1
|
Zhang Q, Zhao L, Riva N, Yu Z, Jiang M, Gatt A, Guo JJ. Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study. BMC Musculoskelet Disord 2024; 25:326. [PMID: 38658972 PMCID: PMC11041033 DOI: 10.1186/s12891-024-07404-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/01/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Hemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis. METHODS Consecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE). RESULTS 38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up. CONCLUSIONS The risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.
Collapse
Affiliation(s)
- Qian Zhang
- Department of Orthopedics and Sports Medicine, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| | - Lingying Zhao
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Ziqiang Yu
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Miao Jiang
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Alexander Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
- Department of Haematology, Mater Dei Hospital, Msida, Malta
| | - Jiong Jiong Guo
- Department of Orthopedics and Sports Medicine, The First Affiliated Hospital of Soochow University, Suzhou, PR China.
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China.
- China-Europe Sports Medicine Belt-and-Road Joint Laboratory of Ministry of Education of PRC, Suzhou, PR China.
| |
Collapse
|
2
|
Santagata D, Abenante A, Squizzato A, Dentali F, Donadini MP, Ageno W, Pabinger I, Tiede A, Ay C. Rates of venous thromboembolism and use of thromboprophylaxis after major orthopedic surgery in patients with congenital hemophilia A or B: a systematic review. J Thromb Haemost 2024; 22:1117-1131. [PMID: 38215910 DOI: 10.1016/j.jtha.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/17/2023] [Accepted: 12/23/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a well-recognized complication after total joint replacement (TJR). Persons with hemophilia A or B are considered at low postoperative VTE risk due to their coagulation factor deficiencies, and administering pharmacologic thromboprophylaxis is often considered contraindicated. However, using factor replacement therapy could increase the postoperative VTE risk. OBJECTIVES To analyze best available evidences of VTE rates in persons with hemophilia A or B undergoing lower limb TJR and the use of postoperative pharmacologic thromboprophylaxis. METHODS We systematically screened 4 online biomedical databases to identify studies reporting VTE rates in patients with hemophilia after TJR. Case reports and case series with less than 10 patients were excluded. RESULTS Twenty-six observational studies were included in this systematic review, reporting 1181 TJRs in patients with hemophilia A or B. Eight studies had VTE rates as the primary outcome. Five studies reported screen-detected VTE, while 21 reported symptomatic VTE events. Overall, 17 VTE events were reported (1.4%; 95% CI, 0.9%-2.3%), including 10 (6.6%) after 151 surgeries with postoperative VTE screening and 7 (0.7%) after 1080 surgeries without postoperative screening. Thromboprophylaxis protocols were specified in 21 studies; postoperative thromboprophylaxis was used in 15 (1.3%) surgeries. This information was not available for 29.0% of the analyzed population. CONCLUSION Despite the low thromboprophylaxis use in patients with hemophilia, rates of symptomatic VTE after TJR appeared to be low. We also highlighted the need to better report the thrombotic outcome in persons with hemophilia to face the ongoing changes in the hemophilia landscape.
Collapse
Affiliation(s)
- Davide Santagata
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Alessia Abenante
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Marco Paolo Donadini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
3
|
Fu H, Peacock C, Wang C, Kader D, Clement N, Asopa V, Sochart D. The effect of HIV prevalence, CD4 counts and disease severity on the outcome of total knee arthroplasty for haemophilic arthropathy: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3235-3254. [PMID: 37212914 DOI: 10.1007/s00590-023-03586-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/10/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count. METHODS A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan-Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV. RESULTS Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94%, 86%, and 76% respectively. NJR-reported survivorship for males < 55 years was 94%, 90%, and 86%. Survivorship improved over time (1973-2018), and correlated inversely with HIV prevalence. Infection rate was 5%, compared to 0.5-1% in the NJR. Infection was not significantly increased with higher HIV prevalence, and CD4 + count had no effect. Complications were inconsistently reported. CONCLUSION Survivorship was similar at 5 years but declined thereafter, and infection rate was six-fold higher. HIV was related to worse survivorship, but not increased infection. Meta-analysis was limited by inconsistent reporting, and standardised reporting is required in future studies.
