Skip to main content
JDRS · Open access journal
Joint Diseases and
Related Surgery
Online manuscript submissionSubmit a manuscript e-ISSN 2687-4792

Original Article · Open access

Perioperative blood management and clinical outcomes in patients with hemophilia undergoing total joint arthroplasty: Our long-term results

PDF Cite this article

Mingling Peng

First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China

ORCID: 0009-0009-3970-8640

Sibei Li

Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China

ORCID: 0000-0003-0204-3584

Xinyuan Wu

Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China

ORCID: 0000-0003-0832-4870

Wuhua Ma

Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China

ORCID: 0000-0003-1277-1681

Yuhui Li

Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China

ORCID: 0000-0001-5235-6090

Abstract

Objectives: This study aims to evaluate the efficacy and safety of a comprehensive, multidisciplinary perioperative blood management (PBM) protocol in patients with Hemophilia A undergoing total joint arthroplasty (TJA).

Patients and methods: Between December 2014 and November 2024, a total of 29 male patients (mean age: 33.38 ± 8.62 years; range, 20 to 55 years) with hemophilic arthropathy (HA), all diagnosed with Hemophilia A, who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) were retrospectively analyzed. All patients received a standardized PBM protocol, including preoperative factor Ⅷ sensitivity testing, individualized factor replacement, restrictive fluid management, ultrasound-guided regional anesthesia, and tranexamic acid administration. Primary outcomes included total blood loss (TBL) and hemoglobin (Hb) drop. Secondary outcomes included operation time, length of hospital stay (LOS), and perioperative complications.

Results: All 29 procedures were successfully completed under our PBM protocol. For the entire cohort, the median TBL was 630.52 (range, 470.95 to 939.64) mL, and the mean Hb decrease on postoperative Day 5 was –41.83 ± 22.81 g/L. The median operative time was 122.0 (range, 91.0 to 182.5) min, and the median LOS was 23.0 (range, 19.0 to 31.0) days. Simultaneous double TJA showed higher TBL and transfusion rates than single TJA, but the outcomes remained within safe clinical limits. Furthermore, THA was associated with significantly shorter operation time (p = 0.008) and lower total FⅧ consumption (p = 0.036) compared to TKA, despite similar TBL (p = 0.860). No major complications, such as inhibitor development, hemorrhage or venous thromboembolism were observed.

Conclusion: A standardized, multidisciplinary PBM protocol ensures surgical safety in patients with end-stage HA. Despite the underlying hemorrhagic diathesis, optimized factor replacement and comprehensive anesthetic strategies can achieve surgical outcomes comparable to the general population. These findings support the broader clinical application of comprehensive PBM for high-risk hemophilic surgical cases.

* These authors contributed equally to this work.

Declarations

Author Contributions

M.P., S.L.: Conceived and designed the study, performed data analysis, and wrote the original draft; X.W.X Was responsible for data collection and literature review; W.M.: Provided materials and supplementary analysis; Y.L., X.W.: Contributed to reference preparation; W.M., Y.L.: Provided critical intellectual input and revised the manuscript; Y.L.: Supervised the project. All authors have read and approved the final version of the manuscript.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

