Since 2001 we have performed 105 radioisotope synovectomy (RS) in 65 children and young adults, age ranging from 3 to 25 years with a average of 15 years in Ege University Hospital, Izmir, Turkey. One fourth of cases were below 10 years of age. All patients had severe haemophilia A and B. Ten patients (17 joints) had high responder inhibitor. We prefer to use Yttrium 90 for all joints (5 mCi for knees; 2 mCi for others). The knees were injected in 56 cases, elbows in 24 cases, ankles in 23 cases and shoulders in two cases. Steroid injections were not preferred as the principle drug of choice. Mean follow-up period after procedure was 2 years (range: 6 months to 3.5 years). All inhibitor patients had satisfactory results. The best results were obtained in elbows than knees and ankles. Excellent rates (no bleeding) were observed in grade-II synovitis 84% for knees, 93% for elbows and 50% for ankles. Because of the excellent and good response (bleeding reduction to 75%), rates were 100% for knees and elbows and 92% for ankles. In six cases, repeated injections were given at 6-month interval and all of them had good results. The grading of synovitis seems to be an important parameter than the age of the patient. Even in patients below 10 years of age, outcomes are not satisfactory in all joints with grade-III vs. grade-II synovitis (12% vs. 73%). No serious complications were observed during and after procedure except two cases. A mild and transient inflammatory reaction was observed in the ankle. There was a minimal radioisotope leakage to superficial skin in the elbow. RS seems to be a safe and effective treatment for chronic synovitis causing recurrent joint bleedings.

The tibial slope is essential in knee biomechanics, both for ligament function and knee kinematics. High tibial osteotomy (HTO) designed primarily to correct frontal plane malalignment in osteoarthritis of the knee joint can cause unintentional tibial slope changes. We evaluated tibial slope changes in 40 knees in patients with medial compartment osteoarthritis treated by dome-type HTO and external fixation on one side, and followed up for 55 months on average. Four different tibial slope measurement methods (anterior tibial cortex, proximal tibial anatomic axis, posterior tibial cortex, and proximal fibular anatomic axis) were used preoperatively and postoperatively on both sides. Patients were allocated into three groups according to their final frontal plane alignment of the knee joint (hypercorrection, normocorrection, and undercorrection groups) based on tibiofemoral anatomic axis angle. As a whole, preoperative slope values (11.2 degrees, 7.5 degrees, 5.6 degrees, and 8.2 degrees for the four methods, respectively) displayed a significant decrease postoperatively (on average 7.9 degrees, 4.8 degrees, 2.2 degrees, and 3.7 degrees, respectively). Patients with undercorrection (or recurrence of deformity) had a more remarkable decrease in slope than those with normocorrection or hypercorrection. The higher the degree of postoperative mechanical axis valgus, the higher the degree of posterior tibial slope that resulted. Sagittal plane changes after dome-type HTO basically decreasing the tibial slope should be taken into account for subsequent reconstructive procedures such as total knee arthroplasty.

This report evaluates the haemostatic efficacy of recombinant factor VIIa (rFVIIa) and activated prothrombin complex concentrate (APCC) in patients with haemophilia and high responding inhibitors who underwent major and minor surgery. Data pertaining to surgeries from 2001 to 2009 at a single centre were retrospectively analysed. During this period, 53 surgical procedures were performed in 30 haemophiliacs with high responding inhibitors. Mean age was 16.2±9.4 years. Eleven major surgeries in 4 patients, 41 radioisotope synovectomies (RS) and one circumcision classified as minor surgery in 28 patients were performed. Among the major surgery procedures, four were treated with rFVIIa, five with APCC and two with sequential use of APCC and rFVIIa. We used rFVIIa at the dosage of 80-120 μg kg(-1) every 2 h and APCC 100 IU kg(-1) every 12 h for the major surgery. When performing RS, we used rFVIIa in 18 patients with 26 target joints and APCC in 9 patients with 15 target joints. Three consecutive doses of rFVIIa (90 μg kg(-1) ) were used at 2-h intervals followed by additional three doses at 6-h intervals. The initial dose of APCC was 75 IU kg(-1) followed by a second and third dose of 50 IU kg(-1) at 12-h intervals. APCC and rFVIIa demonstrated excellent efficacy in our major and minor surgical interventions [100% (22/22) and 94% (31/33), respectively]. We had only two bleeding complications with rFVIIa. There were no thromboembolic complications. APCC and rFVIIa provide an effective and safe first line haemostatic therapy for inhibitor-positive haemophiliacs, allowing both major and minor surgery to be successfully performed.

We have performed 221 radioisotope synovectomy (RS) in more than 150 children and young adults with haemophilia, age ranging 3-30 years (mean 15) in Ege Hemophilia Center, Izmir, Turkey for last 7 years. We always preferred to use Yttrium 90 (Y(90)) for knees; however, since 2005, we started using rhenium 186 (Re(186)) for medium-sized joints with respect to safety. In this article, we have evaluated long-term experience ranging from 6 months to 3 years (mean 18 months) with Re(186) for elbows (n = 35), ankles (n = 26) and shoulders (n = 2) in total of 63 RS procedures for 49 patients. Their age range was 3-30 years and mean age was 15.5. Two mCi of Re(186) intra-articularly injected for treating target joints and chronical synovitis. After RS, joint bleedings were decreased for all patients. The best results were obtained for all joints in patients with grade-II synovitis as like earlier experience with Y(90). Excellent rates (no bleeding) were observed in grade-II synovitis in 81% and 46% for elbows vs. 86% and 57% for ankles after 6 months and after 1 year follow-up of patients, respectively. In grade-III synovitis, excellent rates were 53% and 25% for elbows and 44% and 29% for ankles, respectively. In five joints for five patients, repeated injections were needed for better outcome. No adverse events such as radioisotope leakage, local inflamatory reactions or malignancy development were observed during and after RS. For medium-sized joints, RS with Re(186) seems to be either effective or safe treatment method. Our results confirm those previously published by others on the value of Re(186) synoviorthesis in medium-sized joints in haemophilia patients. After this experience, we changed our protocol and we use Re(186) for all medium-sized joints for treating chronical synovitis.

To evaluate electrophysiological incidence and the type of peroneal nerve lesions seen after high tibial osteotomy we conducted an electrophysiological study (electromyography and nerve conduction velocity studies) in 11 patients who were suffering from medial gonarthrosis and treated by Maquet barrel-vault type high tibial valgization osteotomy. All the patients were tested both pre- and postoperatively. Every patient was examined postoperatively for a minimum of a 6 months after surgery to eliminate spontaneously reversible lesions. Results obtained from nonoperated legs served as controls. Three patients (27%) with peroneal nerve lesions were detected electrophysiologically; one had only motor involvement, one only sensory involvement, and one both motor and sensory involvement. Clinically only one of these patients was symptomatic, and the other two were detected by electrophysiological means. Peroneal nerve lesions which may be overlooked by mild weakness and hypesthesia in the early postoperative period can be detected by electrophysiological means at a higher rate than expected. These lesions persist a relatively long time and even can be permanent despite the absence of clinical symptoms.