Elsevier

Foot and Ankle Surgery

Volume 20, Issue 4, December 2014, Pages 285-292
Foot and Ankle Surgery

Short-term and mid-term outcome of total ankle replacement in haemophilic patients

https://doi.org/10.1016/j.fas.2014.08.004Get rights and content

Highlights

  • Report of the experience on the use of 32 prostheses in haemophilic patients.

  • Gain in the range of motion during dorsiflexion is important for gait cycle.

  • 7 patients were HIV positive, but no infections of the ankle joint in our series.

  • Limitations: retrospective study, presenting only a medium-term review.

Abstract

Background

Ankle arthropathy is very frequent in haemophilic patients. Prostheses are valuable alternatives to arthrodesis in non-haemophilic patients. We report the experience of a single centre in France on the use of prostheses in haemophilic patients.

Methods

Retrospective study of 21 patients with haemarthropathy who underwent ankle arthroplasty (32 ankles), with additional surgery, if needed, from July 2002 to September 2009 (mean follow-up 4.4 ± 1.7 years). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot scale was used to evaluate pain, function, ankle mobility and alignment.

Results

The overall AOFAS score improved from 40.2 ± 19.4 (pre-surgery) to 85.3 ± 11.4 (post-surgery). The function score increased from 23.6 ± 7.7 to 35.9 ± 6.7 and dorsiflexion from 0.3° ± 5.0° to 10.3° ± 4.4°. Two patients underwent further ankle arthrodesis. On X-ray, both tibial and talar components were stable and correctly placed in all ankles. Alignment was good.

Conclusion

Ankle arthroplasty is a promising alternative to arthrodesis in haemophilic patients.

Introduction

Haemophilia A and B are X-linked clotting disorders caused either by factor VIII (FVIII) or IX (FIX) deficiency; significant reduction in these clotting factors (<1 IU/dL) leads to spontaneous bleeding into joints and muscles.

Recurrent bleeding into the same “target” joint [1] leads to inflammatory changes [2], synovial proliferation and eventual chronic synovitis [1], [3].

Small, recurrent haemorrhages can cause degenerative lesions that gradually provide the site for an arthropathy.

Accompanying altered joint motion and poor alignment of component bones due to damaged epiphyseal growth plates exacerbate the progression of the arthropathy. These factors [1] can also affect the overlying knee and hip by adding an abnormal mechanical constraint to the multiple joints in the lower limbs (analysis of gait and tread) [4].

Joints in the elbows, knees and ankles [5] are most affected by bleeding [6]. The ankle is the first target joint in childhood [7] and is the most frequently affected joint in the second decade of life [8], [9], characterised by pain, stiffness and deformity. It is the most prevalent cause of morbidity in patients with severe haemophilia A [7] often associated with mobility-reducing foot/ankle deformities [10] that interfere with daily activities and reduce the quality of life.

Regular prophylaxis with concentrated clotting factors is the most effective method of preventing haemophilic arthropathy [11]. To prevent recurrent bleeding, radio synovectomy or chemical synovectomy can be considered at an early stage [12] and, if unsuccessful, arthroscopic synovectomy. Nonetheless, cautious management and conservative treatment are sometimes inadequate, and invasive surgery may be required.

The current standard treatment for patients with painful, progressive arthropathy is tibio-talar arthrodesis [10], [11], [12], [13], which demonstrates good results in terms of pain and bleeding episodes but with loss of mobility [13]. Based on initial reports [6], [7], which are now outdated, total ankle replacement (TAR) is also indicated [12], [14], [15] in a limited number of cases, but its value is under debate.

The development of third-generation prostheses (cementless, with three components using cross-linked polyethylene meniscal bearings) should make it possible to conserve mobility, restore rolling and rotation, and protect other overlying and underlying joints [16], [17], [18], [19].

Defects in the mechanical axis of the lower limb, ligament instabilities and other growth defects are contraindications. Additional procedures, such as Achilles tendon lengthening, ligament reconstruction, subtalar and midtarsal arthrodesis and malleolar osteotomy, can be combined with arthroplasty to correct these various disorders.

Good short, medium [2], [19], [20], [21] and long-term [22], [23], [24] outcomes have been reported. However, most of these publications were written solely by the inventors of the various prostheses.

Interestingly, neither arthrodesis nor arthroplasty seem to be the sole solution [25].

If selected, arthroplasty is preferable as first intention, even though some suggest performing it after arthrodesis. Arthrodesis is a solution if prosthesis fails [26].

In haemophilic patients, ankle replacement poses special challenges: preventing postoperative bleeding to provide the most favourable conditions for physiotherapy and to avoid complications that may require additional surgery.

Studies available on the outcomes of TAR in a small number of haemophilic patients (1–8) report high levels of patient satisfaction in terms of pain relief, increased range of motion and the low rate of complications [2], [5], [27], [28]. Although reporting the outcomes in 531 cases of TAR, the Swedish national registry does not differentiate particular cases [24] and 21 separate cases with different aetiologies are grouped together – not only haemophilia, but also haemochromatosis, psoriasis and other disorders – making it impossible to draw comparisons.

In this paper, we describe our experience and the medium-term outcomes of 32 TARs in 21 haemophilic patients.

Section snippets

Patients

This is a retrospective study involving all patients with haemorrhagic arthropathy who underwent total ankle replacement (TAR) in our hospital. The patients were fully informed and provided their written consent before the start of data collection.

The protocol was approved by the independent Ethics Committee (Comité consultatif sur le traitement de l’information en matière de recherche [CCTIRS], Paris, France).

Patients were aged at least 18 at the time of the TAR and presented with sequelae of

Results

TARs were performed between July 2002 and September 2009 in 21 patients (17 haemophilia A, 3 haemophilia B, 1 von Willebrand disease type III).

The mean age was 44 ± 12 (range: 24–67 years).

11 patients underwent bilateral TAR (in total, 32 TARs): 2 of these patients during the same procedure, 2 patients had undergone previously unsuccessful TARs, and received the revision AES (Ramses prosthesis, 2 sides for one patient, 1 side for the other).

12 TARs were performed in 7 HIV-positive patients.

All

Discussion

Until now, the standard treatment for haemophilic arthropathy of the ankle has been arthrodesis [7], [10], [13], [28], [29]. This technique is safe, substantially reduces pain, prevents the occurrence of other intra-articular bleeding and allows the positional correction of pre-existing equinus [8]. Nonetheless, it irreversibly sacrifices ankle mobility, worsened by an additional abnormal constraint on the multiple joints of the lower limb (analysis of gait and tread) [4] and mechanical stress

Conclusion

In view of our results, we believe, in agreement with various publications cited in the literature concerning osteoarthritis of the ankle, that, even in haemophilic patients, TAR can provide an alternative to tibiotalar arthrodesis, the current standard treatment. TAR is indicated because of its excellent outcomes in pain reduction and improved ankle motion, in particular dorsiflexion, in our group of 21 patients (32 ankles).

This technique conserves tibiotalar mobility and, by contiguity

Conflict of interest

None declared.

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