Haemophilic Ankle Arthropathy Research Articles

Self-myofascial Release With Foam Roller in Patients With Hemophilic Ankle Arthropathy

Self-myofascial Release With Foam Roller in Patients With Hemophilic Ankle Arthropathy

Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy.

Haemophilic ankle arthropathy may cause joint bleeding, pain, stiffness, erosion and progressive motion limitations, including a decreased range of motion (ROM) secondary to anterior osteophyte impingement. The purpose of this study was to investigate changes in the ROM and symptoms after synovectomy and anterior osteophyte resection for haemophilic ankle arthropathy. We retrospectively reviewed 41 ankles in 35 patients with haemophilic arthropathy who underwent arthroscopic and/or open synovectomy. The mean follow-up period was 59.5months. Indications for the procedure included a lack of improvement with conservative management, and the presence of haemarthrosis and arthralgia. We assessed radiographic images, ankle joint range of motion, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and patients' subjective satisfaction preoperatively and at the last follow-up. Arthroscopic synovectomy was performed in 32 ankles, open synovectomy in 6, and arthroscopic synovectomy with additional mini-open debridement in 3. Ankle dorsiflexion improved from a mean of 2.7° preoperatively to a mean of 7.5° at the final follow-up (P=0.003), whereas plantar flexion improved from a mean of 30.7° preoperatively to a mean of 32.7° at the final follow-up (P=0.276). The AOFAS score improved from 62.2 preoperatively to 79.1 at the final follow-up (P<0.001). Patient satisfaction was "excellent" in 11 ankles, "good" in 22, "fair" in 3 and "poor" in 5. Arthroscopic and/or open synovectomy with anterior osteophyte resection and early rehabilitation in adolescents and adults with haemophilic ankle arthropathy showed improved ankle dorsiflexion and AOFAS scores.

Hindfoot malalignment in adults with haemophilic ankle arthropathy: The importance of early detection and orthotic treatment.

Haemophilic arthropathy (osteoarthritis secondary to haemophilia) of the ankle may result in painful hindfoot malalignment. To analyse hindfoot alignment in subjects with haemophilic arthropathy of the ankle and evaluate the response (improvement of pain, function and alignment) to the orthotic treatment prescribed in patients with malalignment. The study included 163 patients with haemophilia, all of them over 16years of age. Hindfoot alignment and footprint were analysed in patients with and without haemophilic arthropathy of the ankle (as determined by the Pettersson score). Response to the use of an orthosis was evaluated at 6months by means of the AOFAS Ankle-Hindfoot Scale. Fifty-six (59.5%) patients with haemophilic arthropathy presented with concomitant hindfoot malalignment. The most common abnormality was a valgus alignment combined with a neutral footprint. In 14 cases, valgus was associated with a pes planus or a pes cavus. Only 5 patients without haemophilic arthropathy (7.2%) presented with some form of malalignment. The differences between the groups were statistically significant. The probability of having malalignment increased with the degree of arthropathy. Patients with haemophilic arthropathy and malalignment were treated with an orthosis, with insoles as the most commonly used alternative (86%). Such treatment significantly improved patients' pain and function-related scores on the AOFAS Ankle-Hindfoot Scale. Given the high rates of valgus malalignment in subjects with haemophilic arthropathy of the ankle, and the good response rates obtained following individualised orthotic treatment, it seems reasonable to routinely evaluate hindfoot alignment in this group of patients.

Role of Arthroscopic Debridement of Hemophilic Ankles.

Arthroscopic debridement has been used in the treatment of early stages of hemophilic ankle arthropathy. The aim of this procedure is to alleviate pain, improve function, and diminish bleeding episodes. Evaluation of patient-reported outcomes of arthroscopic debridement for hemophilic ankle arthropathies was evaluated in this study. Fifteen patients with hemophilia who had undergone arthroscopic debridement between 2008 and 2017 were included in this study. Preoperative American Orthopaedic Foot & Ankle Society Score (AOFAS) and Foot Function Index (FFI) with its subscales were obtained. Patient-reported outcome was measured using FFI at the latest follow-up. Radiologic severity of hemophilic arthropathy was assessed with the Pettersson score. Preoperative and postoperative intraarticular bleeding frequencies of the hemophilic patients were compared. Patients experienced statistically significant improvements of FFI and its subscales. Median preoperative FFI scores dropped from 42.2% to 22.2% postoperatively. Median value for the Pettersson score was 3. Annual median bleeding frequency of the study group was 18 preoperatively and 1.5 postoperatively ( P = .002). By assessing patient-reported outcomes, pain and functional restrictions associated with hemophilic ankle arthropathy were improved following arthroscopic debridement. By means of subjective measures, this procedure was effective. Level IV, retrospective case series.

