EPITOMES-ORTHOPEDICS
and splints that will be subjected to extreme wear and tear, such as with children or heavy laborers. It is also ideal for long-term use because of its durability. EDGAR G. DAWSON, MD REFERENCES Minutes of American Conference of Governmental and Industrial Hygienists, Forest Park, Ohio, 1972 Lightcast I la, unpublished report. Merck, Sharpe, & Dohme, Inc., Research Laboratories, West Point, Pennsylvania Mathysen A: The invention of plaster appliances-First attempt to use plaster for surgical treatment, In Rang M: Anthology of Orthopaedics. London, E & S Livingston, Ltd, 1966, p 157
Surgical Procedures and Hemophilia RECENT TECHNOLOGICAL ADVANCES with preparation of plasma concentrates of clotting factors have taken the hemorrhage risk out of elective surgical operations on bleeders. Although there are numerous known coagulopathies, deficiencies in Factor VIII (classical hemophilia) and Factor IX (Christmas disease) together constitute the majority of bleeding syndromes encountered clinically. The orthopedist will be consulted for sequelae such as repeated hemarthrosis, joint contracture, destructive joint disease and pseudotumor. To have considered a surgical treatment for such problems carried great risks in the past. The
commercial availability of antihemophilia globulin (AHG), prepared by a variety of methods, and concentrates of Factor IX has altered this. Although the circulating level of Factor VIII required for safe surgery in classical hemophilia has not been established, most authors have advocated raising AHG levels to 100 percent. AHG activity is monitored by the partial thromboplastin time. The duration and level of postoperative therapy is arbitrary; some have allowed circulating AHG activity to decline to maintainance levels of 10 to 25 percent after two or three days. Although the necessary levels may be dictated by the magnitude of the procedure, therapy is usually continued for a minimum of one week. Nonsurgical means of joint management have been described. The use of intra-articular and oral steroids has been evaluated but results are inconclusive. The management of destructive pseudotumor has been described in a collected review by Schneider. Recently, Storti et al and Ewald et al have described the use of synovectomy as a prophylactic measure against repeated hemarthrosis in juveniles. The destructive effects of this are well
known. The problem is universal among hemophiliac children and crippling deformity or ankylosis is the usual sorry result. Knees, elbows and ankles are particularly accessible for surgical synovectomy. An early review of results suggests the incidence of hemarthrosis after synovectomy is much reduced. Ewald has used intravenous and intra-articular epsilon aminocaproic acid to counter local fibrinolysis. This is used for one week i a closed intra-articular irrigation/suction system. It is hoped that these pioneer efforts will have a positive effect on the long-term management of hemophilia. It is encouraging that the means for safe surgical programs have appeared and early intervention is now possible. WILLIAM C. MCMASTER, MD REFERENCES DePalma AF: Hemophilia arthropathy. Clin Orthop 52:145-165, May-Jun 1967 Day AJ: Orthopedic management of hemophilia. Instructional Course Lectures of the American Academy of Orthopaedic Surgeons 20:15-19, 1971 Schneider JR: Hemophilic pseudotumor. Harper Hosp Bull 25: 270-276, Oct-Dec 1967 Storti E, Traldi A, Tosatti E, et al: Synovectomy-A new approach to hemophilic arthropathy. Acta Haematol 41:193-205, 1969 Ewald B, Meyer M, Crooks J: Synovectomy in Hemophilia. Presented to the Abbott Society, San Francisco, Apr 1973
Implants for Arthritics THE PAST DECADE has seen rapid changes in the field of orthopedic surgery. Hip and finger joint replacements have become widely used and accepted; knee joint replacements are rapidly gaining in popularity. Other total joint replacement units for the shoulder, elbow, wrist and ankle are currently still in the experimental stage, but are
promising. There are three prototype units for hip joint replacement. But the Charnley type, which utilizes metal to high density polyethylene contact, is proving the most successful. The units are held to bone with polymethylmethacrylate cement. There are also three prototype units for knee joint replacement: (1) The hinge-requires mechanical linkage between the two metal components; (2) Geometric-metal to high density polyethylene contact uses two components which furnish a broad area of contact. The components, here again, are held to bone with polymethyl-
methacrylate; (3) Polycentric-metal to high density polyethylene contact uses four components that are cemented into position with polymethylmethacrylate. There are a number of modificaTHE WESTERN JOURNAL OF MEDICINE
