Subclinical Deep Venous Thrombosis Affects 10 % of Haemophiliacs Undergoing Major Orthopaedic Surgery.

The management of venous thromboembolism (VTE) in patients with haemophilia undergoing major orthopaedic surgery requiring intensive replacement therapy remains controversial. Information about the incidence of proven VTE in this setting is lacking. Despite the absence of data, half of haemophilia comprehensive centers in Europe recently reported the use of pharmacological antithrombotic prophylaxis in this setting.

We conducted a prospective study to evaluate the occurrence of deep venous thrombosis (DVT) of the lower limbs in all consecutive patients with haemophilia referred for major orthopaedic surgery at the Cliniques universitaires Saint-Luc, Brussels, Belgium. Screening for DVT by unilateral (13) or bilateral (16) compression ultrasonography (US) of the lower limbs was performed 5 to 12 days after 29 major orthopaedic surgeries (total hip replacement (5), total knee replacement (TKR) (15), ankle arthrodesis (4), decompressive laminectomy for lumbar stenosis (1), femoral osteosynthesis (4)) in 22 patients with severe (16), moderate (4) or mild (2) haemophilia A (20) or B (2), intensively treated with continuous infusion of clotting factor concentrate. None of the patients received pharmacological anti-thrombotic prophylaxis with LMWH. There was no case of clinical DVT or pulmonary embolism during the 3-months post-operative clinical surveillance. However distal DVT involving a single peroneal vein without proximal extension was identified in two patients with severe HA after TKR and in one patient with mild HB after decompressive laminectomy. The latter was efficiently treated with a short course of LMWH. The two others resolved spontaneously without antithrombotic therapy.

In conclusion, sub-clinical DVT affects up to 10 % of patients with haemophilia undergoing major orthopedic surgery. All thrombotic events were distal and resolved spontaneously or with a short course of LMWH without complications. This study suggests that routine screening for DVT by compressive US is indicated in patients with haemophilia undergoing major orthopaedic surgery and not receiving pharmacological thromboprophylaxis. Further studies are needed to determine if systematic pharmacological prevention of DVT is required in this setting as in patients without haemophilia.