Arthroscopic synovectomy in haemophilic arthropathy of the knee

From January 1996 to January 2001, arthroscopic synovectomies were performed in 28 knees with haemophilic arthropathy. The mean follow-up period was 5 years and 11 months. Six portals (two anterior, two suprapatellar, two posterior) and a posterior trans-septal portal were used in all cases. The average Hospital for Special Surgery (HSS) knee score increased from 56.4 to 71.5 points at the last follow-up. The average frequency of haemarthrosis reduced from five times per month before operation to once per month. The amount of factor replacement decreased from a mean of 4,633 U to 1,505 U. Progression of arthritis was observed radiographically in three cases at the last follow-up. An arthroscopic synovectomy of the knee using appropriate arthroscopic portals is a useful method in treating haemophilic patients as it decreases bleeding episodes, amount of factor replacement and knee pain.

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Résumé De janvier 1996 à janvier 2001, des synovectomies arthroscopiques ont été exécutées dans 28 genoux avec une arthropathie hémophilique. Le suivi moyen était 5 années et 11 mois. Six abords (deux antérieurs, deux supra-rotuliens, deux postérieurs) et un abord trans-septal postérieur ont été utilisé dans tous les cas. Le score moyen du genou de lHôpital pour Chirurgie Spéciale (HSS) a augmenté de 56,4 à 71,5 points au dernier examen. La fréquence moyenne dhémarthrose sest réduite de cinq fois par mois avant lopération à une fois par mois aprés. La quantité moyenne de remplacement de facteur a diminué de 4,633 à 1,505 unités. Dans lévaluation radiographique, la progression de larthrite a été observée dans trois cas au dernier suivi. Une synovectomie arthroscopique du genou qui utilise des abords arthroscopiques appropriés est une méthode utile pour traiter les malades hémophiliques, diminuant les épisodes de saignement, la quantité de facteur et les douleurs du genou.

     

Total knee replacement in haemophilic arthropathy

The results of primary total knee replacement performed on a group of haemophiliac patients in a single institution by the same surgeon using the same surgical technique and prosthesis are reported. A total of 35 primary replacements in 30 patients were carried out between 1996 and 2005 and were reviewed retrospectively. The mean age of the patients was 31 years (24 to 42) and the mean follow-up was for 7.5 years (1 to 10). There were 25 patients with haemophilia A and five with haemophilia B. The HIV status and CD4 count were recorded, and Knee Society scores determined. Two patients had inhibitors to the deficient coagulation factor. There were no early wound infections and only one late deep infection which required a two-stage revision arthroplasty, with a good final result. The incidence of infection in HIV-positive and negative patients was thus similar. One knee in a patient with inhibitor had excessive bleeding due to a pseudoaneurysm which required embolisation. The results were excellent in 27 knees (77%), good in six (17%) and fair in two (6%). The survival rate at 7.5 years taking removal of the prosthesis for loosening or infection as the end-point was 97%. The mechanical survival of total knee replacements in haemophiliacs is very good. Our results confirm that this is a reproducible procedure in haemophilia, even in HIV-positive patients with a CD4 count > 200 mm(3) and those with inhibitors. Our rate of infection was lower than previously reported. This could be due to better control of the HIV status with highly active anti-retroviral therapy and the use of antibiotic-loaded cement.     

Total knee replacement in haemophilic arthropathy

Eleven total knee replacements were performed in eight patients with severe haemophilia A and the patients were followed up for two to eight years. All the patients had disabling haemophilic arthropathy of one or both knees, which had not responded to conservative treatment. Postoperative complications occurred in 10 knees, including nose bleeding, haemarthrosis, anaphylactic reactions, urinary tract infection with haematuria, recurrent phlebitis at infusion sites, and fever for a few days. There were no wound infections. The outcome, as determined by a standard scoring system, was rated as excellent or good in nine knees, fair in one and poor in one. Nevertheless, all patients were free of pain and all but one returned to full-time or part-time employment. Total knee arthroplasty appears to be a satisfactory procedure in the treatment of disabling haemophilic arthropathy of the knee.     

Joint debridement for haemophilic arthropathy of the knee

Summary Joint debridement was performed for advanced haemophilic arthropathy of the knee in eleven patients. Follow up was for an average of 5.4 years and the results were evaluated retrospectively by the Hospital for Special Surgery disability score sheet. The clinical results were excellent in four, good in five and fair in two. Debridement should be considered in the young haemophiliac to avoid, or delay, total knee arthroplasty. The operation may give the patient years of life without pain and it appears to slow the development of radiographic changes.

