Total knee replacement in haemophilic arthropathy

Morphological Measurement and Clinical Significance of Abnormal Development of Distal Femur with Hemophilia Knee Arthritis: A Consideration on the Renewal of Total Knee Prosthesis

OBJECTIVE

The knee joint of hemophiliacs may face the result of local morphological changes due to long-term irritation of synovitis. This study aims to elucidate the morphological characteristics of distal femur in hemophilic arthritis (HA) and compare the compatibility of three types of prostheses with the anteroposterior (AP) and mediolateral (ML) dimensions of the femoral osteotomy surface.

METHODS

This study retrospectively and randomly selected 50 patients with HA registered for treatment at our hospital from June 2016 to August 2022 as the study subjects, with an equal number of male osteoarthritis (OA) patients and healthy male individuals set as the control group. This study used medical digitalization software to simulate osteotomies on the distal femur during total knee arthroplasties (TKA) for 50 patients with HA, OA patients, and the healthy population, respectively, and measure the morphological parameters to compare with three commonly used femoral components of TKA in clinical practice. The differences between the femur resection of anteroposterior and mediolateral (FRAP, FRML) osteotomy surface and the prosthesis's BOX-AP/ML were compared in three prostheses. One-way ANOVA and multiple Kruskal-Wallis H test were used for the normal or non-normal distribution data, and pairwise comparisons between groups were conducted using the Bonferroni method, and the linear correlation analysis was utilized to assess the relationship between section femoral morphological data and prosthesis parameters.

RESULT

In HA patients, the morphological characteristics of the distal femur were shown as shorter than femur AP (FAP), medial and lateral condyle anterior-posterior dimension (FMCAP, FLCAP), notch width (NW), posterolateral condyle height (PLCH), posteromedial condyle width (PMCW), and posterior condylar axis length (PCAL) dimension. They had comparatively smaller femur section aspect ratios (p < 0.005). They showed longer posterolateral condyle width (PLCW), anterior condyle mediolateral dimension (FRACML), anterolateral condyle height (ALCH), and femur resection anterior condylar mediolateral (FRACML) dimension (p < 0.005). They showed larger distal femur aspect ratio and resection aspect ratio (FAR, FRAR, p < 0.005). All selected prostheses showed ML undercoverage under similar AP dimensions, and ML undersizing of Attune systems was more obvious in three femoral prostheses.

CONCLUSION

The distal femur morphological change of HA patient is shown as smaller AP dimension, narrow posterior condyle spacing, lower and shallower trochlear, thinner anterior condyle, wider and lower intercondylar notch and higher posterior-lateral condyle. The selected prostheses showed ML undercoverage under similar AP dimensions. This typical morphological tendency of the distal femur seems to warrant consideration in the process of knee joint prosthesis upgrading.

Clinical Outcomes of Total Knee Arthroplasty in Patients Who Have Hemophilic Arthropathy: A Prospective Study

PURPOSE

Total knee arthroplasty (TKA) is considered the gold standard treatment for patients who have advanced hemophilic knee arthropathy (HA). However, special considerations are required for these patients. This prospective study reports on the need for soft-tissue procedures, implant types, complication rates, mean 53.3 months implant survivorship, and patient-reported outcome measures (PROMs) of TKA in hemophilic patients.

METHODS

There were twenty primary TKAs that were performed on 15 hemophilic patients from 2012 to 2023. The mean follow-up was 53.3 months (range, 6 to 128; 33.5). The necessity for additional soft tissue procedures, implant type, complications, and revision rates were recorded. Knee Injury and Osteoarthritis Outcome Score, Knee Society Score, Hemophilia-specific Quality of Life Questionnaire for Adults, Haemophilia Activities List, and range of motion, were compared preoperatively and at the last follow-up.

RESULTS

At the last follow-up, implant survivorship was 90%. There were two revisions: one for aseptic loosening and one for periprosthetic joint infection. Additional soft tissue procedures included two quadriceps snips (10%). Tibial augments, tibial stubby stems, and both tibial and femoral traditional stems were used in one (5%), four (20%), and one (5%) TKAs, respectively. A constrained posterior-stabilized bearing was necessary in one case. Clinically and statistically significant improvements were found between the preoperative and final follow-up values of all PROMS, knee flexion (73 versus 108°, P < 0.001), and flexion contracture (11 versus 4°, P = 0.002).

CONCLUSION

This study showed that TKA, in patients who have HA, is a reliable treatment option that improves knee function and patients' QoL with acceptable implant survival rates at mid-term follow-up (mean 53.3 months). Standard implants and approaches can be used in most cases. Despite good outcomes, hemophilic patients carry additional risks for complications that require specific considerations. It is paramount for these patients to be treated in specialized centers by experienced surgeons to achieve good results.

TKR in Hemophilic Arthropathy: A Combination of Special Surgical Considerations and Novel Nonacog Beta Pegol: A Case Report

CASE

A 29-year-old man with hemophilia B presented with advanced arthropathy of the right knee, resulting in poor knee functional scores and difficulties in his livelihood. The patient underwent total knee replacement while receiving nonacog beta pegol factor IX by a multidisciplinary approach.

CONCLUSION

Hemophilias commonly result in end-stage hemophilic arthropathy of the joints at a young age that may warrant joint replacement surgeries. This case report illustrates the surgical protocol of total knee arthroplasty in a patient who received a long-acting factor IX preparation.

Anesthetic considerations for joint replacement surgery in hemophilic arthropathy: a comprehensive review

Managing hemophilia in patients undergoing joint replacement surgery requires a comprehensive approach encompassing preoperative assessment, meticulous intraoperative care, and tailored postoperative management. Evaluation of joint integrity, bleeding history, and inhibitor presence guides surgical planning and hemostatic therapy selection to optimize outcomes. During surgery, careful attention to factor replacement, antibiotic prophylaxis, anesthetic techniques, and orthopedic strategies minimizes bleeding risk and enhances surgical success. Postoperatively, effective pain management, continued hemostatic therapy, and individualized rehabilitation programs are vital for facilitating recovery and preventing complications. Close monitoring for potential complications, such as periprosthetic joint infection and recurrent hemarthrosis, allows for prompt intervention when necessary. Overall, a collaborative approach involving hematologists, orthopedic surgeons, anesthesiologists, and rehabilitation specialists ensures comprehensive care tailored to the unique needs of patients with hemophilia undergoing joint replacement surgery, ultimately optimizing outcomes and improving quality of life. This holistic approach addresses the multifaceted challenges posed by hemophilia and joint replacement surgery, providing patients with the best possible chance for successful outcomes and long-term joint function. By integrating specialized expertise from multiple disciplines and implementing evidence-based strategies, healthcare providers can effectively manage hemophilia in the context of joint replacement surgery, mitigating risks and maximizing benefits for patients.

