Patients with severe haemophilia have a tendency towards recurrent haemarthroses resulting in chronic synovitis and leading to end stage haemophilic arthropathy. From 1997 to 2001 five patients underwent sequential bilateral total knee replacement. We compared these patients with 13 haemophilic patients undergoing primary unilateral total knee replacement. One senior surgeon performed all surgery using an identical prosthesis under similar surgical and haematological conditions. We reviewed information regarding pre-operative medical condition, antibiotic prophylaxis, blood replacement requirement and tourniquet time were all recorded. The rate of post-operative complications and economic evaluation between the two cohorts was calculated. Functional results were assessed using the Hospital for Special Surgery knee scoring system both pre and postoperatively. We have shown that complication rates following bilateral and unilateral total knee replacements are comparable and that there are no differences in the functional outcomes or complication rates between the two groups. Furthermore, we found that bilateral procedures were advantageous with respect to total rehabilitation times, length of in-patient stay clotting factor usage and cost efficiency

Background Recurrent haemarthroses in patients with haemophilia commonly affect the ankles. It can result in haemophilic arthropathy and necessitate arthrodesis. The purpose of this report was to present the results of arthroscopic arthrodesis performed for this condition and to highlight some of the potential difficulties encountered as part of the surgical management. The operative technique is also described. Method Between January 2001 and May 2004, eight male patients underwent nine arthroscopic arthrodeses. The mean age was 34 years (range 19–44). The patients were identified retrospectively from a surgical database and the radiographs and outpatient notes reviewed. Patients were also contacted to determine their level of satisfaction with the procedure. Results The mean length of follow-up was 9 months (range 3–18). All patients had united both clinically and radiographically by the time of maximal follow-up and all were satisfied with the result. One patient had minor post-operative bleeding which settled spontaneously. No other significant complications were encountered. Bony cysts were observed in three patients pre-operatively and these all resolved following the attainment of union. Conclusion Arthroscopic arthrodesis of the ankle is a safe and reliable treatment for haemophilic ankle arthropathy. The union rate is high, the complication rate is low, the risk of disease transmission from patient to staff is lessened and the post-operative rehabilitation regime, including allowing immediate weight bearing is less arduous than with traditional open procedures. Factor requirements are lessened and the length of stay is also reduced compared with open arthrodesis. Collaboration with a haematology unit is essential for a good result to be achieved

Purpose of study:. Total elbow replacement (TER) is one of the surgical options for treatment of severe haemophilic arthropathy of the elbow. There are only a few small series described in the literature. The goal of our study was to evaluate our cases and add these data to the known literature. Methods:. A retrospective analysis of a series of 8 TER's (5 patients) was performed. Patients were seen in clinic and evaluated by physical examination, a VAS score for pain, the Mayo Elbow Performance Score (MEPS, 100 points=excellent) and X-rays of the affected elbow. Mean follow-up was 91 (4–236) months, and 103 months when we excluded a patient with only 4 months follow-up. Primary diagnosis was Hemophilia type A in 4 and von Willebrand disease in 1 patient. 2 patients were positive for Hepatitis C and 3 for HIV. Mean age at primary surgery was 46.7 (31.8–63.1) years. Results:. The mean VAS score for pain improved from 7.9 to 0.5 and the mean Mayo Elbow Performance Score from 36 to 93. The arc for flexion/extension improved from 68° to 91° and from to 75° to 153° for pro- and supination. Revision surgery was performed in 3 out of 8 TER's; 1 because of loosening of the humeral component (18.7 years postop), 1 for loosening of the ulnar component (9.9 years postoperatively) and 1 due to a late deep infection, 4 years postoperatively. The last case was treated with an excision arthroplasty, the others with a revision. No replacement currently shows signs of loosening. Conclusion:. This is a small retrospective study, as are the other studies on TER in haemophilic patients. It demonstrated excellent clinical outcome and an acceptable survival rate of a TER, with a mean follow-up of 7.6 years even in this young patient population

Purpose

This study was performed to evaluate clinical and radiographic outcomes of Hip Resurfacing Arthroplasty for treatment of haemophilic hip arthropathy.

