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Recently, the Guidelines for the Perioperative Management of Hip and Knee Replacement in Hemophilic Osteoarthropathy1, jointly compiled by the Joint Surgery Group of the Orthopedic Branch of the Chinese Medical Association and the China Hemophilia Collaboration Group, were released, which further standardized the perioperative management of hip and knee replacement in hemophilia osteoarthropathy and provided a reference
for related clinical work.
In this issue, the editor summarizes 6 essentials of the recommendations in the guide and shares
them with you.
80% of bleeding occurs in the joints of patients with hemophilia, in turn in the knee, elbow, ankle and hip joints, and in the second and third decades of the disease, 90% of patients can develop hemophilic osteoarthropathy
.
In the study published by the China Hemophilia Collaboration Group in 2021, a total of 17,779 patients with hemophilia A were registered from 166 hospitals in China from 2007 to 2019, and a total of 3,997 patients were recorded related to joint status, of which 61% had joint bleeding, 36% had osteoarthropathy, and the number of patients suffering from osteoarthropathy of the knee joint ranked first
.
Patients with end-stage hemophilic arthropathy who do not respond to conservative management: artificial arthroplasty is preferred, with knee replacement and hip arthroplasty
being the most common.
Surgical team selection: The success of orthopedic surgery relies on the collaboration of a multidisciplinary team (Figure 1).
Figure 1 Surgical team members
03Preoperative multidisciplinary comprehensive assessment: the operation should be performed in a hospital with qualifications in hemophilia diagnosis and treatment centers and integrated management centers, as well as experience in hemophilia orthopedic surgery; Multidisciplinary and adequate preoperative assessment is performed to minimize perioperative complications and ensure the safety and efficacy
of surgery.
Evaluation: A detailed assessment of the patient's symptoms, signs, joint status, etc.
(Figure 2).
Figure 2 Preoperative evaluation
02Management: comprehensive management
of coagulation factors, inhibitors, rehabilitation treatment, surgical planning, etc.
Coagulation factor selection: FVIII coagulation factor is preferred in hemophilia A, including recombinant or hematogenous products; Recombinant or bloodborne FIX coagulation factor
is preferred in hemophilia B.
Inhibitor management: inhibitors
must be routinely tested preoperatively.
Elective surgery for patients with hemophilia with inhibitors involves a variety of treatment options, and elective surgery
such as hip and knee replacement is not recommended for these patients.
If surgery is necessary, multidisciplinary treatment is recommended and individualized treatment
is discussed.
Rehabilitation: Before hip and knee replacement, the rehabilitation team needs to discuss the actual rehabilitation plan and goals with the hemophilia multidisciplinary team and the patient, and reasonably manage the patient's surgical expectations
.
Surgical planning: When there are surgical indications for multiple lesions at the same time, it is recommended to choose a first-stage or staged surgery
according to the size of the operation, the difficulty of the operation, the patient's tolerance and the experience of the orthopedic surgeon.
Tranexamic acid: in patients with hemophilia undergoing hip and knee replacement, perioperative tranexamic acid may reduce factor doses of replacement therapy and reduce surgery-related blood
loss.
Drains: based on the available evidence, it is recommended that indwelling drains be placed after hip and knee replacement in patients with hemophilia
.
After 3-4h of clipping, the drainage is opened in a non-negative pressure state, and it is removed 48-72h after surgery, and the intraarticular blood
is drained under negative pressure before extraction.
Anesthesia and analgesia: general anesthesia is recommended for hip and knee arthroplasty, and neck diseases affecting anesthesia should be excluded before surgery, and cervical spine imaging, cardiopulmonary function, and neurology should be
performed if necessary.
Prophylactic analgesia, multimodal analgesia
.
Coagulation factor management: the replacement treatment of coagulation factors can be described in the table below:
Note: *Drug-restricted regimens may increase the risk of perioperative bleeding
02Anemia management: patients with hemoglobin less than 70 g/L or hemoglobin less than 100 g/L with symptoms of anemia (fatigue, palpitations, pallor, tachycardia, shortness of breath due to anemia) should receive blood transfusion
.
Bleeding management: postoperative hematoma, it is recommended to detect inhibitors, increase the concentration of coagulation factors, use RICE rule to improve bleeding during bleeding, resume rehabilitation physiotherapy in time after bleeding control, and if necessary, hematoma aspiration and compression bandaging can be performed under coagulation factor replacement therapy
.
Thrombosis management: if patients with hemophilia A continue to receive adequate factor replacement therapy after surgery, prophylactic anticoagulation is recommended until the end of
factor replacement therapy.
Infection prevention: surgery should be performed with appropriate coagulation factor replacement therapy and strict sterile conditions, with control of infection predisposing factors and correct application of prophylactic antibiotics
.
Rehabilitation: early postoperative rehabilitation should be started 24 hours after surgery or after drainage tube removal; The patient is again functionally assessed before the start of rehabilitation training, and based on the evaluation results, the rehabilitation team formulates training steps and plans, which are carried out
under the protection of adequate coagulation factor replacement therapy.
Non-bleeding period before surgery: FVIII or FIX 30~50 IU/kg can be pre-transfused, and blood is collected 4h, 24h and 48h after infusion to determine the FVIII level
.
Subsequently, according to the population PK model combined with the calculation tool of the maximum posterior Bayesian method, the PK parameters of the individual patient were obtained for the formulation of subsequent dosing regimens
.
Intraoperative medication adjustment: According to the preoperative PK parameters and the target FVIII level, special calculation software is used to formulate the preoperative starting dose, and after the initial dose is given, the peak concentration of 15-30min after the end of the transfusion of coagulation factors can be detected if the conditions are available to guide the intraoperative medication adjustment
.
During postoperative hospitalization: Trough concentration monitoring
of coagulation factors can be performed intermittently.
If the coagulation factor does not reach the target concentration, the dosing can be adjusted according to the weight-based calculation formula, or the dosing regimen
can be adjusted by recalculating the individual PK parameters.
.
In addition, during postoperative rehabilitation, centers or patients with conditions can use PK calculation software (such as PK software) to guide treatment
.
Hip and knee replacement for hemophilic osteoarthropathy should be managed perioperatively in a standardized period:
A comprehensive assessment should be made before surgery, and coagulation factors and inhibitors should be managed and surgical planning should be done;
Do a good job of hemostasis and analgesic management during surgery;
Postoperative training for the prevention and rehabilitation of anemia, bleeding, blood clots and infections;
Post-discharge follow-up and continuation of coagulation factor management while rehabilitation is conducted
In addition to the weight of the perioperative coagulation factor dosing regimen, PK guidance can also be used to formulate an individualized dosing regimen, after understanding the patient's PK characteristics before surgery, according to the PK parameters and target factor levels, the special calculation software can be used to determine the dose
of administration.
References:
1.
Tong Peijian, Weng Xisheng, Yang Renchi, et al.
Guidelines for perioperative management of hip and knee replacement in hemophilic osteoarthropathy in China.
Chinese Journal of Osteosurgery and Joint Surgery, 2022, 15(7): 481-490.
2.
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75em;">
Approval number: VV-MEDMAT-76597
Approval period: 10/20/2022
Expires: 10/19/2024
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