In those with hemophilia, major postoperative bleeding following total knee arthroplasty (TKA) is common and is associated with significantly worse function, according to the results of a single-center, retrospective cohort study published in The Knee.

Hemophilia can lead to recurrent hemarthroses of the knee joints and impaired function. Recognizing that little is known about the long-term effects of early major postoperative bleeding in individuals with hemophilia, the researchers sought to evaluate the impact of early major postoperative bleeding on final functional outcome, complications, and implant survival in a single-center hemophilia cohort.

All cases of hemophilic arthropathy in which TKA had been performed between 1998 and 2019 were reviewed. Study inclusion criteria included the following: (1) diagnosis of hemophilic arthropathy of the knee; (2) having undergone TKA surgery at Hacettepe University in Ankara, Turkey at 18 or more years of age; and (3) no history of intellectual disabilities or other significant comorbidities that might impair the assessment of outcomes.

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In all participants, demographic data, radiographic images, and clinical data were evaluated. Range of motion in all knees was measured, and functional assessment was performed according to the Hospital for Special Surgery (HSS) score, the Knee Society Score (KSS), and the Knee Society Function Score (KSS-F).

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The study cohort was divided into 2 groups for additional analysis: (1) the bleeding group, which included participants with early major postoperative bleeding who required additional treatment or experienced a prolonged hospitalization; and (2) the control group, which comprised participants who did not experience any early bleeding complications.  

A total of 29 patients and 45 knees fulfilled the study inclusion criteria. All of the participants were male. The mean participant age was 38 years (range, 18-63 years). The mean follow-up duration was 9.67 years (range, 2-22 years).

Based on factor levels, 1 participant had mild hemophilia, 15 individuals had moderate hemophilia, and 13 patients had severe hemophilia. On average, the patients received 54,000 U of factor replacement therapy.

TKA was associated with a significant increase in the mean range of motion from 46.08° to 84.59° (P< .01). HSS scores increased from 48.33 presurgically to 82.67 postsurgically (P< .01). Significant improvements in both KSS and KSS-F scores from 34.22 and 53.30 preoperatively to 82.00 and 84.63, respectively, postoperatively were reported (P< .01).

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Overall, 34% (10 of 29 patients, ie, 10 TKAs) of participants experienced major bleeding during the postsurgical period. Of these 10 individuals, 6 had moderate hemophilia and 4 had severe hemophilia.

The bleeding group compared with the control group experienced significantly worse HSS (63.78 vs 92.75, respectively; P <.001), KSS (61.78 vs 93.25, respectively; P <.001), and KSS-F (60.71 vs 96.25, respectively; P =.005) scores.

The authors concluded that based on the results of the current study, “most patients without major postoperative bleeding showed improved function at follow-up. . . Efforts must be made to avoid major postoperative bleeding after TKA in persons with hemophilia.”


Goker B, Caglar O, Kinikli GI, Aksu S, Tokgozoglu AM, Atilla B. Postoperative bleeding adversely affects total knee arthroplasty outcomes in hemophilia. Knee. 2022;39:261-268. doi:10.1016/j.knee.2022.10.001