Postural control during a transition task in haemophilic children, adolescents and young adults with haemophilic ankle arthropathy.

The aim of this study was to determine whether young haemophilic boys with and without MRI-based signs of ankle arthropathy demonstrate reduced balance ability during a transition task with eyes open and eyes closed. Thirty-four haemophilic bodies and 28 typically developing boys aged 6-20years participated to this study. Structural integrity of the tarsal foot joints of all haemophilic boys was assessed with MRI. All participants performed a standard transition task from double-leg stance to single-leg stance with eyes open and eyes closed. Comparison of balance features derived from the centre of pressure displacement captured by a single force platform was performed between the different haemophilia subgroups and sex-age-height matched peers. The haemophilic boys without signs of arthropathy presented only a higher intermediate phase velocity during the eyes closed condition (P=.05). The haemophilic boys with signs of arthropathy had significantly higher displacement after the time to new stability point, and 95% Ellipse Sway Area and Balance Area compared to their matched peers during eyes open test (P<.05). Similar findings were observed during the eyes closed test for the displacement after the time to new stability point and 95% Ellipse Sway Area (P<.05). No significant differences were observed between affected and non-affected side of the unilateral affected patients. We suggest that the pathophysiological cascade associated with chronic bleeding episodes should not be considered as a "simple" musculoskeletal injury, hence more as a complex neurophysiological dysfunction which may originate both from unilateral and bilateral deterioration of the musculoskeletal system.

Assessment of passive musculoarticular ankle stiffness in children, adolescents and young adults with haemophilic ankle arthropathy.

To measure passive musculoarticular ankle stiffness (PMAAS) and its intra- and interday reliability in adult control subjects without ankle disorders. We also sought to quantify PMAAS in children, adolescents and young adults with haemophilia (CAAwH) taking into account the accurate tibiotalar and subtalar joints structural status obtained by magnetic resonance imaging (MRI). We included 23 CAAwH and 23 typically developing boys (TDB) matched by age, weight and height, along with 25 healthy volunteers for reliability assessment. All CAAwH underwent bilateral ankle MRI, with anatomical status assessed using the International Prophylaxis Study Group MRI scale. All CAAwH underwent PMAAS testing for both sides randomly vs the dominant side (DS) in TDBs. For assessing viscous stiffness (VS) and elastic stiffness (ES), eight different oscillation frequencies were randomly repeated three times for each subject. Good-to-excellent intra- and interday reliability was observed for ES and VS variables. No relevant differences were observed between the ankle viscoelastic properties in CAAwH without joint damage and matched TDBs, whereas the study revealed significantly increased ES in the affected ankles of CAAwH with severe unilateral joint involvement compared to the non-affected joint. This study confirmed increased ES in the severely affected ankles of CAAwH compared to non-affected sides. No differences in the ankle viscoelastic properties of CAAwH with or without joint damage were observed, however, compared to matched TDB.

Safety of fascial therapy in adult patients with hemophilic arthropathy of ankle. A cohort study

BackgroundHemophilic arthropathy is characterized by loss of function and chronic pain. Fascial therapy mobilizes the connective tissue, intervening in the state of the injured fascial complex and the surrounding tissues. ObjectivesThe aim of this study is to evaluate the safety of a physiotherapy program through fascial therapy in adult patients with hemophilic ankle arthropathy. DesignProspective cohort study. MethodsTwenty-three adult patients with hemophilia from 26 to 65 years of age were recruited. The intervention consisted of three sessions of 45-minute fascial therapy for three consecutive weeks. An evaluation was carried out before as well as after treatment. The study variables were joint status (assessed with Hemophilia Joint Health Score), joint pain (using visual analogue scale), ankle range of motion (with a universal goniometer) and bleeding frequency (administering self-registration of bleeding). The mean difference was calculated using the Student's t-test for paired samples and using the Cohen formula we calculated the effect size of the dependent variables. ResultsNone of the patients developed muscular or articular bleeding during the treatment period. After treatment, significant improvements (p < 0.05) in plantar flexion, ankle pain under load and joint condition were observed in both ankles. Similarly, we found improvement in left ankle dorsiflexion. ConclusionsThe application of physiotherapy through fascial therapy does not appear to produce muscle or joint hemorrhages. A treatment through three sessions of fascial therapy may improve joint pain, mobility and joint ankle condition in patients with hemophilic arthropathy.