151
and splints that will be subjected to extreme wear and tear, such as with children or heavy laborers. It is also ideal for long-term use because of its durability. EDGAR G. DAWSON, MD REFERENCES Minutes of American Conference of Governmental and Industrial Hygienists, Forest Park, Ohio, 1972 Lightcast I la, unpublished report. Merck, Sharpe, & Dohme, Inc., Research Laboratories, West Point, Pennsylvania Mathysen A: The invention of plaster appliances-First attempt to use plaster for surgical treatment, In Rang M: Anthology of Orthopaedics. London, E & S Livingston, Ltd, 1966, p 157
Surgical Procedures and Hemophilia RECENT TECHNOLOGICAL ADVANCES with preparation of plasma concentrates of clotting factors have taken the hemorrhage risk out of elective surgical operations on bleeders. Although there are numerous known coagulopathies, deficiencies in Factor VIII (classical hemophilia) and Factor IX (Christmas disease) together constitute the majority of bleeding syndromes encountered clinically. The orthopedist will be consulted for sequelae such as repeated hemarthrosis, joint contracture, destructive joint disease and pseudotumor. To have considered a surgical treatment for such problems carried great risks in the past. The
commercial availability of antihemophilia globulin (AHG), prepared by a variety of methods, and concentrates of Factor IX has altered this. Although the circulating level of Factor VIII required for safe surgery in classical hemophilia has not been established, most authors have advocated raising AHG levels to 100 percent. AHG activity is monitored by the partial thromboplastin time. The duration and level of postoperative therapy is arbitrary; some have allowed circulating AHG activity to decline to maintainance levels of 10 to 25 percent after two or three days. Although the necessary levels may be dictated by the magnitude of the procedure, therapy is usually continued for a minimum of one week. Nonsurgical means of joint management have been described. The use of intra-articular and oral steroids has been evaluated but results are inconclusive. The management of destructive pseudotumor has been described in a collected review by Schneider. Recently, Storti et al and Ewald et al have described the use of synovectomy as a prophylactic measure against repeated hemarthrosis in juveniles. The destructive effects of this are well
known. The problem is universal among hemophiliac children and crippling deformity or ankylosis is the usual sorry result. Knees, elbows and ankles are particularly accessible for surgical synovectomy. An early review of results suggests the incidence of hemarthrosis after synovectomy is much reduced. Ewald has used intravenous and intra-articular epsilon aminocaproic acid to counter local fibrinolysis. This is used for one week i a closed intra-articular irrigation/suction system. It is hoped that these pioneer efforts will have a positive effect on the long-term management of hemophilia. It is encouraging that the means for safe surgical programs have appeared and early intervention is now possible. WILLIAM C. MCMASTER, MD REFERENCES DePalma AF: Hemophilia arthropathy. Clin Orthop 52:145-165, May-Jun 1967 Day AJ: Orthopedic management of hemophilia. Instructional Course Lectures of the American Academy of Orthopaedic Surgeons 20:15-19, 1971 Schneider JR: Hemophilic pseudotumor. Harper Hosp Bull 25: 270-276, Oct-Dec 1967 Storti E, Traldi A, Tosatti E, et al: Synovectomy-A new approach to hemophilic arthropathy. Acta Haematol 41:193-205, 1969 Ewald B, Meyer M, Crooks J: Synovectomy in Hemophilia. Presented to the Abbott Society, San Francisco, Apr 1973
Implants for Arthritics THE PAST DECADE has seen rapid changes in the field of orthopedic surgery. Hip and finger joint replacements have become widely used and accepted; knee joint replacements are rapidly gaining in popularity. Other total joint replacement units for the shoulder, elbow, wrist and ankle are currently still in the experimental stage, but are
promising. There are three prototype units for hip joint replacement. But the Charnley type, which utilizes metal to high density polyethylene contact, is proving the most successful. The units are held to bone with polymethylmethacrylate cement. There are also three prototype units for knee joint replacement: (1) The hinge-requires mechanical linkage between the two metal components; (2) Geometric-metal to high density polyethylene contact uses two components which furnish a broad area of contact. The components, here again, are held to bone with polymethyl-
methacrylate; (3) Polycentric-metal to high density polyethylene contact uses four components that are cemented into position with polymethylmethacrylate. There are a number of modificaTHE WESTERN JOURNAL OF MEDICINE
151
