Arthroscopic ankle surgery in people with haemophilia.

INTRODUCTION: People with haemophilia (PWH) not administered primary haematological prophylaxis since childhood, that is, those treated haematologically on demand or not treated at all, often experience the degeneration of the ankles, leading to pain and functional impairment. AIM: To analyse the outcomes and complications of arthroscopic ankle surgery performed on PWH. METHODS: For this narrative review of the literature, a search was conducted in PubMed on 2, December 2023, using the keywords "haemophilia", "ankle" and "arthroscopy". Of the 29 articles identified, 15 specifically related to ankle arthroscopy in PWH were selected (inclusion criterion). The remaining articles did not meet this requirement (exclusion criterion) and were therefore eliminated. RESULTS: Arthroscopic procedures (arthroscopic synovectomy, debridement and arthrodesis of the ankle) are increasingly used in the surgical treatment of haemophilic ankle arthropathy. Although arthroscopic ankle surgery offers good outcomes in patients with haemophilia, the procedure is not free of complications, which range from 7.9% for arthroscopic ankle debridement to 13.1% in arthroscopic ankle synovectomy and 17.8% in arthroscopic ankle arthrodesis, respectively. The non-union rate of arthroscopic ankle arthrodesis is 7.1% (2/28). CONCLUSION: Although arthroscopic interventions in the haemophilic ankle (synovectomy, debridement, arthrodesis) offer good functional outcomes, they are associated with a non-negligible rate of complications. Arthroscopic ankle surgery in PWH is major surgery and should be treated as such.

Complications of ankle arthroscopy: frequency, prevention, and treatment.

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Knee replacement surgery in a patient with acquired von Willebrand disease: a case study with recommendations for patient management.

Introduction and importance: Acquired von Willebrand disease (AvWD) is a rare underdiagnosed bleeding disorder caused by alterations in the levels of the major blood-clotting protein von Willebrand factor (vWF). The clinical and laboratory parameters of AvWD are similar to congenital vWD, but it is found in individuals with no positive family history with no underlying genetic basis. The disease remains multifactorial and incompletely understood. Proposed mechanisms include the development of autoantibodies to vWF, absorption of high molecular weight vWF multimers that impair normal function, shear stress induced vWF cleavage and increased proteolysis.The aetiology of the disease is variable, the most common being hematoproliferation, lymophoproliferation, myeloproliferation and autoimmune and cardiovascular disorders. Consensus and protocols for AvWD patients that require major surgery are currently lacking. Patients with AvWD can experience thrombotic events during surgery as a result of therapeutic interactions with pro-thrombotic risk factors. Case presentation: Here, the authors report a patient with AvWD requiring a knee prosthesis implantation due to chronic pain, limited range of motion and functional impairment. The patient had a high risk of bleeding during surgery and was at risk of thrombosis due to age and obesity. Clinical discussion: Perioperative care required a collaborative approach and the management of bleeding. The patient was administered vWF concentrate Willfact lacking Factor VIII to prevent haemorrhage and to minimize the risk of thrombosis. Conclusion: The treatment was effective and well-tolerated. The authors use this information to provide recommendations for AvWD patients for whom major surgery is indicated.

Orthopedic surgical procedures in people with hemophilia.

People with hemophilia tend to develop joint lesions secondary to the recurrent hemarthroses typical of their condition. These usually include chronic synovitis and arthropathy chiefly affecting their ankles, knees, and elbows. In addition, muscular hematomas, albeit less frequently, may also result in complications such as acute compartment syndrome, pseudotumors, bone cysts and peripheral nerve compression. Joint lesions may require some of the following surgical interventions: arthroscopic synovectomy (in cases of synovitis), arthroscopic joint debridement, radial head resection, opening-wedge tibial osteotomy, arthrodesis, arthrodiastasis (of the ankle), tendon lengthening (hamstrings, Achilles tendon), progressive extension of the knee by placing an external fixator in cases of flexion contracture of the knee, supracondylar femoral extension osteotomy in cases of knee flexion contracture and, eventually, a total joint arthroplasty when the affected joint has been destroyed and the patient experiences severe joint pain. Total knee arthroplasty in hemophilic patients is associated with a high infection risk (7% on average). As regards the complications following muscle hematomas, acute compartment syndrome requires urgent performance of a fasciotomy when hematological treatment is incapable of resolving the problem. Surgical resection of hemophilic pseudotumors is the best solution, with those affecting the pelvis (secondary to iliopsoas hematomas) being particularly difficult to resolve. Peripheral nerve lesions can often be effectively addressed with hematological treatment, although a surgical neurolysis of the ulnar nerve is indicated if nonoperative treatment fails.

