Risks and patient outcomes of surgical intervention for hemophilic arthropathy

ABSTRACT

Introduction: Surgical interventions usually needed for hemophilic arthropathy include arthroscopic synovectomy, alignment osteotomy, arthroscopic joint debridement, radial head removal, arthrodesis of the ankle, and total joint arthroplasty (elbow, hip, knee, ankle).

Areas covered: Whatever the surgical technique, appropriate surgical hemostasis must be achieved through infusion of concentrate of the deficient factor (factor VIII or factor IX), either in recombinant or plasma-derived form, at the correct dosage (ideally for 10–14 days). In patients with inhibitors, there are also the aPCCs (activated prothrombin complex concentrates) and rFVIIa (recombinant activated FVII). These surgical procedures are safe even in the most complex cases such as patients with inhibitors or who are human immunodeficiency virus-positive (HIV+) and hepatitis C virus-positive (HCV+).

Expert opinion: The risk of bleeding in surgical procedures is higher for hemophilic patients than for other patients and there is also a greater risk of infection. Both these factors increase the risk of a poor outcome. Orthopedic surgery in hemophilia improves the patient’s quality of life.

KEYWORDS:

• Hemophilia
• orthopedic surgery
• indications
• risks
• patient outcomes

Article highlights

• Primary prophylaxis with the deficient clotting factor from the age of 2 until the patient reaches 18 (even for life) appears to be the only efficacious way to lessen the articular bleeding and musculoskeletal problems characteristic of hemophilia in adulthood.

• To avoid joint destruction, correct management of hemarthroses should include early diagnosis, appropriate hematological treatment, arthrocentesis, physical medicine and rehabilitation, and prevention of new hemarthroses

• In the presence of synovitis causing recurrent hemarthroses, radiosynovectomy (RS) should be the first alternative. When 3 consecutive RS with at least a 6-month interval fail, surgical synovectomy is indicated (preferably arthroscopic)

• Surgical interventions that are usually needed for hemophilic arthropathy include arthroscopic synovectomy, alignment osteotomy, arthroscopic joint debridement, radial head removal, arthrodesis of the ankle, and total joint arthroplasty (elbow, hip, knee, ankle).

• Whichever surgical technique is used, appropriate surgical hemostasis must be accomplished by infusion of concentrate of the deficient factor (factor VIII or factor IX), either in recombinant or plasma-derived form, at the correct dosage (ideally for 10–14 days).

• In patients with inhibitor, adequate surgical hemostasis can be accomplished by infusion of bypassing agents: aPCCs (activated prothrombin complex concentrates) and rFVIIa (recombinant activated FVII).

• In orthopedic surgery for people with hemophilia, general anesthesia is advised, because spinal anesthesia can cause dangerous complications (secondary to a spinal hematoma).

• Total knee arthroplasty (TKA) is associated with a high risk of periprosthetic infection (7% on average) in hemophilic patients.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

The manuscript was not funded.