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

Abstract

Introduction Haemophilic arthropathy (osteoarthritis secondary to haemophilia) of the ankle may result in painful hindfoot malalignment. Purpose 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. Methods The study included 163 patients with haemophilia, all of them over 16 years 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 6 months by means of the AOFAS Ankle‐Hindfoot Scale. Results 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. Conclusion 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.

Commentary on the paper: “Hindfoot malalignment in adults with haemophilic ankle arthropathy: The importance of early detection and orthotic treatment”

“…The publication by De la Corte‐Rodriguez et al is the first publication highlighting the importance of early recognition of hindfoot malalignment and early conservative treatment. In their study with 163 patients, 59.5% presented with a concomitant hindfoot deformity with valgus malalignment being the most common deformity . The treatment of haemophilic ankle arthropathy remains controversial and includes conservative and surgical treatment options.…”

“…While the paper by De la Corte‐Rodriguez et al substantially contributed to a better understanding of the impact of hindfoot malalignment in patients with haemophilic ankle arthropathy, it also has some limitations. One of the major limitations is that the malalignment of patients in their study was assessed clinically and not radiographically .…”

“…While the paper by De la Corte‐Rodriguez et al substantially contributed to a better understanding of the impact of hindfoot malalignment in patients with haemophilic ankle arthropathy, it also has some limitations. One of the major limitations is that the malalignment of patients in their study was assessed clinically and not radiographically . It has been demonstrated in several publications that the clinical assessment of hindfoot alignment is often incorrect and underestimates the underlying deformity (Figure ) .…”

“…In their study with 163 patients, 59.5% presented with a concomitant hindfoot deformity with valgus malalignment being the most common deformity. 7 The treatment of haemophilic ankle arthropathy remains controversial and includes conservative [8][9][10][11] and surgical 12 treatment options. Surgical treatment options incorporating advanced arthropathy can be divided into two major groups -joint preserving and joint non-preserving procedures.…”

“…One of the major limitations is that the malalignment of patients in their study was assessed clinically and not radiographically. 7 It has been demonstrated in several publications that the clinical assessment of hindfoot alignment is often incorrect and underestimates the underlying deformity ( Figure 1). 15,16 De Cesar Netto et al 16 (Figure 2).…”