Arthrodesis of the ankle and subtalar joints in patients with haemophilic arthropathy.

SUMMARY: There have been only a few studies in the literature that reported on the outcome of ankle arthrodesis in patients with haemophilia; furthermore, the number of patients was usually low and the operative technique has not been uniform. The aim of this study was to evaluate the outcome of surgery in haemophilic arthropathy of the ankle and subtalar joints, using internal fixation. From 1983 to 2006, 20 fusions were performed in 13 patients with advanced haemophilic arthropathy of the ankle and subtalar joints. There were 11 ankle fusions, one isolated subtalar fusion and eight combined ankle and subtalar fusions. Three of the latter had a subtalar fusion at a second operation. The mean age at operation was 38.7 years and the mean followup was 9.4 years. In the majority of the cases, the ankle fusion was achieved by two crossing screws. For the subtalar fusion, either staples were used or the tibiotalar screws were extended to the calcaneus. Arthrodesis of the ankle was successful in all but one patient, in whose case the procedure was revised and eventually his condition was progressed to fusion. There was also one case of painless non-union of the subtalar joint which was not revised. There was no recurrent bleeding, and no deep infection. Arthrodesis with cross screw fixation is an effective method for fusion of the ankle and subtalar joints in patients with haemophilia.

Physical therapy and imaging outcome measures in a haemophilia population treated with factor prophylaxis: current status and future directions.

Routine infusions of factor VIII to prevent bleeding, known as prophylaxis, and other intensive therapies are being more broadly applied to patients with haemophilia. These therapies differ widely in replacement product usage, cost, frequency of venous access and parental effort. In order to address residual issues relating to recommendations, implementation, and evaluations of prophylaxis therapy in persons with haemophila, a multinational working group was formed and called the International Prophylaxis Study Group (IPSG). The group was comprised of haemophilia treaters actively involved in studies of prophylaxis from North America and Europe. Two expert committees, the Physical Therapy (PT) Working Group and the Magnetic Resonance Imaging (MRI) Working Group were organized to critically assess existing tools for assessment of joint outcome. These two committees independently concluded that the WFH Physical Examination Scale (WFH PE Scale) and the WFH X-ray Scale (WFH XR Scale) were inadequately sensitive to detect early changes in joints. New scales were developed based on suggested modifications of the existing scales and called the Haemophilia Joint Health Score (HJHS) and the International MRI Scales. The new scales were piloted. Concordance was measured by the intra-class correlation coefficient of variation. Reliability of the HJHS was excellent with an inter-observer co-efficient of 0.83 and a test-retest value of 0.89. The MRI study was conducted using both Denver and European scoring approaches; inter-reader reliability using the two approaches was 0.88 and 0.87; test-retest reliability was 0.92 and 0.93. These new PT and MRI scales promise to improve outcome assessment in children on early preventive treatment regimens.

Elective orthopaedic surgery for inhibitor patients.

We report on a series of 108 elective orthopaedic surgical procedures. It includes 88 radiosynoviortheses and 20 major orthopaedic procedures, performed on 51 patients at nine centres worldwide. The average age of patients was 28.5 years (range 5-40 years), and the average follow-up time was 2 years (range 1-5 years). There were 82 good results, 15 fair and 11 poor. In the synoviorthesis group (41 patients, 88 synoviortheses) the average age was 14.3 years (range 5-40 years) and the average follow-up was 6.5 years (range 1-10 years). There were 66 good results, 14 fair and eight poor. There were no complications. In the group of major orthopaedic procedures, the average age of the 10 patients was 32.5 years (range 27-40 years), and the average follow-up was 2.3 years (range 1-5 years). There were 16 good results, one fair and three poor. Postoperative bleeding complications occurred in three of the 20 major orthopaedic procedures performed (15% complications rate). They occurred in three patients treated with insufficient doses of recombinant activated factor VII. Despite such complications, the study has shown that haemophilic patients with inhibitors requiring elective orthopaedic surgery (EOS) can undergo such procedures with a high expectation of success. In other words, EOS is now possible in haemophilic patients with inhibitors, leading to an improved quality of life for these patients. Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Arthroscopic synovectomy: state of the art.