Mid- to long-term results of total ankle replacement in patients with haemophilic arthropathy: A 10-year follow-up.

Haemophilic ankle arthropathy is caused by recurrent spontaneous joint haemorrhaging and leads to pain, deformity and loss of function. In the presence of advanced articular deterioration, therapeutic options are confined to either arthroplasty or arthrodesis, the latter still being referred to as the procedure of choice. However, total ankle replacement (TAR) has recently gained acceptance as an alternative. To investigate the mid- to long-term results of TAR in haemophilic ankle arthropathy. Seventeen TARs in 14 male patients (mean age: 43years [range, 27.4-57.6]), implanted between 1998 and 2012, were retrospectively analysed. Implant survival was estimated using Kaplan-Meier analysis. Haemophilic/viral status, complications and revision surgeries were recorded. Follow-up assessment of 12 TARs was performed 9.6years (range, 3.3-17.8) postoperatively, including clinical examination, pain and satisfaction scales, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and the SF-36. Radiographic evaluation of pre- and follow-up radiographs was conducted. Estimated implant survival was 94% at 5, 85% at 10 and 70% at 15years, respectively. Three cases required revision surgery. At follow-up, 9.6years (range, 3.3-17.8) postoperatively, the level of satisfaction was 76% (range, 50-100) and of pain 2/10 (range, 0-6) on the VAS. Range of motion had increased significantly (P=.037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot score averaged 81 points (range, 73-90). All radiographs revealed component loosening or periprosthetic radiolucency. Total ankle replacement in the presence of advanced haemophilic arthropathy is a viable treatment option with favourable mid-/long-term results, maintaining mobility of the ankle joint.

Management of Hemophilic Arthropathy of the Ankle.

Hemophilic arthropathy (HA) of the ankle is prevalent in people with hemophilia (PWH). It is frequently severe and incapacitating, due to recurrent bleeding into the ankle articulation during infancy. Around 50% of hemophilic patients suffer from ankle pain and radiological signs of HA. To review current treatment of HA of the ankle in PWH. A literature review of hemophilic ankle arthropathy in PWH was performed utilizing MEDLINE (PubMed) and the Cochrane Library. Primary hematologic prophylaxis could keep away from the development of ankle HA if the level of the patient's deficient factor is prevented from dropping below 1% of normal. Recurrent articular bleeding can be prevented by the intravenous infusion of clotting factor concentrates (prophylaxis). Major articular bleeds and chronic hemophilic synovitis should be managed fiercely to prevent ankle HA. In the circumstance of advancing articular involvement, some noninvasive and invasive procedures can procure symptomatic mitigation and ameliorate the patient's function and quality of life. The ideal treatment for the hemophilic ankle when hematologic prophylaxis fails includes physical medicine and rehabilitation, orthoses, radiosynovectomy, arthroscopic ankle debridement (in the initial stages of cartilage degeneration), and ankle distraction, ankle fusion or total ankle replacement (in advanced stages of cartilage degeneration).

Mid- to Long-Term Results of Total Ankle Replacement in Patients with Hemophilic Arthropathy

