DNA extracellular traps as potential biomarker of chronic haemophilic synovitis and therapeutic perspective in patients treated with PRP: A pilot study.

INTRODUCTION: Hemarthrosis causes chronic haemophilic synovitis (CHS). Although neutrophils are major immune cells infiltrating joints after bleeding, their role on the pathogenesis of CHS is unknown. Neutrophils release extracellular DNA traps (ETs), structures of DNA with bound granular enzymes that were associated with tissue damage. AIMS: To evaluate the presence of ETs as pathogenic biomarker and the protective effect of intraarticular injection of platelet-rich plasma (PRP) in patients with CHS. METHODS: Haemophilia Joint Health Score (HJHS) and bleeding episodes (BE) were measured and correlated with ETs indicators (DNA/DNA-Elastase) in synovial fluids (SF), PRP and plasma of 21 patients. RESULTS: Soluble DNA and DNA-Elastase were detected in SF and plasma of patients. The synovial and plasma levels of DNA-Elastase positively correlated with worse HJHS/BE. Interestingly, remaining ETs-inducer factors were present in SF that induced the in vitro release of ETs from blood-isolated neutrophils. This phenomenon was impaired by adding plasma or PRP. Finally, preliminary data obtained from five patients indicate that levels of DNA-Elastase and HJHS/BE decreased after receiving intraarticular injection of PRP. CONCLUSIONS: The synovial and plasma levels of DNA-Elastase correlated with worse HJHS/BE suggesting that ETs formation could be a biomarker and potential therapeutic target for CHS. The intraarticular injection of PRP underlined a new potential alternative therapy, decreasing ETs formation in synovia of patients with CHS. However, our hypotheses must be confirmed in the future with better designed and more statistical power studies. Meanwhile, the use of intraarticular injections of PRP for the treatment of CHS remains controversial.

Bloqueo de nervios periféricos guiados por ecografía en pacientes con hemofilia / Ultrasound-guided peripheral nerve blocks in hemophilia with patients

INTRODUCTION: Hemophilia is a coagulation disorder; it is a recessive disease linked to the X chromosome. In patients with hemophilia (PWH), regional anesthetic blocks have been considered a contraindication. Safety has been increased by performing them guided by Ultrasound. The objective of our work is to show our experience in PWH and peripheral nerve blocks. MATERIAL AND METHOD: 41 PWH were operated under regional analgesia with Ultrasound-Guided Peripheral Nerve Blocks associated with general anesthesia in the period 2006-2019. All patients were Hemophilia A. Three patients had inhibitors. The mean age was 35 years. 40 lower limb blocks and 2 upper limb blocks were performed. The Sonosite® equipment model Micromaxx was used. RESULTS: All patients presented adequate peripheral nerve block for an average time of 12.5 hours (8-24). There were no complications. CONCLUSIÓN: The present study shows that Ultrasound-Guided Peripheral Nerve Blocks in PCH is a safe procedure, which reduces the requirements of opioids and the side effects of them, improving the postoperative period and the recovery of patients.

INTRODUCCIÓN: La hemofilia es un trastorno de la coagulación, es una enfermedad recesiva ligada al cromosoma X. En pacientes con hemofilia (PCH) los bloqueos regionales anestésicos se han considerado una contraindicación. Se ha aumentado la seguridad realizándolos guiados por Ecografía. El objetivo de nuestro trabajo es mostrar nuestra experiencia en PCH y bloqueos de nervios periféricos. MATERRIAL Y MÉTODO: 41 PCH fueron operados bajo analgesia regional con Bloqueos de Nervios Periféricos Guiados por Ecografía asociado a la anestesia general en el período 2006-2019. Todos los pacientes eran hemofilia A. Tres pacientes presentaban inhibidores. La edad media fue de 35 años. Se realizaron 40 bloqueos de miembros inferiores y 2 bloqueos miembros superiores. Se utilizó el equipo Sonosite® modelo Micromaxx. RESULTADOS: Todos los pacientes presentaron adecuado bloqueo de nervio periférico durante un tiempo promedio de 12,5 h (8-24). No se presentaron complicaciones. CONCLUSIÓN: El presente estudio muestra que los Bloqueos de Nervios Periféricos Guiados por Ecografía en PCH es un procedimiento seguro, que reduce los requisitos de los opioides y los efectos secundarios de ellos, mejorando el posoperatorio y la recuperación de los pacientes.

