A Canadian multicenter 3-decade retrospective cohort review of adults with hemophilia, published in Haemophilia, reported a decrease in total knee arthroplasties (TKA) and an increase in the rate of ankle arthrodesis over time. In addition, length of stay (LOS) and factor utilization decreased, reflecting improvements in perioperative management.
Surgical intervention is often needed to address hemophilic arthropathy, a serious complication in people with hemophilia. Over the last 30 years, many clinical advances have been made in the management of hemophilia that have impacted the need for orthopedic interventions and peri-procedural resource utilization.
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In this report, 65 men with hemophilia of all severities (78% with hemophilia A), including those with active inhibitors, who underwent >1 orthopedic procedures from January 2000 to August 2018 were included in the analysis. A marked decline in the proportion of TKAs coincided with an increase in ankle arthrodesis.
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The number of TKAs declined from 56% to 51% to 27% in the years 1990-1999, 2000–2009, and 2010–2018, respectively. Over the same time period, ankle arthrodesis showed a concomitant rise; 18% between 2000 and 2009, and 27% between 2010 and 2018. This may be due to the ankle joint still being prone to bleeds or micro-bleeds despite prophylaxis.
The study also found:
- Over the time frame studied, orthopedic procedures in people with hemophilia were performed at a later age; shifting from the early 40s to the late 40s.
- The amount of perioperative coagulation factor VIII use declined by 32% in knee arthroplasties (749 vs 512 IU/kg), and by 14% in ankle arthrodesis (534 vs 458 IU/kg) from the 2000-2009 period to the 2010-2018 period (P =.003).
- The median LOS for all surgeries declined from 20 days to 5 days to 3 days over the three decades studied (P <.0001).
- Prosthetic joint infections showed a significant decrease over the 3 decades studied. During the last decade, major bleeds, prosthetic joint infections and thrombosis were not observed.
Although this is a Canadian study, the authors note that their “findings were similar to the U.S. Universal Data Collection (UDC) program, which reported a 5.6% reduction in orthopedic procedures in the period from 2000 to 2010.” Overall improvements in prophylaxis that delay the onset of end-stage arthropathy and improvements in the multidisciplinary management of hemophilic arthropathy are likely responsible for the results observed.
Future work will need to include a prospective study design to capture complications occurring beyond the index hospitalization, and data on preoperative and postoperative range of motion data and functional patient outcomes will need to be presented.
Reference
Lin CY, Hosseini F, Squire S, Jackson S, Sun HL. Trends of outcomes and healthcare utilization following orthopaedic procedures in adults with haemophilia: a 3-decade retrospective review. Haemophilia. Published online November 3, 2021. doi:10.1111/hae.14451
