Total Knee Arthroplasty in Hemophiliacs: Gains in Range of Motion Realized beyond Twelve Months Postoperatively

Deficiency of clotting factors in hemophilia leads to recurrent bleeds in the synovial joints, oft en initiated through minimal trauma or even routine daily activity. Hemarthroses account for as much as 80% of hemorrhages seen in hemophiliacs,1) and the knee is the most common joint affected.2) Along with joint destruction and synovial hypertrophy, 3) fibrosis and contractures may occur as secondary complications of recurrent bleeds4) and result in significant pain and functional disability.5) Multiple surgical interventions have been utilized to treat hemophiliac arthropathy in the knee, with total knee arthroplasty (TKA) becoming a safe and successful option for end-stage hemophiliac arthropathy.6) TKA is the most common procedure in hemophiliacs.7) Unlike other patients undergoing TKA, hemophiliac TKA patients have greater challenges, due to potential musculoskeletal bleeding complications in their postoperative rehabilitation.7,8) Hemophiliac patients suffer from widespread joint and soft tissue damage,9) and chronic inflammation leads to flexion deformity.4) As such, hemophiliacs have long-standing extrinsic tightness due to quadriceps/flexion contractures. The surgical armamentarium for hemophiliac arthropathy is broad. Surgical treatment includes pseudotumor excision, synovectomy, soft tissue contracture release, tendon reconstruction, osteotomy, arthrodesis, and amputation.7) Many of these surgical modalities are undesirable or fraught with complications. For example, synovectomy is oft en complicated by recurrent joint bleeds from retained synovial tissue that leads to continued range of motion (ROM) limitations and chronic synovitis.4,5) In addition, once patients develop severe arthropathy, with significant osseous changes, TKA offers a more reliable solution for pain control and increased function.5) Like the patient who suffers from osteoarthritis or rheumatoid arthritis, once osseous changes occur, TKA becomes the best option. When it comes to determining the success of TKA performed in a hemophiliac patient, preoperative ROM is the most important variable influencing outcomes.9) Historically, hemophiliac contractures have been corrected via surgical releases such as modified V-Y quadricepsplasty and/or posterior capsular release. However, these surgical options have fallen out of favor. Instead, attention has been focused onto TKA to address bony pathology, along with focused postoperative physical therapy (PT). In the osteoarthritic patient who undergoes a TKA, literature has shown no significant improvements in ROM beyond twelve to eighteen months postoperatively.10) We hypothesized that hemophilic patients, through intensive postoperative therapy and intensive stretching of the quadriceps mechanism, may experience ROM improvements beyond a year and a half postoperatively. This study aims to 1) determine the ROM outcomes, especially after two years postoperatively, in hemophiliac patients after TKA, and 2) whether long-term improvements could be realized under the guidance of a therapist with experience working with this unique patient population.