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Erturan G, Guevel B, Alvand A, Goddard NJ. Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding. Haemophilia 2018; 25:21-32. [PMID: 30507046 DOI: 10.1111/hae.13647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.
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Affiliation(s)
- Gurhan Erturan
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
| | - Borna Guevel
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
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Rajpurkar M, Cooper DL. Continuous infusion of recombinant activated factor VII: a review of data in congenital hemophilia with inhibitors and congenital factor VII deficiency. J Blood Med 2018; 9:227-239. [PMID: 30568523 PMCID: PMC6276614 DOI: 10.2147/jbm.s184040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction Continuous infusion (CI) of clotting factors as a replacement therapy for perioperative hemostatic protection has been performed for many years, including with factors VIII and IX and recombinant activated factor VII (rFVIIa). This approach provides steady factor levels without requiring frequent administration of bolus doses. Aim To review safety, efficacy, and dosing data regarding CI of rFVIIa for hemostatic management of patients with congenital hemophilia with inhibitors (CHwI) or congenital factor VII deficiency (C7D). Materials and methods A literature review identified instances of CI of rFVIIa in patients with CHwI or C7D undergoing surgery or experiencing bleeding episodes. Data regarding safety, efficacy, and dosing were extracted. Results The safety and efficacy of 50 mcg/kg/h CI of rFVIIa following a 90 mcg/kg bolus injection, vs a standard bolus injection regimen, was reported for 24 patients with CHwI undergoing elective surgery in an open-label, randomized, Phase III trial. Efficacy was similar between CI and bolus injection groups at all postoperative time points assessed. Additionally, a postmarketing surveillance study reported effective (80%) and partially effective (20%) CI of rFVIIa in a Japanese cohort of ten patients with CHwI who underwent 15 surgical procedures. Finally, the safety and dosing of rFVIIa CI in 193 and 26 patients with CHwI and C7D, respectively, were reported in 11 prospective studies, 10 retrospective studies, and 30 case reports. No unexpected safety findings were reported. Conclusion rFVIIa CI has been performed safely and effectively in patients with CHwI and C7D undergoing surgery and during bleeding episodes in patients with CHwI.
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Affiliation(s)
- Madhvi Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA,
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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Escobar MA, Brewer A, Caviglia H, Forsyth A, Jimenez-Yuste V, Laudenbach L, Lobet S, McLaughlin P, Oyesiku JOO, Rodriguez-Merchan EC, Shapiro A, Solimeno LP. Recommendations on multidisciplinary management of elective surgery in people with haemophilia. Haemophilia 2018; 24:693-702. [PMID: 29944195 DOI: 10.1111/hae.13549] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 12/23/2022]
Abstract
Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.
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Affiliation(s)
- M A Escobar
- McGovern Medical School and the Gulf States Hemophilia and Thrombophilia Center, University of Texas Health Science Center, Houston, TX, USA
| | - A Brewer
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - H Caviglia
- Orthopedics and Traumatology Department, "Juan A. Fernandez" Hospital, Buenos Aires, Argentina
| | - A Forsyth
- REBUILD Program/Diplomat Specialty Infusion Group, Cincinnati, OH, USA
| | - V Jimenez-Yuste
- Department of Haematology, La Paz University Hospital - IdiPaz, Madrid, Spain
| | - L Laudenbach
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - S Lobet
- Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - P McLaughlin
- Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - J O O Oyesiku
- Haemophilia, Haemostasis and Thrombosis Centre, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - E C Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital - IdiPaz, Madrid, Spain
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - L P Solimeno
- IRCCS Cà Granda Foundation, Maggiore Hospital of Milan, Milan, Italy
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Dolatkhah R, Bazavar MR, Poureisa M, Asvadi Kermani I, Vaez Gharamaleki J, Sanaat Z, Eivazi Ziaei J, Nikanfar A, Esfahani A, Chavoshi SH. Successful management of total knee replacement in a high responder hemophilia patient with a history of inhibitor. Iran Red Crescent Med J 2013; 15:18-20. [PMID: 23486529 PMCID: PMC3589773 DOI: 10.5812/ircmj.3406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 05/17/2012] [Accepted: 05/19/2012] [Indexed: 11/16/2022]
Abstract
