If continuous prophylaxis is not feasible due to expense or lack of venous access, we must aggressively treat major haemarthroses (including arthrocentesis) to prevent progression to
synovitis, recurrent joint bleeds, and ultimately end-stage
osteoarthritis (haemophilic
arthropathy). For the treatment of chronic haemophilic
synovitis, radiosynovectomy should always be indicated as the first procedure. If, after three procedures with 6-month interval, radiosynovectomy fails, an arthroscopic
synovectomy must be indicated. Between the second and fourth decades, many haemophilic patients develop joint destruction (
arthropathy). At this stage possible treatments include alignment
osteotomy, arthroscopic joint
debridement,
arthrodesis (joint fusion) and total joint
arthroplasty. For the hip press-fit uncemented components (hemispherical acetabulum, flanged femoral stem,
metal-to-
polyethylene) are recommended whilst for the knee a posterior-stabilized (PS) cemented design is advised. Muscular problems must not be underestimated in
haemophilia due to their risk of developing
compartment syndromes (which will require
surgical decompression) and pseudotumours (which will require surgical removal or percutaneous treatment). Regarding patients with inhibitors, the advent of APCCs and
rFVIIa has made major orthopaedic surgery possible, leading to an improved quality of life for
haemophilia patients. Concerning local
fibrin seal, it is not always necessary to achieve haemostasis in all
surgical procedures performed in persons with
haemophilia. However, it could be a good adjunct
therapy, mainly when a surgical field potentially will bleed more than expected (i.e. patients with inhibitors), and also in some orthopaedic procedures (mainly the surgical removal of pseudotumours).