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Résumé Les auteurs présentent les résultats de onze interventions de nettoyage du genou avec remodelage, réalisées au cours d'une période de 15 ans. L'âge moyen des hémophiles au moment de l'opération était de 28 ans, le recul moyen des observations est de 5.4 ans. Les résultats cliniques ont été évalués selon la cotation HSS: quatre sont excellents, cinq bons et deux médiocres. Ces résultats montrent que le nettoyage du genou des hémophiles constitue un traitement efficace des articulations douloureuses avec détérioration radiologique avancée. Il peut ralentir le cours naturel de l'évolution et retarder la nécessité d'une arthroplastie totale du genou chez le jeune hémophile.

     

Long term follow up of haemophilic arthropathy treated by Au-198 radiation synovectomy

Summary Intra-articular injection of Au-198 (gold synoviorthesis) has been used in the treatment of repeated haemarthroses of the elbows, knees, or ankles in 64 haemophiliacs. These patients had continued to have joint haemorrhages despite appropriate, episodic, substitutive therapy over a period of more than six months. Follow-up for an average period of 14 years in one knee in 38 male haemophiliacs showed 8 good, 23 fair, and 7 poor results with regard to their joint scores.It is concluded that Au-198 is an effective agent for radiation synovectomy, particularly in the early stages of the disease with minimal radiographic changes. It appears to reduce the incidence of haemarthrosis and to slow the rate of evolution of radiographic changes.

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Résumé Soixante-quatre hémophiles qui présentaient des hémarthroses récidivantes au niveau d'une ou plusieurs articulations (coude, genou, cheville) malgré une thérapeutique substitutive appropriée ont été traités par injection intra-articulaire d'or radio-actif (Au 198). Trente-huit malades (38 genoux) ont pu être suivis avec un recul de 14 ans. Huit patients ont un bon résultat, 23 un résultat passable, et 8 mauvais. Ces résultats indiquent que l'or radio-actif est un agent efficace pour réaliser une synoviorthèse, spécialement pour les genoux avec aspect radiologique de stade I (2 points à l'échelle radiologique); bien que la synoviorthèse n'arrête pas la détérioration articulaire, elle peut ralentir le cours naturel de l'évolution de la maladie.

     

Open and arthroscopic synovectomy in hemophilic arthropathy of the knee.

Open and arthroscopic synovectomies of the knee in patients with classic hemophilia were evaluated with regard to effectiveness in reducing bleeding episodes, the effect on range of motion (ROM), and roentgenographic progression of hemophilic arthropathy. Eleven patients underwent 13 synovectomies (eight open, five arthroscopic). The average follow-up periods were 7.9 years and 2.2 years for the open and arthroscopic groups, respectively. Both procedures significantly reduced recurrent hemarthroses. Knee ROM in the open synovectomy group was decreased or unchanged in 75% and minimally increased in 25%, whereas there was an increased in 80% and a decrease in 20% of the knees in the arthroscopic group. Furthermore, 62.5% of the knees required manipulation to improve ROM in the open synovectomy group, versus 0% in the arthroscopic group. Hemophilic arthropathy progressed in most knees in both groups. The arthroscopic group had a longer operative procedure (122 versus 59 minutes), but required less hospitalization (9.4 versus 23.1 days) and 25.6% less Factor VIII replacement. Both techniques reduce hemarthroses. There is usually a net loss of ROM with the open versus a net gain with the arthroscopic procedure, and roentgenographic progression hemophilic arthropathy is slowed but not halted after synovectomy.     

Outcome of osteotomies for the treatment of haemophilic arthropathy of the knee

Background and aims The knee is one of the most commonly affected joints in haemophilic arthropathy leading to stiffness and disability. It is the aim of this study to investigate the outcome of corrective osteotomies around the knee.Patients and methods We report on the long-term results of ten osteotomies around the knee for severe haemophilic arthropathy and axial deviation at an average of 7.25±1.8 years postoperatively. Seven high tibial (preoperatively 7.2±2° varus) and three supracondylar osteotomies (preoperatively 7±3° valgus) were performed on seven patients (three of them bilateral).Results The clinical score of the Advisory Board of the World Federation of Haemophilia (average 7.4 points preoperatively) remained unchanged in two patients, improved in three patients and deteriorated in five patients. The radiological Pettersson score (average 8.2 points preoperatively) showed a worsening of 2.5 points over the time. Patients reported a subjective improvement for seven osteotomies, with sports activity in three patients, although the range of motion did not change significantly. Total knee arthroplasty was considered to be a failure, i.e. endpoint of follow-up. Six knees were replaced in four patients by total arthroplasty after a mean of 6.6 years.Conclusion Although survival of osteotomies around the knee in haemophilic arthropathy is lower than in non-haemophilic patients, we think that it is a choice of treatment, which, at least, postpones the indication for total knee arthroplasty in this young patient group.An equal contribution was made by K. Trieb and J. Panotopoulos     

Silastic interposition for haemophilic arthropathy of the elbow

Thirteen elbows affected by severe haemophilic arthropathy and treated by silastic interposition arthroplasty were followed up for at least five years. The severity of pain, the frequency and severity of spontaneous haemorrhage and the range of movement were assessed before operation and at review. All patients were much improved and needed less factor replacement. Three elbows were revised, one for infection and two because of fragmentation of the silastic sheet. They regained good function following revision.     