The development of inhibitors against administered clotting factors may render replacement therapy ineffective for some hemophilia patients. Such patients are therefore at the highest risk of developing arthropathy. Elective orthopedic surgery (EOS) in hemophilic patients having such inhibitors remains a rare, expensive, and difficult surgery, whose management represents a significant challenge. We report the case of a 35-year-old man with a severe form of hemophilia A (factor VIII < 1%), who was suffering from repetitive spontaneous hemarthrosis, especially in his knee joints that had consequently become more susceptible to bleeding. The patient had a history of high levels of factor VIII inhibitor (> 5.0 Bethesda Unit [BU]/ml) as shown by the factor VIII inhibitor assay; therefore, we began treatment with factor VIIa for his mild-to-moderate bleeding (90 µg/kg intravenous bolus injections). The interval between injections varied with the severity of the hemorrhage in each bleeding episode. The inhibitor level reduced to 3.1 BU/ml after three months, to 1.6 BU/ml after six months, and disappeared completely after one year of treatment. We administered factor VIII at a dose of 50 IU/kg every eight hours during the first three post-operative days, then continued administration with a dose of 40 IU/kg every 12 hours for another four days, and observed a very good response to treatment with no bleeding. Recombinant activated factor VII (rFVIIa) is not an inhibitor-removal strategy, but an inhibitor-bypassing product. However, in our patient, the treatment of mild-to-moderate bleeding with short-term use of rFVIIa and no exposure to factor VIII caused a gradual reduction in the inhibitor level over a period of 1 year.
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Affiliation(s)
- Roya Dolatkhah
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Mohammad Reza Bazavar
- Department of Orthopedic, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding author: Mohammad Reza Bazavar, Department of Orthopedic, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel.: +98-4113859314, Fax: +98-4113859314, E-mail:
| | - Masoud Poureisa
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Iraj Asvadi Kermani
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Jalil Vaez Gharamaleki
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Zohreh Sanaat
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Jamal Eivazi Ziaei
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Alireza Nikanfar
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Ali Esfahani
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Seyed Hadi Chavoshi
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
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Chevalier Y, Dargaud Y, Lienhart A, Chamouard V, Negrier C. Seventy-two total knee arthroplasties performed in patients with haemophilia using continuous infusion. Vox Sang 2012; 104:135-43. [DOI: 10.1111/j.1423-0410.2012.01653.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kulkarni R. Comprehensive care of the patient with haemophilia and inhibitors undergoing surgery: practical aspects. Haemophilia 2012; 19:2-10. [PMID: 22925397 DOI: 10.1111/j.1365-2516.2012.02922.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 11/30/2022]
Abstract
Congenital haemophilia is a rare and complex condition for which dedicated specialized and comprehensive care has produced measurable improvements in clinical outcomes and advances in patient management. Among these advances is the ability to safely perform surgery in patients with inhibitor antibodies to factors VIII and IX, in whom all but the most necessary of surgeries were once avoided due to the risk for uncontrollable bleeding due to ineffectiveness of replacement therapy. Nevertheless, surgery continues to pose a major challenge in this relatively rare group of patients because of significantly higher costs than in patients without inhibitors, as well as a high risk for bleeding and other complications. Because of the concentration of expertise and experience, it is recommended that any surgery in patients with haemophilia and inhibitors be planned in conjunction with a haemophilia treatment centre (HTC) and performed in a hospital that incorporates a HTC. Coordinated, standard pre-, intra- and postoperative assessments and planning are intended to optimize surgical outcome and utilization of resources, including costly factor concentrates and other haemostatic agents, while minimizing the risk for bleeding and other adverse consequences both during and after surgery. This article will review the special considerations for patients with inhibitors as they prepare for and move through surgery and recovery, with an emphasis on the roles and responsibilities of individual members of the multidisciplinary team in facilitating this process.
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Affiliation(s)
- R Kulkarni
- Division of Pediatric and Adolescent Hematology/Oncology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA.
