LETTER TO THE EDITOR
Therapeutic shoulder arthroscopy in patients with clotting
J. M. C. THOMAS,* E. G. TUDDENHAM? and P. M. AHRENS*
*Department of Orthopaedic Surgery, The Royal Free Hospital, London; and ?Haemophilia Centre, The Royal Free
Hospital, London, UK
Orthopaedic surgery in patients with clotting disor-
ders represents a technical surgical challenge. Man-
agement of these high-risk patients requires input
from a multidisciplinary team consisting of: an
orthopaedic surgeon, a haematologist, the services
of an expert haemostasis laboratory as well as the
usual input from physiotherapy, occupational ther-
apy and nursing staff. The first documented open
knee synovectomy in a haemophiliac occurred in
1966 performed by Storti . More recently a series
of elective orthopaedic procedures has been docu-
mented confirming that elective orthopaedic surgery
can be successfully performed on haemophilic
patients with inhibitors . The first of these was
in 1988 , under the cover of recombinant FVIIa
with two further reports in 1994 describing the use
of FVIIa in haemophilic patients with inhibitors
undergoing elective orthopaedic procedures .
Arthroscopic techniques have been developing
since the 1970s and the use of arthroscopic synovec-
tomy in the knee is well documented. Arthroscopy of
the shoulder has been performed for synovectomy
but the use of reconstructive shoulder arthroscopy in
patients with clotting disorders has not been previ-
ously documented . Reconstructive arthroscopic
procedures such as tendon and instability repairs
have become increasingly common over the last
10 years in non-haemophilic subjects. Adequate
visualization during these procedures is essential to
ensure the procedure can be performed successfully
and for this adequate haemostasis is required during
the procedure. To our knowledge, there are no
previous reports in the literature addressing this
We report a case series of six therapeutic arthro-
scopic procedures in five patients with clotting
A 29-year-old gentleman suffering with recurrent
right shoulder dislocation had anterior–inferior
instability diagnosed clinically and confirmed with
MRI. He underwent an arthroscopic Bankart labral
repair with anchors and sutures.
abaselineof38 U dL)1,albeitwithseveralepisodesof
haemarthrosis associated with moderate or minor
trauma. He was managed with prothrombin complex
to maintain FX level above 70% for 72 h.
Postoperatively he had no complications and on
follow-up in outpatients he had an uneventful recov-
ery. Postoperative completion of the Matsen Simple
Shoulder Test  confirmed an increase from 9/12
preoperatively to 12/12 at 30 months follow-up.
A 49-year-old lady experienced right shoulder pain
and stiffness secondary to a degenerative supraspin-
atus tear, confirmed by ultrasound. She underwent a
long head of biceps tenotomy, repair of a partial
thickness supraspinatus tear and excision of the
She was known to have a platelet function disorder
described as weak agonist response defect. Her bleed-
ing time was >20 min and she had previously had two
episodes of life-threatening bleeding after minor
trauma and dental extraction. She was prepared for
surgery with washed HLA-matched platelets (because
of earlier severe allergic reaction to platelet infusion)
and tranexamic acid, the latter continued for 5 days.
On outpatient follow-up her symptoms had sig-
nificantly improved with an increase from 2/12
Correspondence: J. M. C. Thomas, The Royal Free Hospital –
Orthopaedics, Pond St, London NW3, UK.
Tel./fax: 0207 7940500;
Accepted after revision 6 February 2008
Haemophilia (2008), 14, 859–861 DOI: 10.1111/j.1365-2516.2008.01683.x
? 2008 The Authors
Journal compilation ? 2008 Blackwell Publishing Ltd859
preoperatively to 9/12 postoperatively at 7 months
using the Matsen Simple Shoulder Test.
A 28-year-old gentleman suffered from right recur-
rent anterio-inferior shoulder instability. Arthoscopic
findings confirmed a Bankart lesion for which he
underwent an arthroscopic Bankart repair using
anchors and sutures.