Arthroscopic synovectomy for first performed for haemophilic arthropathy in 1980 and was considered a major improvement over open surgical synovectomy, causing less postoperative morbidity and fewer hospitalizations, and preserving range of motion. Long-term results have shown that recurrent haemarthroses are decreased and joint function is preserved. Radiographic changes, however, suggest continued progression of the disease process. The procedure is technically demanding and requires considerable resources including skilled personnel, surgical equipment and an adequate supply of factor concentrate, all of which limit the availability of the procedure worldwide. Where this procedure fits into the treatment of chronic haemophilic synovitis depends very much on location and availability of resources. Consequently, the procedure should not be considered as the first-line approach for recurrent haemarthroses, but rather as a secondary procedure if alternative measures have failed.

Total knee replacement in haemophilia.

We believe that total knee replacement (TKR) is a safe and effective procedure for the management of haemophiliac joint arthropathy; however, the increased risk of infection and non-infective complications remain a cause for concern. TKR in haemophilic patients carries with it an increased risk of post-operative infection in comparison to non-haemophiliac patients. Those patients at particular risk are the HIV-positive haemophiliac patients whose CD4 count is less than 200 cells mm-3. The latest techniques have gone a long way to reducing the complication rate and to achieving results that match those of a similar non-haemophiliac population.

Total knee arthroplasty in HIV-positive haemophilic patients.

In the era of total joint replacements in orthopaedics, total knee arthroplasty (TKA) should be indicated in haemophilic patients suffering from severe knee pain and disability. However, the expected high risk of infection and other postoperative complications is a concern. Although the message of this article may seem conservative, it should not be inferred that TKA should still be avoided in a haemophilic patient, but rather that the orthopaedic surgeon should weigh the risks and benefits carefully. Clinical and immunological status should be considered before suggesting a total knee replacement to a haemophilic patient. If TKA is contraindicated, knee arthrodesis is the alternative. However, knee joint debridement can relieve pain for several years and delay the need for TKA.

Infected joint replacements in HIV-positive patients with haemophilia.

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.

General principles and indications of synoviorthesis (medical synovectomy) in haemophilia.

The indication for a synoviorthesis (medical synovectomy) is chronic haemophilic synovitis causing recurrent haemarthroses, unresponsive to haematological treatment. Synoviorthesis is the intra-articular injection of a certain material to diminish the degree of synovial hypertrophy, decreasing the number and frequency of haemarthroses. There are two basic types of synoviorthesis: chemical synoviorthesis and radiation synoviorthesis. On average, the efficacy of the procedure ranges from 76 to 80%, and can be performed at any age. The procedure slows the cartilaginous damage which intra-articular blood tends to produce in the long term. Synoviorthesis can be repeated up to three times with 3-month intervals if radioactive materials are used (Yttrium-90 and Phosphorus-32), or weekly up to 10-15 times if rifampicin (chemical synovectomy) is used. After 30 years of using radiation synovectomy worldwide, no damage has been reported in relation to the radioactive materials. Radiation synovectomy is currently the preferred procedure when radioactive materials are available, however, rifampicin is an effective alternative method if radioactive materials are not available. Several joints can be injected in a single session, although no more than two joints at the same time is probably the best protocol to follow.

MRI findings in haemophilic joints treated with radiosynoviorthesis with development of an MRI scale of joint damage.