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Escobar M, Maahs J, Hellman E, Donkin J, Forsyth A, Hroma N, Young G, Valentino LA, Tachdjian R, Cooper DL, Shapiro AD. Multidisciplinary management of patients with haemophilia with inhibitors undergoing surgery in the United States: perspectives and best practices derived from experienced treatment centres. Haemophilia 2012; 18:971-81. [DOI: 10.1111/j.1365-2516.2012.02894.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2012] [Indexed: 11/28/2022]
Affiliation(s)
- M. Escobar
- Gulf States Hemophilia and Thrombophilia Center; Houston; TX; USA
| | - J. Maahs
- Indiana Hemophilia & Thrombosis Center; Indianapolis; IN; USA
| | - E. Hellman
- OrthoIndy Bone, Joint, Spine & Muscle Care; Indiana Orthopedic Hospital; Indianapolis; IN; USA
| | - J. Donkin
- Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; CA; USA
| | - A. Forsyth
- Penn Hemophilia and Thrombosis Program; Philadelphia; PA; USA
| | - N. Hroma
- Children's Memorial Hospital; Chicago; IL; USA
| | - G. Young
- Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; CA; USA
| | | | - R. Tachdjian
- David Geffen UCLA School of Medicine; Los Angeles; CA; USA
| | | | - A. D. Shapiro
- Indiana Hemophilia & Thrombosis Center; Indianapolis; IN; USA
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CAVIGLIA H, NARAYAN P, FORSYTH A, GIANGRANDE P, GILBERT M, GODDARD N, MULDER K, RAHIM S. Musculoskeletal problems in persons with inhibitors: How do we treat? Haemophilia 2012; 18 Suppl 4:54-60. [DOI: 10.1111/j.1365-2516.2012.02874.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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FORSYTH A, ZOURIKIAN N. How we treat: considerations for physiotherapy in the patient with haemophilia and inhibitors undergoing elective orthopaedic surgery. Haemophilia 2012; 18:550-3. [DOI: 10.1111/j.1365-2516.2012.02755.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Caviglia H, Candela M, Galatro G, Neme D, Moretti N, Bianco RP. Elective orthopaedic surgery for haemophilia patients with inhibitors: single centre experience of 40 procedures and review of the literature. Haemophilia 2011; 17:910-9. [PMID: 21342367 DOI: 10.1111/j.1365-2516.2011.02504.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the introduction of safe and effective factor VIII/IX-bypassing agents--recombinant activated factor VII (rFVIIa) and plasma-derived activated prothrombin complex concentrates (pd-APCC)--elective orthopaedic surgery (EOS) is a viable option for haemophilia patients with inhibitors. We report a series of patients with haemophilia and inhibitors undergoing EOS between 1997 and 2008 using bypassing agents to provide haemostatic cover. All inhibitor patients undergoing EOS and receiving rFVIIa, plasma-derived prothrombin complex concentrates (pd-PCC) or pd-APCC as haemostatic cover were included. Patients were operated on by the same surgeon and were managed by the same haemophilia treatment centre. Forty procedures (25 minor and 15 major) were conducted in 18 patients. Twenty-one minor cases were covered using rFVIIa, three with pd-PCC, and one with pd-APCC; all major cases were covered using rFVIIa. Bleeding was no greater than expected compared with a non-haemophilic population in all 25 minor procedures. In the major procedure group, there was no excessive bleeding in 40% of cases (6/15) and bleeding completely stopped in response to rFVIIa. For the remaining nine cases, bleeding response to rFVIIa was described as 'markedly decreased' or 'decreased' in 4/15 cases and 'unchanged' in 5/15 cases. Overall, efficacy of rFVIIa, based on final patient outcome, was 85%. One death occurred as a result of sepsis secondary to necrotizing fasciitis. Good control of haemostasis can be achieved with bypassing agents in haemophilia patients with inhibitors undergoing minor EOS; rFVIIa was used as an effective bypassing agent, enabling EOS in patients undergoing minor and major procedures.
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Affiliation(s)
- H Caviglia
- Haemophilia Foundation, Buenos Aires, Argentina.