Category: Ankle Arthritis Introduction/Purpose: Hemophilia is a rare hematological disease associated with spontaneous joint hemorrhaging causing hemophilic arthropathy. Symptoms comprise joint pain and deformity, paired with loss of function. In the presence of advanced joint deterioration, therapeutic options are confined to either arthroplasty or arthrodesis. For the ankle, the latter is still referred to as the procedure of choice. However - in light of its capacity to reduce pain while preserving ankle motion - total ankle replacement (TAR) has recently gained acceptance as an alternative. The aim of this study was to investigate the mid- to long-term results of TAR in hemophilic ankle arthropathy. Methods: Seventeen TARs were implanted between 1998 and 2012 (mean age: 43 years). Preoperative demographic and disease specific data, complications and revision surgeries were recorded. With a mean follow-up of 9.3 years (range, 2.2-17.8) implant survival was estimated using Kaplan-Meier analysis. Follow-up assessment of 12 TARs was performed after 9.6 years (5 lost to follow-up). Satisfaction and pain scales, the AOFAS hindfoot-score, and the SF-36 were obtained to assess clinical outcome. Radiographic evaluation of pre- and follow-up radiographs was conducted. Results: Three cases (17.6%) had undergone TAR removal secondary to loosening at an average interval of 7.5 years. The estimated implant survival was 94% at 5, 85% at 10, and 70% at 15 years (95% CI, 11.9-17.7). The mean estimated implant survival was 14.77 years (95% CI, 11.9-17.7). The mean level of satisfaction was 76%, and of pain 2/10 (VAS). ROM had increased significantly (p=0.037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot-score averaged 81/100 points. Conclusion: TAR is a viable treatment option for advanced hemophilic ankle arthropathy. Based on the herein presented follow- up, implant survival compares to that of non-hemophilic populations. Clinical mid- to long-term results are favorable. However, the majority of follow-up radiographs revealed component loosening and/or periprosthetic lucency. Considering the study population’s young age and specific risk factors, need for revision surgery secondary to symptomatic component loosening may arise.

Arthroscopic debridement for advanced haemophilic ankle arthropathy

Arthroscopic debridement for advanced haemophilic ankle arthropathy

Deficits of ankle muscle strength not found in children, adolescents and young adults with haemophilic ankle arthropathy.

Adequate management of haemophilia patients requires early detection of joint impairment in relatively asymptomatic patients. This study sought to quantify the impact of the ankle's structural impairment on muscle strength in children, adolescent and young adults with haemophilia (CAAwH). Twenty-three CAAwH underwent bilateral magnetic resonance imaging (MRI) assessing the anatomical status of tibiotalar joint (TTJ) and subtalar joint (STJ) using the International Prophylaxis Study Group MRI scale. An isokinetic dynamometer enabled a detailed evaluation of muscle strength at slow and fast speed. In parallel, 10 typically developing healthy boys (TDB) participated in a 1-week interval test-retest assessment to assess the test's reliability. Forty-six MRI ankle scores were obtained, with 11 patients unilaterally affected and one bilaterally. Of the 13 affected feet, nine showed abnormalities at TTJ, three at the posterior STJ and the remaining one at both joints. Muscle strength was not reduced in CAAwH exhibiting TTJ and/or STJ arthropathy, as compared to healthy TDB, nor was there any difference between the CAAwH's affected or unaffected sides. Contrarily to adult patients, CAAwH with repeated ankle bleeding may be less impaired than current structural evaluations imply, with possibly a latency between the occurrence of structural and functional damage.

Total ankle replacement in patients with haemophilic arthropathy: primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty.

There are two general surgical approaches for operative treatment of end-stage haemophilic ankle arthropathy: ankle arthrodesis and total ankle replacement (TAR). The aim of this study was to determine intraoperative and postoperative complications and evaluate the mid-term clinical and radiographic outcomes of TAR in patients with haemophilic arthropathy. Fourteen patients with a mean age of 51.4 ± 10.2 years (range = 32.9-63.7) were treated for end-stage haemophilic ankle arthropathy. Nine procedures were primary arthroplasties, five procedures were conversions of painful ankle arthrodesis to TAR. The mean duration of follow-up was 5.8 ± 2.3 years (range = 2.0-9.2). Component stability and alignment was assessed with weight-bearing radiographs. Clinical assessment was performed. One patient sustained an intraoperative medial malleolar fracture. In two patients, delayed wound healing was observed. In one patient, open arthrolysis was performed due to painful arthrofibrosis. Both components were neutrally aligned. Visual analogue scale (VAS) significantly decreased from 8.5 ± 0.9 (range = 8-10) to 1.3 ± 1.6 (range = 0-6). Significant functional improvement including range of motion (ROM) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was observed. The summarized components of the SF-36 physical and mental outcomes score significantly improved at the latest follow-up. Complication rates and clinical/radiographic outcomes were comparable in patients with primary TAR and conversion of ankle arthrodesis to TAR. The mid-term results following TAR or a conversion procedure in patients with haemophilic arthropathy are encouraging. However, for postoperative success, access to an experienced, multidisciplinary team including a haematologist is mandatory.

Biomechanical markers and theoretical concepts related to haemophilic ankle and subtalar joint arthropathy: introducing the term 'haemophilic tarsal pan-arthropathy'.