Total Knee Arthroplasty in Patients With Prior Ipsilateral Hip Fusion: A Surgical Technique.

BACKGROUND: In patients with severe osteoarthritis of the knee with prior ipsilateral hip fusion who require total knee arthroplasty (TKA), a controversial issue is whether to first convert the hip fusion to a total hip arthroplasty (THA) or to perform TKA without reconstruction of the hip. Also, immobility of the ipsilateral, fused hip adds significant technical challenge because the usual positioning of the leg requires modification in order to gain access needed for the TKA. TECHNIQUE: In such cases, we position the patient with the knee suspended, similar to how we perform knee arthroscopy. In our experience, the ipsilateral knee has significant deformity and is best addressed with a constrained, hinged TKA. RESULTS: In 3 patients with severe knee osteoarthritis with prior ipsilateral hip fusion-a 72-year-old man and a 79-year-old woman with hip arthrodesis due to posttraumatic arthritis and an 81-year-old woman with hip arthrodesis due to congenital dislocation of the hip-rotating-hinge knee prostheses were implanted due to severe knee instability. All 3 patients had satisfactory results, without complications, after follow-up of 1 to 5 years. CONCLUSIONS: We obtained satisfactory results in the short and medium term without previously converting the hip arthrodesis to THA by positioning patients with the knee suspended, in a way similar to when knee arthroscopy is performed, and implanting rotating hinge TKAs due to severe preoperative knee instability.

Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health.

INTRODUCTION: The purpose of this article has been to review the literature on total knee arthroplasty (TKA) in people with hemophilia (PWH), to mention the lessons we have learned from our own experience and to try to find out what the future of this type of surgery will be. AREAS COVERED: A Cochrane Library and PubMed (MEDLINE) search of studies related to TKA PWH was analyzed. In PWH, the complication rate after TKA can be up to 31.5%. These include infection (7.1%) and bleeding in the form of hematoma, hemarthrosis or popliteal artery injury (8.9%). In a meta-analysis the revision arthroplasty rate was 6.3%. One-stage or two-stage revision arthroplasty due to infection (septic loosening) is not always successful despite providing correct treatment (both hematological and surgical). In fact, the risk of prosthetic re-infection is about 10%. It is necessary to perform a re-revision arthroplasty, which is a high-risk and technically difficult surgery that can sometimes end in knee arthrodesis or above-the-knee amputation of the limb. EXPERT OPINION: TKA (both primary and revision) should be performed in centers specialized in orthopedic surgery and rehabilitation (knee) and hematology (hemophilia), and with optimal coordination between the medical team.

Complications and Implant Survival of Total Knee Arthroplasty in People with Hemophilia.

Total knee arthroplasty (TKA) is a commonly used option in advanced stages of knee arthropathy in people with hemophilia (PWH). The objective of this article is to determine what the complication rates and implant survival rates in PWH are in the literature. A literature search was carried out in PubMed (MEDLINE), Cochrane Library, Web of Science, Embase and Google Scholar utilizing the keywords "hemophilia TKA complications" on 20 October 2022. It was found that the rate of complications after TKA in PWH is high (range 7% to 30%), although it has improved during the last two decades, possibly due to better perioperative hematologic treatment. However, prosthetic survival at 10 years has not changed substantially, being in the last 30 years approximately 80% to 90% taking as endpoint the revision for any reason. Survival at 20 years taking as endpoint the revision for any reason is 60%. It is possible that with a precise perioperative control of hemostasis in PWH, the percentage of complications after TKA can be diminished.

Radiosynovectomy for the Treatment of Chronic Hemophilic Synovitis: An Old Technique, but Still Very Effective.

A radiosynovectomy (RS) should be indicated when recurrent articular bleeds related to chronic hemophilia synovitis (CHS) exist, established by clinical examination, and confirmed by imaging techniques that cannot be constrained with hematological prophylaxis. RS can be performed at any point in life, mainly in adolescents (>13−14 years) and adults. Intraarticular injection (IAI) of a radioactive material in children might be arduous since we need child collaboration which might include general anesthesia. RS is our initial option for management of CHS. For the knee joint we prescribe Yttrium-90, while for the elbow and ankle we prescribe Rhenium-186 (1 to 3 IAIs every 6 months). The procedure is greatly cost efficient when compared to surgical synovectomy. Chemical synovectomy with rifampicin has been reported to be efficacious, inexpensive, simple, and especially practical in developing countries where radioactive materials are not easily available. Rifampicin seems to be more efficacious when it is utilized in small joints (elbows and ankles), than when utilized in bigger ones (knees). When RS and/or chemical synovectomy fail, arthroscopic synovectomy (or open synovectomy in some cases) should be indicated. For us, surgery must be performed after the failure of 3 RSs with 6-month interims. RS is an effective and minimally invasive intervention for treatment of repeated articular bleeds due to CHS. Although it has been published that the risk of cancer does not increase, and that the amount of radioactive material used in RS is insignificant, the issue of chromosomal and/or deoxyribonucleic acid (DNA) changes remains a concern and continued surveillance is critical. As child and adulthood prophylaxis becomes more global, RS might become obsolete in the long-term.