Purpose: Total knee arthroplasty (TKA) is safe and effective in patients with advanced hemophilic arthropathy. This procedure is extremely successful in pain relief and improving functional status, however the limited restoration in motion due to preexisting soft tissue contractures, remains a concern. The purpose of this study is to report the results of TKA in patients with hemophilia using posterior cruciate ligament (PCL) sacrificing prostheses.

Materials and Methods: The records of 18 consequtive hemophilic arthropathy patients who underwent total knee arthroplasty at our institution between 1998 and 2003 were retrospectively reviewed. The patients were evaluated by International Knee Society (IKS) Scoring system with specific attention to range of motion parameters and functional status at preoperative and postoperative clinical evaluation. Postoperative radiologic evaluation was based on the knee Society roent-genographic evaluation and scoring system.

Results: The average age at operation was 34 years (range, 18–60) with an average follow-up of 51 months (range, 12–74). TKA resulted in an improvement in functional and knee scores, and range of motion parameters (p< 0,01). However, the functional status of the patients improved better than the knee status (p < 0,01). No signs of radiographic loosening were seen in any of the components at the final follow-up evaluation. There were two early hemarthrosis which required open lavage. Four patients had late complications. One patient had a periprosthetic fracture, which was treated with open reduction and internal fixation. Another patient had tibial tubercle avulsion and conservative treatment was choosen. One patient had revision secondary to progression of flexion contracture due to repetitive intraarticular hemorrhage, at the third year (26th month). One patient had deep infection.

Conclusions: Our results demonstrate the excellent results in terms of functional scores and to a lesser extent in knee scores. Evaluation of the subcategories of the knee score demonstrated the limited restoration of motion as the reason for lower success rate in knee scores. Although PCL sacrificing designs allow better motion restoration, futher techniques should be developed to release the extraarticular structures that contribute to the flexion contracture, such as hamstring release.

Purpose: Recurrent hemarthrosis is a common clinical entity in hemophiliacs. They not only interfere with daily life but also trigger hemophilic arthropathy. Synovial hypertrophy has a pivot role in hemarthrosis related joint damage and ablation of the synovium prevents further deterioration. Current treatment strategy is to ablate synovium in the early stages in order to prevent progression of the arthropathy. We report a series of hemophilia patients with advanced arthropathy who had been treated with radionuclide synoviorthesis.

Materials and Methods: The patients who had been treated with radionuclide synoviorthesis for either knee or elbow disease between 2002 and 2004 were included in this study. The inclusion criteria were having > 1 hemarthrosis episode per month in the index joint, chronic synovial hypertrophy, advanced degenerative changes of grade III and IV as defined by Arnold-Hilgartner Classification, F8 inhibitor level < 3. The frequency of hemarthrosis, range of motion of the affected joint, pain level that was evaluated by visual analog scale, was recorded during each follow-up. 90Y was used for the synoviorthesis of the knee, whereas 186Re was used for the elbow cases. Patients were screened for radionuclide leak by using a gamma camera following the injection.

Results: Twenty radionuclide synoviorthesis were performed in 14 knees. The average age was 20 (range, 10–31) with an average follow-up of 17 months (range, 3–29). There were 12 severe hemophilia A and 2 severe hemophilia B patients. The frequency of intaarticular bleeding episodes was significantly reduced at the final follow-up (p< 0,05). Although the range of motion and the pain scores were improved, the change was not statistically significant (p> 0,05). Six patients required repeated treatment because of inadequate response. No radioactive material leakage were detected at the draining lymph nodes.

Conclusions: Our results demonstrate that radionuclide synoviorthesis significantly reduces the number of the bleeding episodes even in the knees presenting with advanced arthritis, and increases the quality of life. Although most patients respond to single injection, some patients may require more than one injection, to achieve a satisfactory clinical outcome.

