Eptacog alfa(Novo Nordisk A/S)

Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against factor VIII and may present with life-threatening hemorrhage. Postoperative presentation is uncommon and may lead to delayed diagnosis, as bleeding is often initially attributed to surgical causes. We report a 64-year-old man with post-traumatic knee arthritis and retained hardware who underwent navigation-assisted total knee replacement. The procedure was uneventful with an estimated blood loss of 300 mL. On postoperative day two, he developed acute knee swelling with persistent bleeding through a negative-pressure wound dressing. Urgent re-exploration and hematoma evacuation were performed; however, diffuse bleeding persisted despite adequate surgical hemostasis, requiring activation of a massive transfusion protocol. Laboratory investigations demonstrated isolated prolongation of activated partial thromboplastin time (aPTT) at 65.3 seconds. Further coagulation studies revealed markedly reduced factor VIII activity with circulating factor VIII inhibitors, confirming AHA. Hemostasis was achieved following treatment with FEIBA and NovoSeven under hematology guidance. The patient subsequently recovered well and was discharged with outpatient follow-up. This case highlights acquired hemophilia A as a rare but important differential diagnosis in persistent postoperative bleeding following total knee replacement. Early recognition, prompt coagulation workup, and multidisciplinary management are essential to improve outcomes.

Epidural anesthesia is generally avoided in patients with hemophilia due to the risk of spinal or epidural hematoma. However, with careful factor replacement and perioperative management, neuraxial techniques may be feasible in selected cases. Mechanical complications, such as catheter twisting, are rare but can mimic serious neurological events, requiring careful differential diagnosis.

A 37-year-old man with severe hemophilia A and factor VIII inhibitors underwent bilateral total knee arthroplasty (TKA) under epidural anesthesia. He received recombinant activated factor VIIa (rFVIIa) and tranexamic acid for hemostatic management. Postoperatively, he developed left leg weakness and paresthesia. Emergency MRI ruled out hematoma but revealed a twisted epidural catheter at L4–L5. The catheter was promptly removed after rFVIIa administration, and conservative treatment led to complete recovery within 3 months.

This case highlights the rare mechanical complication of epidural catheter twisting in a high-risk hemophilia patient, mimicking epidural hematoma. It highlights the importance of timely imaging, individualized risk–benefit assessments, and adherence to safety protocols for neuraxial anesthesia (NA) in individuals with hemophilia. Comparison with existing guidelines and limited case reports emphasizes the need for standardized protocols and vigilant postoperative monitoring.

NA can be safely used in selected patients with hemophilia, provided that rigorous hemostatic management is employed. Mechanical complications like catheter twisting, though rare, should be considered in the differential diagnosis of postoperative neurological deficits, and robust monitoring protocols should be implemented.