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

Authors: Kleiboer, B; Layer, MA; Cafuir, LA; Cuker, A; Escobar, M; Eyster, ME; Kraut, E; Leavitt, AD; Lentz, SR; Quon, D; Ragni, MV; Thornhill, D; Wang, M; Key, NS; Buckner, TW

Affiliations: Univ N Carolina, Dept Med, Chapel Hill, NC USA. Univ N Carolina, UNC Blood Res Ctr, Chapel Hill, NC USA. Emory Univ, Sch Med, Atlanta, GA USA. Univ Penn, Dept Med, Philadelphia, PA USA. Univ Penn, Perelman Sch Med, Dept Pathol Lab Med, Philadelphia, PA USA. Univ Texas Hlth Sci Ctr Houston, McGovern Med Sch, Houston, TX USA. Penn State Hershey Med Ctr, Hershey, PA USA. Ohio State Univ, Hemostasis & Thrombosis Ctr, Columbus, OH USA. Univ Calif San Francisco, Dept Lab Med, San Francisco, CA USA. Univ Calif San Francisco, Dept Internal Med, San Francisco, CA USA. Univ Iowa, Dept Internal Med, Carver Coll Med, Iowa City, IA USA. Orthopaed Inst Children, Orthopaed Hemophilia Treatment Ctr, Los Angeles, CA USA. Univ Pittsburgh, Dept Med, Pittsburgh, PA USA. Univ Pittsburgh, Clin & Translat Sci, Sch Med, Pittsburgh, PA USA. Univ Colorado, Sch Med, Aurora, CO USA.

Publication: Journal of Thrombosis and Haemostasis ; February 2022

Abstract: 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.