Short-term outcome of total knee replacement in a patient with hemophilia: A case report and review of literature

BACKGROUND

Hemophilia A is a rare inherited bleeding disorder caused by mutations in the factor VIII gene. This clotting factor plays an intrinsic role in the blood coagulation pathway. Patients with hemophilia may develop orthopedic manifestations such as hemarthrosis, but multiple malunion of fractures over the knee is rare and difficult to treat.

CASE SUMMARY

We report a patient with hemophilia A who developed severe knee osteoarthritis along with fracture malunion and nonunion. Total knee replacement was performed using a custom-made modular hinged knee prosthesis (cemented) equipped with extended distal and proximal stems. At 3 years’ follow-up, the patient exhibited excellent clinical function and remained satisfied with the surgical outcome. Surgical intervention was accompanied by rigorous coagulation factor replacement.

CONCLUSION

This case highlights various unique scenarios specific to individuals with hemophilia and fracture deformity.

Total knee arthroplasty exhibits satisfactory long-term clinical efficacy in the treatment of hemophilia patients with stiff knees

Objective

This study aimed to (1) determine the long-term clinical efficacy of total knee arthroplasty (TKA) in the treatment of hemophilia patients with stiff knessknees, (2) assess the 5- and 10-year prosthesis survival in hemophilia, and (3) determine whether the severity of preoperative stiffness would affect postoperative clinical outcomes and complication rates.

Methods

The clinical data of 71 patients (78 knees) with hemophilia and concomitant knee stiffness who had undergone TKA between September 2007 and June 2018 were retrospectively analyzed. All patients were male, their mean age at the time of surgery was 38.4. ± 7.9 years (range: 21-63 years), and the mean follow-up time was 8.7 years. To determine the effect of stiffness severity on clinical outcomes, the participants were categorized into two groups: severe [preoperative range of motion (ROM): <50°, 34 knees] and moderate (preoperative ROM: 50-90°, 44 knees). At preoperative and final follow-up, patients' post-TKA clinical and radiological outcomes, quality of life, complications, and long-term survival were assessed.

Results

Flexion contracture improved from 23.2 ± 10.8° before surgery to 5.9 ± 7.5° upon final follow-up, the Knee Society Score (KSS) increased from 31.4 ± 12.4 to 74.9 ± 11.5, and the KSS functional score increased from 37.6 ± 9.3 to 81.4 ± 12.8. The mean ROM improved from 54.6 ± 32.6° preoperatively to 80.9 ± 34.5° postoperatively. The 36-Item Short Form Survey physical and mental scores also improved significantly. All these differences were statistically significant before and after surgery (P < 0.001). The following postoperative complications occurred in 10 knees (12.8%): hemarthrosis (n = 3), stiffness (n = 4), superficial infection (n = 1), skin necrosis (n = 1), and periprosthetic infection (n = 2), and revision TKA was performed on two knees. The 5- and 10-year survival rates of the prostheses were 98.5% and 93.7%, respectively. The mean ROM in the severe group increased from 30.7 ± 18.7° preoperatively to 70.5 ± 28.3° postoperatively (p < 0.001). The mean flexion contracture decreased from 27.3 ± 10.8° to 6.4 ± 12.0° (p < 0.001). The mean KSS improved from 27.0 ± 7.8 to 68.3 ± 9.6 (p < 0.001). The mean ROM in the moderate group improved from 84.3 ± 22.7 to 92.9 ± 28.8 (p < 0.001), while the mean flexion contracture decreased from 12.8 ± 11.0° to 4.8 ± 5.0° (p < 0.001) and the mean KSS improved from 41.3 ± 11.5 to 81.3 ± 12.2 (p < 0.001). The severe group had worse postoperative ROM and functional scores than the moderate group. Furthermore, the severe group used varus-valgus constrained or hinged prostheses more frequently (52.8% vs. 18.1%) and had more complications (18.9% vs. 9.0%) than the moderate group.

Conclusion

TKA exhibits satisfactory long-term efficacy in patients with hemophilic knee joint disease involving preoperative stiffness, thus potentially providing a significant improvement in function and reducing pain. Furthermore, severely stiff knee joints have worse clinical outcomes and more complications than moderately stiff knee joints.

Effectiveness of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in predicting the incidence of nausea and vomiting after total knee arthroplasty in patients with hemophilia A

Objective

To investigate the ability of preoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) to predict postoperative nausea and vomiting (PONV) after total knee arthroplasty (TKA).

Methods

The clinical data of 108 male patients with hemophilia A who underwent TKA an our institution were collected and analyzed. Confounding factors were adjusted by propensity score matching. The best cutoffs of the NLR and PLR were determined by the area under the receiver operating characteristic curve (ROC). The predictive ability of these indexes was assessed by measuring the sensitivity, specificity, and positive and negative likelihood ratios.

Results

There were significant differences in the use of antiemetics (p = 0.036) and the incidence of nausea (p < 0.001) and vomiting (p = 0.006) between the two groups (NLR <2 and ≥2). An increase in preoperative NLR was an independent risk factor for PONV in patients with hemophilia A (p < 0.05). ROC analysis showed that NLR significantly predicted the occurrence of PONV (cutoff value: 2.20, ROC: 0.711, p < 0.001). In turn, the PLR did not strongly predict PONV.

Conclusions

The NLR is an independent risk factor for PONV in patients with hemophilia A and can significantly predict this event. Thus, follow-up monitoring is essential for these patients.

Postoperative bleeding complications in patients with hemophilia undergoing major orthopedic surgery: A prospective multicenter observational study

BACKGROUND

Persons with hemophilia (PWH) are at risk for chronic hemophilic arthropathy (HA). Joint replacement surgery may be used to relieve intractable pain and/or restore joint function.

OBJECTIVES

This multicenter, prospective, observational cohort study evaluated the rate of bleeding during the postoperative period after total hip (THA) or knee arthroplasty (TKA).