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VALENTINO LA, COOPER DL, GOLDSTEIN B. Surgical Experience with rFVIIa (NovoSeven) in congenital haemophilia A and B patients with inhibitors to factors VIII or IX. Haemophilia 2011; 17:579-89. [DOI: 10.1111/j.1365-2516.2010.02460.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Johansson PI, Ostrowski SR. Evidence supporting the use of recombinant activated factor VII in congenital bleeding disorders. Drug Des Devel Ther 2010; 4:107-16. [PMID: 20689697 PMCID: PMC2915535 DOI: 10.2147/dddt.s11764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa, NovoSeven) was introduced in 1996 for the treatment of hemophilic patients with antibodies against coagulation factor VIII or IX. OBJECTIVE To review the evidence supporting the use of rFVIIa for the treatment of patients with congenital bleeding disorders. PATIENTS AND METHODS English-language databases were searched in September 2009 for reports of randomized controlled trials (RCTs) evaluating the ability of rFVIIa to restore hemostasis in patients with congenital bleeding disorders. RESULTS Eight RCTs involving 256 hemophilic patients with antibodies against coagulation factors, also known as inhibitors, were identified. The evidence supporting the use of rFVIIa in these patients was weak with regard to dose, clinical setting, mode of administration, efficacy, and adverse events, given the limited sample size of each RCT and the heterogeneity of the studies. CONCLUSION The authors suggest that rFVIIa therapy in hemophilic patients with inhibitors should be based on the individual's ability to generate thrombin and form a clot, and not on the patient's weight alone. Therefore, assays for thrombin generation, such as whole-blood thromboelastography, have the potential to significantly improve the treatment of these patients.
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Affiliation(s)
- Pär I Johansson
- Capital Region Blood Bank, Section for Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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BONNET PO, YOON BS, WONG WY, BOSWELL K, EWENSTEIN BM. Cost minimization analysis to compare activated prothrombin complex concentrate (APCC) and recombinant factor VIIa for haemophilia patients with inhibitors undergoing major orthopaedic surgeries. Haemophilia 2009; 15:1083-9. [DOI: 10.1111/j.1365-2516.2009.02038.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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SCALONE L, MANTOVANI LG, BORGHETTI F, VON MACKENSEN S, GRINGERI A. Patients’, physicians’, and pharmacists’ preferences towards coagulation factor concentrates to treat haemophilia with inhibitors: results from the COHIBA Study. Haemophilia 2009; 15:473-86. [DOI: 10.1111/j.1365-2516.2008.01926.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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TEITEL JM, CARCAO M, LILLICRAP D, MULDER K, RIVARD GE, ST-LOUIS J, SMITH F, WALKER I, ZOURIKIAN N. Orthopaedic surgery in haemophilia patients with inhibitors: a practical guide to haemostatic, surgical and rehabilitative care. Haemophilia 2009; 15:227-39. [DOI: 10.1111/j.1365-2516.2008.01840.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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RODRIGUEZ-MERCHAN EC, QUINTANA M, JIMENEZ-YUSTE V. Orthopaedic surgery in haemophilia patients with inhibitors as the last resort. Haemophilia 2008; 14 Suppl 6:56-67. [DOI: 10.1111/j.1365-2516.2008.01891.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jiménez-Yuste V, Rodriguez-Merchan EC, Alvarez MT, Quintana M, Fernandez I, Hernandez-Navarro F. Controversies and challenges in elective orthopedic surgery in patients with hemophilia and inhibitors. Semin Hematol 2008; 45:S64-7. [PMID: 18544428 DOI: 10.1053/j.seminhematol.2008.03.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Until recently, orthopedic surgery was strongly contraindicated in patients with hemophilia and inhibitors. However, recent advances in our knowledge of bypassing agents (particularly recombinant activated factor VII [rFVIIa]) that provide effective surgical hemostasis have allowed us to successfully perform major orthopedic procedures in these patients. Adequate hemostasis during surgery and postoperative rehabilitation is crucial, as development of a wound hematoma may jeopardize long-term outcomes. It also should be noted that success depends not only on appropriate drug therapy but also on preoperative preparations and adequate perioperative surveillance. Preoperative assessment of vascular status is very important, and strong motivation--on the part of the patient, the surgeon, and the hematologist--is needed to ensure a satisfactory result. Although inhibitor patients undergoing surgery face a higher risk of bleeding and other complications than their non-inhibitor counterparts, outcomes are generally good if a multidisciplinary team approach is applied.
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OBERGFELL A, AUVINEN MK, MATHEW P. Recombinant activated factor VII for haemophilia patients with inhibitors undergoing orthopaedic surgery: a review of the literature. Haemophilia 2008; 14:233-41. [DOI: 10.1111/j.1365-2516.2007.01617.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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