Laser synovectomy of the knee joint

The clinical impact of laser-assisted synovectomy was investigated in a two-part study consisting of a morphological part with morphometric measurements and an in vivo part using an animal model. A continuous wave Nd:YAG laser ( = 1064 nm; power density 18–106 W/mm²; exposure 0.5–5 s) and a XeCl excimer laser ( = 308 nm; pulsewidth 20 ns; repetition rate 10–70 Hz; energy density 20–45 mJ/mm²; exposure 10–60 s) were employed in combination with a fused silica fiber with diameters of 600 m and 800 m, respectively. In vitro study. Under light microscopy, synovium exposed to Nd:YAG laser energy presents a transitional band (with a mean diameter of 2 mm) with three zones: a carbonized area, a vesicular zone, and a coagulated part. In contrast, pulsed UV-laser irradiation leads only to a narrow transitional zone extending 10–70 m. Scanning electron microscopy reveals a clear-cut surface following excimer synovectomy, whereas Nd:YAG laser irradiation forms an irregular surface with numerous bursts due to vaporizing activity. In vivo study. Partial synovectomy of the knee joint was performed in two groups of 14 New Zealand white rabbits with a 1064-nm Nd:YAG laser and a 308-nm XeCl excimer laser. Another 14 animals synovectomized in a conventional technique served as a control. Morphological examination and histopathological scoring of the synovial membrane were performed 4 days to 6 months after the operation. The progress of synovial regeneration following excimer laser synovectomy did not differ from observations in the control group. However, Nd:YAG laser irradiation led to a significantly delayed formation of a neosynovium. In addition, Nd:YAG laser application provided an efficient hemostasis. In conclusion, the Nd:YAG laser is a suitable instrument for synovectomy and is superior to conventional techniques, as it provides sufficient hemostasis, an appropriate extent of synovial resection, and delayed formation of a neosynovium, thus interrupting the vicious cycle that may lead to an early recurrence of synovitis.     

Interposition arthroplasty in the management of advanced haemophilic arthropathy of the elbow

Six patients with severe haemophilic arthropathy of the elbow have been treated by limited excision arthroplasty using a sheet of silicone rubber as an interposition membrane. There were no complications. The symptoms and signs before and after operation have been assessed using the grading system advocated recently by the World Federation of Haemophilia. In all cases there was relief of pain and increased movement. Moreover, the subsequent incidence of spontaneous haemorrhage into the elbow has been reduced with considerable cost benefit.     

Total knee arthroplasty in hemophilic arthropathy of the knee

Twenty-five total knee arthroplasties were performed in 21 patients with hemophilia. The mean patient age was 35.8 years and mean follow-up time was 6.2 years. The average preoperative knee score increased from 18.6 points (range, 3-29) to 82.8 points (range, 44-99). The average preoperative knee function score increased from 41.4 points (range, 20-60 points) to 75.8 points (range, 45-95 points). The average preoperative range of motion was 73.4 degrees with an average flexion contracture of 22.6 degrees, whereas the average postoperative range of motion increased to 92.2 degrees with an average flexion contracture of 5.6 degrees. Median consumption of coagulation factor concentrate decreased from 4837 U/month before operation to 1500 U/month 1 year after surgery. The total knee arthroplasty is a useful treatment in severe hemophilic arthropathy to obtain pain relief and functional improvement, and to reduce the need for ongoing treatment using coagulation factor concentrate.     

Experimental model of haemophilic arthropathy with high pressure haemarthrosis

Summary An experimental model of haemophilic arthropathy was developed in 12 growing dogs by anastomosing the popliteal artery to the joint cavity of the knee to produce haemarthrosis under considerable pressure. The dogs were sacrificed at intervals of one to eight weeks and the morphological and radiological changes found in the specimens mimicked those occurring in haemophilic arthropathy. In some of the animals total destruction of the articular cartilage and subchondral bone occurred. The significance of a high pressure haemarthrosis is discussed in relation to the development of changes found in haemophilic arthropathy.

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Résumé Un modèle expérimental d'arthropathie hémophilique a été réalisé chez 12 jeunes chiens en anastomosant l'artère poplitée à l'articulation du genou de façon à produire une hémarthrose sous une très importante tension. Les chiens ont été sacrifiés à des intervalles de une à huit semaines. Les modifications macroscopiques et radiologiques découvertes étaient tout à fait comparables à celles que l'on observe dans les arthropathies hémophiliques. Quelques animaux présentaient même une destruction complète du cartilage articulaire et de l'os sous-chondral. L'auteur discute la signification d'une hémarthrose sous forte tension et sa relation avec la survenue des altérations caractéristiques de l'arthropathie hémophilique.