Cartilage damage in the haemophilic joints: pathophysiology, diagnosis and management

Intra-articular bleeding affects the metabolism and repair of articular cartilage. Biomechanical data have shown that blood causes harmful effects on overall cartilage function under loading conditions. Therefore, haemophilic patients suffering a haemarthrosis should be subjected to blood aspiration (arthrocentesis) to prevent cartilage damage. MRI and ultrasonography have shown themselves to be excellent noninvasive tools for the evaluation of early cartilage damage that remains undetectable by conventional radiography in haemophilic patients. Prophylaxis with the deficient factor can prevent cartilage deterioration and reduce the incidence of joint haemorrhage in children with haemophilia. Radiosynovectomy has proved to be a highly effective procedure to decrease both the frequency and the severity of recurrent intra-articular bleeding episodes. Nowadays, the most usual surgical procedures for treating articular cartilage defects (cartilage repair) include abrasion chondroplasty, microfracture, mosaicplasty, autologous chondrocyte implantation (ACI), and matrix-induced ACI. In small defects (<2-4 cm(2)), ostechondral autograft or microfracture are the recommended options. In large defects (>2-4 cm(2)), ACI or osteochondral allograft are indicated. However, these techniques have not been applied in haemophilic patients because inflammatory conditions and advanced degenerative change (>50% joint space narrowing) are contraindications for cartilage repair. Thus, prevention of cartilage damage is paramount in haemophilia. The definitive remedy for advanced cartilage damage is either (knee or hip) replacement or (ankle) arthrodesis. Primary prophylaxis and radiosynovectomy are the best alternatives at our disposal to protect our patients against cartilage damage and arthropathy in haemophilic joints.     

The treatment of patellar tendinopathy

Background

Patellar tendinopathy (PT) presents a challenge to orthopaedic surgeons. The purpose of this review is to revise strategies for treatment of PT

Materials and methods

A PubMed (MEDLINE) search of the years 2002–2012 was performed using "patellar tendinopathy" and "treatment" as keywords. The twenty-two articles addressing the treatment of PT with a higher level of evidence were selected.

Results

Conservative treatment includes therapeutic exercises (eccentric training), extracorporeal shock wave therapy (ESWT), and different injection treatments (platelet-rich plasma, sclerosing polidocanol, steroids, aprotinin, autologous skin-derived tendon-like cells, and bone marrow mononuclear cells). Surgical treatment may be indicated in motivated patients if carefully followed conservative treatment is unsuccessful after more than 3–6 months. Open surgical treatment includes longitudinal splitting of the tendon, excision of abnormal tissue (tendonectomy), resection and drilling of the inferior pole of the patella, closure of the paratenon. Postoperative inmobilisation and aggressive postoperative rehabilitation are also paramount. Arthroscopic techniques include shaving of the dorsal side of the proximal tendon, removal of the hypertrophic synovitis around the inferior patellar pole with a bipolar cautery system, and arthroscopic tendon debridement with excision of the distal pole of the patella.

Conclusion

Physical training, and particularly eccentric training, appears to be the treatment of choice. The literature does not clarify which surgical technique is more effective in recalcitrant cases. Therefore, both open surgical techniques and arthroscopic techniques can be used.     

Intra-articular corticosteroid injections in haemophilic arthropathy: are they recommended?

Introduction: Intra-articular (IA) corticosteroid (CS) injections are commonly used in the treatment of osteoarthritis. However, they are rarely utilized in haemophilic arthropathy. In fact, the efficacy of this method in haemophilic arthropathy is frequently discussed and debated in clinical practice.

Aim: To investigate the effectiveness of IA CS injections in patients with painful haemophilic arthropathy.

Methods: A review of the literature on the topic was performed.

Results: In osteoarthritis, reports with a high level of evidence state that the efficacy of IA injections of CS is controversial. In haemophilic arthropathy, some low-level evidence reports seem to indicate that short-term pain alleviation can be achieved.

Conclusions: Considering that pain relief after IA injections of CS is controversial and that the cost of the haematologic treatment required to perform the procedure is high in haemophilic arthropathy, we do not recommend the routine use of CS IS injections in haemophilia. Moreover, point of care (POC) ultrasound (US)-guided injections are not advised, because the injection procedure is so simple that the use of POC-US will unnecessarily prolong the duration of the procedure.     

Surgical Treatment of Isolated Patellofemoral Osteoarthritis

Background

Isolated patellofemoral (PF) osteoarthritis (OA) affects 9% of persons older than 40 years. Nonoperative treatment should be exhausted fully before surgical treatment.

Questions/Purposes

The purpose of this article is to review the literature after 2008 with the aim of answering the following question: Which of the following surgical procedures has the highest survival rate and the lowest revision rate in advanced isolated PF OA: patellofemoral arthroplasty (PFA), total knee arthroplasty (TKA) or lateral facetectomy.

Methods

The search engine was MedLine. The keywords used were: PF OA and PFA. Three hundred and fifty-three articles were found between 2008 and 25 July 2013. Of those, only 23 were selected and reviewed because they were strictly focused on the topic and the question of this article.

