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Postoperative Bleeding Complications in Patients with Hemophilia Undergoing Major Orthopedic Surgery: A Prospective, Multicenter Observational Study

1University of Colorado School of Medicine, Aurora, United States, 2University of North Carolina School of Medicine, Chapel Hill, United States, 3Emory University School of Medicine, Atlanta, United States, 4Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States, 5McGovern Medical School, University of Texas Health Science Center at Houston, Houston, United States, 6Penn State Hershey Medical Center, Hershey, United States, 7The Ohio State University Wexner Medical Center, Columbus, United States, 8University of California, San Francisco School of Medicine, San Francisco, United States, 9The University of Iowa Carver College of Medicine, Iowa City, United States, 10Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles, United States, 11University of Pittsburgh Medical Center, Pittsburgh, United States

Abstract Number: PB0527

Meeting: ISTH 2021 Congress

Theme: Hemophilia and Rare Bleeding Disorders » Hemophilia - Clinical

Background: Chronic hemophilic arthropathy develops in persons with hemophilia (PWH) after recurrent intra-articular bleeding. Joint replacement surgery may provide relief from intractable pain and improve quality of life in PWH who have end-stage arthropathy.

Aims: To determine the risk of bleeding during the immediate postoperative hospitalization period following total hip (THA) and total knee arthroplasty (TKA).

Methods: We conducted a multicenter, prospective, observational cohort study at 14 Hemophilia Treatment Centers (HTCs) in the United States. We included subjects with hemophilia A or B of all severities undergoing THA or TKA who were at least 18 years old. All clinical treatment decisions were made per local standards of care. All subjects provided informed consent. Clinical information describing treatments, evaluations, procedures, and outcomes were abstracted from medical records in real time. We defined major bleeding as that which occurred in a critical site, resulted in a decrease in hemoglobin of >2 g/dL over any 24-hour period, resulted in transfusion of >2 units of packed red blood cells (pRBC) during hospitalization, or led to death. The impact of clinical factors on the likelihood of bleeding was examined using univariate logistic regression analyses.

Results:
Major bleeding events during hospitalization following 131 total hip and knee arthroplasty procedures in men with hemophilia A or B.

Relationship of clinical factors potentially related to bleeding risk in men with hemophilia A or B during hospitalization following THA or TKA: univariate logistic regression. 
Variable Number with Major Bleeding, n/total (%) Odds Ratio
(variable in second column is referent value)		 95% Confidence Interval p vlaue
Procedure Type THA: 15/33 (45.5) TKA: 24/98 (24.5) 2.54 1.10 – 5.85 0.03
Active Inhibitor* Present: 6/12 (50) Not Present: 33/119 (27.7) 2.44 0.73 – 8.13 0.15
Clotting Factor Administration Type Continuous Infusion: 13/46 (28.3) Bolus Only: 24/75 (32) 1.20 0.53 – 2.67 0.67
Use of Antifibrinolytic Medication AF used: 8/38 (21.1) AF not used: 31/93 (33.3) 0.48 0.20 – 1.18 0.11
Use of Pharmacologic Thromboprophylaxis Yes (LMWH): 2/7 (28.6) No: 37/124 (29.8) 0.88 0.16 – 4.72 0.88
*Active inhibitor defined as use of bypass agent as primary hemostatic medication during / after procedure.
THA=total hip arthroplasty; TKA=total knee arthroplasty; AF=antifibrinolytic; LMWH=low molecular weight heparin

Relationship of clinical factors potentially related to bleeding risk in men with hemophilia A or B during hospitalization following THA or TKA: univariate logistic regression.
131 procedures (98 TKA and 33 THA) were performed. Of these, 39 (29.8%) were associated with major bleeding, including 46% of those undergoing THA and 25% TKA. Half of those with active inhibitors (6 of 12) experienced a major bleed. Neither use of continuous clotting factor infusion nor pharmacologic thromboprophylaxis was associated with differences in bleeding risk. Use of concomitant antifibrinolytic medication was associated with a non-statistically significant reduction in bleeding rate from 33% to 21% of procedures.  

Conclusions: The risk of bleeding during the immediate post-operative period after THA and TKA is significant, despite factor replacement. These data suggest the need for standard guidelines for postoperative hemostasis in PWH undergoing these procedures.

To cite this abstract in AMA style:

Buckner TW, Kleiboer B, Layer M, Cafuir L, Cuker A, Escobar M, Eyster ME, Kraut E, Leavitt AD, Lentz SR, Quon D, Ragni M, Thornhill D, Wang M, Key NS. Postoperative Bleeding Complications in Patients with Hemophilia Undergoing Major Orthopedic Surgery: A Prospective, Multicenter Observational Study [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/postoperative-bleeding-complications-in-patients-with-hemophilia-undergoing-major-orthopedic-surgery-a-prospective-multicenter-observational-study/. Accessed September 22, 2023.

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