Surgery in haemophilia patients with inhibitors, with special emphasis on orthopaedics: Madrid experience.

We report on a series of 92 surgical procedures (90 patients). It includes 35 orthopaedic procedures (33 patients) and 57 non-orthopaedic procedures (57 patients). The orthopaedic procedures include 27 radiosynovectomies (minor surgery) and eight major orthopaedic procedures. The non-orthopaedic procedures include 52 minor interventions and five major procedures. The average age of patients was 34 years (range: 8-56), and the average follow-up time was 3 years (range: 1-6). Of the 92 surgical procedures, 42 were performed with activated prothrombin complex concentrates [factor eight inhibitor bypassing agent (FEIBA)] and 47 with recombinant-activated factor VIIa (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark). Regarding FEIBA treatment in minor surgery, the initial dose was 100 IU kg(-1). After 6 h, we continued with 50 IU kg(-1) every 12 h for at least 4 days (radiosynovectomies). In minor non-orthopaedic procedures, the dose was continued until day 14. In patients who underwent surgery with the haemostatic control achieved by means of rFVIIa, the initial dose of rFVIIa in minor procedures (both orthopaedic and non-orthopaedic) was 90-120 microg kg(-1). In postoperative days 1-5, the dose was 2-4 x 90-120 microg kg(-1) q3-6 h for 24 h. In major procedures (both orthopaedic and non-orthopaedic), the dose was 120 microg kg(-1) pre-operatively, 120 microg kg(-1) q 3 h day 2/day 3-5, and then 90-120 microg kg(-1) q 6 h until day 14. There were 87 good results, four fair results and one poor result. Our study has shown that haemophilic patients with inhibitors requiring surgery can undergo orthopaedic and non-orthopaedic procedures with a high expectation of success. In other words, surgery (orthopaedic and non-orthopaedic) is now possible in haemophilia patients with inhibitors, leading to an improved quality of life for these patients.

Delayed union of a fracture of the middle third of the clavicle presenting with a late subclavian pseudoaneurysm.

This is the case of a 46-year-old man who presented 3 months following a fracture of the middle third of the clavicle with an expanding mass in the supraclavicular fossa. Upon admission, a pulsatile mass was identified and X-rays showed delayed union of the fracture. Seven days after admission, skin necrosis developed. Arteriography performed 3 days later demonstrated a round subclavian pseudoaneurysm measuring 5 cm in diameter. It was occluded by means of an endovascular prosthesis. Four days after arteriography, the delayed union was treated by excision of the necrotic skin and internal fixation with a plate and screws. After 1 year of follow-up, the outcome was clinically and radiologically satisfactory.

Tratamiento de las secuelas de las lesiones ocultas en las fracturas de fémur / Treatment of clinical sequels from hidden injuries in broken femurs

Las fracturas diafisarias de fémur se acompañan de un elevado número de lesiones asociadas y siempre hay que sospechar y descartar lesiones ipsilaterales. El diagnóstico y tratamiento precoz son fundamentales para la obtención de resultados satisfactorios pues las secuelas resultantes de una lesión asociada que pasa desapercibida son muy limitantes y difíciles de tratar

Diaphyseal fractures of the femur are accompanied by a high proportion of associated lesions, and the possible presence of ipsilateral lesions must always be suspected and discarded. Early diagnosis and treatment are essential to secure satisfactory results, since the sequelae of an undetected associated lesion are very limiting and are difficult to treat

Infección protésica de rodilla / Knee prosthesis infection

El recambio en dos tiempos es la recomendación para el tratamiento de las infecciones protésicas de rodilla. La supervivencia libre de extracción del implante por re-infección tras dicha técnica es del 93,5% a los 5 años y del 85% a los 10 años. Además, las cifras de curación iniciales se mantienen con el paso del tiempo. El riesgo de recidiva de la infección no está relacionado con el tipo de germen, ni con el tipo de fijación protésica en el segundo tiempo, ni con los datos demográficos de los pacientes. La supervivencia libre de retirada del implante por cualquier motivo es del 90% a los 5 años y del 77,3% a los 10 años

Two-step replacement surgery is recommended for treating infected knee prostheses. The extraction-free survival of implants secondary to reinfection following this technique is 93.5% after 5 years, and 85% after 10 years. In addition, the initial healing rates are maintained over time. The risk of infection relapse is unrelated to the type of microorganism, the type of prosthetic fixation used in the second step, or the patient demographic characteristics. The extraction-free survival of implants secondary to any cause is 90% after 5 years, and 77.3% after 10 years