Ankle arthrodesis in patients with haemophilia-associated ankle arthropathy - does the technique influence the outcome?

Management of symptomatic osteoarthritis (OA) of the ankle in patients with haemophilia can be challenging. Arthroscopic ankle arthrodesis has been shown in non-haemophiliac patients to provide similar or superior rates of fusion to open ankle fusion. However, the literature regarding ankle arthrodesis in patients with haemophilia is limited. Our aim was to compare the rate of successful fusion between open and arthroscopic assisted ankle arthrodesis in patients with haemophilia. A retrospective study was performed. All patients with haemophilia who underwent ankle arthrodesis at our centre were included. Outcomes including peri- and post-operative complications, and lengths of stay were extracted from patients' records. Radiographs were reviewed for signs of successful arthrodesis. Seventeen arthrodesis procedures were performed in 13 patients between 1980 and 2017. Nine procedures were performed arthroscopically and eight were open. Ten patients were diagnosed with haemophilia A and three with haemophilia B. The success rates of arthroscopic and open tibiotalar arthrodesis were 100% and 87.5% respectively. Four complications occurred. In the open technique group, there was one non-union. The same patient also developed subsequent haematoma after revision surgery. One patient developed a superficial wound infection which resolved with antibiotics. In the arthroscopic group, one patient developed a pseudoarthrosis of the distal tibiofibular joint which required a revision procedure. The results of this study suggest that arthroscopic ankle fusion for haemophilia- associated arthropathy is a viable option, with the rate of successful fusion being comparable to open procedures.

Characteristics and management of the haemophilia-associated pseudotumours.

The management of haemophilia-associated pseudotumours presents an ongoing challenge to the haematologist, surgeon and interventional radiologist alike. There is a range of therapeutic approaches including factor replacement, embolization, radiotherapy and a variety of surgical interventions. However, there remains little evidence regarding the most appropriate treatment. We aimed to evaluate the available options of management for the haemophilia-associated pseudotumour. A literature review was performed using relevant terminology and reviewed for treatment approaches and outcomes. The results demonstrated that most of the data is from single case reports with a small number of single- and multicentre case series. In total, 133 patients with 134 described pseudotumours were identified. Adequate haemostatic control with factor replacement was a key component to successful treatment. Surgical excision was the most commonly reported surgical intervention with various composites used for filling of the surgical cavity. The use of radiotherapy has been described particularly in the paediatric population and sites of difficult surgical access. Embolization can be considered as a method of presurgical optimization. Patients with both factor inhibitors and pseudotumours have poorer postoperative outcomes. This review demonstrates that although a lack of large-centre, randomized studies, timely surgical intervention with adequate haemostatic support and the consideration adjuvant therapies in selected cases can achieve acceptable outcomes in this cohort of patients.

Three Cases of Femoral Stem Failure in Rotating Hinge Revision Total Knee Arthroplasty: Causes and Surgical Considerations.

Catastrophic failure of stemmed components in arthroplasty is an uncommon but a serious complication. Stem fractures and techniques for addressing these have been described following hip arthroplasty but much less so following total knee arthroplasty (TKA). We review three cases of catastrophic failure of the stem in rotating hinge revision TKA prostheses. We discuss the possible mechanism of failure and review the current literature addressing this topic. Metaphyseal support needs to be optimized in order to minimize load transfer to the stem and to the junction (and the risk of fracture) if a modular component is used. When constrained components are used, radiographs need to be carefully assessed for signs of proximal loosening. Nonmodular stems are also an option in this situation.

Biomechanical properties of bovine tendon xenografts treated with a modern processing method.

Xenograft tendons have been used in few human studies, with variable results. With the advent of novel tissue processing techniques, which may mitigate against an immune-mediated rejection response without adversely affecting mechanical properties, there may now be a clinical role for xenograft tendons, particularly in knee ligament reconstruction. We hypothesize that 'BioCleanse®' processed bovine extensor digitorum medialis (EDM) tendons exhibit favorable time-zero pre-implantation biomechanical characteristics when compared to both unprocessed bovine EDM tendons and BioCleanse® processed human cadaveric allograft tibialis anterior tendons. In this in vitro case controlled laboratory study, three groups of tendons underwent a 5-stage static loading test protocol: 15 BioCleanse® bovine (BCB), 15 fresh frozen unprocessed bovine (FFB), and 12 BioCleanse® human allograft (BCA) tendons. Cross-sectional area of the grafts was measured using an alginate molding technique, and tendons were mounted within an Instron® 5565 Materials Testing System using cryogenic clamps. BCB tendons displayed a higher ultimate tensile stress (p<0.05), with equivalent ultimate failure load, creep, and modulus of elasticity when compared to the FFB tendons (p>0.05). BCB tendons had an equivalent cross-sectional area to the BCA tendons (p>0.05) whilst exhibiting a greater failure load, ultimate tensile stress, less creep and a higher modulus of elasticity (p<0.05). The BioCleanse® process did not adversely affect the time-zero biomechanical properties of bovine xenograft EDM tendons. BioCleanse® processed bovine xenograft EDM tendons exhibited superior biomechanical characteristics when compared with BioCleanse® processed allograft tibialis anterior tendons. These findings support further investigation of xenograft tendons in orthopedic soft tissue reconstructive surgery.

Red cell distribution width is an independent predictor of mortality in hip fracture.