We hypothesized that magnetic resonance imaging (MRI) scans taken prior to radiosynoviorthesis may be predictive of response to the procedure in persons with haemophilia. Specifically, response would be inversely related to the severity of synovial hyperplasia. Radiosynoviorthesis was administered to 21 joints with recurrent haemorrhage (target joints). A detailed self-report of haemorrhage history, joint evaluation with scoring according to the World Federation of Haemophilia orthopaedic joint and pain scales, plain radiographs, and MRI studies of the joints were performed pre- and post-radiosynoviorthesis. To augment comparison of the MRI findings to those assessed using the Arnold-Hilgartner and Pettersson scales, a provisional MRI scale for evaluation of haemophilic arthropathy was designed. We found the MRI findings prior to the procedure were not predictive of clinical response; independent of the severity of synovial hyperplasia, most joints bled less and showed improvement by the WFH orthopaedic score. There was generally no change in the severity of synovial hyperplasia after the procedure. We conclude that MRI evaluation is not routinely indicated prior to radiosynoviorthesis.

Revision total knee arthroplasty using the porous-coated anatomic revision prosthesis: six- to twelve-year results.

The porous-coated anatomic (PCA) revision prosthesis was one of the earliest revision total knee systems to feature more constraint for stability, stems for fixation, and thicker femoral components to address bone loss. From 1981 to 1989, 36 revision total knee arthroplasties were performed using the PCA prosthesis. Patients were evaluated by clinical examination, radiographs, and the Hospital for Special Surgery Knee Rating Scale. Six patients died and three were lost to follow-up; 27 knees remained for follow-up. The average age at surgery was 66 years. Follow-up averaged 9.8 years (range, 6-12.4 years). Range of motion averaged 4 degrees to 91 degrees before surgery and 1 degrees to 92 degrees after surgery. Knee scores averaged 48 before surgery and 86 after surgery. Three femoral and 10 tibial components showed lucent lines, with 3 tibial components showing progressive lucency. Six patients required reoperation: 3 for tibial component loosening, 1 for wound infection, 1 for deep infection, and 1 for persistent pain. These results suggest that the use of an implant specifically designed for revision can yield successful long-term results.

One-stage revision of periprosthetic fractures around loose cemented total hip arthroplasty.

Fourteen cases of femoral fracture occurring about a loose cemented proximal femoral prosthesis are presented. All fractures occurred with relatively minor trauma, and significant preinjury osteolysis was present in all cases. Treatment consisted of immediate surgical revision of the loose femoral component using a long-stem noncemented component in conjunction with cerclage wiring. In most instances, morselized bone graft was used. Strut grafts were used in seven cases to improve stability. Two patients with extensive bone loss were unable to support a prosthesis and were treated with whole femoral allografts. Follow-up ranged from 24 to 84 months (mean, 49 months), except for one patient lost to follow-up at 12 months; evaluations consisted of Harris hip scores and radiographic analysis for fracture healing and implant stability. All fractures healed, and patient function increased dramatically. Postoperative Harris hip scores increased to an average of 74 points. Complications consisted of one postoperative fracture and four patients with femoral component loosening. No cases of component loosening were seen in the five cases in which components were designed for distal stability (four fully porous-coated, one fluted). Of the seven cases relying on proximal stability, two cases of early loosening and two cases of late loosening occurred. We recommend revision with long-stem, cementless implants in conjunction with cerclage wiring and strut grafts for the treatment of femoral fractures about loose cemented hip prostheses. Implant stability distal to the fracture is emphasized.

Arthroscopic synovectomy of the knee in hemophilia: 10-to-15 year followup.

Nine knees in 8 patients with severe hemophilia A and 1 patient with hemophilia B underwent arthroscopic synovectomy during the period of 1980 to 1985. This group of patients has been observed prospectively for the past 10 to 15 years. One complication occurred immediately postoperatively in an 8-year-old boy in whom a severe hemarthrosis developed that required arthroscopic evacuation. His postoperative recovery was compromised leading to significant loss of motion. Recurrent hemarthroses developed in only 1 patient after an injury to the knee. A second arthroscopic synovectomy was performed 45 months after the initial procedure. Other than the patient who lost motion after the postoperative complication, all patients initially regained or improved their range of motion. The latest followup, however, showed several patients losing motion which correlated with clinical and radiographic evidence of progressive changes of the hemophilic arthropathy. The 1 patient with Factor IX deficiency required a total knee replacement 8 years after synovectomy. Arthroscopic synovectomy was effective in reducing recurrent hemarthrosis and maintaining range of motion; however, joint deterioration continued to occur although probably at a slower rate.