Management of bone loss in revision total knee arthroplasty: therapeutic options and results.

The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic.Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves).A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years.Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%.The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively. Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007.

Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective.

Introduction: In underdeveloped countries, patients with hemophilia often experience repetitive ankle joint hemorrhages due to a shortage of coagulation factors (factor VIII [FVIII] and factor IX [FIX] for hemophilia A and B, respectively).Areas covered: This is a narrative literature review in which we searched the Cochrane Library and PubMed for articles related to ankle arthrodesis in patients with hemophilia. The searches covered the period from the databases´ inception to 28 February 2021. In the event of unsuccessful hematologic prophylaxis and conservative measures (e.g. analgesics, cyclooxygenase-2 inhibitors, taping, intra-articular injections of hyaluronic acid and corticosteroids, physical and rehabilitation medicine, orthoses, radiosynovectomy, and joint-preserving surgery (e.g. removal of the distal tibia by open surgery or by arthroscopic surgery, joint debridement by arthroscopic surgery), the classical surgical solution is ankle arthrodesis, which does not preserve the ankle joint.Expert opinion: Ankle pain is reduced after ankle arthrodesis (75% of patients experience no pain). Approximately 5% of patients require reoperation due to lack of fusion, and deep infection occurs in 2.5%. After tibiotalar fusion, a self-reported activity scale shows that approximately 12% of patients improve, 9% worsen, and 79% show no improvement. The results of ankle arthrodesis therefore appear to be poor.Therefore, although 75% of the patients stopped having ankle pain after arthrodesis, according to a self-reported activity scale 88% of them did not improve or worsened.

Dislocation of rotating-hinge total knee arthroplasty.

The number of rotating-hinge total knee arthroplasties (RH-TKAs) is increasing. As a result, the number of complications related to these procedures will also increase.RH-TKAs have the theoretical advantage of reducing bone implant stresses and early aseptic loosening. However, these implants also have complication rates that cannot be ignored. If complications occur, the options for revision of these implants are limited.Dislocation of RH-TKAs is rare, with an incidence between 0.7% and 4.4%. If it occurs, this complication must be accurately diagnosed and treated quickly due to the high incidence of neurovascular complications.If the circulatory and neurological systems are not properly assessed or if treatment is delayed, limb ischemia, soft tissue death, and the need for amputation can occur.Dislocation of a RH-TKA is often a difficult problem to treat. A closed reduction should not be attempted, because it is unlikely to be satisfactory. In addition, in patients with dislocation of a RH-TKA, the possibility of component failure or breakage must be considered.Open reduction of the dislocation should be performed urgently, and provision should be made for revision (that is, the necessary instrumentation should be available) of the RH-TKA, if it proves necessary.The mobile part that allows rotation can have various shapes and lengths. This variance in design could explain why the reported outcomes vary and why there is a probability of tibiofemoral dislocation. Cite this article: EFORT Open Rev 2021;6:107-112. DOI: 10.1302/2058-5241.6.200093.

Complications of surgical reconstruction of multiligament injuries of the knee joint: diagnosis, prevention and treatment.

The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery.Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications.Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance.To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure.Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest.However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint. Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057.

The outerbridge classification predicts the need for patellar resurfacing in TKA.

UNLABELLED: Patellar resurfacing (PR) in total knee arthroplasty (TKA) is controversial. The Outerbridge classification of cartilage defects in the patella is commonly used in the literature. The purpose of this study was to determine if the Outerbridge classification can predict the need for PR as part of total knee arthroplasty. Between 1995 and 2000, we performed a prospective, randomized study of 500 TKAs. We carried out PR depending on the Outerbridge classification of the patella at the time of surgery. Patients with Outerbridge Grades I, II, and III formed Group A, whereas patients with Grade IV formed Group B. Within each group, resurfacing was completed on half of the patients. Group A had 328 patients (164 with PR, 164 without PR). In Group B, there were 172 patients (86 with PR, 86 without PR). An identical prosthetic design was used for both groups. The minimum followup was 5 years (average, 7.8 years) for both Group A and Group B. At the end of followup, we assessed the number of patients in each group that required secondary resurfacing as a result of patellofemoral pain. Patients in Group A required fewer revisions for PF pain. In Group A, only one patient required a secondary PR (0.6% rate), whereas in Group B, 10 patients needed PR (11.6% rate). In Group B, the risk of need of a patellar resurfacing was 21.5 times greater than in Group A. On the basis of these findings, we recommend PR in Outerbridge Grade IV patellae, but not in Grades I, II, and III. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Postoperative analgesia in TKA: ropivacaine continuous intraarticular infusion.

