A. C. Strauss

Total ankle replacement in patients with haemophilia and virus infections--a safe alternative to ankle arthrodesis?

Despite reliable results of ankle fusion for advanced haemophilic arthropathy, total ankle replacement (TAR) may be functionally advantageous. There is only very limited literature data available on TAR in patients with haemophilia. The objective of this study is to evaluate the short‐ and mid‐term results after TAR in patients with end‐stage haemophilic ankle arthropathy and concomitant virus infections. In a retrospective study, results after eleven TAR in 10 patients with severe (n = 8) and moderate (n = 2) haemophilia (mean age: 49 ± 7 years, range, 37–59) were evaluated at a mean follow‐up of 3.0 years (range, 1.2–5.4). Nine patients were positive for hepatitis C, five were HIV‐positive. Range of motion (ROM), AOFAS‐hindfoot‐score, pain status (visual analogue scale, VAS) as well as patient satisfaction were evaluated. In two cases deep prosthesis infection occurred leading to the removal of the implant. In the remaining eight patients the mean AOFAS score improved significantly from 21.5 to 68.0 points (P < 0.0005), the VAS score decreased significantly from 7.6 to 1.9 points (P < 0.0005). ROM increased from 23.2 to 25.0 degrees (P = 0.51). At final follow‐up all patients without any complications were satisfied with the postoperative results. Radiographic examination did not reveal any signs of prosthetic loosening. TAR is a viable surgical treatment option in patients with end‐stage ankle osteoarthritis due to haemophilia. It provides significant pain relieve and high patient satisfaction. However, due to the increased risk of infection and lack of long‐term results, TAR particularly in patients with severe haemophilia and virus infections should be indicated carefully.

MALDI imaging of predictive ferritin, fibrinogen and proteases in haemophilic arthropathy.

Arthropathy as a result of repeated joint bleeding is a severe complication in patients with haemophilia. In the evaluation of synovial tissue specimens, histology alone is non‐specific and there is considerable morphological overlap with other joint diseases. Formalin‐fixed paraffin‐embedded specimens are available in pathological institutes and can be studied to understand the pathogenesis of haemophilic arthropathy. A powerful technique to identify hundreds of proteins in a tissue section combining proteomics with morphology is imaging mass spectrometry (IMS). We determined whether matrix‐assisted laser desorption/ionization (MALDI) IMS can be used to identify and map protein signatures in the synovial tissue of patients with haemophilic arthropathy. MALDI IMS was applied to synovial tissue of six patients with haemophilic arthropathy. We detected several peaks predictive in mass with ferritin light (m/z 1608) and heavy chain (m/z 1345), alpha‐ (m/z 1071) and beta (m/z 1274) haemoglobin subunits, truncated coagulation factor VIII peptide (m/z 1502, 1176), beta‐ and gamma fibrinogen peptides (m/z 980, 1032, 1117 and 1683), and annexin A2 (m/z 1111, 1268, 1460, 2164). In addition, the distribution of these proteins in synovial tissue sections was demonstrated. MALDI IMS identified and mapped specific proteins in the synovial membrane of patients with haemophilic arthropathy known to be involved in the pathogenesis of other joint diseases. This technique is a powerful tool to analyse the distribution of proteins in synovial tissue sections.

Outcome after total knee arthroplasty in haemophilic patients with stiff knees

Advanced haemophilic arthropathy of the knee is associated with progressive joint stiffness. Results after total knee arthroplasty (TKA) in stiff knees are considered to be inferior compared to those with less restricted preoperative range of motion (ROM). There is only very limited data on the results of primary TKA in haemophilic patients with stiff knees.

RANK-ligand and osteoprotegerin as biomarkers in the differentiation between periprosthetic joint infection and aseptic prosthesis loosening

AIM To assess serum levels of RANK-ligand (RANKL) and osteoprotegerin (OPG) as biomarkers for periprosthetic joint infection (PJI) and compare their accuracy with standard tests. METHODS One hundred and twenty patients presenting with a painful total knee or hip arthroplasty with indication for surgical revision were included in this prospective clinical trial. Based on standard diagnostics (joint aspirate, microbiological, and histological samples) and Musculoskeletal Infection Society consensus classification, patients were categorized into PJI, aseptic loosening, and control groups. Implant loosening was assessed radiographically and intraoperatively. Preoperative serum samples were collected and analyzed for RANKL, OPG, calcium, phosphate, alkaline phosphatase (AP), and the bone-specific subform of AP (bAP). Statistical analysis was carried out, testing for significant differences between the three groups and between stable and loose implants. RESULTS All three groups were identical in regards to age, gender, and joint distribution. No statistically significant differences in the serum concentration of RANKL (P = 0.16) and OPG (P = 0.45) were found between aseptic loosening and PJI, with a trend towards lower RANKL concentrations and higher OPG concentrations in the PJI group. The RANKL/OPG ratio was significant for the comparison between PJI and non-PJI (P = 0.005). A ratio > 60 ruled out PJI in all cases (specificity: 100%, 95%CI: 89, 11% to 100.0%) but only 30% of non-PJI patients crossed this threshold. The positive predictive value remained poor at any cut-off. In the differentiation between stable and loose implants, none of the parameters measured (calcium, phosphate, AP, and bAP) showed a significant difference, and only AP and bAP measurements showed a tendency towards higher values in the loosened group (with P = 0.09 for AP and P = 0.19 for bAP). CONCLUSION Lower RANKL and higher OPG concentrations could be detected in PJI, without statistical significance.

