To the Editor:

In a very interesting paper published in the November issue of 2004 of the JBJS-American, Mehta, et al. have presented the results of three TKAs performed in two hemophilic patients with inhibitors using rFVIIa as a hemostatic drug (1). In their article they state that “the orthopedic literature regarding TKA in patients with hemophilia is limited, with little emphasis on patients with inhibitors”. They also state that “no consensus has been reached with regard to the appropriate dosing regimen” to be used in hemophilic patients with inhibitors.

I would like to supplement the information presented by Mehta et al by citing two publications in which I have participated. One of them is a multicenter study in which 6 TKAs were carried out with good results and similar conclusions to those reached by Mehta et al (2). The other publication makes reference to a consensus reached regarding the dosing regimen in these type of patients (3).

To sum up, I would like to congratulate Metha et al for their 3 cases, but I bring to the attention of the reader the other articles mentioned to note that the topic is not as unusual as they state. Moreover, it should be of help to readers of the Journal to know that a consensus does exist regarding the dosing regimen for surgery in hemophilic patients with inhibitors, not only with rFVIIa but also with another product called FEIBA.

References

1.Mehta S, Nelson CL, Konkle BA, Vannozzi B. Total knee arthroplasty using recombinant factor VII in hemophilia A patients with inhibitors. A report of three cases. J Bone Joint Surg Am 2004; 86-A:2519-21.

2. Rodriguez-Merchan EC, Wiedel JD, Wallny T, et al. Elective orthopaedic surgery for inhibitors patients. Haemophilia 2003; 9:625-31.

3. Rodriguez-Merchan EC, Rocino A, Ewenstein B, et al. Consensus perspectives on surgery in haemophilia patients with inhibitors: summary statement. Haemophilia 2004; 10 (Suppl. 2): 50-2.

To the Editor:

We agree with the comments of Drs. Panotopoulos and Trieb regarding our use of recombinant factor VIIa in three patients with hemophilia-A and inhibitors who underwent total knee arthroplasty.

Total knee arthroplasty can be performed safely using recombinant factor VIIa as described in our cases. Alternatively, immune tolerance can be successfully established in some patients with inhibitors allowing surgery using Factor VIII. We have previously published an article in which different strategies were discussed to safely perform total knee replacement in such patients (1). We recommend review of this article for interested individuals.

References:

1.Konkle BA, Nelson C, Forsyth A, Hume E. Approaches to successful total knee arthroplasty in haemophilia A patients with inhibitors. Haemophilia.2002; 8:706 -10.

To the Editor:

We read with interest the case report “Total knee arthroplasty using recombinant factor VII in hemophilia-A patients with inhibitors” by Metha et al.(2004; 86-A: 2519-21).

As the authors report, TKA in patients with inhibitors poses a challenging problem. Nevertheless the authors were able to show that TKA in patients with inhibitors is possible when adequate replacement therapy is carried out.

We treated about 70 patients with bleeding disorders. Only one patient had the development of high-titer inhibitors (high responder) with a Bethesda Unit of 30 at an age of 5 years. High dose therapy with F VIII was unable to eliminate the inhibitors. Severe bleeding episodes were treated with Feiba TM (F II, VII, IX, X). Tolerance was induced with the Malmö protocol in 1994. In 1994 the patient received a TKA on the right knee because end stage hemophilic arthropathy of this joint. The factor replacement consisted of a bolus given preoperatively. Postoperatively the substitution consisted of a continuous infusion with a recombinant F VIII concentrate (500 IE / h). The patient received during the stay in hospital 3 red blood concentrates.

5 years later we performed a total hip arthroplasty and last year a synovectomy of the elbow. For both operations the replacement therapy remained unchanged. No complications were observed during the postoperative course.

We agree with the authors that total joint arthroplasty is an effective therapeutic option for patients with hemophilic arthropathy and that even in patients with inhibitors, as the authors proved, total joint arthroplasty is possible under adequate management.