Minimally invasive surgery for haemophilic pseudotumour of the limbs: 28 years of experience.

INTRODUCTION: Haemophilic pseudotumour (HP) is an encapsulated haematoma in patients with haemophilia (PWH) which has a tendency to progress and produce clinical symptoms related to its anatomical location. AIM: To show the experience of one surgeon who has been using mini-invasive technique to treat pseudotumours of limbs in PWH with and without inhibitors at one centre for 28 years. MATERIALS AND METHODS: Thirty-three patients with 39 HP were treated. All patients had haemophilia A. Twenty-four patients had no inhibitors (72.8%), and 9 had inhibitors (27.2%). The mean follow-up was 16 years (1-25). All patients had x-rays and MRIs. All of them received Buenos Aires protocol as conservative treatment for 6 weeks. MRIs were repeated after 6 weeks' treatment to assess response to treatment. Surgery was performed in patients who did not respond to conservative treatment. RESULTS: After Buenos Aires protocol, four pseudotumours did not shrink (10.24%), 33 (84.61%) shrank, and two (5.12%) healed. Thirty-seven pseudotumours had surgery, 35 pseudotumours (94.59%) healed with minimally invasive treatment, and two did not heal (5.41%). No infection was observed with this treatment. The mortality rate for the series was 0%. CONCLUSION: The minimally invasive treatment of pseudotumours was effective in 95% of the cases and resulted in no mortality in this series after 28 years.

Inhibition of Fenton reaction is a novel mechanism to explain the therapeutic effect of intra-articular injection of PRP in patients with chronic haemophilic synovitis.

INTRODUCTION AND AIM: Haemarthroses cause major morbidity in haemophilia resulting in chronic haemophilic synovitis (CHS) and arthropathy. Oxidation of haemoglobin-coupled iron released in synovium after haemolysis induces chondrocytes death and cartilage damage, allowing postulate using iron-chelating drugs as potential therapeutic tool for haemophilic joint damage. Considering that albumin, the most abundant plasma protein, is a physiologic iron chelator, we aim to demonstrate that impediment of haemoglobin oxidation is exerted by plasma as a mechanism involved in the therapeutic effect of intra-articular injection of platelet-rich plasma in CHS. METHODS: Oxidation of haemoglobin (Hb) to methaemoglobin (MeHb) through Fenton reaction was induced in vitro by addition of potassium ferricyanide in the presence or absence of peripheral blood-derived platelets-rich or platelets-poor plasma (PRP/PPP) or albumin. The relevance of in vitro findings was analysed in synovial fluid (SF) samples from one patient with CHS obtained before and after 6 months of PRP intra-articular injection. RESULTS: MeHb formation was completely impaired either by of PPP, PRP or albumin indicating that PRP exerts an anti-oxidative effect, probably due by plasma albumin. Analysis of SF samples revealed the presence of MeHb levels and haemosiderin-laden macrophages in SF obtained before PRP treatment. Reduction of synovial MeHb, normalization of cellular composition and improvement of health joint haemophilic score, pain and bleeding episodes were registered after 6 months of PRP intra-articular injection. CONCLUSION: Inhibition of Fenton reaction and the consequent normalization of joint cellular composition is a noncanonical mechanism underlying the therapeutic effect of PRP intra-articular injection in CHS.

Gene expression and proliferation analysis in young, aged, and osteoarthritic sheep chondrocytes effect of growth factor treatment.

Cartilage is a support tissue with a poor capacity to self-repair. Its cells, chondrocytes, are responsible for synthesizing and renewing the matrix that surrounds them in a constant turnover mechanism. Autologous chondrocyte implantation (ACI) is one of the techniques that promises to be an alternative to common strategies for chondral lesions. To apply this technique, a large amount of cells must be obtained. In our work, we studied the state of cells from different cartilage (young, aged, and osteoarthritic sheep) cultured in monolayer by analyzing their proliferation rate using bromodeoxyuridine and their gene expression profile by RT-PCR. A decrease was found in expression of type II collagen and aggrecan in aged, osteoarthritic, and passaged chondrocytes. Treatment of cells with growth factors aFGF, IGF-I, TGF-beta, and OP-1 improved the proliferation rate in all cells studied and stimulated gene expression of type II collagen, aggrecan, and TGF-beta. Osteoarthritic cells showed a poor response according to matrix gene expression, while young cells responded properly, and aged chondrocytes showed a moderate response. These results suggest that the state of cartilage may affect the behavior of cultured chondrocytes.