Although regular factor replacement can reduce the incidence of joint bleeds and slow down the development of haemophilic arthropathy, the ankle joint remains particularly vulnerable even in children with haemophilia on primary or secondary prophylaxis and is now the primary joint affected. The heterogeneity in the pathoaetiology of haemophilic ankle arthropathy means that the functional consequences of early stage of ankle arthropathy are difficult to define as early morphological and structural changes can be observed in clinically asymptomatic ankles. In this context, understanding biomechanics of the normal and arthritic foot is complex and difficult to quantify unless considering the foot as multiple functional segments using more sophisticated assessment tools such as multisegment foot models. However, this understanding can undoubtedly aid in the analysis of an underlying clinical problem and provide a strategic basis for a more optimal management. The purpose of this narrative review was firstly to revise information on the anatomy and biomechanics of the foot and ankle. Finally, related biomechanical markers of human motor performance, which are potentially implicated in the development of haemophilic ankle arthropathy, will be discussed based on published literature and expert opinion. Searches in published literature were limited to the year 2000 onwards. Although the ankle (tibiotalar joint) is the most commonly affected joint, associated subtalar joint (SJT) involvement is often seen. This would therefore imply that an alternative phraseology might be better. In this context, the authors propose the use of 'haemophilic tarsal pan-arthropathy' (HTPA) which encompasses both tibiotalar and subtalar joints.

Surgical procedures in patients with haemophilic arthropathy of the ankle.

In haemophilia, the ankle joint is one of the most common and earliest joints affected by recurrent bleeding, commonly resulting in end-stage ankle osteoarthritis during early adulthood. The surgical treatment of haemophilic ankle arthropathy is challenging. This review aims to highlight the literature addressing clinical outcomes following the most common approaches for different stages of haemophilia-induced ankle osteoarthritis: arthroscopic debridement, joint distraction arthroplasty, supramalleolar osteotomies, total ankle replacement, and ankle arthrodesis. A systematic literature review was performed using established medical literature databases. The following information was retrieved from the literature: patients' demographics, surgical technique, duration of follow-up, clinical outcome including pain relief and complication rate. A total of 42 clinical studies published between 1978 and 2015 were included in the systematic literature review. Eight and 34 studies had prospective and retrospective design, respectively. The most common studies were level IV studies (64.3%). The orthopaedic treatment of patients with haemophilic ankle osteoarthritis is often challenging and requires complete and careful preoperative assessment. In general, both joint-preserving and joint non-preserving procedure types can be performed. All specific relative and absolute contraindications should be considered to achieve appropriate postoperative outcomes. The current literature demonstrated that orthopaedic surgeries, with appropriate indication, in patients with haemophilic ankle arthropathy result in good postoperative results comparable to those observed in non-haemophiliacs. The surgical treatment should be performed in a setting with the ability to have multidisciplinary management, including expertise in haematology.

Hindfoot fusion in haemophilic arthropathy: 6-year mean follow-up of 41 procedures performed in 28 adult patients.

Haemophilic arthropathy of the ankle is rare disorder caused by recurrent haemarthorses beginning in early adulthood. Our aim was to evaluate the fusion rate of various techniques of hindfoot fusion using internal fixation for the treatment of haemophilic arthropathy of the hindfoot. We have evaluated the fusion rate of various techniques of hindfoot (tibiotalar and subtalar joints) fusion for the treatment of haemophilic arthropathy of the hindfoot. Twenty-eight patients underwent a total of 41 procedures. Thirty-four ankle (tibiotalar) fusions were performed, seven were done arthroscopically, six using a minimal access approach and 21 with an open approach. There were two isolated subtalar fusions, three combined tibiotalar and subtalar fusions, one of which included a talonavicular fusion at the second operation. There was one peritalar ankle fusion (tibiotalar, subtalar and talonavicular). The mean age at operation was 40.3years (SD, 12.3; range, 18.7-65.7years). The mean time to last follow-up was 77months (SD, 50.4; range, 7-190). The overall non-union rate was 9.7%. All non-unions occurred in tibiotalar fusions (there were no non-unions in cases of subtalar or talonavicular fusion). A single deep infection (2.4%) occurred in an arthroscopically fused ankle. The revision rate was 4.8% (2 cases) and was carried out for non-unions. Both revisions were successful. Hindfoot arthrodesis in patients with haemophilic ankle arthropathy provides a high fusion rate with few complications. Arthroscopic tibiotalar fusion did not result in shorter hospital stays. Revision surgery for the haemophilic hindfoot is successful, and fusion of the entire hindfoot can be achieved without complications.