Introduction

Although total knee arthroplasty (TKA) in end-stage hemophilic arthropathy can reduce the severe joint pain and improve the functional disability, it is technically demanding. In addition, it has generally reported a high rate of complication including periprosthetic joint infection (PJI) and component loosening up to 20%. Although the Knee Society classification system of TKA complication was introduced, the complications of TKA in hemophilic arthropathy has not stratified using this classification system in previous articles to the best of our knowledge.

The purpose of this study was to evaluate the mid-term outcomes and complications of TKA in hemophilic arthropathy.

This is a non controlled experimental prospective4 clinical study that obtained satisfactory results in the chemical Synovectomy with Oxitetracycline Clorhydrate (Emicine), in dfferent joints, demonstrating that it is an Effective method in the treatment of recurrent haemarthrosis in haemophilia.

Materials: 84 patients of whom 77 concluded the complete treatment. 82 joints were injected. The dosage injected was 5 cc of the drug (25 mgms.) in 5 cc of anaesthesia for the knee. 2 cc with 1 cc anaesthesia for the elbow. 1 cc plus 1 cc anaesthesia for the ankle. These injections were performed once weekly with a reinforcement in one month. In case of failure the same can be done repeatedly.

Evaluation and results: Subjective parameters. Pain, range of movement and use of the joint involved. Pain decreased from a mean of 6.5 to 0.9 (Likert scale). Range of movement increased from 5.9 to 9 and joint use increased from 5.9 to 9.2. Objective parameters. Joint diameter and range of movement. Range of movement for flexion and extensiòn improved from 72.2 and 149.2 to 73.7 and 167 respectively for the knees. From 57.3 and 160 to 66.6 and 170 respectively for the shoulder. And from 22.7 and 10.8 to 34 and 18.6 respectively for the ankle.

Conclusion: This procedure has multiple advantages such as immediate therapeutic effect, short period of treatment, easy technique, much les AHF coverage (•0% above coagulation level, less cost than radiocolloid treatment which makes it an perfect alternative of treatment for developing countries and not so underdeveloped.

Besides the experimental demonstration of its action in rabbits is exposed.

The surgical treatment of a secondary gonarthrosis caused by haemophilic arthropathy needs high quality in soft tissue balancing and accurate alignment in total knee arthroplasty (TKA), which are essential for good long-term results. Due to the early-onset severe arthropathy, haemophiliacs undergo prosthetic surgery at a younger age than general population; therefore to ensure a longer duration of implantation is a major objective to be reached in this setting. As several prospective randomised studies could show, Computer navigation in prosthetic surgery improve precision concerning geometry of axes, resection planes and implant alignment, by the determination of joint centres (actual axis), amount of bone resection, size of prostheses and check of ligament balance. At our department, since January 2006, we implanted four TKA in four patients (age range 45–52 years) affected by severe Haemophilia B; the same surgeon used a single system (Orthopilot system) in all cases. The quality of implantation was studied on postoperative standardized long leg coronal and lateral x-rays. Our results showed that CAS had greater consistency and accuracy in implant placement. Complications influencing the clinical outcome did not occur. In our experience, drawbacks of the navigation systems are the additional costs and the additional operation time between 15 and 25 min. However, one of the most important advantages of using of this technique in patient affected by coagulation disease, according to the international literature, is the reduction of blood loss after operation. A long-term follow-up of these and of larger samples of patients is needed for testing cost/risk-benefit ratio of Orthopilot in prosthetic surgery of haemophiliacs. Therefore navigated total knee arthroplasty in haemophilic arthropathy is not yet a standard procedure, but this technique could become an important surgical choice in management of severe secondary osteoarthritis in the future

