Solimeno.qxp 30/4/08 14:50 Page 33
Surgical Haemostasis
Blood-sparing Knee Surgery in Patients with Haemophilia –
Use of a Novel Haemostatic Matrix
a report by
Luigi Piero Solimeno,
1
Cristiano Casadei,
1
Gianluigi Pasta
2
and Olivia Perfetto
1
1. Department of Orthopaedics, Haemophilic Arthropathy Treatment Centre ‘MG Gatti-Randi’, CTO Hospital, Milan;
2. Trauma Department and ‘A Bianchi Bonomi Haemophilia Centre’, IRCCS Maggiore Hospital Foundation, Milan
Total knee arthroplasty (TKA) frequently results in substantial blood loss bleeding during the operation is indicative of a problem that can
and associated complications. While lost blood can be replaced using usually be solved. However, in haemophilia patients spontaneous
allogenic supplies, this procedure also has its own complications, including bleeding does not necessarily relate to a mistake or a surgery-related
transfusion errors,
1
allergic reactions,
2
a declining but still present risk of complication, as it could be due to a poor response to the pre-
infection
3
and other adverse effects on the immune system.
4
As such, it is administered factor.
usually a last resort and the gold standard is to perform surgery without
allogenic transfusion. More bleeding and longer procedure times mean a higher risk of
infection for the patient. In general, there is an infection rate of about
The problems of blood loss become even more urgent when the patient 1–2% in primary TKA.
7,8
In patients with haemophilia who have
has haemophilia. Arthropathy – disease of a joint – is a complication of conditions such as soft-tissue fibrosis, flexion contractures and poor
haemophilia; therefore, TKA is a common operation and it is essential that bone quality, the rate is about 9–18%.
9–11
When coupled with HIV and
everything possible is carried out to reduce the risk to the patient and to low CD4+ cell counts, the infection rates for haemophilia patients
reduce bleeding events and total blood loss. following TKA can reach 30%. Healing and recovery times are also
adversely affected if bleeding is not adequately controlled.
There are many different blood-sparing techniques that are useful in
peri-operative blood management. For patients with haemophilia, a The Milan Experience
clotting factor such as factor VIII or IX is given prophylactically In our practice, we routinely put our TKA patients under general
(100UI/kg on the day of surgery and in decreasing amounts for 15–20 anaesthetic with controlled hypotension. This is not easy, especially
days afterwards). Erythropoietin can also be administered prior to or with HIV/HCV-positive patients, yet it is our standard practice. Owing
during surgery to help reduce the need for an allogenic transfusion,
5
to the infection status of the blood, we never use autologous
increase the amount of blood available for pre-operative autologous donations. In most cases we start surgery without a tourniquet,
donation (PAD) and help reduce post-operative anaemia.
6
Acute applying one only when we start to cut the bone; this reduces
normovolaemic haemodilution is an alternative to PAD, whereby a tourniquet time by about 20–25 minutes. We always remove
roughly equivalent number of blood units are collected and replaced in the tourniquet before cementing the bone. Overall, tourniquet use is
vivo by crystalloid and colloid solutions. The patient’s own blood is related to the infective status of the patient.
kept to hand and returned to him or her during or after the operation,
as required. We have developed modern, minimally invasive surgical techniques
and tested them to observe their effect on blood loss. Figure 1 shows
During the operation there are standard haemostasis tools such as the traditional versus mini and quad-sparing incisions. The theory was
sutures, clamps, tourniquets and cautery devices that the surgeon will that a smaller incision would result in less bleeding. However, our
use. Furthermore, minimally invasive, tissue-sparing techniques have experience has not found this to be the case, as blood loss is roughly
been developed, and the patient can be kept under general the same for both the general and the haemophilia populations. As
anaesthesia with controlled hypotension, all of which can help these techniques spare the extensor mechanism of the knee, the
minimise blood loss. The most recent addition to the surgeon’s toolbox healing and rehabilitation times are reduced, which is nonetheless a
are haemostasis agents that can seal the wound and/or promote blood positive outcome.
clotting. This article provides an overview of our experiences in Milan
of performing TKA in patients with haemophilia using these tools. Even with an autologous blood donation before surgery for use during
Matters Concerning Blood
Luigi Piero Solimeno is Chief of the Department of
Blood loss causes problems for both patients and surgery staff.
Orthopaedics at the Haemophilic Arthropathy Treatment
Practically speaking, it can obscure vision of the operating field, and
Centre at CTO Hospital, Milan, and has held previous
attending to bleeding increases the overall time of the operation.
positions at the University of Milan, Vialba Hospital, and the
Orthopaedic Clinic of Colorado. He is Vice President of
Unfortunately, many patients with haemophilia will have contracted the Musculoskeletal Committee of the World Federation of
blood-borne diseases such as HIV or hepatitis C virus (HCV), so there
Hemophilia (WFH) and is a member of the Italian Society
of Arthroscopy.
is the additional risk to the operating staff of contracting an infection
from the blood. It is also important to consider the effect of bleeding
E: luigi.solieno@icp.mi.it
on staff stress levels. In the general population, a site that starts
© TOUCH BRIEFINGS 2008 33
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92