Possibilities and perspectives in orthopaedic treatment of articular changes related to inherited clotting factor deficiencies

Nawracające wylewy krwi do stawów w przebiegu wrodzonych osoczowych skaz krwotocznych nieuchronnie prowadzą do uszkodzenia stawów, a co za tym idzie — do znacznego upośledzenia ich funkcji i ostatecznie do kalectwa. W patogenezie uszkodzenia stawów główną rolę odgrywa bezpośredni toksyczny wpływ krwi, a szczególnie jonów żelaza, na chrząstkę stawową oraz przerost błony maziowej. Największe znaczenie w przeciwdziałaniu artropatii ma profilaktyka z wykorzystaniem koncentratów niedoborowych czynników krzepnięcia. Leczenie nieoperacyjne obecnej już artropatii polega na rehabilitacji. Jeżeli doszło do znacznego przerostu błony maziowej, częstość krwawień dostawowych może zmniejszyć synowektomia izotopowa. Jeśli destrukcja zajętych stawów jest zaawansowana, pozostaje leczenie operacyjne. W przypadku stawu kolanowego i biodrowego najczęściej polega ono na alloplastyce stawu. Jeśli chodzi o stawy skokowo-goleniowe, zwykle wykonuje się usztywnienie stawów, jednak próbuje się również wykonywać alloplastykę stawu skokowo-goleniowego. Staw łokciowy rzadko poddaje się leczeniu operacyjnemu; na ogół sprowadza się ono do resekcji przerośniętej głowy kości promieniowej połączonej z synowektomią. Podejmowane są też próby zastosowania alloplastyki. Wyniki alloplastyk stawów u pacjentów z osoczowymi skazami krwotocznymi są nadal gorsze niż u pacjentów z chorobą zwyrodnieniową. Nowoczesne metody rekonstrukcji chrząstki oparte na stymulacji szpiku kostnego i inżynierii tkankowej nie okazały się jak dotąd skuteczne w leczeniu artropatii hemofilowej.Recurrent intraarticular bleeds in patients with inherited clotting disorders inevitably lead to their impairment and major disability. Direct toxic effect of blood, mostly that of iron ions, on cartilage as well as synovium overgrowth contribute to arthropathy pathogenesis. Most effective for arthropathy prevention is prophylaxis with concentrates of deficient clotting factors. Nonoperative treatment of affected joints is based on physiotherapy. In cases of marked synovium overgrowth radiosynovectomy is helpful for reducing the number of bleeds. In cases of advanced joint destruction surgery is performed. In knees and hips total joint replacement is most frequent. Fusion is usually chosen for ankles but attempts at joint replacement are becoming more frequent. Elbows are rarely addressed and the most popular procedure is resection of radial head with open synovectomy. There are incidental reports of total elbow replacement in this group of patients. In general, for patients with clotting disorders the results of operative treatment are inferior to those performed in patients with degenerative arthritis. Modern techniques of cartilage reconstruction which are based on bone marrow stimulation or bioengineering have not been proved effective in haemophilic arthropathy

Ocena ryzyka sercowo-naczyniowego przed operacjami ortopedycznymi

Patients undergoing orthopaedic surgery of hip or knee joints are burdened with increased risk of cardiovascular disease, postoperative complications and death. Besides routine preoperative assessment of risk associated with surgical procedure, type of anaesthesia and general clinical condition of a patient, should be also paid attention to modifiable and non-modifiable cardiovascular risk factors and estimated total cardiovascular risk. Implementation of preventive procedures before surgery allows to minimize risk of cardiovascular complications and faster recovery of a patient in the postoperative period.Pacjenci poddawani zabiegom ortopedycznym stawów biodrowych lub kolanowych są obciążeni podwyższonym ryzykiem wystąpienia chorób układu sercowo-naczyniowego, komplikacji pooperacyjnych oraz zgonu. Oprócz rutynowej przedoperacyjnej oceny ryzyka związanego z samą procedurą chirurgiczną, rodzajem znieczulenia i stanem klinicznym chorego, szczególną uwagę należy zwrócić także na modyfikowalne i niemodyfikowalne czynniki ryzyka sercowo-naczyniowego oraz oszacować całkowite ryzyko sercowo-naczyniowe. Wdrożenie działań prewencyjnych jeszcze przed operacją pozwoli na zminimalizowanie ryzyka powikłań sercowo-naczyniowych oraz szybszy powrót pacjenta do sprawności w okresie pooperacyjnym

