Orthopaedic management of haemophilia arthropathy of the ankle

Abstract

Summary. Joint bleeding, or haemarthrosis, is the most common type of bleeding episode experienced by individuals with haemophilia A and B. This leads to changes within the joints, including synovial proliferation, which results in further bleeding and chronic synovitis. Blood in the joint can also directly damage the cartilage, and with repeated bleeding, there is progressive destruction of both cartilage and bone. The end result is known as haemophilic arthropathy. The joints most commonly affected are the knees, elbows and ankles, although any synovial joint may be involved. In the ankle, both the tibiotalar and subtalar joints may be affected and joint bleeding and arthropathy can lead to a number of deformities. Haemophilic arthropathy can be prevented through regular factor replacement prophylaxis and implementing physiotherapy. However, when necessary, there are multiple surgical and non‐surgical options available. In early ankle arthropathy with absent or minimal joint changes, both radioisotopic and chemical synoviorthesis can be used to reduce the hypertrophied synovium. These procedures can decrease the frequency of bleeding episodes, minimizing the risk of articular cartilage damage. Achilles tendon lengthening can be performed, in isolation or in combination with other surgical measures, to correct Achilles tendon contractures. Both arthroscopic and open synovectomies are available as a means to remove the friable villous layer of the synovium and are often indicated when bleeding episodes cannot be properly controlled by factor replacement therapy or synoviorthesis. In the later stages of ankle arthropathy, other surgical options may be considered. Debridement may be indicated when there are loose pieces of cartilage or anterior osteophytes, and can help to improve the joint function, even in the presence of articular cartilage damage. Supramalleolar tibial osteotomy may be indicated in patients with a valgus deformity of the hindfoot without degenerative radiographic findings. Joint fusion, or arthrodesis, is the treatment of choice in the advanced stages of ankle arthropathy although total ankle replacement is currently available. Early ankle replacement components were associated with a poor outcome, but as implant designs have improved, there have been successful outcomes achieved. As the ankle is a commonly affected joint in many individuals with haemophilia, it is important to add to the knowledge base to validate indications and timing of surgical and non‐surgical interventions in ankle arthropathy.

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

“…As mentioned previously, ankle arthrodesis puts strain on the adjacent joints, most commonly the subtalar joint and thus can contribute to their deterioration . TAR may prevent the transfer of such stresses .…”

Estimation of tensile properties of the Achilles tendon in haemophilic arthropathy of the ankle: case study

“…1) are higher than those reported in the literature [6,7], both in healthy subjects and in subjects with Achilles tendinopathy [4]. Regarding the high hysteresis and stiffness values found in HP, this relationship is controversial, for example, there has been an inverse relationship between the hysteresis and stiffness [1,6], this means that low percentage of hysteresis are related to high values of stiffness, however, this relationship was not observed in other studies [10].…”

Total ankle replacement in patients with von Willebrand disease: mid‐term results of 18 procedures

“…However, VWD is a known reason for haemophilic arthropathy. ankle arthrodesis, TAR) [15,29,[55][56][57][58][59][60][61][62][63]. Sood et al [8] described similarity in joint function limitations in patients with Type 3 VWD and moderate haemophilia A.…”