PATIENTS/METHODS

We included PWH of any severity ≥18 years of age who were undergoing THA or TKA. Clinical decisions were made at the discretion of the treating physician according to local standards of care. Clinical data were prospectively recorded. Major bleeding was defined as bleeding in a critical site, bleeding that resulted in either a 2 g/dl or greater decrease in hemoglobin during any 24-h period, or transfusion of two or more units of packed red blood cells.

RESULTS

One hundred thirty-one procedures (98 TKA and 33 THA) were performed, 39 (29.8%) of which were complicated by major bleeding, including 46% of THA and 25% of TKA. The risk of major bleeding was increased in THA compared to TKA (OR 2.50, p = .05), and by the presence of an inhibitor (OR 4.29, p = .04), increased BMI (OR 4.49 and 6.09 for overweight and obese, respectively, compared to normal BMI, each p < .01), and non-use of an antifibrinolytic medication (OR 3.00, p = .03). Neither continuous clotting factor infusion (versus bolus infusion) nor pharmacologic thromboprophylaxis were associated with bleeding risk.

CONCLUSIONS

The bleeding risk remains substantial after THA and TKA in PWH, despite factor replacement. Use of antifibrinolytic medications is associated with decreased risk.

Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes-A Systematic Review and Meta-Analysis

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.

Total knee replacement for patients with severe hemophilic arthropathy in Taiwan: A nationwide population-based retrospective study

BACKGROUND

Total knee replacement (TKR) surgery is a treatment option for advanced hemophilic arthropathy. Due to its rarity and complexity, previous reports could only demonstrate the results of single-site studies including few cases. This population-based study aimed to investigate the major epidemiological characteristics, mean consumption of coagulation factors, length of hospital stays, complications, and failure rate of primary TKR for severe hemophilia patients in Taiwan.

METHODS

A cohort of 996 hemophilia patients registered between 1995 and 2011 was included, and 103 primary TKRs were performed on 75 patients. Unilateral TKR was performed on 47 patients and bilateral TKRs on the remaining 28 patients, including 12 simultaneous and 16 staged surgeries. The mean age at surgery was 32.3 years (range, 17.3-55.7), and the mean follow-up duration was 77.9 months (range, 2.3-176.8).

RESULTS

Failure was noted in 8 patients (8.5%) at mean 32.8 months (range, 2.3-95) after surgery. Four patients revealed aseptic loosening, whereas infection in 4. The 10-year prosthesis survivorship was 88.6%. For patients receiving unilateral TKR, the mean length of hospital stay was 15 days (range, 7-32). The mean cost of factor supplement was United States Dollar (USD) 43 543 with a mean 4-unit packed red blood cells transfusion (range, 0-38). The total admission cost was USD 48 326 (range, USD 4165-262 619).

CONCLUSION

The prevalence of TKA for hemophilia patients was 7.5% in Taiwan. The mean hospital stay was 14 days, and the 10-year prosthesis survivorship was 88.6%. The mean daily factor usage was decreased from 235.7 units preoperatively to 202.1 units postoperatively. In comparison with the staged-bilateral TKRs, the simultaneous procedures significantly reduced the mean total cost from USD 101 923 to USD 61 587 (p = 0.023). Therefore, in terms of cost-effectiveness, bilateral simultaneous TKR is more preferable than staged procedures.

Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health

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.

[Orthopedic treatment of musculoskeletal disorders in hemophilic patients]

Objective: To study the orthopedic treatment strategy for hemophilia complicated with musculoskeletal disorders as well as the peri-operative consumption of clotting factor. Methods: Total 338 orthopedic surgeries were performed for 261 patients, average age of 30.6 y (6-65 y) , with hemophilia between January 1996 and December 2019 at our institute. Two hundred and twenty-six patients presented with bleeds within the joints. Sixty-one patients presented with intramuscular bleeds, 45 presented with hemophilic pseudotumors, and six presented with miscellaneous complaints. Strategy of clotting factor replacement therapy was designed as per differences in the level of the operation procedure. Information regarding clinical manifestation, operative strategy, clotting factor consumption, and re-operation for complications was retrospectively recorded. The costs for multiple joint procedure and single joint procedure were studied. Results: We found that 270 of the 338 surgical procedures were major surgical procedures (79.9%) . There were 203 procedures of joint arthroplasty (60%) . Fourteen patients underwent reoperations for local recurrence (4.2%) . The average factor Ⅷ consumption before the surgery was 44.4 ± 8.1 IU/kg. The average FⅧ consumption within postoperative 2 weeks was 40 962 IU (647±177 IU/kg) . Seven type A hemophilic patients developed F Ⅷ inhibitor following the surgical procedure, with an average level of 13.7±11.2 BU/mL. Sixty-eight patients underwent multiple joint procedures under one anesthesia session (26%) . There was no significant difference in the factor consumption between the multiple joint procedure and single joint procedure. Conclusions: Surgical treatment was found to be effective for hemophilic arthropathy and lesion of the musculoskeletal apparatus, with the clotting factor replacement therapy. Multiple joint procedures under one anesthesia were more cost effective for patients with hemophilia, with less factor consumption than staged single joint procedure.

Mid-to Long-Term Survival of Total Knee Arthroplasty in Hemophilic Arthropathy

While satisfactory results have been reported during short-to mid-term follow-up assessments of hemophilic patients who have undergone total knee arthroplasty (TKA), limited literature focusing on long-term survival following TKA exists to date. As part of this investigation, a consecutive series of 78 TKAs in 56 patients with hemophilic arthropathy was reviewed. The mean patient age at the time of operation was 38.7 years old and the mean length of follow up was 10.2 years. Clinical and radiologic outcomes, quality of life, complications, and long-term survivorship of TKA were evaluated. At the latest point of follow up, the average American Knee Society (AKS) knee and function scores had improved from 32.1 to 85.7 points and 41.5 to 83.3 points, respectively. Moreover, the average range of motion (ROM) was significantly increased from 64.2° preoperatively to 84.2° postoperatively. The physical and mental Short Form-36 results were also significantly improved at the latest point of follow up. Postoperative complications appeared in 12 knees (15.4%). The readmission rate in the 30 days after discharge was 6.4%. Revision TKA was performed in three knees for periprosthetic joint infection (n = 2 knees) and tibial component loosening (n = 1 knee). The Kaplan-Meier 10- and 13-year prosthesis survival rates were 97.1% and 93.2%, respectively. The current study suggests that the mid-to long-term results of TKA in patients with hemophilic arthropathy are favorable, with successful long-term prosthesis survival achievable in most cases.