Long-term outcome of total hip arthroplasty in patients with haemophilia.

Besides the target joints (elbow, knee and ankle), the hip is one of the commonly affected joints in haemophilic arthropathy. Hip arthroplasty is the therapy of choice after failure of conservative treatment. There are only limited data on long‐term results after primary total hip arthroplasty (THA).

Two-stage knee arthrodesis with a modular intramedullary nail due to septic failure of revision total knee arthroplasty with extensor mechanism deficiency

BACKGROUND Periprosthetic joint infection is a serious complication and reconstruction after failed revision total knee arthroplasty with significant bone loss and compromised soft-tissues can be challenging. Objective of this study was to assess clinical and functional results, implant survival and infection recurrence rates in patients treated with two-stage arthrodesis after failed revision TKA with extensor mechanism deficiencies due to PJI, and to identify the factors that affect outcomes after surgery. METHODS Thirty seven patients with PJI treated within a two-stage exchange and reimplantation of an arthrodesis nail between 2008 and 2014 were included. Systemic and local risk factors were graded preoperatively according to McPherson et al. All patients were treated according to a structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford Knee Score and the Visual Analogue Scale. RESULTS Thirty two of 37 patients (86.5%) were graded as free of infection. Five patients (13.5%) had recurrent infection after arthrodesis with the need of revision surgery. Mean leg-length discrepancy was 2.2cm. The mean VAS for pain was three, the mean Oxford Knee Score was 38±9. Total implant survival at a 74month follow-up was 74.3% (95% CI: 45.4 to 91.1%), as determined by Kaplan-Meier survival curves. Local McPherson Score, as well as number of revisions was found to be of significant influence to the survival rate. CONCLUSIONS Septic failure of revision knee arthroplasty can be effectively treated with two-stage arthrodesis using a modular intramedullary nail, providing a stable and painless limb with satisfactory functional results and acceptable infection eradication rates.

Two-year clinical results of patients with sacroiliac joint syndrome treated by arthrodesis using a triangular implant system

BACKGROUND Sacroiliac joint (SIJ) syndrome can cause various symptoms and may also be one reason for persistent low back pain, especially in patients with prior spinal fusions. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches have emerged recently providing a good alternative to conventional methods. A novel triangular implant system (iFuse) can achieve an arthrodesis of the SIJ without the use of additional screws or bone material. OBJECTIVE Aim of the present study was an evaluation of short-term safety and efficacy of the implant system. METHODS Twenty-four patients were included in the study and treated with the iFuse system. In addition to demographic data, pain intensity (visual analogue scale) and functional impairment (Oswestry-disability index) were assessed prior to surgery and 1 month, 3 months, 6 months, 12 months and 24 months thereafter. During surgery and the follow up period all adverse events were documented and the correct implant position was controlled via plain radiographs. RESULTS VAS scores and ODI improved significantly directly after surgery from 84.3 ± 9.2 mm to 40.7 ± 9.2 mm and from 76.8 ± 9.2% to 40.7 ± 9.2 % (p < 0.001). The ODI improved further to 31 ± 5.4% after 24 months whereas the VAS improved until the 3 months examination and ten stayed constant between 27.7 mm and 26.5 mm to 27 ± 6.6 mm at 24 months. No adverse events, intraoperative complications, implant malpositioning or loosening could be recorded at any time. CONCLUSIONS The iFuse system is an effective and safe treatment for minimally invasive surgical arthrodesis of the SIJ. Pain and functional impairment can be significantly improved. However, in addition to this case series, further controlled studies are necessary, particularly in terms of a previous spinal fusion history.

Falling and fall risk in adult patients with severe haemophilia

The objective of this study was to define fall rates and to identify possible fall risk factors in adult patients with severe haemophilia. PATIENTS, MATERIAL, METHODS 147 patients with severe haemophilia A and B were evaluated using a standardized test battery consisting of demographic, medical and clinical variables and fall evaluation. RESULTS 41 (27.9 %) patients reported a fall in the past 12 months, 22 (53.7 %) of them more than once. Young age, subjective gait insecurity and a higher number of artificial joints seem to be risk factors for falling. CONCLUSION Falls seem to be a common phenomenon in patients with severe haemophilia. Fall risk screening and fall prevention should be implemented into daily practice.

Elective total knee arthroplasty in haemophilic patients. Proposal for a clinical pathway.

UNLABELLED Total knee arthroplasty (TKA) provides significant pain relief and better function in patients with end-stage haemophilic knee arthropathy. Peri- and postoperative care tends to be more complex than in non-haemophilic patients undergoing TKA and requires a multidisciplinary team approach. AIM The implementation of standardized clinical pathways in non-haemophilic patients undergoing TKA has been shown to increase quality of care and to reduce postoperative complication rates. Consequently, the use of clinical pathways in haemophilic patients undergoing TKA may be beneficial to this particular subpopulation of patients. METHODS A clinical pathway for TKA for haemophilic patients was designed in a consensus process involving all participating departments. RESULTS We propose a specifically adjusted clinical pathway for TKA for haemophilic patients to show that standardization of elective orthopaedic surgery in haemophilia is feasible. CONCLUSION The authors emphasize that there are limitations on categorizing haemophilic patients and stress that individual interdisciplinary treatment should take precedence over a standardized approach.Total knee arthroplasty (TKA) provides significant pain relief and better function in patients with end-stage haemophilic knee arthropathy. Peri- and postoperative care tends to be more complex than in non-haemophilic patients undergoing TKA and requires a multidisciplinary team approach. Aim: The implementation of standardized clinical pathways in non-haemophilic patients undergoing TKA has been shown to increase quality of care and to reduce postoperative complication rates. Consequently, the use of clinical pathways in haemophilic patients undergoing TKA may be beneficial to this particular subpopulation of patients. Methods: A clinical pathway for TKA for haemophilic patients was designed in a consensus process involving all participating departments. Results: We propose a specifically adjusted clinical pathway for TKA for haemophilic patients to show that standardization of elective orthopaedic surgery in haemophilia is feasible. Conclusion: The authors emphasize that there are limitations on categorizing haemophilic patients and stress that individual interdisciplinary treatment should take precedence over a standardized approach.

Treatment options for haemophilic arthropathy of the elbow after failed conservative therapy. A single centre experience.

UNLABELLED After ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. The objective of this retrospective single centre study is to evaluate the results of treatment of elbow arthropathy after failed conservative therapy. PATIENTS, METHODS In 21 consecutive patients, 11 radiosynoviortheses (RSO), four arthroscopic and six open synovectomies were performed, among them four with additional resection of the radial head. The mean duration of follow-up was 4.8 (RSO) and 5.3 years (surgery), respectively. Pain status (visual analogue scale, VAS), bleeding frequency, range of motion (ROM) as well as patient satisfaction were evaluated. RESULTS Both, RSO and surgical synovectomy, achieved a significant reduction of pain and bleeding frequency (p < 0.05). Surgical synovectomies were associated with a marked yet not statistically significant increase of postoperative ROM. Radial head resection improved forearm rotation in all cases. No complications occurred. 20 out of 21 patients were satisfied or highly satisfied with the result of the treatment and would undergo the respective procedure again. CONCLUSION Due to the effectiveness and safety RSO is considered to be the primary treatment option in haemophilic arthropathy of the elbow after failed conservative therapy. Arthroscopic synovectomy should be considered if RSO shows inadequate effect or in the presence of contraindications. Open synovectomy with resection of the radial head yields good results in the case of advanced arthropathy with radial head impingement.After ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. The objective of this retrospective single centre study is to evaluate the results of treatment of elbow arthropathy after failed conservative therapy. Patients, methods: In 21 consecutive patients, 11 radiosynoviortheses (RSO), four arthroscopic and six open synovectomies were performed, among them four with additional resection of the radial head. The mean duration of follow-up was 4.8 (RSO) and 5.3 years (surgery), respectively. Pain status (visual analogue scale, VAS), bleeding frequency, range of motion (ROM) as well as patient satisfaction were evaluated. Results: Both, RSO and surgical synovectomy, achieved a significant reduction of pain and bleeding frequency (p < 0.05). Surgical synovectomies were associated with a marked yet not statistically significant increase of postoperative ROM. Radial head resection improved forearm rotation in all cases. No complications occurred. 20 out of 21 patients were satisfied or highly satisfied with the result of the treatment and would undergo the respective procedure again. Conclusion: Due to the effectiveness and safety RSO is considered to be the primary treatment option in haemophilic arthropathy of the elbow after failed conservative therapy. Arthroscopic synovectomy should be considered if RSO shows inadequate effect or in the presence of contraindications. Open synovectomy with resection of the radial head yields good results in the case of advanced arthropathy with radial head impingement.