Osteochondral repair in hemophilic ankle arthropathy: from current options to future perspectives.

Young hemophilic patients are frequently affected by ankle arthropathy. At the end stage of the disease, the current treatments are arthrodesis and arthroplasty, which have significant drawbacks. Validated procedures capable of slowing down or even arresting the progression towards the end stage are currently lacking. This review aims to discuss the rationale for and feasibility of applying, in mild hemophilic ankle arthropathy, the main techniques currently used to treat osteochondral defects, focusing in particular on ankle distraction, chondrocyte implantation, mesenchymal stem cell transplantation, allograft transplantation and the use of growth factors. To date, ankle distraction is the only procedure that has been successfully used in hemophilic ankle arthropathy. The use of mesenchymal stem cells have recently been evaluated as feasible for osteochondral repair in hemophilic patients. There may be a rationale for the use of growth factors if they are combined with the previous techniques, which could be useful to arrest the progression of the degeneration or delay end-stage procedures.

Treatment of Hemophilic Ankle Arthropathy with One-Step Arthroscopic Bone Marrow-Derived Cells Transplantation.

ObjectiveAnkle arthropathy is a frequent and invalidating manifestation of hemophilia. Arthrodesis is the gold standard surgical procedure in end-stage disease, with many drawbacks in young patients. Recent literature has shown increase interest in regenerative procedures in hemophilic arthropathy, which may be desirable to delay or even avoid arthrodesis. The aim of this article is to present five cases of osteochondral lesions in ankle hemophilic arthropathy treated with a regenerative procedure: bone marrow–derived cells transplantation (BMDCT).DesignWe report five hemophilic patients (four cases with hemophilia type A; one case with hemophilia type B) who have undergone BMDCT treatment, synovectomy, and arthroscopic debridement, with the use of autologous platelet-rich fibrin, to treat osteochondral lesions in hemophilic ankle arthropathy. The patients, included within this retrospective study, were clinically and radiologically evaluated with serial follow-ups, using the American Orthopaedic Foot and Ankle Society (AOFAS) scores, radiographs, and magnetic resonance imaging (MRI).ResultsThe mean preoperative AOFAS score was 35. After a mean follow-up of 2 years, the mean postoperative AOFAS score was 81, which included three patients returning back to sporting activities. The MRI Mocart score demonstrated signs of regeneration of chondral and bony tissue. No progression of joint degeneration was shown radiographically.ConclusionBMDCT is a promising regenerative treatment for osteochondral lesions in mild ankle hemophilic arthropathy, which may be useful to delay or even avoid ankle arthrodesis. Nevertheless, longer follow-ups and a larger case series are required.

Productive plasmapheresis by Nigale NGL XJC 2000: quality controls on plasma collected

Methods: We report a case study of a patient, 26 year old, with severe hemophilia A. The patient, a physical education’s university student, because hemophilic arthropathy of the right ankle, had difficulty to carry out the physical activity required by his course of study, despite being a prophylaxis regimen. MRI (magnetic resonance imaging) of the ankle showed the following: Outbreak chondromalacia (grade II/III) borne by tibial limiting of tibial–astragalus joint and the talar dome on the medial side; similar but smaller entities’ framework borne by the calcaneal articular surface of the talocalcaneal joint. Fair inflammatory thickening of the tibial–talar sinovial tissue. Deformed appearance of the talar dome. Tenosynovitis of tibialis anterior tendon. We used a therapeutic protocol consisting of a cycle of three infiltrations of PRG at weekly intervals (7/10 days), for a total of about 12ml (about 4ml per infusion). The intraarticular infiltration, ultrasonography-guided, is conducted, after intravenous infusion of recombinant FVIII concentrate, following careful disinfection of the skin, with the patient in the supine position and the ankle to be treated flexed in neutral position. Results: After three infusions the patient obtained a clear decrease in pain and an improvement in joint function. There was a significant reduction in articular Pettersson Score which passed from 7 to 3. Conclusions: Our work is a pilot study on the use of PRG in joints affected by hemophilic arthropathy; the preliminary data provide an excellent starting point for further development of the technique with possible applications also in other anatomical districts.

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±7years, range, 37-59) were evaluated at a mean follow-up of 3.0years (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.