Purpose. To evaluate the radiological changes after metal on metal resurfacing arthroplasty. Materials and Methods. Between December 1998 and August 2004, 166 hips in 150 patients who underwent metal resurfacing arthroplasty and followed up more than 4 years. Their mean age at the time of operation was 37.3 years(range, 15–68 years) and mean period of follow-up was 6.1 years(range, 48–95 months). The cause of arthroplasty included 115 avascular necrosis, 43 osteoarthritis, 7 ankylosing spondylitis, 1 haemophilic arthropathy. All patients had anteroposterior, translateral radiographs of the hip made preoperatively and each follow-up visit, and we analyzed radiographic findings such as radiolucencies or impingement signs around implant, neck narrowing and heterotopic ossification. Results. There was a no significant difference between preoperative and postoperative Harris hip score and range of motion. The mean stem-shaft angle was 137.4°, and 55.4% were ranged 130° to 140°. The mean inclination of acetabular component was 44.9°. There were no radiolucent lines or osteolytic lesion around the acetabular components, but 3 hips showed radiolucency around the head-neck junction(1.8%) and 4 hips showed radiolucent line around the stem (2.4%). 12 hips had impingement signs around the head-neck junction (7.2%), and 2 cases showed neck narrowing (1.2%). 3 cases had some heterotopic ossification (1.8%). In 12 cases with impingement signs, the stem-shaft angle and inclination of acetabular component were lower than control group. Pseudotumor was not found in this cohort. Conclusions. This study demonstrates no serious radiological problems till the midterm follow-up after resurfacing arthroplasty, but osteolytic lesion such as radiolucent line around head-neck junction, neck narrowing can be a potential cause of failure in future. Even though the radiolucent line around stem of femoral component revealed no subjective symptom yet, it suggests the micromotion of femoral component which can lead to femoral component loosening. The most common radiological findings, impingement signs, seem not to have clinical significance

The history of synoviorthesis in haemophiliacs and recent studies has shown that it is a safe procedure and that the results are similar to those seen following open or arthroscopic synovectomy. Colloidal Yt 90 silicate is a beta emitter with a half life of 2.7 days and a mean depth of penetrating soft tissue of 4mm. We evaluate the outcome of Yt 90 injection in patients with chronic haemophilic synovitis of the knee. A retrospective study was done from 1998–2006 of 35 patients with 44 joint injections. Indications were repeated bleeds (4 episodes); chronic synovitis. The age range was 4–27 years. A dose of 2–5 mCu was injected intra-articularly using a sterile technique and local anaesthetic, after an intravenous factor V111 infusion (5 patients had antibodies) and initial joint lavage. The knees were immobilized in above knee backslabs for 2/7. Patient follow up of up to 8 years was conducted. Patients were assessed for pain relief, range of movement, repeated bleeds, cost saving, quality of life and progression to haemophilic arthropathy. Pain relief of 2 or more points on VAS was reported by 30 patients (85.7%). 18 Patients reported a decrease in bleeding frequency (51.4%). 11 Patients had no further bleeds (31.4%). We conclude that there was a significant cost saving as a result of the decreased need for the use of cryo-precipitate. Two patients experienced localised areas of necrosis from radio colloid extravasation. These wounds healed after 3 weeks of local dressings. 60% of joints had and increased range of movement. 92% reported improved quality of life. We have found yttrium synoviorthesis to be an inexpensive, relatively simple and painless technique for treating chronic haemophilic synovitis. The majority of patients were satisfied, experiencing pain relief, increased range of motion and significant monetary saving from reduced cryoprecipitate use