He was under the care of haemophilia team for a
complex coagulopathy secondary to portal vein
thrombosis. The haematological defects included
thrombocytopenia (PLT 40 · 109L)1), low FVII
(36 IU dL)1), FV (17 IU dL)1), FXI (42 IU dL)1),
FXIII (A subunit 56 U dL)1), antithrombin (activity
76 IU dL)1), Protein C (activity 46 IU dL)1) and
protein S (free 48 IU dL)1). Roteg indicated delayed
weak clot formation with excessive fibrinolysis. He
was prepared for surgery with 6 units of Octaplas
(virus-inactivated plasma), one pool of platelets and
tranexamic acid, 1 g i.v. Postoperatively he was
given 1 unit of Octaplas daily and 1 g of tranexamic
acid 6 hourly, orally for 5 days. There was no
excessive blood loss during or after surgery.
Postoperatively he made an uneventful recovery
and on outpatient follow-up he had regained a full
range of movement and had no evidence of instabil-
ity at 5 months postoperation.
A 46-year-old lady was experiencing bilateral shoul-
der pain. She was known to have mild FXI defi-
ciency, baseline level 60 U dL)1.
She underwent a left arthroscopic subacromial
decompression in September 2005; 2 years later she
had a revision of right subacromial decompression
and repair of a supraspinatus tear using sutures.
She was prepared for surgery by infusion of 1 g
tranexamic acid with oral tranexamic acid, 1 g
6 hourly for 5 days for both procedures. Functional
recovery was compromised by associated upper limb
generalized tendonopathy. She had no postoperative
untoward bleeding and her Matsen shoulder score
for her left shoulder improved from 2 to 5 at
20 months, and her left shoulder improved from 7 to
9 at 3 months of follow-up.
A 51-year-old gentleman presenting with a right
shoulder supraspinatus tear. This was repaired arth-
roscopically with anchors and sutures, he also
underwent a long head of biceps tenotomy and
arthroscopic subacromial decompression.
He was under the care of the haemophilia unit
with chronic consumptive coagulopathy of unknown
4 years. The coagulopathy was characterized by
persistently low fibrinogen (?0.9 g L)1), D-Dimer
>1000 ng mL)1, FXIII A subunit 24 U dL)1but with
only moderately reduced platelets 137 · 109L)1.
He was prepared for operation by infusion of
desmopressin (DDAVP) 0.3 lg kg)1. He developed a
haematoma around posterior portal incision on day
2 for which he was given a further dose of DDAVP.
His discharged was delayed by 3 days because of
this but the haematoma subsequently resolved with-
out the need for surgical intervention. He made a full
On outpatient follow-up his Matsen Shoulder
Score had increased from 5/12 to 10/12 at 24 months
and his symptoms were not recurred.
patients with clotting disorders recommend that
the use of orthopaedic surgery to relieve the
chronic pain caused by arthropathy and improve
patient quality of life . Although patients with
haemophilia represent a clinical challenge they also
suffer with orthopaedic problems some of which
may be unrelated to their bleeding disorder. Care-
ful liaison with a haemophilia centre can ensure
that a patient has optimized haemostasis perioper-
atively to benefit from the therapeutic procedures
that are available.
Therapeutic shoulder arthroscopy poses specific
challenges in these patients. The use of a tourniquet
is not possible and bleeding can lead to problems
with visualization with arthroscopic procedures in
the shoulder. Complex reconstructive procedures
involve an increase in operative time compared to
simple synovectomies, and require adequate haemo-
stasis to be maintained throughout.
In this series, there were no perioperative problems
with bleeding and no procedure was compromised.
Surgical time was no longer than with other patients.
The only postoperative complication was a portal
haematoma, an event documented in patients with
haemophilia  and it had no impact on patient
outcome. The improvement in patients? condition
was monitored using the validated Matson Simple
Shoulder Score and showed a significant increase in
In conclusion, clotting disorders do not preclude
the use of reconstructive arthroscopic techniques in
the shoulder as long as the appropriate specialist
multidisciplinary team manages these patients.
LETTER TO THE EDITOR
? 2008 The Authors
Haemophilia (2008), 14, 859–861Journal compilation ? 2008 Blackwell Publishing Ltd
Disclosures Download full-text
The authors stated that they had no interests which
might be perceived as posing a conflict or bias.
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LETTER TO THE EDITOR
? 2008 The Authors
Journal compilation ? 2008 Blackwell Publishing LtdHaemophilia (2008), 14, 859–861