Elective orthopaedic surgery for inhibitor patients

Abstract

We report on a series of 108 elective orthopaedic surgical procedures. It includes 88 radiosynoviortheses and 20 major orthopaedic procedures, performed on 51 patients at nine centres worldwide. The average age of patients was 28.5 years (range 5-40 years), and the average follow-up time was 2 years (range 1-5 years). There were 82 good results, 15 fair and 11 poor. In the synoviorthesis group (41 patients, 88 synoviortheses) the average age was 14.3 years (range 5-40 years) and the average follow-up was 6.5 years (range 1-10 years). There were 66 good results, 14 fair and eight poor. There were no complications. In the group of major orthopaedic procedures, the average age of the 10 patients was 32.5 years (range 27-40 years), and the average follow-up was 2.3 years (range 1-5 years). There were 16 good results, one fair and three poor. Postoperative bleeding complications occurred in three of the 20 major orthopaedic procedures performed (15% complications rate). They occurred in three patients treated with insufficient doses of recombinant activated factor VII. Despite such complications, the study has shown that haemophilic patients with inhibitors requiring elective orthopaedic surgery (EOS) can undergo such procedures with a high expectation of success. In other words, EOS is now possible in haemophilic patients with inhibitors, leading to an improved quality of life for these patients. Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Surgery in haemophilia patients with inhibitors, with special emphasis on orthopaedics: Madrid experience

“…Contemporary surgical and haematological advances (FEIBA, rFVIIa) allow us to perform major operations on haemophilic patients with inhibitors, however, also with a higher risk of bleeding complications than in haemophilic patients without inhibitors [14][15][16].…”

Evidence Supporting the Use of Recombinant Activated Factor VII in Congenital Bleeding Disorders

“…They found that most bleeding complications could be resolved by increasing the rFVIIa dose or administering an extra dose and concluded that the optimal initial rFVIIa bolus dose for orthopedic surgery may be higher than 90 µg/kg. Furthermore, in the major orthopedic interventions reported by Solimeno et al 23 and Rodriguez-Merchan et al, 24 bleeding complications were only observed in patients receiving the dose of 90 µg/ kg rFVIIa. Based on these data, a minimum initial dose of 120 µg/kg rFVIIa, followed by a similar or 90 µg/kg dose every 2 hours, was suggested for patients in the BI group.…”

“…15 The considerable heterogeneity in the assessment of hemostatic efficacy and in sampling time points is in agreement with reports from nonrandomized studies. 10,[22][23][24][25][32][33][34][37][38][39] Obviously, this constitutes a significant problem for the interpretation and comparison of results from the studies of patients with hemophilia. Thus, data interpretation and the comparison of efficacy in the future studies on patients with hemophilia would be improved if efficacy parameters were standardized.…”

Meeting Report: Abstracts of the 9th World Federation of Hemophilia Musculoskeletal Congress, September 9‐‐11, 2005, Istanbul, Turkey

“…The maximum dose of rVIIa used in this series was 90 lg/kg every 2 hours initially for 24-48 hours and significant postoperative bleeding was reported in three cases (15%), including 2/6 cases of total knee arthroplasty. It would be fair to say that nowadays the view is that higher doses of rVIIa should be used in the setting of surgery and a standard regimen of 150-200 lg /kg body weight every 2 hours for the first 48 hours has been advocated [6]. Laboratory monitoring of treatment in patients with inhibitors is a particular problem.…”