Total Knee Arthroplasty in Patients with Hemophilia: What Do We Know?

Total knee arthroplasty is considered as the treatment of choice for those with end stage hemophilic arthropathy. Compared to other patients undergoing TKA, these patients have specific features such as bleeding tendency, younger age, pre-operative restricted range of motion (ROM), altered anatomy, and increased complications. This narrative review of literature is going to investigate several issues regarding the TKA in hemophilic patients including indications, perioperative factor replacement, surgical challenges, postoperative rehabilitation, outcomes, and complications.

Perioperative laboratory monitoring in congenital haemophilia patients with inhibitors: a systematic literature review

: Although the use of clotting factor concentrates is the mainstay of haemophilia care, the development of inhibitors complicates disease management. Perioperative management of patients with inhibitors is therefore a challenge. A systematic literature review was performed to identify literature reporting on the perioperative monitoring and management of haemophilia. MEDLINE, Embase and Cochrane databases were searched from database inception to 26 March 2018. Recent congress proceedings were also searched. Titles and abstracts, then full texts, were screened for relevance by two reviewers. Quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Of the 2033 individual entries identified, 86 articles met the inclusion criteria. The identified studies were screened again to find articles reporting perioperative laboratory monitoring in patients with congenital haemophilia A or B, resulting in 24 articles undergoing data extraction. Routine perioperative assay monitoring practices were the most commonly reported (n = 20/24); thrombin generation assay was the least commonly reported (n = 2/24). Other monitoring practices described were factor VII and factor VIII coagulation activity (n = 8/24, n = 5/24, respectively), and thromboelastography or rotational thromboelastometry assessments (n = 3/24). The impact of monitoring on treatment decisions was, however, rarely reported. In conclusion, many methods of perioperative monitoring of haemophilia patients with inhibitors have been identified in this review, yet there is a lack of reporting in larger scale cohort studies. More detailed reporting on the impact of monitoring outcomes on treatment decisions is also needed to share best practice, particularly as new therapeutic agents emerge.

Challenges in successful management of haemophilic knee arthropathy: Our experience in a tertiary centre

Background

Haemophilia is characterized by a partial or complete deficiency of clotting factor VIII or IX. The repeated bleeding episodes into the joints contributes to subsequent chronic arthropathy which debilitates the patient and affects the quality of life. There are lot of hurdles in successful management of such patients. We present our experience in dealing such patients.

Materials and Methods

24 patients (27 knees) with haemophilic knee arthropathy were included. The preoperative VAS (Visual Analogue Scale) and KSS (Knee Society Score) were assessed. All underwent total knee arthroplasty with stemmed constrained prosthesis. Postoperatively VAS and KSS were analysed at the end of 12 months.

Results

The mean preoperative VAS was 8.2 (Range: 7-10), mean KSS clinical score was 39.9 (Range: 12-61) and mean KSS functional score was 51.4(Range: 20-70). The mean postoperative VAS was 2.7(Range: 2-4), mean KSS clinical score was 70.5 (Range: 61-80) and mean KSS functional score was 74.2(Range: 60-80). There was statistical significant difference between preoperative and post-operative scores. At the end of 12 months, 17 patients (63%) had good outcome, seven patients (26%) had fair and three patients (11%) had excellent outcome as per the KSS scores.

Conclusions

Total knee arthroplasty has good outcome with respect to clinical as well as functional outcome in haemophilic arthropathy. Although the results and outcome of total knee arthroplasty in haemophilic knee arthropathy may still be inferior to the results seen in a normal individual, a multidisciplinary approach yields a better functional and quality of living in such haemophilic patients.

Does Hemophilia Increase Risk of Adverse Outcomes Following Total Hip and Knee Arthroplasty? A Propensity Score-Matched Analysis of a Nationwide, Population-Based Study

BACKGROUND

End-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA.

METHODS

This retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1:4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital.

RESULTS

After propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval [CI] = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P < .001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups.

CONCLUSION

Hemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA.

Tranexamic acid may benefit patients undergoing total hip/knee arthroplasty because of haemophilia

BACKGROUND

The lower limb joints, including hip and knee, are the most commonly involved joints in haemophilic arthropathy. With a higher risk of transfusion, total hip and knee arthroplasty (THA and TKA) are still the first choice after failure of conservative treatment. In the present study, we aimed to analyze clinical outcomes and complications rate after total joint arthroplasty of the lower limbs using tranexamic acid (TXA) or not.

METHODS

Thirty-four patients with haemophilia A undergoing 24 TKA and 18 THA were evaluated in this retrospective study (No. 201302009). Based on using TXA or not, they were divided into either TXA (12 knees and 10 hips) or Non-TXA groups (12 knees and 8 hips). Total blood loss, intraoperative blood loss, total amount of FVIII usage, range of motion, inflammatory biomarkers, joint function, pain status, complication rate and patient satisfaction were assessed and compared at a mean follow-up of 68 months.

RESULTS

Usage of TXA can decrease not only the perioperative blood loss (p = 0.001), transfusion rate (p = 0.017) and supplemental amount of FVIII (p < 0.001) but also swelling ratio, surgical joint pain. Moreover, compared with non-TXA group, the patients in TXA group had a lower level of inflammatory biomarkers and better joint function.

CONCLUSION

The hemophiliacs treated with TXA had less perioperative blood loss, hidden blood loss, transfusion rate, a lower ratio of postoperative knee swelling, less postoperative joint pain, lower levels of inflammatory biomarkers and better joint function. Further studies need performing to assess the long-term effects of TXA in these patients.

Musculoskeletal treatment in haemophilia

Haemophilia is a group of coagulation disorders inherited in an X-linked recessive pattern.

Nearly three-quarters of all haemorrhages in haemophilia occur in the musculoskeletal system, usually in the large muscles and joints of the lower extremity.

While prevention of bleeding with active prophylaxis is the recommended optimal therapy for severe haemophilia, there are many patients suffering from musculoskeletal system complications subsequent to uncontrolled bleeding.

Recombinant clotting factor concentrates led to home treatment of acute bleeding episodes as well as allowing for minor and major surgical interventions.

Avoiding of further complications by radiosynoviorthesis is the first-line recommendation, and arthroplasty is regarded as the effective salvage procedure for patients presenting with severe disability.