AI Disclosure

The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

References

  1. Gualtierotti R, Solimeno LP, Peyvandi F. Hemophilic arthropathy: Current knowledge and future perspectives. J Thromb Haemost 2021;19:2112-21. DOI: 10.1111/jth.15444.
  2. Fenelon C, Murphy EP, Fahey EJ, Murphy RP, O’Connell NM, Queally JM. Total knee arthroplasty in hemophilia: Survivorship and outcomes-a systematic review and metaanalysis. J Arthroplasty 2022;37:581-92.e1. DOI: 10.1016/j.arth.2021.10.015.
  3. Gillinov SM, Burroughs PJ, Moore HG, Rubin LE, Frumberg DB, Grauer JN. Total hip arthroplasty in patients with classic hemophilia: A matched comparison of 90-day outcomes and 5-year implant survival. J Arthroplasty 2022;37:1333-7. DOI: 10.1016/j.arth.2022.02.107.
  4. Camarasa MA, Ollé G, Serra-Prat M, Martín A, Sánchez M, Ricós P, et al. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: A randomized clinical trial. Br J Anaesth 2006;96:576-82. DOI: 10.1093/bja/ael057.
  5. The Joint Surgery Branch of the Chinese Orthopaedic Association, Hemophilia Treatment Center Collaborative Network of China. Guideline for perioperative management of hemophilia patients undergoing orthopaedic surgery in China. Chin J Orthop 2023;43:215-22.
  6. Group of Joint Surgery, Chinese Orthopedic Association; Hemophilia Treatment Center Collaborative Network of China; Tong P, Weng X, Yang R, Wang K. Guideline for perioperative management in hemophilic arthropathy patients undergoing hip and/or knee arthroplasty in China. Chin J Bone Joint Surg 2022;15:481-90.
  7. Mercuriali F, Inghilleri G. Proposal of an algorithm to help the choice of the best transfusion strategy. Curr Med Res Opin 1996;13:465-78. DOI: 10.1185/03007999609115227.
  8. Bourke DL, Smith TC. Estimating allowable hemodilution. Anesthesiology 1974;41:609-12. DOI: 10.1097/00000542-197412000-00015.
  9. Song X, Zhong J, Xue F, Chen L, Li H, Yuan D, et al. An overview of patients with haemophilia a in China: Epidemiology, disease severity and treatment strategies. Haemophilia 2021;27:e51-9. DOI: 10.1111/hae.14217.
  10. Berntorp E, Fischer K, Hart DP, Mancuso ME, Stephensen D, Shapiro AD, et al. Haemophilia. Nat Rev Dis Primers 2021;7:45. DOI: 10.1038/s41572-021-00278-x.
  11. Xie J, Ma J, Yao H, Yue C, Pei F. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss after primary total knee arthroplasty without tourniquet: A randomized clinical trial. J Arthroplasty 2016;31:2458-64. DOI: 10.1016/j.arth.2016.04.034.
  12. Zou L, Pan XY, Xu XD, Qu YY. Application of combined anesthesia with spontaneous breathing in the surgery of intertrochanteric fracture of femur in elderly patients. Jt Dis Relat Surg 2024;35:562-73. DOI: 10.52312/jdrs.2024.1571.
  13. Heeg M, Meyer K, Smid WM, Van Horn JR, Van der Meer J. Total knee and hip arthroplasty in haemophilic patients. Haemophilia 1998;4:747-51. DOI: 10.1046/j.1365-2516.1998.00183.x.
  14. Yuan S, Song L, Jiang H, Wang J, Ning X, Jiang W. Perioperative blood loss during joint replacement: Comparison between patients with and without hemophilia. J Orthop Surg Res 2022;17:324. DOI: 10.1186/s13018-022-03217-y.
  15. Lobet S, Pendeville E, Dalzell R, Defalque A, Lambert C, Pothen D, et al. The role of physiotherapy after total knee arthroplasty in patients with haemophilia. Haemophilia 2008;14:989-98. DOI: 10.1111/j.1365-2516.2008.01748.x.
  16. Forsyth A, Zourikian N. How we treat: Considerations for physiotherapy in the patient with haemophilia and inhibitors undergoing elective orthopaedic surgery. Haemophilia 2012;18:550-3. DOI: 10.1111/j.1365-2516.2012.02755.x.
  17. Poston JN, Kruse-Jarres R. Perioperative hemostasis for patients with hemophilia. Hematology Am Soc Hematol Educ Program 2022;2022:586-93. DOI: 10.1182/hematology.2022000387.
  18. Paul JE, Ling E, Lalonde C, Thabane L. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: A meta-analysis of randomized controlled trials. Can J Anaesth 2007;54:799-810. DOI: 10.1007/BF03021707.
  19. Huang ZY, Huang Q, Zeng HJ, Ma J, Shen B, Zhou ZK, et al. Tranexamic acid may benefit patients undergoing total hip/knee arthroplasty because of haemophilia. BMC Musculoskelet Disord 2019;20:402. DOI: 10.1186/s12891-019-2767-x.
  20. Romano LGR, Schütte LM, van Hest RM, Meijer K, Laros-van Gorkom BAP, et al. Peri-operative desmopressin combined with pharmacokinetic-guided factor VIII concentrate in non-severe haemophilia a patients. Haemophilia 2024;30:355-66. DOI: 10.1111/hae.14946.
  21. Ahmed HS, Jayaram PR. Anesthetic considerations for joint replacement surgery in hemophilic arthropathy: A comprehensive review. Anesth Pain Med (Seoul) 2024;19:194- 208. DOI: 10.17085/apm.24047.
  22. Sripada R, Reyes JJ, Sun R. Peripheral nerve blocks for intraoperative management in patients with hemophilia A. J Clin Anesth 2009;21:120-3. DOI: 10.1016/j.jclinane.2008.06.030.
  23. Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 2000;7:151-5. DOI: 10.1016/s0968-0160(00)00047-8.
  24. Yin H, Zhang Y, Hou W, Wang L, Fu X, Liu J. Comparison of complications between total hip arthroplasty following failed internal fixation and primary total hip arthroplasty for femoral neck fractures: A meta-analysis. Jt Dis Relat Surg 2025;36:479-88. DOI: 10.52312/jdrs.2025.2230.