Haemophilia is a lifelong inherited bleeding disorder characterized by spontaneous bleeding resulting in painful joint deformities. Even if prosthetic surgery and the effectiveness and safety of clotting factor concentrate have improved the therapeutic options available, sometimes the orthopaedic surgeon has to treat substance losses. First, we have to distinguish: 1) sub-chondral cysts, 2) intra-osseous cysts, 3) pseudo-tumour (a chronic expanding blood cyst with the ability to displace and destroy adjacent tissues) Surgical treatment is in relation to its anatomical location and extension and is always associated with prolonged treatment with clotting factor concentrate. In our 20 years’ experience, we have used several therapeutic options. In some cases, we use filling with bone graft and fibrin seal and today platelet derived growth factor; in the others we have used amputation or custom made prosthesis.

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment.

The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential.