Total Knee Arthroplasty Using Recombinant Factor VII in Hemophilia-A Patients with Inhibitors

Elective orthopaedic surgery, including total joint arthroplasty, has become a safe and effective therapeutic option for most patients with hemophilic arthropathy and has been reported to reduce the rate of hemarthrosis and the clinical consequence of severe joint damage1. However, the 10% to 30% of patients with severe hemophilia who have development of neutralizing antibodies (inhibitors) to factor VIII (FVIII) or factor IX (FIX) do not fare as well2. The development of an inhibitor is one of the most serious complications associated with hemophilia because inhibitors may neutralize clotting factor concentrates. Patients with inhibitors often have substantially worse joint function secondary to inadequate treatment and traditionally have not been candidates for elective joint replacement surgery3. The orthopaedic literature regarding total knee arthroplasty in patients with hemophilia is limited, with little emphasis on patients with inhibitors4-9. Previous studies of total knee arthroplasty in patients with inhibitors, involving a variety of treatment regimens (including immune therapy, Factor VIIa, and Factor VIII), have been reported in the literature, but the duration of clinical follow-up has been limited and no consensus has been reached with regard to the appropriate dosing regimen2,10-13. Recombinant Factor VIIa has a short half-life but a high bioavailability when administered intravenously, and therefore the clinical impact has been difficult to predict in patients undergoing elective surgery14,15. In the present report, we describe three successful total knee arthroplasties that were performed with use of recombinant human factor VIIa (rFVIIa) in two patients who had different inhibitor characteristics and who were followed for more than two years.