Postoperative bleeding adversely affects total knee arthroplasty outcomes in hemophilia

Published:October 22, 2022DOI:


      • Total knee arthroplasty (TKA) is associated with functional improvement for advanced hemophilic arthropathy.
      • Nearly a third (34%) of patients experience major postoperative bleeding complications (hemarthrosis, hemorrhagic bullae, hematoma formation, prolonged wound bleeding).
      • Hemophilia patients with early bleeding after TKA have worse long-term functional outcomes.
      • Early bleeding causes lesser improvements in range of motion, flexion contracture, and knee function scores.



      Hemophilic arthropathy can result in severe degenerative arthritis and functional limitations in the knees of relatively young patients. Total knee arthroplasty (TKA) provides pain relief and gain of function in advanced-stage hemophilic arthropathy cases. However, little is known about the long-term effects of early major postoperative bleeding (MPOB) in people with hemophilia (PWH). The aim of this study was to evaluate the effects of early MPOB on the final functional outcome, complications, and implant survival of TKA in a single-center hemophilia cohort.


      PWH who underwent TKA between 1998 and 2019 in a single center were reviewed. Demographic data, clinical data, and radiographic images were evaluated. Hospital for Special Surgery (HSS), Knee Society Score (KSS), and Knee Society Function Score (KSS-F) scores were used to determine function. Patients with early bleeding complications (wound dehiscence, ecchymosis, hemarthrosis, hematoma formation, prolonged or recurrent bleeding attacks) were defined as the bleeding group. Patients who did not experience these complications were assigned to the control group. The bleeding group was compared with controls. Survival of the primary arthroplasty was analyzed by Kaplan–Meier curves.


      Forty-five TKAs in 29 patients were included in the study. TKA led to an increase in the mean range of motion from 46.08° to 84.59° (P < 0.01). HSS scores increased from 48.33 preoperatively to 82.67 postoperatively (P < 0.01). There were improvements in both KSS and KSS-F scores from 34.22 and 53.3 preoperatively to 82.00 and 84.63 (P < 0.01), respectively. Ten patients (10 TKAs) (34%) experienced major bleeding during the postoperative period. Six of these patients had moderate hemophilia, and four had severe hemophilia. Three of these patients had hemarthroses (10.2%), one patient had a hematoma (3.4%), one patient had hemorrhagic bullae formation (3.4%), and five had excessive/prolonged bleeding from the wound (17%). The bleeding group (34%) had significantly worse HSS (63.78 vs 92.75, P < 0.001), KSS (61.78 vs 93.25, P < 0.001), and KSS-F (60.71 vs 96.25, P = 0.005) scores compared with controls. Preoperative and postoperative flexion contractures were positively correlated (+0.33, P = 0.003). One of the patients with postoperative hemarthrosis also had an accompanying transient common peroneal nerve palsy, and one patient (3.4%) had a periprosthetic fracture. Three knees (6.6%), two of whom were in the bleeding group, developed periprosthetic infections. Four knees (8.8%) in three patients underwent revision surgery, and two knees (4.4%) ended up in arthrodeses. Kaplan–Meier analysis revealed a mean survival duration of 17.04 years for the bleeding group and 22.15 years for the control group (P = 0.83). Survival rates were 80.0% for the bleeding group and 96.4% for the control group (P = 0.83).


