0 joint bleeds/year (IQR 0.8-3.7 bleeds/year). Joint function was good: 82% scored<10 out of 126 points of the Haemophilia Joint Health Score (HJHS). Nevertheless, 29% of patients with moderate haemophilia had a history of prophylaxis, because of a high bleeding frequency. Median age at first joint bleed was 4.8 years (IQR 3.5-8.5). Use of prophylaxis was more associated with age at first joint bleed (P<0.01) than with baseline factor activity (P=0.12). Most patients (52%) who suffered their first joint bleed before the age of 5 years required prophylaxis later in life.

DISCUSSION

The majority of patients with moderate haemophilia have few bleeds and complications; however, a considerable subset of patients with a more severe bleeding pattern need prophylactic treatment. These latter patients may be identified by the onset of joint bleeding before the age of 5 years.

Long-term efficacy and safety of prophylaxis with recombinant factor VIII in Chinese pediatric patients with hemophilia A: a multi-center, retrospective, non-interventional, phase IV (ReCARE) study

BACKGROUND

The first recombinant factor VIII (rFVIII) product was launched in China in 2007. However, until now, no study has been conducted to describe the efficacy and safety of prophylaxis with rFVIII in Chinese pediatric patients with hemophilia A (HA).

OBJECTIVE

To summarize the efficacy and safety data on prophylaxis with rFVIII in Chinese pediatric patients with HA.

METHODS

ReCARE (Retrospective study in Chinese pediatric hemophilia A patients with rFVIII contained regular prophylaxis) was a retrospective study conducted in 12 hemophilia treatment centers (HTCs) across China. The primary endpoints included reduction in annualized bleeding rate (ABR); the secondary endpoints included evaluation of joint function (number and sites of target joints) using Gilbert score and Hemophilia Joint Health Score (HJHS), quality of life (QoL) and factors affecting treatment choices. Safety assessment of rFVIII was also conducted.

RESULTS

We analyzed a total of 183 male pediatric patients (mean age, 7.1 ± 4.23 years) who received prophylaxis between 1 November 2007 and 31 May 2013. Compared with baseline, prophylaxis with rFVIII significantly reduced overall annualized joint bleed rate (AJBR) (p < .001) and ABR (p < .001). Inhibitor formation was reported in 5 (2.7%) patients and hemarthrosis was reported in 1 patient. The mean number of target joints was positively related to age (p < .001) and weight (p = .003) at baseline. Responses from survey questionnaires reported that effective bleeding control, joint protection, improvement in quality of life, favorable medical insurance policies, and economic capability were reasons for choosing prophylaxis.

CONCLUSION

Prophylaxis with rFVIII reduced bleeding and number of target joints, even with a low-dose regimen, in Chinese pediatric patients with HA. Other than the efficacy and safety, factors such as poor disease control, improved economic stability and stable financial support made prophylaxis as an attractive treatment option. ClinicalTrials.gov ID: NCT02263066.

Traumatic haemarthrosis of the knee

BACKGROUND

Haemarthrosis of the knee after trauma is a common problem often seen in accident and emergency departments.

OBJECTIVE

: To evaluate the injuries sustained after haemarthrosis of the knee in a relatively young population, and to assess the need for performing cultures on aspirated blood.

PATIENTS AND METHODS

The notes of 510 patients who were seen at the accident and emergency department of the Alexandra Hospital, Redditch, between 1990 and 1999 were retrospectively studied. The age, sex, mechanism of injury, final diagnosis and management were recorded. The exact diagnosis was confirmed by a magnetic resonance imaging scan or arthroscopy findings. All the patients had their knee aspirate cultured, and the reports on the culture of aspirated blood were obtained from the department of pathology.

RESULTS

A fall was the major cause of haemarthrosis in 52%, followed by sports injury in 38%. The medical records of all 510 patients were reviewed. All patients' follow-up records were seen, most patients were followed up in the orthopaedic outpatient clinic and some in the accident and emergency follow-up clinic, all attended at least three or more clinics before discharge.

CONCLUSION

Culture of the aspirate of all patients was felt to be a waste of time and money. Nearly 40% of cases were thought to be idiopathic and settled conservatively without intervention.

[Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee]

OBJECTIVE

To evaluate the potential bleeding risks of arthrocentesis in patients with different arthropathies and taking oral anticoagulants.

MATERIALS AND METHODS

Fifteen consecutive patients, 8 males and 7 females, treated with anticoagulant therapy for atrial fibrillation (9 pts), deep venous thrombosis (4 pts) and replacement of cardiac valves (3 pts) were submitted to arthrocentesis for synovial fluid effusion due to different arthropathies. In all patients INR was </= 5. Nine of them were assuming AINS for the joint pain.

RESULTS

Two of fifteen patients have hemarthrosis, the first only lightly, the second more frankly. Both the patients were in therapy with AINS and INR was 3.8 and 5, respectively.

CONCLUSIONS

The hemarthrosis or bleeding frequency associated with intraarticular injections in patients taking anticoagulant therapy seems not very high. Therefore the therapy with oral anticoagulants would not be an absolute contraindication to the arthrocentesis execution.

[The diagnostic accuracy of MRT in cruciate ligament injuries]

Lesions of the anterior cruciate ligaments may be demonstrated by MRI with an accuracy of 99%. Standardised technique with sagittal and coronal projections produces excellent results. Localisation of the site of rupture can be achieved in 95% of cases. MRI provides a valuable method for diagnosing lesions of the cruciate ligaments.

Surgical synovectomy in haemophilic arthropathy of the knee

Twenty seven patients with haemophilia who had repeated haemarthroses affecting the knee joint, despite appropriate substitution therapy, were treated by surgical synovectomy. Open operations were carried out on 18 and 9 had an arthroscopic procedure. The average age at the time of synovectomy was 13 years for both the open and arthroscopic groups. The open group was followed up for an average of 15.2 years and the closed for 5.4 years. Operation took 70 minutes on average in the arthroscopic group and 50 minutes in the open. Patients who had an arthroscopy were in hospital for an average of 5 days and those with an open operation for 10. Synovectomy by both methods significantly reduced bleeding episodes. The results were assessed according to the classification recommended by the Orthopaedic Advisory Committee of the World Federation of Haemophilia. In the open group 2 patients had a good result, 10 were fair and 6 poor; in the arthroscopic group 3 had a good result, 5 were fair and 1 poor. Both operations appeared to slow, but did not halt, the radiographic deterioration of the joints.

[Breakthrough bleeding in adult patients with severe hemophilia A receiving low- and intermediate-dose FVIII for tertiary prophylaxis: characteristics and influencing factors]

OBJECTIVE

To investigate the characteristics of breakthrough bleeding in adult patients with severe hemophilia A (SHA) receiving low- and intermediate-dose FVIII for tertiary prophylaxis and explore the factors affecting the outcomes of the treatment.

METHODS

Forty-nine patients (mean age 31.53∓7.33 years) with SHA receiving tertiary prophylaxis FVIII treatment were divided into low-dose group (n=15) and intermediate-dose group (n=34). The data including clinical bleeding phenotype (Pre?AJBR), 72 h FVIII trough activity, and Functional Independence Score in Hemophilia (FISH) were recorded in all the patients, and Hemophilia Steward APP was used to record the bleeding episode and the treatment data. All the patients were followed up for at least 6 months.

RESULTS

In the low-dose and intermediate-dose groups, the number of joint bleeding (AJBR) episodes were 18.79∓13.03 and 9.28∓7.02 per year (P=0.016), and the proportions of spontaneous bleeding were 75.0% and 47.7%, respectively. The proportions of patients with target joint were 80% and 44%, target joint bleeding occurred in 59% and 41%, and cataract bleeding after 0-12 h of prophylactic injection occurred in 4.86% and 5.18% of the patients with a median breakthrough bleeding time of 40.08 h and 46.08 h (P=0.008), respectively. The proportions of patients with 72 h FVIII trough activity <1% were 44.4% and 34.8% in the two groups, respectively. AJBR was negatively correlated with the preventive dose consumed (r=-0.57, P=0.000, n=49) and FISH, but positively correlated with Pre-AJBR in the two groups (P<0.05).