Collapse
Affiliation(s)
- Howell Fu
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK.
| | - Christian Peacock
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK
| | - Chao Wang
- Faculty of Health, Science, Social Care and Education, Kingston University, Kingston Hill, Kingston upon Thames, Surrey, KT2 7LB, UK
| | - Deiary Kader
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK
| | - Nick Clement
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Cres, Old Dalkeith Rd, Edinburgh, EH16 4SA, UK
| | - Vipin Asopa
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK
| | - David Sochart
- Academic Surgical Unit, South West London Elective Orthopaedic Centre, Epsom General Hospital, Dorking Road, Epsom, KT18 7EG, UK
| |
Collapse
|
4
|
Beckers G, Massé V, Vendittoli PA, Morcos MW. Primary total knee arthroplasty in hemophilic arthropathy. EFORT Open Rev 2023; 8:830-840. [PMID: 37909693 PMCID: PMC10646519 DOI: 10.1530/eor-23-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Advanced hemophilic knee arthropathy is a frequent and devastating manifestation of severe hemophilia with significant implications for activities of daily living. Hemophilic arthropathy is caused by repeated bleeding, resulting in joint degeneration, pain, deformity and disability. In patients with hemophilia and advanced disease, total knee arthroplasty (TKA) has proven to be the most successful intervention, improves physical function and reduces knee pain. Hemophilic patients carry additional risks for complications and required specific pre/postoperative considerations. Expert treatment center should be used to improve patient outcome. Hemophilic patients present significant surgical challenges such as joint destruction, bone loss, severe ankylosis and oligoarticular involvement. The surgeon performing the arthroplasty must be experienced to manage such problems.
Collapse
Affiliation(s)
- Gautier Beckers
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal University, Montréal, Quebec, Canada
- Personalized Arthroplasty Society, Atlanta, Georgia, USA
| | - Vincent Massé
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal University, Montréal, Quebec, Canada
- Personalized Arthroplasty Society, Atlanta, Georgia, USA
- Clinique Orthopédique Duval, Laval, Quebec, Canada
| | - Pascal-André Vendittoli
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal University, Montréal, Quebec, Canada
- Personalized Arthroplasty Society, Atlanta, Georgia, USA
- Clinique Orthopédique Duval, Laval, Quebec, Canada
| | - Mina W Morcos
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montréal University, Montréal, Quebec, Canada
- Personalized Arthroplasty Society, Atlanta, Georgia, USA
| |
Collapse
|
5
|
Rodriguez-Merchan EC, De la Corte-Rodriguez H, Alvarez-Roman T, Gomez-Cardero P, Encinas-Ullan CA, Jimenez-Yuste V. Complications and Implant Survival of Total Knee Arthroplasty in People with Hemophilia. J Clin Med 2022; 11:6244. [PMID: 36362472 PMCID: PMC9658035 DOI: 10.3390/jcm11216244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 08/29/2023] Open
Abstract
Total knee arthroplasty (TKA) is a commonly used option in advanced stages of knee arthropathy in people with hemophilia (PWH). The objective of this article is to determine what the complication rates and implant survival rates in PWH are in the literature. A literature search was carried out in PubMed (MEDLINE), Cochrane Library, Web of Science, Embase and Google Scholar utilizing the keywords "hemophilia TKA complications" on 20 October 2022. It was found that the rate of complications after TKA in PWH is high (range 7% to 30%), although it has improved during the last two decades, possibly due to better perioperative hematologic treatment. However, prosthetic survival at 10 years has not changed substantially, being in the last 30 years approximately 80% to 90% taking as endpoint the revision for any reason. Survival at 20 years taking as endpoint the revision for any reason is 60%. It is possible that with a precise perioperative control of hemostasis in PWH, the percentage of complications after TKA can be diminished.