Physiotherapy and rehabilitation in haemophilia patients are important to return the normal status of joint motion, to regain the muscle strength, to obtain the optimal functional levels and to improve patients’ quality of life.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180068

The role of orthopaedic surgery in haemophilia: current rationale, indications and results

The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.

Early continuous haematological primary prophylaxis by means of the intravenous infusion of the deficient coagulation factor (ideally from cradle to grave) is of paramount importance because the immature skeleton is very sensitive to the complications of haemophilia: severe structural deficiencies may develop quickly.

If primary haematological prophylaxis is not feasible due to expense or lack of venous access, joint bleeding will occur. Then, the orthopaedic surgeon must aggressively treat haemarthrosis (joint aspiration under factor coverage) to prevent progression to synovitis (that will require early radiosynovectomy or arthroscopic synovectomy), recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy).

Between the second and fourth decades, many haemophilic patients develop articular destruction. At this stage the main possible treatments include arthroscopic joint debridement (knee, ankle), articular fusion (ankle) and total joint arthroplasty (knee, hip, ankle, elbow).

Cite this article: EFORT Open Rev 2019;4:165-173. DOI: 10.1302/2058-5241.4.180090

An exploratory comparison of single intra-articular injection of platelet-rich plasma vs hyaluronic acid in treatment of haemophilic arthropathy of the knee

INTRODUCTION

Intra-articular platelet-rich plasma (PRP) injection therapy has been extensively applied in clinical practice to treat musculoskeletal disorders such as osteoarthritis, but the treatment for haemophilic arthropathy is rarely reported.

AIMS

This study aimed to compare the efficacy of intra-articular PRP vs hyaluronic acid (HA) injections in treating haemophilic arthropathy of knee joints.

PATIENTS

Twenty-two haemophilia patients (mean age, 41.1 ± 1.7 [range, 20-50] years) with painful haemophilic arthropathy of the knee were enrolled for this open-label and observer-blind study.

METHODS

Eleven patients were treated with a single intra-articular injection of PRP and the other 11 received five consecutively weekly intra-articular injections of HA. Outcome assessment included pain by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Chinese Version and synovial change determined by ultrasonography.

RESULTS

Platelet-rich plasma and HA intra-articular injection showed statistically significant reduction in VAS, WOMAC total score and hyperaemia score from baseline to 6-month post-treatment. Inter-group comparison showed statistically significant difference in the change in VAS score, WOMAC pain score, physical function score and total score at 6 months, wherein PRP group showed sustained beneficial effect than HA group at 6 months.

CONCLUSION

Our study demonstrates that, in comparison with five weekly injections of HA, a single PRP injection resulted in better improvement in pain relief and knee joint function, and greater reduction in synovial hyperaemia for up to 6 months. Our results suggest that PRP may be practical and effective for haemophilic knee arthropathy, and further investigation is warranted.

Range of motion after total knee arthroplasty in hemophilic arthropathy

BACKGROUND

Outcomes of total knee replacement in cases of hemophilic patients are worse than in patients who undergo operations due to osteoarthritis. Previous publications have reported varying rates of complications in hemophilic patients, such as infection and an unsatisfactory range of motion, which have influenced the survival of prostheses. Our retrospective study evaluated the data of hemophilic patients regarding changes in the development of the range of motion.

METHODS

The data and clinical outcomes of 72 total knee replacements in 45 patients with hemophilia types A and B were reviewed retrospectively. Patients were operated between 1998 and 2013. All of the patients were systematically followed up to record the range of motion and other parameters before and after surgery.

RESULTS

The mean preoperative flexion contracture was 17° ± 11° (range, 0°-40°), and it was 7° ± 12° (range, 0°-60°) postoperatively. The mean flexion of the knee was 73° ± 30° (range, 5°-135°) before the operation and 80° ± 19° (range, 30°-110°) at the last follow-up. The mean range of motion was 56° ± 34° (range, 0°-130°) before the operation and 73° ± 24° (range, 10°-110°) at the last follow-up.

CONCLUSIONS

Statistical analysis suggested that the range of motion could be improved until the 9th postoperative week. The patient should be operated on until the flexion contracture reaches 22° to obtain a contracture < 15° postoperatively or until the contracture reaches 12° to obtain less than 5°. The operation generally does not change the flexion of the knee in cases of hemophilic patients, but it reduces the flexion contracture and therefore improves the range.

Mid-term outcomes and complications of total knee arthroplasty in haemophilic arthropathy: A review of consecutive 131 knees between 2006 and 2015 in a single institute

INTRODUCTION

Although total knee arthroplasty (TKA) in haemophilic arthropathy can reduce severe joint pain and improve functional disability, it is technically demanding.

AIM

To evaluate mid-term outcomes and complications of TKA in haemophilic arthropathy.

METHODS

This study retrospectively reviewed 131 consecutive primary TKAs in a single institute. The mean age was 41.0 years old, and the mean follow-up period was 6.8 years. Clinical and radiographic results were evaluated. Complications were categorized according to the classification system of the Knee Society for TKA complications.

RESULTS

The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre- and postoperative maximum flexion did not differ (80.9° vs 85.6°, respectively). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal positions of the femoral and tibial components and the sagittal positions of these components were within ±3° in 83.2%, 89.3%, 63.4% and 73.3% of cases, respectively. Complications occurred in 17 knees (13.0%): hemarthrosis (n = 7), medial collateral ligament injury (n = 1), stiffness (n = 2), deep periprosthetic joint infection (PJI) (n = 3) and periprosthetic fracture (n = 4).

CONCLUSIONS

The mid-term results of TKA in haemophilic arthropathy were satisfactory in pain relief, improved function and decreased flexion contracture. Bleeding and PJI continue to be major concerns for TKA in haemophilic arthropathy, and risk of periprosthetic fracture must be taken into account for patient education and appropriate prevention.

Knee and Ankle Arthroplasty in Hemophilia

Today, major surgical procedures can be safely performed in hemophilic patients with chronic arthropathy, using available factor concentrates. In this setting, total knee replacement is considered the "gold standard", while the use of total ankle replacement is still debated. Indeed, the unsatisfactory results obtained with the previous available design of implants did not raise enthusiasm as knee or hip replacement. Recently, the introduction of new implant designs and better reported outcomes have renewed the interest in total ankle replacement in people with hemophilia. In this review, the role of replacement surgery in the treatment of chronic hemophilic arthropathy will be described.

