Gillinov Stephen M, Modrak Maxwell, Park Nancy, Monahan Peter F, Wilhelm Christopher V, Lee Michael S, Mahatme Ronak J, Fong Scott, Moran Jay, Grauer Jonathan N, Jimenez Andrew E
Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
Penn State College of Medicine, Hershey, PA, USA.
Clin Orthop Relat Res. 2025 Feb 1;483(2):268-275. doi: 10.1097/CORR.0000000000003209. Epub 2024 Sep 3.
Patients with hemophilia A can develop joint hemarthroses, degenerative changes, and eventually undergo total shoulder arthroplasty (TSA). Few data exist concerning complications and prosthesis survival after TSA in this population.
QUESTIONS/PURPOSES: (1) Is hemophilia A associated with more bleeding and thromboembolic adverse events after TSA relative to matched controls? (2) Is 5-year TSA prosthesis survival reduced in patients with hemophilia A compared with matched controls?
The 2010 to 2022 PearlDiver M161 database was used to identify patients who underwent primary anatomic or reverse TSA. Given that the X-linked recessive condition hemophilia A presents nearly exclusively in males, male patients with hemophilia A who underwent TSA were matched 1:10 with male patients without hemophilia who underwent TSA based on age and Elixhauser comorbidity index (ECI). This yielded 73 patients with hemophilia A who underwent TSA who were matched 1:10 with 729 patients without hemophilia. Ninety-day adverse events were compared with multivariable analysis. Revision within 5 years was assessed using Kaplan-Meier analysis.
Compared with the control cohort, patients with hemophilia had greater odds of bleeding issues (hematoma, OR 6.8 [95% CI 3.0 to 15.3]; p < 0.001; anemia, OR 2.5 [95% CI 1.5 to 4.2]; p < 0.001, transfusion, OR 5.0 [95% CI 2.4 to 10.3]; p < 0.001), venous thromboembolic events (VTE) (OR 1.9 [95% CI 1.1 to 3.1]; p = 0.01), and prosthetic loosening (OR 3.5 [95% CI 1.4 to 8.0]; p = 0.004). Based on available data, 5-year implant survival was not different in patients with hemophilia (97.3% [95% CI 93.6% to 100.0%]) relative to matched controls (95.2% [95% CI 93.4% to 97.2%]; p = 0.60).
The elevated risks of both 90-day bleeding complications (hematoma, anemia, and transfusion) and VTE (DVT and PE) in patients with hemophilia emphasize the special challenges of carefully balancing factor replacement and VTE prophylaxis pre-, intra-, and postoperatively on an individual patient basis with careful hematologist coordination. Further study on Factor VIII levels and targets as well as tranexamic acid and VTE prophylaxis in this population is necessary to provide further guidance. Furthermore, 5-year implant survival was not different between patients with hemophilia and matched controls (patients without hemophilia) based on available data, suggesting that TSA survivorship remains durable and may be offered to patients in this population as indicated.
Level III, therapeutic study.
甲型血友病患者可发生关节积血、退行性改变，并最终接受全肩关节置换术（TSA）。关于该人群TSA术后并发症和假体生存率的数据很少。
问题/目的：（1）与匹配的对照组相比，甲型血友病是否与TSA术后更多的出血和血栓栓塞不良事件相关？（2）与匹配的对照组相比，甲型血友病患者的TSA假体5年生存率是否降低？
使用2010年至2022年的PearlDiver M161数据库来识别接受初次解剖型或反向TSA的患者。鉴于X连锁隐性疾病甲型血友病几乎仅见于男性，接受TSA的甲型血友病男性患者与接受TSA的非血友病男性患者按年龄和埃利克斯豪泽合并症指数（ECI）进行1:10匹配。这产生了73例接受TSA的甲型血友病患者，他们与729例非血友病患者按1:10匹配。通过多变量分析比较90天不良事件。使用Kaplan-Meier分析评估5年内的翻修情况。
与对照组相比，血友病患者发生出血问题（血肿，比值比6.8[95%可信区间3.0至15.3]；p<0.001；贫血，比值比2.5[95%可信区间1.5至4.2]；p<0.001，输血，比值比5.0[95%可信区间2.4至10.3]；p<0.001）、静脉血栓栓塞事件（VTE）（比值比1.9[95%可信区间1.1至3.1]；p=0.01）和假体松动（比值比3.5[95%可信区间1.4至8.0]；p=0.004）的几率更高。根据现有数据，血友病患者的5年植入物生存率（97.3%[95%可信区间93.6%至100.0%]）与匹配的对照组（95.2%[95%可信区间93.4%至97.2%]；p=0.60）没有差异。
血友病患者90天出血并发症（血肿、贫血和输血）和VTE（深静脉血栓形成和肺栓塞）的风险升高，强调了在血液科医生的仔细协调下，根据个体患者情况在术前、术中和术后仔细平衡因子替代和VTE预防的特殊挑战。有必要对该人群中的凝血因子VIII水平和目标以及氨甲环酸和VTE预防进行进一步研究，以提供进一步的指导。此外，根据现有数据，血友病患者与匹配的对照组（非血友病患者）之间的5年植入物生存率没有差异，这表明TSA的生存率仍然持久，可根据需要为该人群的患者提供。
III级，治疗性研究。
