Treatment options for haemophilic arthropathy of the elbow after failed conservative therapy

Summary

After ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. objective: 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 radiosyn-oviortheses (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.

Zusammenfassung

Neben dem oberen Sprung- und Kniegelenk ist das Ellenbogengelenk häufig von der hämophilen Arthropathie betroffen. Ziel der Studie ist, die eigenen Behandlungsergebnisse der Ellenbogengelenksarthropathie zu evaluieren und einen Behandlungsalgorithmus vorzuschlagen. Patienten, Material, Methoden: Anhand einer retrospektiven Untersuchung wurden die Behandlungsergebnisse von 21 konsekutiven Patienten evaluiert. Es wurden 11 Radiosynoviorthesen (RSO), vier arthroskopische und sechs offene Synovialektomien, darunter vier mit zusätzlicher Radiuskopfresektion durchgeführt. Der durchschnittliche Nachuntersuchungszeitraum betrug 4,8 Jahre nach RSO und 5,3 Jahre nach Operation. Es wurden die Parameter Schmerz (VAS-Score), Blutungsfrequenz, Bewegungsumfang (ROM) und die subjektive Patientenzufriedenheit bestimmt. Ergebnisse: Sowohl die RSO als auch die operativen Synovektomien führten zur signifikanten Reduktion von Schmerz und Blutungsfrequenz. Durch die operativen Eingriffe verbesserte sich die globale Gelenkfunktion tendenziell, während die Resektion des Radiuskopfes die Pro- und Supination signifikant verbesserte. Komplikationen traten in keinem Fall auf. 20 von 21 Patienten waren mit dem Behandlungsergebnis zufrieden oder sehr zufrieden und würden den jeweiligen Eingriff wiederholen lassen. Schlussfolgerung: Die RSO ist aufgrund ihrer Effektivität und Sicherheit bei konservativ therapieresistenter Synovialitis als primäre Therapieoption zu empfehlen. Bei unzureichender Wirkung ist eine arthroskopische Sy-novektomie zu erwägen, wobei wie bei der RSO keine wesentliche Funktionsverbesserung des Gelenks zu erwarten ist. Die isolierte offene Synovektomie sollte nur in Kombination mit arthroplastischen Eingriffen am Ellenbogengelenk, wie z.B. der Radiuskopfresektion, durchgeführt werden.