Evaluation of the biomechanics of the hip following a triple osteotomy of the innominate bone.

The biomechanics of the hip joint were evaluated in seventeen patients (twenty-two hips), twelve to forty-one years old (mean, twenty-four years old), who had a triple osteotomy of the innominate bone for treatment of symptomatic dysplasia of the hip. The duration of follow-up ranged from 2.2 to 13.8 years (mean, 6.8 years). Hip load, the area of the weight-bearing surface, and stress were determined from measurements on pelvic radiographs that were made preoperatively, postoperatively, and at the time of the latest follow-up; the values were compared with those in twenty-one hips from control subjects. The Harris hip-rating system was used for clinical assessment. According to the biomechanical analysis, there was significantly less relative stress on the hip after the triple osteotomy and at the time of the latest follow-up (p < 0.001 for both) than there had been preoperatively. The decrease in stress was a direct result of a significant increase in the area of the weight-bearing surface of the hip (p < 0.001). The load on the hip was not altered significantly, with the numbers available. The functional outcome was improved substantially when the biomechanical goals were achieved. Through the application of basic biomechanical principles, we were able to demonstrate the biomechanical efficacy of a triple osteotomy of the innominate bone. We recommend the use of biomechanical analysis as an adjunct to the clinical decision-making process in the treatment of a dysplastic hip.

Structural allografting in revision total knee arthroplasty.

Between 1985 and 1991, 15 patients underwent structural allografting as part of revision total knee arthroplasty. All patients had large segmental, cavitary, or combination defects of the femur and/or tibia. Seven distal femurs and 12 proximal tibias required allografting. Patients were evaluated with physical examination, radiographs, and The Hospital for Special Surgery knee rating scale. Three patients died, leaving 15 allografts for follow-up study. The average age at surgery was 63 years. The follow-up period averaged 47 months (range, 30-101 months). Average range of motion before surgery was 4 degrees to 93 degrees, and after surgery, 2 degrees to 104 degrees. Average knee score was 47 before and 86 after surgery. Preoperative alignment averaged 5 degrees varus, ranging from 25 degrees valgus to 20 degrees varus, and postoperative alignment averaged 4 degrees valgus, ranging from neutral to 6 degrees valgus. All patients, except one, had improvement of pain and stability. All of the 15 allografts healed to host-bone and 13 showed evidence of incorporation. There were no infections or fractures of the allografts. One complication directly related to the allograft occurred; that patient had a tibial component fracture over a proximal tibial allograft 3 years after surgery. Three other complications occurred. One was tibial loosening in a patient who received a distal femoral allograft, the second was a proximal tibial fracture in a patient who received a distal femoral allograft, and the third was an intraoperative patellar tendon avulsion. These results suggest that structural allografting can provide a satisfactory method of managing large bone defects in the failed total knee arthroplasty.

Femoral head autograft in simultaneous primary and revision total hip arthroplasty.

Bilateral total hip arthroplasty during one anesthetic procedure can be beneficial in properly selected patients. For patients who have a failed hip arthroplasty requiring revision and a contralateral arthritic hip requiring primary arthroplasty, bilateral surgery permits the resected femoral head from the primary procedure to be used as a fresh autogenous bone-graft during the revision procedure. Four patients underwent combined primary hip arthroplasty and contralateral revision hip arthroplasty during one anesthetic procedure. The femoral head obtained during the primary procedure was used as a structural acetabular bone-graft in three patients, and bone slurry was used to fill cavitary acetabular defects in one patient. A femoral neck autograft was used to reconstruct a calcar defect in one of the patients. After an average follow-up period of 27 months, all hips were functioning well with healed bone-grafts and stable prosthetic components.

Noncemented revision total knee arthroplasty.