Background. The quest for the perfectly designed elbow prosthesis continues as instability and loosening remain the foremost reasons for the failure of total elbow replacement (TER). The Discovery® Elbow System (Biomet, UK) (Figure 1), which has been used in UK since 2003, is one of the latest generations of linked prosthesis. This system was designed to decrease polyethylene-bushing wear, improve anatomic stem design, restore elbow joint biomechanics, and produce a hinge that could be easily revised. This report describes the short term outcome of TER using the Discovery® Elbow System. Patients and Methods. A total of 60 TERs including 48 primary and 12 revisions were performed between 2003 and 2008. Patients included 21 males (37%) and 36 females (63%) with a mean age of 63 years. The indications for primary TER were advanced rheumatoid arthritis (n=19), osteoarthritis (n=16), post traumatic osteoarthritis (n=9), acute fractures (n=3), and haemophilic arthropathy (n=1). The outcome was assessed using pain score, Liverpool Elbow Score (LES), and range of movement during a mean follow-up of 26 months. Associated complications were documented. Radiological assessment included evaluation for loosening, instability and periprosthetic fractures. Results. The mean LES was significantly (p<0.001) improved from 3.8 (±1) pre-operatively to 6.9 (±2) at the final follow- up. Significant improvements were noted in elbow flexion from 100° (±22) to 120° (±15), supination from 41° (±28) to 65° (±20) and pronation from 52° (±22) to 72° (±18). There was no significant change in elbow extension. Mean improvement in flexion-extension and pronation-supination arc was 22° and 44°, respectively. 46 cases (77%) were completely pain-free at the final follow-up. The main complications included deep infection (4 cases – treated with staged revision TER), postoperative ulnar neuropathy (3 cases–treated with decompression), intra-operative fractures of medial condyle (3 cases – treated non-operatively with brace), and elbow haemarthrosis (1 case). Discussion. TER with Discovery® Elbow System resulted in either no pain or mild pain in 87% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 22° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSB III (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 44° in pronation-supination arc in our series is also comparable to that of 31–67° reported for GSB III and higher than the Coonrad-Morrey prosthesis (21–28°). In terms of complications, an infection rate of 6.7% is consistent with those reported for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy was lower compared to GSB III TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%). While the survival of Discovery TER was 93%, the survival of GSB III (5–6 years) and Coonrad-Morrey (5 years) has been reported as 71–85% and 72–90%. The results indicate that Discovery® Elbow System is an effective device for total elbow arthroplasty in terms of functional improvement, pain relief and range of motion at short-term follow-up

Introduction and Objectives: The goal of this study is to present results from a series of arthroplasties performed in our hospital in the past 3 years in terms of pain and mobility. Materials and Methods: In this study, a total of 14 arthroplasties were performed on 12 patients (including 2 revisions). Follow-up was lost on 3 patients. Of the 9 remaining patients, 5 were females and 4 were male. Average age was 59 years (42–75) at time of surgery. Two prosthetic models were used: Coonrad-Morrey in 5 cases (including one revision) and GSB-III in 6 cases (including one revision). The following conditions were treated: 5 cases of post-traumatic arthrosis of the elbow, one haemophilic arthropathy of the elbow with the elbow as the target joint, one case of rheumatoid arthritis, one supracondylar fracture with nonunion in an elderly patient, and one humeral fracture with post-traumatic arthrosis of the elbow. Results: At the functional level, a postoperative articular balance of 118° flexion and −20° extension and free pronosupination was obtained, with the exception of 2 cases. There was complete elimination or a significant decrease in pain except in 2 cases where a certain level of pain persisted. Radiographically, poor positioning was not seen, but there was one case of septic loosening (resulting in resective arthroplasty) and one peri-prosthetic fracture requiring revision, since it led to instability and repeated dislocation. Other complications included neurologic problems (2), extension deficit > 30° (2), and residual pain (2). Discussion and Conclusions: Although this study is still in the early stages and follow-up time is short (the study was initiated in 2000), we are seeing promising results in terms of mobility and cessation of pain, similar to various other studies. In terms of the percentage of revisions, complications, and patient satisfaction, results are also comparable to other studies, even though our study thus far has the disadvantage of being shorter. Nonetheless, we wish to present this study to demonstrate that even though elbow arthroplasties are in their infancy, results are promising, and there is hope that they will improve further in future with improved selection criteria, as happened in the past with knee and hip arthroplasties