Approximately one-third of patients with hemophilia needing a total knee replacement (TKR) surgery have moderate-to-severe synovial hyperemia, which can be safely reduced via genicular artery embolization prior to surgery, according to a study published in Haemophilia. 

TKR may be necessary in individuals with severe hemophilic knee arthropathy. Genicular artery embolization is sometimes performed in patients with symptomatic knee osteoarthritis. Studies indicate that this procedure is also safe and effective in treating severe joint bleeding in individuals with hemophilia. 

Prior to TKR, physicians often perform a preoperative angiography with genicular artery embolization. Imaging is important because it may reveal synovial hyperemia and pseudoaneurysms, which can be treated preoperatively to minimize the risk of bleeding complications during surgery. This, in turn, may have a significant impact on postoperative recovery and rehabilitation. 

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The authors of the study sought to explore the prevalence of synovial hyperemia prior to TKR in individuals with hemophilia and to investigate if preoperative genicular artery embolization on synovial hyperemia has any effects on 3-month postoperative joint bleeding. They conducted a retrospective study, looking at case files of individuals with hemophilia who underwent preoperative angiography and TKR between January 2009 and December 2020. 

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The indication for TKR for each patient was reached in a multidisciplinary manner. Prior to surgery, the hospital’s protocol was for all patients to receive angiography to assess for the presence of synovial hyperemia, and for genicular artery embolization to be performed if indicated. To control bleeding during surgery, an initial bolus of factor VIII/factor IX was administered to achieve levels between 80% and 100%, followed by bolus therapy or continuation infusion.

Twenty-four individuals with hemophilia were selected in whom 33 preoperative angiography procedures were performed for each knee requiring TKR. Of the 33 knee joints, 21 (64%) had preoperative synovial hyperemia. After genicular artery embolization, synovial hyperemia decreased in 13 of 15 joints (87%). In total, 5 of 32 joints (16%) demonstrated postoperative bleeding at the 3-month mark. There was no statistically significant difference between nonembolized and embolized joints in terms of 3-month postoperative bleeding. 

“Without any observed complications, a successful decrease in synovial hyperaemia postembolization was observed in 87% of joints after genicular artery embolization,” the authors wrote. “Three-month postoperative bleeding appears to occur independently of the presence of residual mild synovial hyperemia.” 


Foppen W, van der Schaaf IC, van Leeuwen FHP, et al. Pre-operative synovial hyperaemia in haemophilia patients undergoing total knee replacement and the effects of genicular artery embolization: a retrospective cohort studyHaemophilia. Published online August 7, 2023. doi:10.1111/hae.14835