Supracondylar femoral osteotomy and knee joint replacement during the same surgical procedure in a type A haemophiliac patient with knee flexion deformity and ankylosis

BACKGROUND

Haemophilia A is the cause of diverse musculoskeletal disorders such as ankylosis, arthritis and associated angular deformity. There are few reported cases in patients with haemophilia A in which simultaneous supracondylar femoral osteotomy and knee joint replacement has been performed to treat knee angular deformity and ankylosis. Here we present the case of an 18year old male patient, with an evolution of two years, who was unable to walk due to the presence of an untreated supracondylar fracture in the left femur and ipsilateral haemophilic arthropathy which led him to develop an ankylosis in flexion close to 70°.

METHODS AND RESULTS

Supracondylar osteotomy of the femur and of the left knee joint was performed in the same surgical procedure. Bleeding control was achieved with a protocol of factor VIII supply. The patient was followed up for eight years, and recovered a 0 to 90° range of motion and regained his gait pattern.

CONCLUSIONS

This case potentially provides a new alternative approach for haemophilia patients presenting with angular deformities and complex ankylosis. We suggest that mixed lesions of intra- and extra-articular deformity in haemophiliac patients can be corrected during the same surgical intervention. In addition, interdisciplinary management including haematology for operative and immediately postoperative control of intra-bleeding using factor VIII supply and control, combined with a controlled rehabilitation plan, can yield good functional outcomes in patients with haemophilic arthropathy.

Meta-analysis: outcomes of total knee arthroplasty in the haemophilia population

INTRODUCTION

People with haemophilia (PWH) experience end stage joint disease as a result of repeated hemarthrosis, commonly leading to total knee arthroplasty (TKA).

AIM

The goal of this meta-analysis is to calculate expected outcomes for range of motion (ROM), functional mobility, and complication rates in PWH following TKA.

METHODS

Studies published between 1980 and 2015 were identified.

INCLUSION CRITERIA

PWH having TKA, reporting Hospital for Special Surgery Knee Score or Knee Society Score, knee ROM, and incidence of complications for more than 5 TKAs. Inhibitor status, haemophilia severity and HIV status were not criteria for inclusion or exclusion. Meta-analysis was performed using mean, standard deviation, or P-value data to create effect sizes (ES) and 95% confidence intervals for each variable.

RESULTS

Twenty studies met inclusion criteria; ten had sufficient data for meta-analyses. A total of 336 TKAs in 254 PWH were analysed with mean follow-up of 6.3 years. Statistically significant ROM improvements were found with 9.72° improvement of flexion contracture (-0.73 effect size (ES) (-0.91 to -0.56)), and 15.69°increase into flexion (0.63 ES (0.34-0.91)). Knee scores showed statistically significant improvements: clinically, 37.9 point increase (3.21 ES [1.79-4.63]) and functionally, 13.50 point increase (1.50 ES [0.80-2.21]). A 31.5% complication rate was calculated with 106 reported in 336 TKAs.

CONCLUSIONS

TKA is an effective procedure for improving ROM and decreasing functional deficits resulting from haemophilic arthropathy. Knee score data shows TKA improves overall function. This study guides clinicians regarding outcome expectations post-TKA in PWH.

Revision Knee Arthroplasty in Patients with Inherited Bleeding Disorders: A Single-Center Experience

Background

The results of total knee arthroplasty (TKA) in patients with inherited bleeding disorders (IBDs) are poorer when compared with those in the general population, with a notably higher risk of complications and higher revision rates. Thus, revision procedures are becoming a growing concern in this group of patients. The aim of this study was to evaluate the results of revision TKA in patients with IBD.

Material/Methods

A retrospective cohort study with longitudinal assessment of hemophilia patients scheduled for revision TKA between January 2010 and September 2015 was performed. The clinical status of the patients was assessed based on the Knee Society Score, and the Numeric Rating Scale was used to assess knee pain severity and patient satisfaction with the surgery. Radiological examination, post-operative complications, and reinterventions were recorded and analyzed.

Results

Very good results were obtained in all patients treated for aseptic loosening of the implant. However, inferior results were found in cases with infection. All patients operated on for aseptic loosening required only single-stage TKA, whereas patients with infection underwent multiple interventions. Complications were observed only in cases with infection.

Conclusions

Our study clearly outlined the differences in results based on failure mode, with far inferior results obtained in cases with infection. Given the lack of data in this area as well as the high specificity of this population, further high-quality studies are needed.

Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced

BACKGROUND

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) and allowed patients to live for many decades. HIV and HAART are known risk factors for osteonecrosis of bone, osteopenia, and osteoporosis. Therefore, the demand for total joint arthroplasty (TJA) in HIV-infected patients is on the rise. We attempted to determine whether modern treatments for HIV have impacted the rate of periprosthetic joint infection (PJI).

METHODS

Conducting a systematic review, 25 studies with a total of 722 TJAs were identified. We extracted data on rates of PJI after primary TJA in HIV-infected patients with and without hemophilia and data on administration of HAART at the time of arthroplasty.

RESULTS

Three hundred eighty-one TJAs were performed in 293 patients with HIV infection without hemophilia. The follow-up ranged between 1.5 months and 11 years. Nine patients developed PJI. In patients with both HIV and hemophilia, 341 primary TJAs were performed. Forty-five received treatment for PJI. Follow-up ranged between 1 year and 26 years. Rates of PJI were 2.28% and 10.98% for HIV-only patients and patients with HIV and hemophilia, respectively. This difference was statistically significant (P < .0001) with a 5.28 odds ratio for hemophilia. HAART was associated with fewer infections overall (odds ratio, 0.12).

CONCLUSION

The rates of PJI after TJA in HIV-only patients are lower than those in patients with both HIV and hemophilia. Treatment of patients with HAART and optimization of underlying comorbidities appears to lower the rate of PJI in this patient population.

Functional outcome of total knee arthroplasty in patients with haemophilia

INTRODUCTION

Haemophilic arthropathy (HA) is a debilitating complication of haemophilia which leads to TKA in severe cases.

AIM

We conducted a prospective study of the outcome of TKA in our haemophilia cohort to define the outcomes in this population and increase the cost effectiveness of the procedure in our developing country.