BACKGROUND: the red cell distribution width (RDW), an automated measure of variability in the red blood cell size on full blood count (FBC) is an independent predictor of mortality in several disease states and in healthy older people. OBJECTIVE: we wanted to determine the prognostic value of RDW in patients following a hip fracture-a condition associated with high mortality. DESIGN: we examined the relationship between admission RDW and mortality in 698 consecutive patients admitted with hip fracture. METHOD: regression analysis was used to examine admission RDW and subsequent mortality, adjusting for admission haemoglobin, mean corpuscular volume, age, gender, pre-morbid residence and independence level, Charlson co-morbidity index and post-operative complications. RESULTS: the mean age was 78 ± 13 years. Unadjusted 1-year mortality was 12, 15, 29 and 36% across quartiles of increasing RDW. Along with age and post-operative complications, RDW remained significantly associated with in-hospital, 120-day and 1-year mortality [adjusted hazard ratios: HR: 1.119, 95% CI: (1.000-1.253), P = 0.05, 1.134 (1.047-1.227), P = 0.004 and 1.131 (1.067-1.199), P < 0.001, respectively]. These relationships remained significant at all three time points on repeat analysis in non-anaemic patients (n = 548). CONCLUSION: RDW, a widely available parameter on FBC, is independently associated with an increased risk of short- and long-term mortality following hip fracture.

Supracondylar femoral fracture after anterior cruciate ligament reconstruction with transfemoral fixation.

Femoral fractures following anterior cruciate ligament (ACL) reconstruction are rare. These injuries often are related to increased stresses at the femoral tunnel. Hamstring tendon autograft is often used for ACL reconstruction, and transfemoral fixation is one of many graft fixation techniques with few reported complications. This article reports an atraumatic transverse supracondylar femoral fracture occurring through the transfemoral fixation tract following hamstring ACL reconstruction in a 38-year-old woman.

Incidence of heterotopic ossification after hip resurfacing.

BACKGROUND: Heterotopic ossification has been noted around total hip arthoplasty in numerous studies. With hip resurfacing growing in popularity, we have prospectively evaluated the incidence in a cohort undergoing hip resurfacing. METHODS: Two hundred and twenty consecutive hip-resurfacing procedures were prospectively reviewed at a minimum of 2 years follow up to assess the incidence of heterotopic ossification and its effect on function and clinical outcome. We also reviewed the preoperative diagnosis, age, sex and previous surgery. RESULTS: The overall percentage of heterotopic ossification was 58.63%. The incidence of Brooker 1 was 37.27%, Brooker 2 was 13.18% and Brooker 3 was 8.18%. Male osteoarthritis had the highest incidence of heterotopic bone formation (HBF). Three men underwent excision of heterotopic bone, two for pain and stiffness and one for decreased range of movement. Both anteroposterior and lateral radiographs were reviewed for evidence of HBF. In all, 12.7% had no evidence of HBF in the first view but clearly had in the second view. CONCLUSIONS: Overall, we found no evidence that HBF affected the clinical or functional outcome of the hip resurfacing at a mean of 3 years follow up. However, in light of the high incidence of HBF seen in a yet unproven long-term prosthesis, we conclude that the Cochrane database recommendations with regard to prophylaxis should be implemented.

How do serum cobalt and chromium levels change after metal-on-metal hip resurfacing?

We prospectively monitored changes in serum cobalt and chromium levels after a new generation metal-on-metal hip resurfacing and the affect on renal function. Levels were measured using inductively coupled plasma mass spectrometry and atomic absorption spectrometry, preoperatively then sequentially at 3, 6, 9, 12, and 24 months. For serum cobalt, there was an initial increase to a peak level at 6 months, followed by a gradual decline during the next 15 months. A similar trend was observed in serum chromium, although the peak level occurred slightly later, at 9 months. There was no adverse affect on renal function during the 2-year study period. All implants were functioning well, with no radiographic evidence of loosening. These levels will continue to be monitored to establish when minimum metal ion levels are reached.

The nonoperative management of periprosthetic fractures associated with the Birmingham hip resurfacing procedure.

We reviewed the outcome of 7 patients sustaining undisplaced femoral neck periprosthetic fractures associated with the Birmingham hip resurfacing procedure. All fractures presented within 4 months of initial surgery. All fractures were treated conservatively with a period of nonweight bearing. The 7 patients were assessed clinically and radiologically at a minimum of 16 months postfracture. All fractures had fully united. There was no evidence of impaired function or abnormal radiological findings after this conservative treatment strategy in 6 patients. One patient had marked femoral neck narrowing but no functional impairment.

The octogenarian total knee arthroplasty.

Sixty-five patients aged > 80 years were compared to 65 patients aged between 60 and 70 years to assess total knee arthroplasty (TKA) outcome using the octogenarian postoperative Knee Society knee and function scores. Knee Society knee scores showed excellent outcomes with no statistically significant difference in the younger cohort (preoperative score, P = .7156; 5-year score, P = -.0677). Knee Society function scores also showed good outcomes with no statistically significant difference between the groups (preoperative score, P = .1147; 5-year score, P = .1348). Average length of stay increased by 3 days for octogenarians. Octogenarians had more pre-existing medical conditions and suffered more postoperative confusion. All but 1 patient rated the result as good/excellent. Patients maintained their independence for approximately 3.5 years before requiring more social input. With careful preoperative planning and counseling, TKA is recommended for the octogenarian.