Results

The types of studies reported so far have a low level of evidence (levels III and IV). Most of them are prospective case series (level IV). Some are systematic reviews of level III studies. Reported survival rate of lateral facetectomy is 85% at 5 years, 67% at 10 years and 47% at 20 years. Reported failure rate of lateral facetectomy is 26% at 10 years and 16% at 12 years. The reported average time of reoperation is 8 years and 37% of such procedures fail. Survival rate of PFA has been reported to be 87.5% on average (range, 60–100%). The revision rate of PFA is 20%. Recent improvements in PFA design have resulted in improvements in short-and medium-term results, similar to those of TKA.

Conclusions

There is still no gold standard for the surgical treatment of isolated PF OA. However, PFA or TKA appear to be the most recommendable treatment in cases that do not respond to conservative treatment.     

Hemophilic arthropathy

The most common clinical manifestation of hemophilia is arthropathy secondary to recurrent hemarthroses and chronic synovitis. Joint-surface erosions secondary to chronic synovitis often occur in early childhood and progress to advanced arthropathy by late adolescence. The knee, elbow, ankle, hip, and shoulder are the most commonly involved joints. Management of hemophilic arthropathy has advanced with the development of purified clotting factor concentrates and procedures to prevent chronic synovitis. Radiosynovectomy using beta particle-emitting radiocolloids has been effective in dramatically reducing the frequency of hemarthroses and resolving chronic synovitis. The most common surgical procedures used to manage hemophilic arthropathy are synovectomy, joint debridement, fusion, and joint arthroplasty. Late infection and arthrofibrosis complicate joint arthroplasty more often in these patients than in patients with other forms of arthritis. The high incidence of late infection may relate to frequent intravenous self-infusion of clotting factor combined with immune suppression. Despite the medical and surgical complexities of hemophilic arthropathy, orthopaedic procedures have a high incidence of patient satisfaction.     

Single Local Infiltration Analgesia (LIA) Aids Early Pain Management After Total Knee Replacement (TKR): An Evidence-Based Review and Commentary

Background

There is controversy in the literature regarding the role of single local infiltration analgesia (LIA) after total knee replacement (TKR).

Questions/Purposes

Is single LIA really efficient in controlling pain after TKR?

Methods

A Cochrane Library and PubMed (MEDLINE) search related to the justification LIA after TKR was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question.

Results

Two hundred ninety-nine articles were found until February 9, 2017, but only 27 were selected and reviewed because they were focused on clinical experience with LIA following TKR. Fifteen of them were considered level of evidence (I-II) while 12 had a lower level of evidence (III-IV). LIA reduced the amount of perioperative opioid administration and enabled adequate pain management in conjunction with oral medication without adverse effects. No clinically marked effects on the functional outcome after TKR were detected.

Conclusion

Single dose LIA provides effective analgesia in the initial postoperative period after TKR in most randomized clinical trials, systematic reviews, and meta-analyses.

     

The technique of synoviorthesis

Synoviorthesis (medical synovectomy) is a commonly utilized procedure employed in the management of recurrent intra-articular bleeds and secondary chronic synovitis in haemophilic patients. The procedure involves the intra-articular administration of an agent in order to induce fibrosis in the inflamed synovium so reducing the bleeding tendency. Such agents may either be chemical based (osmic acid, rifampicin) or radioactive (yttrium, gold or phosphorus). Whichever agent is employed care must be taken to avoid extra-articular complications (radiation burn and/or inflammatory reaction) as a result of extravasation or needle track contamination. The most frequently affected joints in haemophilia are the elbows, knees and the ankles, and to a lesser extent the shoulders and hips. This article outlines the techniques of injection of the five aforementioned joints, with details of the anatomical landmarks to perform the injections correctly. Injection of the elbows, knees and ankles may be carried out simply on an out-patient basis under local anaesthesia. However, it is advisable to perform injection of the shoulder or hip under radiographic control in order to ensure accurate placement. Very young children may require either sedation or a general anaesthetic. Strict asepsis is naturally a paramount requirement.     

Orthopaedic Problems about the Ankle in Hemophilia

Hemophilia is an inherited recessive, sex-linked bleeding disorder. The lack of sufficient coagulation factor VIII produces hemophilia A, and the lack of factor IX causes hemophilia B. The prevention and treatment of the disease requires intravenous infusion of the deficient factor. Hemophilic patients present with multiarticular joint degeneration (hemophilic arthropathy), secondary to recurrent hemarthroses. With the availability of deficient factors, hemophilic patients requiring elective ankle surgery can undergo such surgery with a high expectation of success. A thorough analysis of each case by a multidisciplinary team will increase the likelihood of successful surgical intervention in the hemophilic patient. Radiosynovectomy decreases both the frequency and the intensity of recurrent ankle bleeding episodes related to ankle synovitis. The general recommendation is that when 3 early consecutive radiosynovectomies (repeated every 6 months) fail to halt synovitis, arthroscopic synovectomy should be considered. For advanced hemophilic arthropathy of the ankle, the first alternative for treatment, in our opinion, is arthroscopic ankle debridement. In the most severe cases, we recommend either ankle arthrodesis or total ankle replacement. In every other case, we feel that the best therapy is prophylaxis and radiosynovectomy in order to avoid hemophilic synovitis and ankle arthropathy.