BACKGROUND: Postoperative pain control is a challenge in patients undergoing TKA due to side effects and technical limitations of current analgesic approaches. Local anesthetic infiltration through continuous infusion pumps has been shown to reduce postoperative pain in previous studies. QUESTIONS/PURPOSES: We assessed the effectiveness of intraarticular ropivacaine infusions in reducing pain and postoperative opioid use after TKA and determined whether such infusions accelerate functional recovery of the patient and reduce length of hospital stay. METHODS: In a randomized, prospective, double-blind study, two groups were assigned: Group A (n = 25) underwent continuous intraarticular infusion with 300 mL ropivacaine 0.2% at a speed of 5 mL/hour through an elastomeric infusion pump and Group B (n = 25) had an elastomeric pump insertion with 300 mL saline solution at an infusion speed of 5 mL/hour. All patients had the same prosthesis model implanted. Parameters analyzed over the first 3 days, at discharge, and 1 month later included postoperative pain, joint function, opioid use, and length of hospital stay. RESULTS: All patients in Group A showed a decrease in pain intensity measured by a visual analog scale and opioid use in the first 3 days. Mean length of hospital stay was also reduced in Group A (5.72 days) compared to Group B (7.32 days). There were no device-related complications. CONCLUSIONS: Use of an infusion pump is effective in treating pain after TKA, reducing postoperative pain and opioid use. It also improves immediate functionality and patient comfort, reducing the mean length of hospital stay, without increasing the risk of complications. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intra-articular Tranexamic Acid in Primary Total Knee Arthroplasty Decreases the Rate of Post-operative Blood Transfusions in People with Hemophilia: A Retrospective Case-Control Study.

BACKGROUND: Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia. QUESTIONS/PURPOSES: Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion. METHODS: This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (n = 15) and a second group treated without it (n = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL. RESULTS: The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion. CONCLUSION: This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.

Unicompartmental knee arthroplasty: Current indications, technical issues and results.

An age younger than 60 years, a body weight of 180 lb (82 kg) or more, performing heavy work, having chondrocalcinosis and having exposed bone in the patellofemoral (PF) joint are not contraindications for unicompartmental knee arthroplasty (UKA).Severe wear of the lateral facet of the PF joint with bone loss and grooving is a contraindication for UKA.Medial UKA should only be performed in cases of severe osteoarthritis (OA) as shown in pre-operative X-rays, with medial bone-on-bone contact and a medial/lateral ratio of < 20%.The post-operative results of UKA are generally good. Medium-term and long-term studies have reported acceptable results at 10 years, with implant survival greater than 95% for UKAs performed for medial OA or osteonecrosis and for lateral UKA, especially when fixed-bearing implants are used.When all implant-related re-operations are considered, the 10-year survival rate is 94%, and the 15-year survival rate is 91%.Aseptic loosening is the principal failure mechanism in the first few years in mobile-bearing implants, whereas OA progression causes most failures in later years in fixed-bearing implants.The overall complication rate and the comprehensive re-operation rate are comparable in both mobile bearings and fixed bearings.The survival likelihood of the all-polyethylene UKA implant is similar to that of metal-backed modular designs for UKA.Notable cost savings of approximately 50% can be achieved with an outpatient UKA surgery protocol. Outpatient surgery for UKA is efficacious and safe, with satisfactory clinical results thus far. Cite this article: EFORT Open Rev 2018;3:363-373. DOI: 10.1302/2058-5241.3.170048.

Arthroscopic knee debridement can delay total knee replacement in painful moderate haemophilic arthropathy of the knee in adult patients.