CONCLUSION

Tertiary prophylaxis with low- and intermediate-dose FVIII is not sufficient to achieve the goal of preventing progression of joint disease in Chinese adult patients with SHA. Although the prophylactic dose is the most important factor to affect the treatment efficacy, other non-factor approaches may also help to improve the efficacy of the treatment.

[Hemophilic arthropathy: echography and radiology]

Our experience is reported with the combined use of radiology and US in the study of 210 joints of hemophilic patients. The study was carried out considering that in hemophilia the classification of the grades of disease generally relies upon X-ray findings which, although reliable in the advanced stages of the disease, appear inadequate in the early stages. In fact, synovial hypertrophy, cartilage erosions and initial subchondral cysts are most often missed on X-ray films. In the examined cases, US was employed to evaluate: 1) the degree of synovial hypertrophy, 2) the status of the explorable cartilage, 3) the presence of effusions and 4) the status of bone linings--whenever erosions, even of minimal extent, were suspected, X-rays were always performed and the results employed as the reference standard. The examined joints did not exhibit the same grade of involvement: the knee, elbow and ankle had advanced arthropathy in 85% of cases, corresponding to > or = 7 according to Pettersson score. On the contrary, the shoulder and hip were found to be equally involved either by initial (Pettersson score: 0-6) or by advanced arthropathy (Pettersson score: > or = 7). Moreover, in nearly 10% of the cases, hemarthrosis was found which showed no correlation with the grade of joint involvement. Our results indicate that: 1) US appears very useful in the early stages of the disease when the X-ray picture is negative or poorly significant. The demonstration of early alterations is useful mainly in those cases in whom synoviectomy is considered (for prevention); the latter is useful only if performed before cartilage erosion appear; 2) US appears equally useful in hemarthrosis cases, especially in those of limited extent in which the clinical therapeutic management may be difficult; 3) US appears unnecessary in the cases of advanced arthropathy in which X-rays serve as the reference standard.

Avoidable complications of arthroscopic surgery

The incidence of complications from arthroscopic surgery is low. Between 1978 and 1991, 8500 arthroscopies were performed by the two senior authors (J.N. and D.R.A.D.). Several significant complications were recorded, and these are presented to show how they occurred, and how our practice of arthroscopy was subsequently modified. There were four cases of clinically detectable deep vein thrombosis of which three were associated with pulmonary embolus, three cases of haemarthrosis, two deep infections, three compartment syndromes with one case of impending compartment syndrome, six cases of instrument failure and one case of persistent synovial fistula.

[The effects of the weather on hemophilic hemarthrosis (author's transl)]

Hemophilic hemarthroses occur more frequently in spring and autumn. In the present study, possible weather situations are investigated which are characterized by a particular action on the increasing of hemorrhagic tendency. In 574 hemarthroses in 45 patients, the regional weather events were set in relation to the hemarthroses by means of a computer program. The following weather constellations significantly increase the tendency to bleed: Regional west weather conditions combined with longer lasting ascending procedures. The weather dynamics are dominated by the warm face of weak frontal zones with formation of a warm front. The biotropic weather elements demonstrated are also shown to be biotropic in other disease processes.

Efficacy and safety of a monoclonal purified factor VIII concentrate: 5-year follow-up in previously treated HIV-negative haemophiliacs

The efficacy and safety of a monoclonal purified factor VIII concentrate (Hemofil M) were assessed in a historically controlled study in 22 HIV-negative patients with haemophilia A, previously treated with various concentrates. Data from 5 years of follow-up were compared with those from the preceding 6 months. Factor VIII consumption remained unchanged. A temporary increase in the number of reported bleedings was attributed to more frequent follow-up visits in the first year. Allergic reactions, inhibitor formation and HIV infection were not seen. Liver function parameters fluctuated in individual patients, and were not related to the ultrapure concentrate used. No clinical evidence of liver insufficiency was seen. The number of CD4-positive lymphocytes was stable, while platelet numbers showed a remarkable increase. We conclude that in previously treated HIV-negative haemophiliacs, treatment with a monoclonal purified factor VIII concentrate is efficacious and safe with regard to HIV transmission, allergic reactions, induction of inhibitors, and deterioration of immune abnormalities.