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Background: The importance of the radial head to elbow function and stability is increasingly apparent. Although preservation of the native radial head is preferred, severely comminuted fractures may necessitate resection or arthroplasty. Silastic radial head arthroplasty has been condemned on the basis of several sporadic reports of silicone synovitis. However, problems of "overstuffing," cartilage wear, and motion loss are becoming apparent with metal prostheses, indicating this also is not an ideal solution. Thus, the choices remain controversial., Questions/purposes: We asked whether intact or reconstructed primary elbow stabilizers permit use of silastic radial head implants without fragmentation, failure, and silicone synovitis., Methods: We retrospectively reviewed 23 patients with unreconstructable radial head fractures who were treated with silastic radial head arthroplasty and concomitant repair and/or reconstruction of the medial ulnar collateral ligament and/or lateral ulnar collateral ligament. Analysis included range of motion, pain, stability, and radiographic assessments; Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; and Mayo Elbow Performance Score (MEPS). The minimum followup was 16 months (average, 69.6 months; range, 16-165 months)., Results: At last followup, the mean elbow flexion was 145°, extension 11°, supination 80°, and pronation 83°. The mean MEPS score was 88.9. The mean DASH score was 11.8. There were eight reoperations, none resulting from failure of the radial head implants., Conclusions: These results demonstrate silastic radial heads can be used with low complication rates and without evidence of synovitis when concomitant elbow ligament repair or reconstruction is performed., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A 7- to 9-month protocol of prophylactic transfusion was used to treat 33 joints in 19 children with severe hemophilia (< 1 U/dL Factors VIII or IX) and hypertrophic synovitis. The overall rate of hemarthrosis was reduced, but only 36% (12 of 33 joints) achieved a good result (defined as 0-0.5 bleeding episodes per month and decreased synovial hypertrophy 1 year after completing treatment). Age and severity of arthropathy at initiation of treatment did not affect the result. The degree of synovial hypertrophy and involvement of the knee joint showed an adverse trend, but these factors did not achieve statistical significance. The number of episodes of breakthrough bleeding during the first 6 weeks of therapy was significantly associated with a poor result. Based on the results of this study, a trial of transfusion therapy is recommended for recurrent hemarthroses and synovitis in patients with hemophilia, but the duration of thrice weekly treatment has been increased and the duration of prophylaxis has been reduced in selected cases.

The knee joint is the most frequently affected articulation in patients suffering from hemophilia. Before the availability of active coagulation factors, orthotic use was aimed at corrective functions. Orthotics in the modern era play a protective and preventative role, and they are used in the treatment of hemarthroses and in joints affected by chronic synovitis. Because levels of availability of clotting factors and orthotic material vary extensively world-wide, an overview is provided whereby each group of therapists can adapt themselves to the principles.

A prospective study from 1974 to 1996 was done to determine optimal treatment for chronic hemophilic synovitis of the knee and synovitis of the elbow. Sixty-five patients with synovitis affecting 65 knee joints and 40 patients who had synovitis of the elbow (44 elbows), despite a 3-month trial of prophylactic substitution therapy, were treated by synovectomy. Radiation synovectomies (Au-198 synoviorthesis) were done on 38 knees, open surgical synovectomy on 18, and nine had an arthroscopic procedure. Radioactive gold synoviorthesis was performed on 29 elbows, and 15 had a resection of the radial head and partial open synovectomy. Synovectomy (by any method) significantly reduced bleeding episodes, but did not halt the radiographic deterioration of the joints. It is thought that radiation synovectomy is the best choice for patients with persistent synovitis of the knee and synovitis of the elbow unresponsive to a 3-month trial of prophylactic factor replacement. If two to three consecutive synoviortheses with 3 to 6 months intervals had been ineffective, or when the radiographic score is more than two points, an open synovectomy is indicated.

The most common clinical manifestation of hemophilia is intraarticular bleeding (hemarthrosis). Although any joint can be involved, the articulations most frequently affected are the knees, elbows, and ankles. Hemorrhages may occur spontaneously, or as a result of trauma. Because hemophilia is a genetically determined coagulation disorder, the bleeding incidences may start early in a child's life. After several hemarthroses, hemophilic synovitis will develop and, because of the profusion and fragility of vessels within the tissue, will lead to a vicious cycle of bleeding-synovitis-bleeding. If the synovitis is not controlled, cartilage damage will occur. hemophilic arthropathy then will become apparent clinically and radiographically, causing functional impairment of the affected joint. Prophylaxis and early diagnosis of acute hemarthrosis are essential to prevent the development of hemophilic synovitis. Hemarthroses must be treated aggressively if hemophilic synovitis is to be prevented. Continuous prophylaxis from age 2 to 18 years has been claimed to reduce the incidence of chronic hemophilic synovitis and joint damage, which remain the main causes of disability in the life of the patient who has hemophilia.

Acute hemarthroses are probably the most frequent type of bleeding in the patient with hemophilia. Delayed and/or inadequate treatment can trigger a series of pathologic changes within the joint leading to a painful and disabling arthropathy. Despite the advent of prophylactic treatment with factor concentrates, the majority of patients in the world have no access to even on demand factor replacement. Care for all patients involves a team approach led by the hematologist but including input from orthopaedic surgeons and physiotherapists. Optimal treatment involves a combination of factor replacement, rest, ice, and supervised rehabilitation. In certain cases, joint aspiration may be considered. In developing countries, where factor concentrates are in short supply, such bleeding episodes usually are treated by physical means alone or with the addition of cryoprecipitate or fresh frozen plasma. After successful resolution of such episodes by whatever means, the events leading to the bleeding episode and its subsequent management should be considered within the setting of the treating unit. Such debriefings should aim to provide counsel regarding any appropriate lifestyle modifications and, where necessary, treatment should be arranged to minimize the risk of additional episodes.

Hemophilia is a hereditary lifelong bleeding disorder affecting males. The nature of the condition predisposes the person to bleed intraarticularly and intermuscularly. Without intervention with replacement factor therapy and physiotherapy, the consequences can lead to chronic synovitis and severe joint hemarthropathy. Physiotherapeutic interventions are available that may help to prevent and treat the sequelae of recurrent hemarthrosis. No particular method of treatment has been shown to eradicate hemorrhages; however, there are protocols that can help. The use of physiotherapy techniques including electrotherapy, joint care, and exercise are extremely important, especially in developing countries where blood products are scarce.

The ankle is the second most affected joint in hemophilia. Recurrent bleeding leads to chronic synovitis. Prevention of chronic synovitis should start with prophylactic replacement therapy or on demand treatment of recurrent hemarthrosis. Attention must be given to the function of the ankle joint. When instability is present, an extensive range of exercises is important. An orthotic or shoe adaption may be useful during the rehabilitation process. Viscoheels worn in shoes seem to reduce the bleeding frequency and pain.