METHODS

We reviewed patients with haemophilia who underwent TKA between April 2010 and April 2014. Patients with at least 6 months of follow-up were included. Preoperative knee scores (KSS and WOMAC) and the scores of the quality of life were recorded. Radiographic indices were registered pre- and postoperatively. Any complications were recorded. The patients underwent TKA with medial parapatellar approach. We had a low threshold for quadriceps snip when exposure was difficult. As our routine we did not use suction drains postoperatively.

RESULTS

We included 83 patients (all males, 103 knees). The mean age of the patients was 35.8 years. The mean follow-up period was 45.1 months. Three patients (3.6%) had factor inhibitors. Twenty patients (24.1%) underwent bilateral simultaneous TKA. The mean admission time was 13.87 days. We had two cases of wound infection and one case of haematoma. None of our patients needed transfusion. All knee scores were significantly improved (P < 0.000).

CONCLUSION

Total knee replacement is an effective procedure in treatment of HA. Definition of standards of care for this procedure, which are tailored for resources of a developing country, can have major impact in improving outcomes while maximizing cost effectiveness of this surgery.

Perioperative Period of a Hemophilia-related Osteoarthropathy Therapeutic Regimen and Analysis of Complications

OBJECTIVE

To investigate the effectiveness of our department's therapeutic regimen and treatment of complications during the perioperative period of hemophilia-related osteoarthropathy.

METHODS

In this retrospective study, data on 101 patients with hemophilia who had undergone operative treatment in our hospital from January 2000 to August 2014 were assessed. Ninety-one of the patients had hemophilia A and 10 hemophilia B. All patients were male. Changes in Hospital for Special Surgery (HSS), Harris and American Orthopedic Foot and Ankle Society (AOFAS) scores, occurrence of complications during the perioperative period and the clinical treatment and prognosis pre- and postoperatively and during follow-up were analyzed. Relevant clinical data were obtained through telephone calls, outpatient follow-up, and medical clinical record searches.

RESULTS

The 101 patients who were followed up (for an average of 96 months) had 147 orthopedic operations, including joint replacement, hemophilia-related false tumor resections, and tendo-achillis lengthening. The HSS scores for knee surgeries increased from 52 points preoperatively to 86 postoperatively, Harris scores for hip joint surgery from 26 to 87 points, respectively, and AOFAS scores for foot and ankle surgeries from 39 to 81 points, respectively. Eight patients had wound complications, four intra-articular hematomas, two peroneal nerve injuries, one a proximal femur splitting fracture and one deep venous thrombosis.

CONCLUSIONS

Surgical treatment is a safe and reliable choice for addressing complications including hemophilia-related osteoarthropathy given the implementation of effective measures for treatment during the perioperative period.

Perioperative management of hemophilia patients receiving total hip and knee arthroplasty: a complication report of two cases

It has been recognized that perioperative hemostasis management after joint-replacement surgery for hemophilia patients is complicated and cumbersome, due to the necessity of rigorous monitoring for clotting-factor levels throughout the infusion. Between 2005 and 2014, we examined seven patients with hemophilia A (ten joints: six hips and four knees) receiving total hip or knee arthroplasty (THA or TKA) for hemophilic arthropathy. One male patient (31 years old) showed an intra-articular hematoma formation after THA (case 1). In another male patient (46 years old) receiving TKA, the postoperative trough factor VIII level became lower significantly than reference levels (80%–100% for the 5–10 postoperative days) recommended by the guidelines from the Japanese Society on Thrombosis and Hemostasis, despite sufficient coagulant based on the guidelines being administered (case 2). In the latter patient, deep infection and hematoma formation were observed postoperatively. In this article, we provide a detailed clinical report regarding these two complication cases at the early postoperative periods, and the management of bleeding control for hemophilia patients is discussed.

Elective total knee arthroplasty in haemophilic patients. Proposal for a clinical pathway

Total knee arthroplasty (TKA) provides significant pain relief and better function in patients with end-stage haemophilic knee arthropathy. Peri- and postoperative care tends to be more complex than in non-haemophilic patients undergoing TKA and requires a multidisciplinary team approach.

AIM

The implementation of standardized clinical pathways in non-haemophilic patients undergoing TKA has been shown to increase quality of care and to reduce postoperative complication rates. Consequently, the use of clinical pathways in haemophilic patients undergoing TKA may be beneficial to this particular subpopulation of patients.

METHODS

A clinical pathway for TKA for haemophilic patients was designed in a consensus process involving all participating departments.

RESULTS

We propose a specifically adjusted clinical pathway for TKA for haemophilic patients to show that standardization of elective orthopaedic surgery in haemophilia is feasible.

CONCLUSION

The authors emphasize that there are limitations on categorizing haemophilic patients and stress that individual interdisciplinary treatment should take precedence over a standardized approach.

Outcome after total knee arthroplasty in haemophilic patients with stiff knees

INTRODUCTION

Advanced haemophilic arthropathy of the knee is associated with progressive joint stiffness. Results after total knee arthroplasty (TKA) in stiff knees are considered to be inferior compared to those with less restricted preoperative range of motion (ROM). There is only very limited data on the results of primary TKA in haemophilic patients with stiff knees.

AIM

The purpose of this retrospective study was to evaluate the clinical outcome after TKA performed in haemophilic patients with preoperative ROM of 50° or less.

METHODS

Twenty one patients (23 knees) undergoing TKA with stiff knees were retrospectively evaluated. Mean follow-up was 8.3 years (range, 2-25). Clinical assessment included ROM, degree of flexion contracture and complication rate. Functional evaluation and pain status were assessed using the Knee Society's Scoring System (KSS).

RESULTS

Range of motion improved from 26.7° preoperatively to 73.0° postoperatively. Flexion contracture decreased from 21.7° to 8.3°. KSS increased from 22.9 to 72.9 points. Evaluation of pain revealed a decrease from 8.4 points preoperatively to 2.1 points postoperatively. All these differences were statistically significant (P < 0.005). The complication rate was 8.7% including one late periprosthetic infection, and one aseptic implant loosening. Nine patients who required VY-quadricepsplasty for knee exposure developed a mean postoperative extensor lag of 7°.

CONCLUSION

Total knee arthroplasty in haemophilic patients presenting with stiff knees results in significant improvement of function and reduction in pain. Although the clinical outcome is inferior compared to nonstiff knees reported in the literature, joint replacement surgery can be successfully performed in this particular group of patients.