Collapse
Affiliation(s)
- Emerito Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, 28046 Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain
| | | | - Teresa Alvarez-Roman
- Department of Hematology, La Paz University Hospital-IdiPaz, 28046 Madrid, Spain
| | | | | | - Victor Jimenez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPaz, 28046 Madrid, Spain
| |
Collapse
|
6
|
Fenelon C, Murphy EP, Fahey EJ, Murphy RP, O'Connell NM, Queally JM. Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes-A Systematic Review and Meta-Analysis. J Arthroplasty 2022; 37:581-592.e1. [PMID: 34756977 DOI: 10.1016/j.arth.2021.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/16/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR. METHODS A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B). RESULTS Twenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A. CONCLUSION TKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.
Collapse
Affiliation(s)
| | - Evelyn P Murphy
- Department of Orthopaedic Surgery, Cork University Hospital, Cork, Ireland
| | - Eoin J Fahey
- Department of Orthopaedic Surgery, St. James's Hospital, Dublin, Ireland
| | - Robert P Murphy
- Health Research Board Clinical Research Facility, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Niamh M O'Connell
- National Coagulation Centre, Department of Haematology, St. James's Hospital, Dublin, Ireland
| | - Joseph M Queally
- Department of Orthopaedic Surgery, St. James's Hospital, Dublin, Ireland
| |
Collapse
|
7
|
Rodriguez-Merchan EC, De la Corte-Rodriguez H, Alvarez-Roman T, Gomez-Cardero P, Encinas-Ullan CA, Jimenez-Yuste V. Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health. Expert Rev Hematol 2022; 15:65-82. [PMID: 35041571 DOI: 10.1080/17474086.2022.2030218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article has been to review the literature on total knee arthroplasty (TKA) in people with hemophilia (PWH), to mention the lessons we have learned from our own experience and to try to find out what the future of this type of surgery will be. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to TKA PWH was analyzed. In PWH, the complication rate after TKA can be up to 31.5%. These include infection (7.1%) and bleeding in the form of hematoma, hemarthrosis or popliteal artery injury (8.9%). In a meta-analysis the revision arthroplasty rate was 6.3%. One-stage or two-stage revision arthroplasty due to infection (septic loosening) is not always successful despite providing correct treatment (both hematological and surgical). In fact, the risk of prosthetic re-infection is about 10%. It is necessary to perform a re-revision arthroplasty, which is a high-risk and technically difficult surgery that can sometimes end in knee arthrodesis or above-the-knee amputation of the limb. EXPERT OPINION TKA (both primary and revision) should be performed in centers specialized in orthopedic surgery and rehabilitation (knee) and hematology (hemophilia), and with optimal coordination between the medical team.
Collapse
Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
| | | | | | | | | | | |
Collapse
|
8
|
Dou X, Poon M, Yang R. Haemophilia care in China: Achievements in the past decade. Haemophilia 2020; 26:759-767. [DOI: 10.1111/hae.14101] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/23/2020] [Accepted: 06/16/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Tianjin Laboratory of Blood Disease Gene Therapy CAMS Key Laboratory of Gene Therapy for Blood DiseasesTianjin China
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health ServicesCalgary AB Canada
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Tianjin Laboratory of Blood Disease Gene Therapy CAMS Key Laboratory of Gene Therapy for Blood DiseasesTianjin China
| |
Collapse
|
9
|
Abstract
Hemophilia A is a rare genetic disorder involving a deficiency of clotting factor VIII. Coagulation factor replacement therapy has prolonged the life expectancy of patients with hemophilia, but recurrent hemarthrosis of major joints is often a common occurrence. Therefore, orthopaedic adult reconstructive surgeons increasingly encounter hemophilic arthropathy in young adults and consider treating with total joint arthroplasty. In this report, the authors describe a patient with hemophilia A and severe knee osteoarthritis, who was subsequently treated with primary total knee arthroplasty. This rare case is an opportunity to explore a variety of unique clinical scenarios specific to patients with hemophilia, including the maintenance of optimal factor VIII levels through clotting factor infusions and prevention of a venous thromboembolic event.
Collapse
|
10
|
Rodriguez-Merchan EC. Risks and patient outcomes of surgical intervention for hemophilic arthropathy. Expert Rev Hematol 2019; 12:325-333. [DOI: 10.1080/17474086.2019.1602035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|