The role of arthroscopic debridement of the knee in haemophilia is controversial in the literature. The purpose of this study is to describe the results of arthroscopic knee debridement (AKD), with the aim of determining whether it is possible to delay total knee replacement (TKR) for painful moderate haemophilic arthropathy of the knee in adult patients. In a 14-year period (1998-2011), AKD was performed for moderate haemophilic arthropathy of the knee in 27 patients with haemophilia A. Their average age at operation was 28.6 years (range 26-39 years). Indications for surgery were as follows: more than 90° of knee flexion, flexion deformity less than 30°, good axial alignment of the knee, good patellar alignment, and pain above >60 points in a visual analogue scale [0 (no pain) to 100 points]. Secondary haematological prophylaxis and rehabilitation (physiotherapy) was given for at least 3 months after surgery. Follow-up was for an average of 7.5 years (range 2-14 years). We assessed the clinical outcome before surgery and at the time of latest follow-up using the Knee Society pain and function scores, the range of motion, and the radiological score of the World Federation of Haemophilia. Knee Society pain scores improved from 39 preoperatively to 66 postoperatively, and function scores improved from 36 to 52. Range of motion improved on an average from -15° of extension and 90° of flexion before surgery, to -5° of extension and 110° of flexion at the last follow-up. A radiological deterioration of 2.8 points on average was found. There were two (7.4%) postoperative complications (haemarthroses resolved by joint aspiration). One patient (3.7%) required a TKR 12.5 years later. AKD should be considered in painful moderate haemophilic arthropathy of the knee in adult patients to delay TKR.

Low-volume formulation of intra-articular tranexamic acid, 25-ml tranexamic acid (2.5 g) plus 20-ml saline, is effective in decreasing blood transfusion rate in primary total knee replacement even without preoperative haemoglobin optimization.

UNLABELLED: The efficacy of intra-articular tranexamic acid (TXA) to decrease blood loss after total knee replacement (TKR) has been confirmed in randomised clinical trials (RCTs) and meta-analysis. However, insufficient data are still available about the efficacy in clinical practice of intra-articular TXA administration in reducing the rate of postoperative blood transfusion. To prove the efficacy of a low-volume formulation of intra-articular TXA in current clinical practice, and the role of preoperative variables to influence the transfusion risk after primary TKR. We performed a retrospective study (using data that were gathered concurrently with the treatments but without a specific protocol to address the research question) in patients undergoing cemented TKR and receiving a low-volume formulation (2.5 g-25 ml TXA plus 20-ml saline) of intra-articular TXA (group B, study group, N = 85), and compared it with a cohort of high volume (3 g-30 ml TXA plus 70-ml saline) half topical half intra-articular TXA (group A, N = 39). Lower volume may diffuse less into the knee joint, and effectiveness assessment is required. To further confirm the effectiveness of the strategy, we compared this cohort with the historical cohort in our centre without TXA (group C, N = 393). End-point variables were compared and a multiple regression model was adjusted to obtain the odds ratio for confounding preoperative variables. Transfusion rates significantly differed between groups B (7%) and C (30%), but not between group A and group B, proving effectiveness of the low-volume formulation of intra-articular administration of TXA, despite in group B 18% of patients has less than 13 g/dl haemoglobin (Hb) vs. 0% in group A. The effectiveness of intra-articular TXA after TKR has been confirmed for a low-volume formulation (2.5 g-25 ml TXA plus 20 ml saline) even if Hb is less than 13 g/dl. Preoperative HB optimization (>13 g/dl) is also important. LEVEL OF EVIDENCE: Level IV.

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty.

BACKGROUND: Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients. PURPOSE: To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients. METHODS: We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75-86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5-10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss). RESULTS: At a minimum followup of 5 years (mean, 7.3 years; range, 5-10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from -15° of extension and 80° of flexion before surgery to -5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection. CONCLUSIONS: Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Arthroscopic debridement for ankle haemophilic arthropathy.

The purpose of this study is to describe the results of arthroscopic ankle debridement (AAD) with the aim of determining whether it is possible to avoid or delay ankle fusion or total ankle replacement for advanced haemophilic arthropathy of the ankle in young patients. In a 12-year period (2000-2011), 24 AADs (one bilateral in two stages) were performed for advanced haemophilic arthropathy of the ankle in 23 patients (22 had haemophilia A, 1 haemophilia B, 0 with inhibitors against the deficient factor). Their average age at operation was 25.3 years (range 21-36). Inclusion criteria were: more than 50% of ankle motion, good axial alignment of the ankle (increased varus or valgus angulation was a contraindication for AAD) and pain greater than 6 points on a visual analogue scale (0-no pain to 10 points). Follow-up was for an average of 5.4 years (range 2-14 years). The results were evaluated retrospectively by the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The clinical results were excellent in 13 (54.2%), good in nine (37.5%) and fair in two (8.3%). There were two (8.3%) postoperative complications (haemarthroses resolved by join aspiration). Three patients (12.5%) required an ankle fusion. AAD should be considered in the young haemophiliac to delay ankle fusion or total ankle replacement. The operation may give the patient years of life without intense pain.