ELECTIVE ORTOPHAEDIC SURGERY IN PATIENTS WITH INHIBITORS THE(A) - - PowerPoint PPT Presentation

ELECTIVE ORTOPHAEDIC SURGERY IN PATIENTS WITH INHIBITORS THE(A) PATIENT(S) PERSPECTIVE

Miguel Crato Brussels - June, 27 - 2017

PATIENT BACKGROUND

• Long life inhibitors(since 12 years old, bypassing

agents only since 20 years old)

• Long history of target joint bleeding(right knee)
• Pain and mobility severely affected
• Other joints affected (domino effect)
• Quality of life decreasing through the years

PATIENT BACKGROUND

• Range of motion Ext: 25° Flex. 75°
• No bleeds in the last 3 years
• No previous synovectomy of the knee
• On prophylaxis 2 x week(before physio)
• Frequent knee inflammation
• Severe pain
• Half an hour to start walking

in the morning

PRE SURGERY KNEE STATUS

• Years of talks with hematologist and orthopedist
• The inhibitor factor – life threatening surgery!
• Higher risk vs better quality of life(rate of success)
• First time for a knee replacement surgery (KRS) in

Portugal to a patient with inhibitors (pwi)

• Is there a real reason to wait, in pwi?
• Joint decision for KRS taken one year before

TIME FOR A DECISION

• Multidisciplinary team meetings

(hematologist/orthopedist/physiatrist/chief nurse)

• Dental care near optimum

(to minimize the risk of infection)

• Water physio one year before KRS

(Muscular strengthening)

• Be mentally prepared

(support of family, friends, work, day to day tasks)

• Be prepared to have a very slow recovery after KRS

PREPARING THE KRS

• Previous surgery in 2007 with rFVII (Cholecystectomy)
• Previous synovectomy of the elbow with rFVII
• Adapted prophylaxys 2 x week with APCC (just before

water physio)

• Joint bleedings treated with APCC
• Other bleedings(major cuts, dental extractions) treated

with rFVII

Patient history

CHOOSING THE BYPASING AGENT

Decision with the hematologist to do a thrombin generation test(TGT) and ROTEM – Thromboelastometry

• Conclusion : Shared decision to choose rFVII

for the KRS and for the first two weeks, and APCC after that

• TGT – very similar results
• RT – Better results with rFVII

(faster clot formation and clot more consistent)

TESTING

• Technically equal, with extra control for hemostasis

(regardless the option for rFVII, APCC was available)

• 2 hours and a half duration
• Implant of Triathlon PS(striker)
• No transfusion needed

THE SURGERY ( 20 March 2017)

• 48 hours in intensive care

(just for precaution)

• Good hemosthasis
• Hemoglobin dropped to 11g/dl

after surgery (no transfusion needed)

• Low levels of pain
• Hospital discharge on day 15

rFVII

• 8mg – Immediate pre surgery

7 mg - 2/2 hours for 32 hours 7 m - 3/3 hours for 57 hours 7 mg - 4/4 hours for 44 hours 7 mg - 6/6 hours for 66 hours 7 mg -8/8 hours for 24 hours 7 mg 1 x per dia - day 10 to day 14 post surgery TRANEXAMIC ACID

1g – for surgery, intra-articular 500mg - 6/6h, first week , 8/8h until day 10

TREATMENT PLAN

POST SURGERY

DAY 3 Day 15 DAY 75

KNEE RECOVERING EVOLUTION

• Started 48 hours after surgery
• Range of motion: ext: -5° flex 40°
• On foot at day 3(marvellous sensation)
• First steps with a walker on day 4, crutches on day 6
• Stairs on day 12
• rFVII infusion pre physio
• n hospital
• Hospital discharge:

ext: -5° flex 75°

HOSPITAL

PHYSIOTHERAPY

• Physio 3 x day/week on gym (with APCC)

General objectives Adaptation for a pwi

• Recuperation slighty delayed due to painfull arthropaty

in both ankles and a tendinitis in the left shoulder

• Range of motion now – ext 0° flex 90°

AFTER HOSPITAL

PHYSIOTHERAPY

• Shared objectives between pwi and

physio therapist

• Reduce stress
• Avoid bleeding and inflammation
• Use of ice and periods of rest
• Longer sessions
• Teaching for home therapy and

autonomy

• Recover joint amplitudes
• Promove knee cap mobility
• Soft tissues functionality
• Gain of flexibility, strength and motor

control

• New joint vs dynamic body posture

“You look so taller” – My wife after first standing up straight “ I´m so happy with the results, everything went so well “ – My orthopedist who performed the surgery “ The hemosthasis control was perfect and the knee looks so good” – My hematologist “I do not remember the last time I slept without a cushion under my knee” – me 20 May 2017 - APH Parents Conference- two months after KRS

THANK YOU FOR YOUR ATTENTION