Simultaneous bilateral total knee arthroplasty in severe hemophilia: a retrospective cost-effectiveness analysis

INTRODUCTION

Simultaneous bilateral total knee arthroplasty (TKA) is proposed in the general population as an alternative to staged bilateral TKA and has the advantage of reducing costs with equivalent complication rates. The aim of this study was to evaluate the cost-effectiveness of this alternative in a population of patients with severe hemophilia.

HYPOTHESIS

Simultaneous bilateral TKA is less expensive than staged bilateral TKA.

MATERIALS AND METHODS

We performed a retrospective case control study in patients with severe hemophilia A to compare the direct costs of coagulation factors, the length of hospital stay and sick leave as well as the clinical outcome (KKS) of simultaneous bilateral TKA (group 1; G1: 5 patients) and staged bilateral TKA (group 2; G2: 12 patients).

RESULTS

The mean cost of coagulation factors was 65,880 € in G1 and 139,000 € in G2 (P<0.001). The length of the hospital stay (24 days vs 44 cumulative days, respectively) and sick leave (105 days vs 183 cumulative days, respectively) was significantly reduced in G1. There was no significant difference in clinical outcome at the final follow-up. One patient in G2 had a late knee infection.

DISCUSSION

Simultaneous bilateral TKA in severe hemophilia is associated with lower costs than staged bilateral TKA with equivalent clinical results.

LEVEL OF EVIDENCE

Level 3, case control study.

Total knee replacement in patients with haemophilia: the Scottish experience

INTRODUCTION

Patients with haemophilia commonly develop arthropathy secondary to recurrent haemarthroses. Although modern treatment with replacement coagulation factors has reduced the prevalence of end-stage arthropathy, total joint replacement is still required in a small group of patients. These patients may be at higher risk of complications and the outcome of surgery may not be comparable to reports of outcomes of total joint replacement in the general population. The purpose of this study was to describe the change in function in patients undergoing total knee replacement for haemophilic arthropathy.

PATIENTS AND METHODS

Patients undergoing total knee arthroplasty in a tertiary centre had prospective evaluations of patient reported outcome measures and range of movement. Their post-operative function was evaluated in a combined orthopaedic-haematology clinic. Eight male patients underwent 13 total knee replacements from 1999 to 2007 and were followed up for a median of 78 months (range 17-116).

RESULTS

The median Oxford knee score improved from 45.5 pre-operatively to 28 (p = 0.049). There was a similar improvement in SF-12 physical (p = 0.017) and Knee Society scores (objective p = 0.001; function p = 0.002). Four total knee replacements were performed in patients with inhibitor antibodies and were treated with recombinant activated factor VIIa. These patients had reduced range of movement (p = 0.047). No patients suffered deep infection.

CONCLUSIONS

Total knee replacement in patients with haemophiliac arthropathy resulted in improvement in range of movement and function. The presence of factor VIII inhibitors resulted in reduced range of movement, but similar patient reported outcome measures.

Thromboprophylaxis and Incidence of Venous Thromboembolism in Patients With Hemophilia A or B Who Underwent High-Risk Orthopedic Surgeries

Total hip replacement (THR) and total knee arthroplasty (TKA) carry a high risk of postoperative venous thromboembolism (VTE); therefore, anticoagulation prophylaxis is recommended in these patients. Unfortunately, there are no guidelines about VTE prophylaxis in patients with hemophilia who underwent these high-risk surgeries. To determine whether these patients have high risk of VTE, we conducted a retrospective study on patients with hemophilia who underwent elective THR/TKA at our institute from 2004 to 2012. Postoperatively, we collected information on duration and method of factor VIII/IX infusion, VTE-prophylaxis, and complications. There were 23 patients with hemophilia, 18 (78%) with hemophilia A and 5 (22%) with hemophilia B, who underwent high-risk surgeries (39% THR and 61% TKA). The VTE prophylaxis included sequential compression device, 12 (52%), and prophylactic enoxaparin, 1 (4%). Ten (43%) patients did not receive VTE prophylaxis. At 1-year follow-up, we did not find any evidence of clinical VTE in our patients. Better risk stratification is needed to identify patients who would benefit from pharmacological prophylaxis.

Total hip replacement in HIV-positive patients

We report the short-term follow-up, functional outcome and incidence of early and late infection after total hip replacement (THR) in a group of HIV-positive patients who do not suffer from haemophilia or have a history of intravenous drug use. A total of 29 patients underwent 43 THRs, with a mean follow-up of three years and six months (five months to eight years and two months). There were ten women and 19 men, with a mean age of 47 years and seven months (21 years to 59 years and five months). No early (< 6 weeks) or late (> 6 weeks) complications occurred following their THR. The mean pre-operative Harris hip score (HHS) was 27 (6 to 56) and the mean post-operative HHS was 86 (73 to 91), giving a mean improvement of 59 points (p = < 0.05, Student’s t-test). No revision procedures had been undertaken in any of the patients, and none had any symptoms consistent with aseptic loosening. This study demonstrates that it is safe to perform THR in HIV-positive patients, with good short-term functional outcomes and no apparent increase in the risk of early infection.

Cite this article: Bone Joint J 2014; 96-B:462–6.

Outcome of total knee arthroplasty in hemophilic arthropathy

The clinical histories of 45 consecutively performed TKAs in 32 patients with hereditary bleeding disorders were reviewed retrospectively. The mean follow up was 88.7 (range, 24-232) months. The cumulative probability of infection free-survival was 87.8% after 180 months. When removal of component was defined as endpoint, the survival probability was 86.4% after 180 months. In regression analysis no significant independent risk factors for infection or aseptic loosening were identified. The HSS score improved significantly from 45 to 85 points. Hemophilic patients can be considered to be at high risk for prosthetic failure, our study has demonstrated favorable functional results of total knee arthroplasty in hemophilic patients.

Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty

We hypothesized that infection rates following total joint arthroplasty (TJA) in those with the human immunodeficiency virus (HIV) without hemophilia or drug use would be similar to rates in HIV-negative patients. Records at an urban HIV referral hospital were searched for patients who underwent primary total hip and knee arthroplasty from 2003 to 2010. The primary outcome was revision for infection. 372 HIV-negative and 22 HIV-positive TJA patients met inclusion criteria. The HIV-positive group had more deep infections than the HIV-negative group (9.1% v 2.2%, P=0.102). There were no infections in those with AIDS-defining CD4 counts. Those with HIV may have a higher risk of developing a deep infection. A low CD4 count is not an absolute contraindication to TJA in HIV positive patients.