Title : Total Knee Arthroplasty (TKA) in hemophilic arthropathy: Modern outcomes and perioperative strategies
Abstract:
Background: Severe hemophilic arthropathy of the knee presents distinct surgical and hemostatic challenges, historically marked by high perioperative bleeding, infection, and stiffness rates, posing one of the greatest quality-of-life burdens for patients and technical challenges for orthopedic surgeons. Contemporary factor-replacement strategies, antifibrinolytic use, and technical refinements may have significantly improved outcomes.
Objectives: To synthesize modern outcomes of Total Knee Arthroplasty (TKA) in adults with severe hemophilia and identify perioperative and surgical strategies that enhance function, reduce complications, and inform joint-preservation and minimally invasive approaches, contrasted with historical experience.
Methods: A targeted systematic PubMed search identified English-language clinical studies (2015–2025) reporting outcomes after TKA in adults with hemophilia A or B. Ten predefined strategies captured core TKA outcomes, revision and complication reports, perioperative factor and inhibitor management, and preservation procedures. Earlier literature (1980–2014) was reviewed narratively for historical comparison. Data elements extracted included study design, cohort size, factor-replacement protocol, antifibrinolytic use, surgical technique, functional outcomes, implant survival, and complication rates.
Results: Across contemporary reports, mean postoperative range of motion (ROM) improved by approximately 25–35° (range 15°–50°), with preoperative ROM commonly 30–70° and postoperative 65–100°. Mean or median follow-up averaged 5–12 years (range 4–20). Pooled implant survivorship was ~92–98 % at 5 years and ~88–94 % at 10 years (range 85.8–97 %), confirming mid-term durability comparable to complex primary arthroplasty in other high-risk populations. Complications remained concentrated in bleeding/hemarthrosis (5–25 %, mean ~8–12 %), periprosthetic joint infection (3–9 %, mean ~6–7 %), and postoperative stiffness requiring intervention (2–12 %, mean ~7 %). Pharmacokinetic-tailored factor replacement was reported in ~20–25 % of studies, while ~35–40 % incorporated tranexamic acid (TXA), most often via combined intra-articular and intravenous administration. Cemented fixation predominated, with modular and constrained designs addressing bone loss and instability. Early evidence suggests computer navigation or robotic assistance improves alignment precision. Joint-preserving arthroscopic synovectomy and radiosynoviorthesis reduced bleeding frequency and deferred arthroplasty, informing surgical timing and rehabilitation planning. Compared with pre-2015 series, modern cohorts demonstrated substantially lower bleeding and infection rates and superior survivorship, reflecting true hemostatic and technical advancement.
Conclusions: Within multidisciplinary frameworks utilizing standardized, PK-guided factor replacement and TXA, TKA for severe hemophilia now yields durable pain relief, functional gains, and mid-term implant survival approaching that of non-hemophilic arthroplasty. Infection and stiffness remain principal threats to long-term success, underscoring meticulous hemostasis, early mobilization, and individualized rehabilitation. Preservation strategies optimize timing, while navigation/robotics and next-generation implant materials promise further refinements in alignment, stability, and survivorship.
Keywords: Hemophilia A; Hemophilia B; total knee arthroplasty; hemophilic arthropathy; perioperative management; factor VIII/IX; pharmacokinetic dosing; tranexamic acid; infection; stiffness; synovectomy; radiosynoviorthesis; navigation; robotic assistance; implant survivorship; rehabilitation.
