BACKGROUND:
Advances in blood conservation have reduced the need for allogeneic transfusions in total knee and hip arthroplasty (TKA/THA). This study aimed to assess whether perioperative bleeding complications, including hemorrhage/hematoma, allogeneic transfusions, and postoperative anemia, occurred at similar rates between patients with hereditary bleeding disorders (BDs) and controls. Using a national health care database, we assessed the use of clotting factor concentrates (CFCs), perioperative outcomes, and resource utilization.
METHODS:
A retrospective cohort study was conducted using the Premier Health Database (2017–2021) to analyze differences in outcomes and costs between 1528 patients with hereditary BDs and 20,509 non-BD controls undergoing elective TKA and THA. Summary statistics, bivariate analyses, and odds ratios (ORs) were used to evaluate perioperative outcomes and resource use.
RESULTS:
Patients with hereditary BDs were slightly younger, predominantly female, and more often treated at larger, urban hospitals compared to controls. Bleeding complications, including hemorrhage and hematoma, were infrequent but higher in the BD group (1.1% vs 0.2%; P < .0001). Transfusion rates were higher in THA than TKA, with significantly increased odds for patients with hereditary BD: for THA, OR 2.7 (95% confidence interval [CI], 2.0–3.7; P < .0001); and for TKA, OR 2.6 (95% CI, 1.9–3.8; P < .0001). CFC exposures occurred in 16.4% of patients with hereditary BD compared to 0.03% in controls. Of 270 reported CFC exposures, factor VIII (FVIII) and von Willebrand factor (VWF) were most commonly used (49.6% and 23.0%, respectively), followed by FIX concentrate (12.6%) and bypassing agents, including FVIIa (8.5%) and anti-inhibitor coagulant complex (AICC; 3.7%). Antifibrinolytic therapy was administered in most cases. Pharmacy costs for patients with hereditary BD were significantly higher, with a mean of $23,792 (95% CI, $8722–$39,312), being over 30 times the mean cost in controls ($750; 95% CI, $739–$762). Other outcomes were not different, except for a higher incidence of venous thromboembolism in the BD group (OR 3.9, 95% CI, 2.4–6.1; P < .0001).
CONCLUSIONS:
THA and TKA in patients with hereditary BDs are relatively safe, with most outcomes comparable to controls. However, higher rates of bleeding, transfusion, and VTE underscore the need for optimizing anemia management and targeted use of CFCs along with antifibrinolytic therapy.
KEY POINTS
- Question: Does the incidence of bleeding-related events, such as perioperative hemorrhage/hematoma, perioperative transfusion, use of clotting factor concentrates (CFC), and postoperative anemia differ between patients with hereditary bleeding disorders (BDs) and the control without any BD in total knee and hip arthroplasty?
- Findings: Patients with hereditary BDs had higher rates of bleeding complications, allogeneic transfusion, CFC use, postoperative anemia, and venous thromboembolism (VTE) compared to the controls. While other clinical outcomes were generally similar, CFC use led to significantly higher pharmacy costs, particularly in cases requiring CFC replacement with agents like factor VIII (FVIII) concentrates or bypassing agents.
- Meaning: Understanding variations in clinical outcomes and costs for BDs in orthopedic surgeries is essential for optimizing care strategies. Future research is needed for optimizing preoperative anemia management, incorporating targeted use of CFCs and antifibrinolytic therapy, and enhancing strategies to monitor the delicate balance between hemostasis and thrombosis.