From 1985 to 1991, 16 patients underwent 17 revision total knee arthroplasties using porous-coated tibial or femoral components, or both, without cement. Eight knees had both components implanted without cement, 4 the femoral component without cement and 5 the tibial component without cement. Fifteen revisions were performed for aseptic loosening, 1 for instability, and 1 for infection. Patients were evaluated by clinical examination, radiographs, and the Hospital for Special Surgery Knee Rating Scale. Two patients died, leaving 15 revision total knee arthroplasties for followup. The average age at surgery was 65 years old. Followup averaged 5.6 years (range, 2.4-10.0 years). Range of motion preoperatively averaged 4 degrees to 96 degrees, and postoperatively 0 degree to 102 degrees. Average knee scores were 52 points preoperatively and 87 points postoperatively. Two tibial components showed lucent lines > or = 1 mm in 1 or more zones, 1 of which showed progressive lucencies. One femoral component showed a 1-mm lucent line in 1 zone, which was not progressive. Two tibial components were revised, 1 for a proximal tibial fracture below the prosthesis, and the other for prosthesis loosening and breakage. There was 1 stitch abcess with intrarticular extension, but no other infections. These results show that successful revision total knee arthroplasty can be accomplished using noncemented porous-coated components, with results comparable with those of cemented revisions.

An in vitro study of proximal femoral allograft strains in revision hip arthroplasty.

Bone allografts are used frequently to replace bone stock subsequent to total hip arthroplasty. Revision of the failed hip replacement results in a complex structure of allograft bone, host bone and a metal femoral component. To evaluate the mechanics of the allograft-implant-host bone structure at the time of surgery, a strain gauge study was undertaken with six fresh/frozen human femora. Under defined loading conditions, cortical strain distributions were measured for five different cases: (1) normal bone, (2) bone with a femoral implant, (3) bone with the femoral component and an osteotomy at the mid-stem level of the implant (i.e. to stimulate the proximal allograft-host junction around the femoral stem), (4) bone with an osteotomy and an implant cemented into the 'allograft' (i.e. the proximal end of the femur), and (5) bone with an osteotomy and the implant cemented into both the proximal 'allograft' and the distal host bone. The results showed that, prior to making the osteotomy, proximal femoral strains were decreased with the insertion of a femoral stem. These strains were further decreased when an osteotomy had been made. This strain distribution did not change when the stem was cemented into the proximal 'allograft' bone, or cemented into the proximal 'allograft' and distal host bone. The decreases in strain for these test cases implied that the discontinuity between the bony segments caused an extended reduction in the tensile or compressive stresses transmitted through the cortices.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging visualization of hemorrhage into a suprapatellar pouch in a child with hemophilia.

PURPOSE: Magnetic resonance imaging (MRI) was used for evaluation of refractory joint swelling in a 7-year-old boy with hemophilia. PATIENT AND METHODS: This patient with no evidence of an inhibitory had refractory left knee swelling despite receiving appropriate factor VIII concentrate infusions. RESULTS: A plain radiograph showed soft tissue swelling and a calcification in the left suprapatellar region. On MRI a discrete suprapatellar pouch could be detected and was subsequently surgically resected. CONCLUSION: We believe that MRI should be considered when evaluating children with hemophilia who have refractory joint swelling and no evidence of an inhibitor.

Version of the osteoarthritic knee.

Version of normal and osteoarthritic knees is evaluated by computed tomography in this study. Version of the knee is defined as the static rotation of the tibia with respect to the femur in full knee extension. It is measured as the difference between the transverse axes of the femoral condyles and tibia. The average knee version, or external rotation of the tibia with respect to the femur across the normal knee, was 0 degree. Version of the osteoarthritic knee was 5 degrees. Rotation of the tibia with respect to the femur across the extended osteoarthritic knee is a relationship that will affect the placement of components in total knee arthroplasty. This relationship should be addressed in alignment instrumentation and technique to avoid component malalignment in total knee arthroplasty.