Results of Knee and Hip Joint Arthroplasty in Hemophiliacs

Introduction

Joint arthroplasty is considered the gold standard for addressing advanced stages of joint degeneration in hemophiliacs. However, patients with bleeding disorders exhibit numerous specificities compared to the general population, including a higher tendency for bleeding and related complications, a younger age at the time of implantation, limited range of motion before the procedure due to irreversible joint damage, altered joint anatomy, and an overall increased risk of complications.

In earlier times, the implantation of total endoprostheses in hemophilic patients often did not achieve satisfactory results. However, according to recently published studies, advances in perioperative care, surgical techniques, and implant design and materials have brought outcomes closer to those of the general population.

Study Results

Functional outcomes and implant survival rates after total knee endoprosthesis implantation in hemophiliacs still show a degree of inferiority compared to knee replacements in patients with osteoarthritis. Nonetheless, surgical outcomes in recent years have shown significant improvement. Moore et al. published a systematic review indicating that the average range of motion after total knee endoprosthesis implantation in hemophiliacs is 6–82°, which remains significantly less compared to patients without a history of hemophilia (0–129°). Although the average final functional improvement in patients without hemophilia is higher, the average improvement in hemophiliacs is similar.

A similar trend is observed in the average implant survival rates. Goddard et al. reported a 20-year implant survival rate of 94%, while Zingg et al. reported a 10-year survival rate of 88%, which are values comparable to the general population. Patient satisfaction with total knee joint replacement is also essential. Wang et al. published a study in which 83% of patients rated their satisfaction with the surgery using the Knee Society clinical score as excellent, and 88% of patients would undergo the surgery again. The main reasons for patient satisfaction included pain relief and increased quality of life, particularly due to improved knee extension.

Similar improvements are observed in the area of total hip endoprostheses. In 1995, for instance, Kelley et al. observed a loosening rate of 52.9% and an infection complication rate of 8.8%. In 2015, Carulli et al. described a 100% implant survival rate without cases of infection or implant loosening. Wu et al. evaluated functional outcomes and hip total endoprosthesis survival in 21 hemophiliacs, with an average follow-up period of 113 months (range 5–15 years). Patients showed an improvement in functional results using the Harris Hip Score from 37 points (15–81) before surgery to 90 points (70–96) at the last check-up. During the follow-up period, the implant survival rate was 100%, and no cases of infection, loosening, or other complications were observed.

Marginally, it is also appropriate to mention the results of arthroplasty in the area of ankle and elbow joints, which are also commonly affected by hemophilic arthropathy. Since these procedures are less frequently performed, there is currently a lack of data from larger patient cohorts, and available studies present results from smaller cohorts or individual case descriptions. Ernstbrunner et al., for instance, evaluated the long-term outcomes of 13 implanted endoprostheses in elbow joints in 9 patients with an average follow-up period of 9.1 years. Good clinical outcomes were presented in this cohort, but also a high number of revision procedures. Similarly, cases of ankle joint arthroplasties have shown good clinical outcomes but also a higher number of infections and revision procedures.

Conclusion

Based on the findings from available studies, the results of total knee and hip joint replacements in hemophiliacs are gradually improving, as is the long-term survival of implants. Nevertheless, the complication rate due to the underlying disease remains high compared to the population without a bleeding disorder history and requires meticulous perioperative and postoperative care. Therefore, these procedures are concentrated in specialized hematological and orthopedic centers − in the Czech Republic, this includes cooperation between the Institute of Hematology and Blood Transfusion in Prague in cooperation with head physician MUDr. Radovan Kubeš, Ph.D., from the Orthopedic Clinic of the 1st Medical Faculty of Charles University, the Institute for Postgraduate Medical Education and Bulovka Hospital.

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