Arthroscopic synovectomies combined with reduced weight-bearing using patella tendon-bearing braces were very effective for progressed haemophilic ankle arthropathy in three paediatric patients.

The major goals of synovectomy for haemophilic arthropathy are considered to be reduction of bleeding and maintenance of joint function [1]. Synovectomy is generally thought to retard, but not halt, the progression of haemophilic arthropathy. It is thus not typically indicated for advanced haemophilic arthropathy. Rodriguez-Merchan [1] stated that the best solution for advanced arthropathy of the ankle is ankle arthrodesis. Although arthrodesis represents the gold standard for progressed ankle arthropathy, we prefer to avoid this option, particularly for paediatric patients. We therefore devised a treatment to reduce weight-bearing using a patella tendon-bearing (PTB) brace after synovectomy. The purpose of the present study was to report the clinical results of this procedure in three paediatric patients. Arthroscopic synovectomy was performed through anteromedial, anterolateral and posterolateral portals with non-invasive mechanical distraction (Achflex; Smith & Nephew, Tokyo, Japan). A 2.7mm, 30 arthroscope was used. Full-radius shaves and an electrothermal bipolar vapor system (Mitek, Westwood, MA, USA) were used for synovectomy. Defective cartilage areas were treated using a bone marrow stimulation technique with drilling. Drilling was performed with a 1.8-mm diameter Kirschner wire through anteromedial and anterolateral portals and across the medial malleolus. A below-the-knee cast was applied for 5 days. Immediately after removing the cast, the PTB brace was applied and range-of-motion exercises were initiated. Use of the PTB brace was continued for 1 year (Fig. 1). Preoperative factor levels were raised to nearly 100 U dL in all patients. Secondary prophylaxis was performed postoperatively. Three male paediatric haemophilic patients (11, 5 and 8 years) with progressed ankle arthropathy were treated (Table 1). Case 1 was diagnosed as having moderately severe haemophilia B at 24 months of age, where as case 2 and 3 were diagnosed as severe haemophilia A at 8 and 7 months, respectively. In case 3, an inhibitor was detected for the first time at 15 months (the maximum inhibitor level: 12 Bethesda U mL). At the age of seven, immune tolerance induction (ITI) was attempted. Three months after ITI was commenced, the inhibitor disappeared and the recovery rate of factor VIII: C after the administration of factor VIII concentrates was normalized. Contralateral side of the ankle and the other joints were unaffected in all patients. Frequent bleeding was observed in the affected ankle and severe or moderate pain was reported during walking. The three patients were followed for a mean duration of 30 months (range, 24–40 months). Two patients showed no intra-articular bleeding after treatment (Table 2). The other patient experienced only one episode of bleeding at 18 months after surgery and a cast was applied for one week. No recurrent bleeding occurred thereafter. Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale, which includes scores for pain (40 points), function (50 points) and alignment (10 points). Mean AOFAS score improved from 41 points preoperatively to 96 points at follow-up. Dorsiflexion of the all ankles were improved Correspondence: Yasuhito Tanaka, MD, Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara 6348522, Japan. Tel.: +81 74 429 8873; fax: +81 74 425 6449; e-mail: yatanaka@naramed-u.ac.jp