Avascular Necrosis of Femoral Head—Overview and Current State of the Art

Avascular necrosis (AVN) of the femoral head is caused by disruption of the blood supply to the proximal femur. The alterations in the blood supply may occur following a traumatic event or result from a non-traumatic cause. Femoral neck fracture and hip dislocation and associated surgical procedures, corticosteroid therapy, and alcohol abuse frequently lead to AVN development. Type of fracture (displaced or undisplaced) and time between injury and surgery are the most critical factors in assessing the risk of developing AVN. Diagnosis of AVN can be established based on patients’ complaints, medical history, and radiographic findings. There is no consensus on the treatment of patients with AVN to date. Non-surgical methods are dedicated to patients in the early pre-collapse stages of the disease and consist of pharmacotherapy and physiotherapy. Surgery is recommended for patients with advanced disease

Bone Infarcts and Tumorigenesis—Is There a Connection? A Mini-Mapping Review

(1) Background: Avascular necrosis (AVN) may affect every part of the bone. Epiphyseal infarcts are likely to be treated early because most are symptomatic. However, meta- and diaphyseal infarcts are silent and are diagnosed incidentally. Sarcomas developing in the necrotic bone are extremely rare, but they have been reported in the literature. (2) Methods: We conducted a mapping review of recent evidence regarding these malignancies. Methods: A mapping review using a systematic search strategy was conducted to answer research questions. We limited our research to the last ten years (2012–2022). (3) Results: A total of 11 papers were identified, including 9 case reports and 3 case series. The pathomechanism of carcinogenesis in AVN was not investigated to date. Histologically, most tumors were malignant fibrous histiocytoma. The prognosis is relatively poor, especially for patients with metastases, but adjuvant chemotherapy may increase short- and long-term survival. (4) Conclusions: Since AVN-related malignancies are sporadic, no prospective studies have been conducted. The majority of evidence comes from small case series. More research is needed to identify the risk factors that would justify follow-up of patients after bone infarcts at higher risk of developing a malignancy

Early complication after total knee arthroplasty in a haemophilia A patient

Total knee replacement in patients with haemophilia A is a challenging procedure with high risk of complications. Due to the massive destruction of the joint and significantly reduced range of motion, total knee replacement should be performed only by a surgeon with high degree of expertise and experience. During the perioperative period, patients require factor VIII (FVIII) replacement therapy supervised by a haematologist, under control of plasma activity levels. Possible early complications include delayed wound healing, soft tissue and joint bleeding, development of pseudoaneurysm and early infection. Once complications occur, prompt detection and introduction of proper treatment is fundamental

The Risk of Avascular Necrosis Following the Stabilization of Femoral Neck Fractures: A Systematic Review and Meta-Analysis

Background: Avascular necrosis (AVN) of the femoral head often requires surgical treatment and is often associated with femoral neck fractures. We conducted a systematic review and meta-analysis of recent research on the risk of AVN following the stabilization of fractured femoral neck with implants in PubMed. We assessed the effect of age on AVN incidence among patients aged > 50 and younger, depending on fracture type, Garden stage, Pouwels degree, Delbet stage, and age category. We followed PRISMA guidelines. Relevant studies were defined as research articles describing real-world studies reporting on the risk of AVN following primary surgical fracture stabilization with implants, published between 1 January 2011 and 22 April 2021. Fifty-two papers met the inclusion criteria, with a total of N = 5930 with surgically managed fractures. The pooled mean AVN incidence was significantly higher among patients with displaced fractures (20.7%; 95% CI: 12.8–28.5%) vs. those with undisplaced fractures (4.7%; 95% CI: 3.4–6.0%). No significant correlation was observed between AVN incidence weighted by sample size and time interval from injury to surgery (p = 0.843, R2 = 0.01). In conclusion, the risk of AVN following femoral neck fractures was generally high, especially in patients with displaced fractures. The time from injury to surgery did not correlate with AVN incidence

Revision Hip Arthroplasty in Patient with Acetabulum Migration into Subperitoneal Space—A Case Report

Revision hip arthroplasty procedures have been extensively discussed in the literature. At the same time, discussions of the management of acetabular component protrusion into the pelvic cavity, and, more specifically, the subperitoneal space, necessitating an additional abdominal approach for the revision arthroplasty, have only been published as case reports and descriptions of transperitoneal approaches have been even rarer. This paper presents the case of a 63-year-old female patient in whom a peritoneal approach was necessary to access a migrated acetabular component. The outcome of the treatment, which represented a complex orthopedic and general surgical problem, was good. We believe that the complexity of revision hip arthroplasty in patients with protrusion of the acetabular component together with the head and proximal part of the stem of the implant into subperitoneal space calls for a careful re-analysis of the category of Type III bony acetabulum defects according to Paprosky, where the recognition of two subtypes would facilitate analysis of such cases