      In this study, MPOB after TKA in PWH was common and led to significantly worse function. MPOB after TKA in PWH was associated with a higher rate of complications and lower survival rates, although the differences were not statistically significant. Efforts must be made to avoid MPOB after TKA in PWH.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Knee
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Roosendaal G.
        • TeKoppele J.M.
        • Vianen M.E.
        • van den Berg H.M.
        • Lafeber F.P.
        • Bijlsma J.W.
        Blood-induced joint damage: A canine in vivo study.
        Arthritis Rheum. 1999; 42: 1033-1039
        • Stein H.
        • Duthie R.B.
        The pathogenesis of chronic haemophilic arthropathy.
        J Bone Joint Surg Br. 1981; 63: 601-609
        • Niibayashi H.
        • Shimizu K.
        • Suzuki K.
        • Yamamoto S.
        • Yasuda T.
        • Yamamuro T.
        Proteoglycan degradation in hemarthrosis: Intraarticular, autologous blood injection in rat knees.
        Acta Orthop Scand. 1995; 66: 73-79
        • Song S.J.
        • Bae J.K.
        • Park C.H.
        • Yoo M.C.
        • Bae D.K.
        • Kim K.I.
        Mid-term outcomes and complications of total knee arthroplasty in haemophilic arthropathy: A review of consecutive 131 knees between 2006 and 2015 in a single institute.
        Haemophilia. 2017; 24: 299-306
        • Atilla B.
        • Caglar O.
        • Pekmezci M.
        • Buyukasik Y.
        • Tokgozoglu A.M.
        • Alpaslan M.
        Pre-operative flexion contracture determines the functional outcome of haemophilic arthropathy treated with total knee arthroplasty.
        Haemophilia. 2012; 18: 358-363
        • Anderson J.A.
        • Mason J.A.
        • Halliday B.
        Clinical outcomes and patient satisfaction following total hip and knee arthroplasty in patients with inherited bleeding disorders: A 20-year single-surgeon cohort.
        Haemophilia. 2018; 24: 786-791
        • Narin S.
        • Unver B.
        • Bakirhan S.
        • Bozan O.
        • Karatosun V.
        Crosscultural adaptation reliability and validity of the Turkish version of the Hospital for Special Surgery HSS Knee Score.
        Acta Orthop Traumatol Turc. 2014; 48: 241-248
        • Ozden F.
        • Tugay N.
        • Tugay B.U.
        • Kilinc C.Y.
        Psychometrical properties of the Turkish translation of the New Knee Society Scoring System.
        Acta Orthop Traumatol Turc. 2019; 53: 184-188
        • Panotopoulos J.
        • Ay C.
        • Trieb K.
        • Schuh R.
        • Windhager R.
        • Wanivenhaus H.A.
        Outcome of total knee arthroplasty in hemophilic arthropathy.
        J Arthroplasty. 2014; 29: 749-752
        • Kubeš R.
        • Salaj P.
        • Hromadka R.
        • et al.
        Range of motion after total knee arthroplasty in hemophilic arthropathy.
        BMC Musculoskelet Disord. 2018; 19: 162
        • Cancienne J.M.
        • Werner B.C.
        • Browne J.A.
        Complications after TKA in patients with hemophilia or Von Willebrand's disease.
        J Arthroplasty. 2015; 30: 2285-2289
        • Chevalier Y.
        • Dargaud Y.
        • Lienhart A.
        • Chamouard V.
        • Negrier C.
        Seventy-two total knee arthroplasties performed in patients with haemophilia using continuous infusion.
        Vox Sang. 2013; 104: 135-143
        • Powell D.L.
        • Whitener C.J.
        • Dye C.E.
        • Ballard J.O.
        • Shaffer M.L.
        • Eyster M.E.
        Knee and hip arthroplasty infection rates in persons with haemophilia: a 27 year single center experience during the HIV epidemic.
        Haemophilia. 2005; 11: 233-239
        • Huang Z.
        • Xie X.
        • Li L.
        • et al.
        Intravenous and topical tranexamic acid alone are superior to tourniquet use for primary Total knee arthroplasty: A prospective, randomized controlled trial.
        J Bone Joint Surg Am. 2019; 99: 2053-2061
        • Huang Z.Y.
        • Huang Q.
        • Zeng H.J.
        • et al.
        Tranexamic acid may benefit patients undergoing total hip/knee arthroplasty because of haemophilia.
        BMC Musculoskelet Disord. 2019; 20: 402
        • Rodriguez-Merchan E.C.
        • Encinas-Ullan C.A.
        • Gomez-Cardero P.
        Intra-articular tranexamic acid in primary total knee arthroplasty decreases the rate of post-operative blood transfusions in people with hemophilia: A retrospective case-control study.
        HSS J. 2020; 16: 218-221
        • Kleiboer B.
        • Layer M.A.
        • Cafuir L.A.
        • et al.
        Postoperative bleeding complications in patients with hemophilia undergoing major orthopedic surgery: A prospective multicenter observational study.
        J Thromb Haemost. 2022; 20: 857-865
        • Kizilocak H.
        • Yukthman C.L.
        • Marquez-Casas E.
        • Lee J.
        • Donkin J.
        • Young G.
        Management of perioperative hemostasis in a severe hemophilia A patient with inhibitors on emicizumab using global hemostasis assays.
        Ther Adv Hematol. 2019; : 10
        • Evans M.S.
        • Davis C.
        • Eyster M.E.
        Total knee replacement with and without emicizumab: a unique comparison of perioperative management.
        Blood Adv. 2020; 4: 855-857
        • Chiasakul T.
        • Buckner T.W.
        • Li M.
        • et al.
        In-hospital complications and readmission in patients with hemophilia undergoing hip or knee arthroplasty.
        JBJS Open Access. 2020; 5: e0085
        • Hermans C.
        • Hammer F.
        • Lobet S.
        • Lambert C.
        Subclinical deep venous thrombosis observed in 10% of hemophilic patients undergoing major orthopedic surgery.
        J Thromb Haemost. 2010; 8: 1138-1140
        • Coppola A.
        • Franchini M.
        • Makris M.
        • et al.
        Thrombotic adverse events to coagulation factor concentrates for treatment of patients with haemophilia and von Willebrand disease: A systematic review of prospective studies.
        Haemophilia. 2012; 18: e173-e189
        • Manucci P.M.
        Venous thromboembolism in von Willebrand disease.
        Thromb Haemost. 2002; 88: 378-379
        • Carulli C.
        • Innocenti M.
        • Linari S.
        • et al.
        Joint replacement for the management of haemophilic arthropathy in patients with inhibitors: A long-term experience at a single Haemophilia centre.
        Haemophilia. 2021; 27: e93-e101
        • Buckner T.W.
        • Leavitt A.D.
        • Ragni M.
        • et al.
        Prospective, multicenter study of postoperative deep-vein thrombosis in patients with haemophilia undergoing major orthopaedic surgery.
        Thromb Haemost. 2016; 116: 42-49
        • Holderness B.M.
        • Goto Y.
        • McKernan L.
        • et al.
        Thromboprophylaxis and outcomes for total joint arthroplasty in congenital bleeding disorders: A single-center experience.
        Clin Appl Thromb Haemost. 2016; 22: 563-568
        • Hermans C.
        Venous thromboembolic disease in patients with haemophilia.
        Thromb Res. 2012; 130: 50-52
        • Verhamme P.
        • Tangelder M.
        • Verhaeghe R.
        • et al.
        Single intravenous administration of TB-402 for the prophylaxis of venous thromboembolism after total knee replacement: A dose-escalating, randomized, controlled trial.
        J Thromb Haemost. 2011; 9: 664-671
        • Rodriguez-Merchan E.C.
        Correction of fixed contractures during total knee arthroplasty in haemophiliacs.
        Haemophilia. 1999; 5: 33-38
        • Goddard N.J.
        • Rodriguez-Merchan E.C.
        • Wiedel J.D.
        Total knee replacement in haemophilia.
        Haemophilia. 2002; 8: 382-386