If deformities caused by hemarthrosis cannot be corrected by conservative closed methods, surgical correction is indicated. For example, if equinus deformity is very severe and rigid, tendo Achillis lengthening is indicated.
Open surgery has become relatively safe, provided the clotting mechanism is restored to near normal by the administration of antihemophilic factor. This should be continued for three weeks. Sutures should be removed on the fourteenth to sixteenth day postoperatively.
Wounds heal normally in hemophilic patients.
Hematologic Management
During surgery and the first postoperative day, the factor level should be raised to 100 percent by infusion of factor concentrate. During the first postoperative week, the factor level is maintained at 50 percent, and subsequently for the first postoperative month at 30 to 40 percent by daily infusions of factor concentrate.
Synovectomy
Synovectomy is done to prevent progression of hemophilic arthropathy. It helps by
- Decreases the vulnerability to trauma of the highly vascular synovial tissue i
- Hemophilic synovial tissue has a high level of fibrinolytic activity that tends to prolong the bleeding episodes.
- Hypertrophic synovial tissue in hemophilia contains increased levels of acid phosphatase and cathepsin D.
- Hemosiderin deposition in the synovium interferes with the production of collagenases, which may cause death of chondrocytes.
Indications
- History of severe recurrent hemarthrosis -two or three major bleeding episodes per month
- Patients who fail to respond to aggressive medical management for a period of at least six months.
- Failure of response to orthopedic nonsurgical treatment
- Radiographic Stage II or Stage III hemophilic arthropathy
In stages IV and V synovectomy is not effective and contraindicated.
Complications
- loss of range of joint motion due to adhesions
- Massive bleeding.
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