Keywords

Elbow - haemophilia - arthropathy - treatment

Schlüsselwörter

Ellenbogen - Hämophilie - Arthropathie - Behandlung

• References

• 1 Manco-Johnson MJ, Abshire TC, Shapiro AD. et al. Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med 2007; 357: 535-544.
• 2 Bajekal RA, Phillips AM, Ribbans WJ. Elbow arthropathy in haemophilia. JBJS Br 1996; 2 (Supp) 1: 15.
• 3 Malhotra R, Gulati MS, Bhan S. Elbow arthropathy in hemophilia. Arch Orthop Trauma Surg 2001; 121: 152-157.
• 4 Rodriguez-Merchan EC. Effects of hemophilia on articulations of children and adults. Clin Orthop Relat Res 1996; 328: 7-13.
• 5 Wallny T, Hess L, Seuser A. et al. Pain status of patients with severe haemophilic arthropathy. Haemophilia 2001; 07: 453-458.
• 6 Utukuri MM, Goddard N. Haemophilic arthropathy of the elbow. Haemophilia 2005; 11: 565-570.
• 7 Johnson RP, Babbitt DP. Five stages of joint disintegration compared with range of motion in hemophilia. Clin Orthop Relat Res 1985; 201: 36-42.
• 8 Pasta G, Mancuso ME, Perfetto OS, Solimeno LP. Radiosynoviorthesis in children with haemophilia. Hämostaseologie 2009; 29 (Suppl. 01) 62-64.
• 9 Rodriguez-Merchan EC. Haemophilic synovitis of the elbow: Radiosynovectomy, open synovectomy or arthroscopic synovectomy?. Thromb Res 2013; 132: 15-18.
• 10 Kamineni S, Adams RA, O’Driscoll SW, Morrey BF. Hemophilic arthropathy of the elbow treated by total elbow replacement. A case series. J Bone Joint Surg Am 2004; 86-A: 584-589.
• 11 Heim M, Beeton K, Blamey G, Goddard N. Management of the elbow joint. Haemophilia 2012; 18: 101-104.
• 12 White GC, Rosendaal F, Aledort LM. et al. Definitions in hemophilia. Recommendation of the scientific subcommittee on factor VIII and factor IX of the scientific and standardization committee of the International Society on Thrombosis and Haemostasis. Thromb Haemost 2001; 85: 560.
• 13 Silva M. Radial Head Excision and Synovectomy in Patients with HemophiliaSurgical Technique. J Bone Joint Surg Am Surgical Techniques 2008; 90 (Suppl. 02) 254.
• 14 Gilbert MS. Prophylaxis: musculoskeletal evaluation. Semin Hematol 1993; 30 (3 Suppl 2): 3-6.
• 15 Pettersson HH, Ahlberg AA, Nilsson IMI. A radiologic classification of hemophilic arthropathy. Clin Orthop Relat Res 1980; 149: 153-159.
• 16 Coughlin MJ. Arthrodesis of the first metatarsophalangeal joint with mini-fragment plate fixation. Orthopedics 1990; 13: 1037-1044.
• 17 Högh J, Ludlam CA, Macnicol MF. Hemophilic arthropathy of the upper limb. Clin Orthop Relat Res 1987; 218: 225-231.
• 18 Adams JE, Reding MT. Hemophilic arthropathy of the elbow. Hand Clin 2011; 27: 151-163.
• 19 Le Balc’h T, Ebelin M, Laurian Y. et al. Synovectomy of the elbow in young hemophilic patients. J Bone Joint Surg Am 1987; 69: 264-269.
• 20 Arnold WD, Hilgartner MW. Hemophilic arthropathy. Current concepts of pathogenesis and management. J Bone Joint Surg Am 1977; 59: 287-305.
• 21 Zulfikar B, Turkmen C, Kilicoglu O. et al. Longterm outcomes in haemophilic synovitis after radiosynovectomy using rhenium-186: a singlecentre experience. Haemophilia 2012; 19: 1-6.
• 22 Silva M, Luck JV, Siegel ME. 32P chromic phosphate radiosynovectomy for chronic haemophilic synovitis. Haemophilia 2001; 07 (Suppl. 02) 40-49.
• 23 Corte-Rodriguez Hde la, Rodriguez-Merchan EC, Jimenez-Yuste V. What patient, joint and isotope characteristics influence the response to radiosynovectomy in patients with haemophilia?. Haemophilia 2011; 17: e990-e998.
• 24 Dunn AL, Busch MT, Wyly JB. et al. Arthroscopic synovectomy for hemophilic joint disease in a pediatric population. J Pediatr Orthop 2004; 24: 414-426.
• 25 Journeycake JM, Miller KL, Anderson AM. et al. Arthroscopic synovectomy in children and adolescents with hemophilia. J Pediatr Hematol Oncol 2003; 25: 726-731.
• 26 Storti E, Traldi A, Tosatti E, Davoli PG. Synovectomy, a new approach to haemophilic arthropathy. Acta Haematol 1969; 41: 193-205.
• 27 Post M, Watts G, Telfer M. Synovectomy in hemophilic arthropathy. A retrospective review of 17 cases. Clin Orthop Relat Res 1986; 202: 139-146.
• 28 Greene WB. Synovectomy of the ankle for hemophilic arthropathy. J Bone Joint Surg Am 1994; 76: 812-819.
• 29 Verma N, Valentino LA, Chawla A. Arthroscopic synovectomy in haemophilia: indications, technique and results. Haemophilia 2007; 13 (Suppl. 03) 38-44.