Surgery in hemophilia. The general view: patient selection, timing, and preoperative assessment.

Although often overlooked, the life of the patient with severe hemophilia is characterized by both intermittent and chronic pain. Bleeds into joints and muscles cause extensive pressure on sensory nerves and, following recurrent bleeds, joint destruction, and synovial reaction is accompanied by constant pains that are frequently mistaken for further bleeding. The orthopedic surgeon may break the vicious cycle of chronic synovitis by excising inflamed and hypertrophic synovium or severely damaged cartilage and adjacent bone ends, and implanting an artificial joint. Numerous technical solutions are now available and orthopedic surgery is increasingly on offer to those hemophilia patients who, since childhood, have been victims of insufficiently treated bleeds because no or limited treatment was available, and because the concept of prophylaxis had not yet been developed. Nonetheless, orthopedic surgery in patients with hemophilia requires much more effort and planning than surgery in non-hemophilic patients. In this overview, we will address issues related to surgery in hemophilic patients, as well as some practical issues related to the timing of surgery, preoperative testing, perioperative hemostasis, and patient rehabilitation.