An expert panel comprising haematologists (MAE, AS, VJ‐Y), orthopaedic surgeons (LPS, HC, ECR‐M), specialist haemophilia nurses (LL, JOOO), specialist physiotherapists (AF, PM, SL) and a dental expert (AB) reviewed the topic of multidisciplinary surgical care in haemophilia. The outcomes of this meeting are reported here as a narrative summary with supporting references.

The role of coordinator may shift between MDT members, depending on the phase of planning. For example, the surgeon may be best suited to coordinate in the intraoperative period, and a physiotherapist suited for the outpatient period. In all cases, the MDT assures smooth handover between different phases, is aware of the patient's requirements and expectations, and ensures continuity of care. The coordinator role may be held by a specialist local to the patient, with extensive communication back to the HTC.

Role of the multidisciplinary team coordinator. The multidisciplinary team is a comprehensive model of surgical care of people with haemophilia. Information should be able to flow freely between all specialists (white boxes) and the MDT coordinator (black box). Patients, their family and caregivers (grey oval) are included in decision‐making and can communicate with key members of the MDT. MDT, multidisciplinary team; PMR, physical medicine and rehabilitation

In addition to their specific responsibilities, a full‐time permanent member of the MDT may take on a leadership role as a coordinator (summarized in Figure 1 ). The coordinator is responsible for ensuring that all steps associated with surgical preparation, procedure performance and required rehabilitation are executed efficiently and thoroughly. A checklist may be utilized (Table 2 and Table S1 ). The coordinator facilitates consistent communication among the MDT members and the patient/family, and confirms the availability of resources, services and facilities to support surgery and rehabilitation.

Throughout all phases of surgery, it is important that patient expectations of the outcome are communicated, recorded, understood and managed by the MDT, and aligned with the procedure.

Ongoing communication among the MDT and early involvement of a physiotherapist and/or PMR physician are required for prompt referral to surgery. Before the patient provides consent it is important that they understand the planning process, surgical procedure and potential outcomes; discuss their personal goals; and have any concerns and fears allayed. In advance of surgery the haemophilia nurse, psychologist or social worker explores with the patient their mindset and assesses their social support structure. The physiotherapist may discuss realistic postoperative rehabilitation and disposition planning.

Frequent, recurrent and uncontrolled joint bleeding resulting from chronic synovitis leads to persistent pain and joint deformity that may be addressed by radiosynovectomy and orthopaedic surgery, respectively. 1 , 16 Delayed referral to an orthopaedic surgeon may result in chronic synovitis and joint damage, requiring more aggressive surgical intervention. 16 Regular monitoring at the HTC of joint status of patients who experience frequent joint bleeds and/or pain can help to identify candidates for orthopaedic surgery and prevent delayed referral. Although not the focus of this article, fractures, septic joints and compartment syndromes must be treated as an emergency. With compressed preparation time these episodes are best referred to an HTC with an experienced MDT, where resources and specialist experience are available to respond to the urgency of the condition.

2.2 Outpatient preoperative planning period

The preoperative planning period begins following an agreement to proceed to surgery. The duration of the planning phase varies case‐by‐case, according to urgency, pathology, needs and status of the patient, haemostatic complexity and resource availability. MDT members must agree on the clinical implementation of treatment protocols for surgery to assure team alignment translates into consistent communication with the patient/family, treatment plan development and conduct. In some countries it is required to communicate with and obtain authorization from the healthcare insurer for haemostatic coverage and rehabilitation far in advance of surgery.

2.2.1 Managing patient expectations Meetings between the patient/family and the MDT are held early to ensure alignment between the patient's and the MDT's expectations of surgical outcomes, realistic functional goals and the patient's role in their own recovery.17, 18 Requirements differ between patients; the needs of a 20‐year‐old with a painful knee who desires to participate in activities with his friends will contrast with those of a 60‐year‐old with limited elbow motion. Motivations and expectations affect patient perception about surgery; reluctance, fears, individual capability for, and commitment to, rehabilitation is identified and discussed with the relevant MDT members. The haemophilia nurse is often best able to address these issues, but a social worker or psychologist may be involved to gain a deeper understanding of a patient's concerns. Discussion of “the road to surgery” between the MDT must include procedure description, associated risks, required commitment during the rehabilitation period, and expected outcome. Commitment during rehabilitation includes any practical difficulties the patient may face travelling to the HTC for rehabilitation appointments (eg limited mobility or access to transport after a knee replacement). Postoperative infusion requirements for patients with moderate haemophilia may include training on infusing clotting factor or insertion of a peripherally inserted central catheter for home treatment during the recovery period. With the patient, the physiotherapist and social worker evaluate the home recovery environment and physical aids required. The coordinator ensures that these meetings occur in a timely fashion and that outcomes are communicated between MDT members so that plans are established.

2.2.2 Dental care Adequate oral hygiene is important in PWH to prevent periodontal disease and other dental complications, which can be a source of postoperative infection, particularly in the case of total joint replacement.19, 20 As resolution of oral infection may require several weeks, a dental surgeon should be involved early in the planning process to assess possible oral sources of infection. Prophylactic antibiotic treatment is typically not required.6, 21 The MDT should keep apprised of issues identified by the dental surgeon and any need for invasive procedures, as these may create the need for an additional procedure and procedural planning.

2.2.3 Pain management planning The haematologist, anaesthetist and patient discuss the patient's pain threshold and assess any increased tolerance to opioid medications; this information can influence plans for pain management, postoperative recovery and physical rehabilitation. Analgesics currently used should be identified and the need for increased doses in the perioperative period assessed.6 In patients with inhibitors, a nerve block would typically be avoided, owing to the risk of perforating a blood vessel and the consequences of bleeding into a confined space.6, 15 A postoperative pain management plan is prepared, covering inpatient recovery and postdischarge. Preparations for postoperative pain management, both in the hospital and following discharge, are made. The anaesthetist liaises with the haemophilia nurse to confirm other medications the patient is taking. It is important for the haemophilia nurse to raise awareness that medication dosages for daily and acute pain may be greater than in patients without haemophilia. Guidelines from the World Federation of Hemophilia cover postoperative pain management.1

2.2.4 Physical assessment and prehabilitation A comprehensive PMR baseline assessment is necessary to identify reduced muscle strength or damage to multiple other joints that may affect postoperative rehabilitation.15 This information may be used to predict postoperative function and ascertain rehabilitation limitations postprocedure.22 In patients with advanced joint disease, the physiotherapist (or PMR physician if available at the site), haemophilia nurse, social worker and psychologist work together to ensure that the patient's physical and mental condition prior to surgery is optimal. Assessments of multiple joint involvement and target areas can make the surgical team aware of special positioning or considerations for the procedure. The physiotherapist, surgeon and haematologist work with the patient to determine the optimal approach to physical rehabilitation and assess progress. “Prehabilitation,” defined as a proactive approach to health and behaviour change to improve an identified outcome, should be initiated. Preoperative physiotherapy to prepare joints/muscles in the region of the procedure theoretically enhances a patient's capacity to withstand surgery and preserve function in the postoperative period.15, 23, 24 Some patients may find exercise too painful to perform; prehabilitation then involves discussing what will happen before, during and after surgery, building familiarity with postoperative exercises and use of mobility aids, and further developing a trusting patient–MDT relationship. Proactive attempts to manage self‐efficacy and patient expectations before surgery help to mitigate anxiety and decrease postoperative pain.25 Patient adherence, a key factor affecting outcomes, can also be assessed.23, 26 Although the role of prehabilitation in the general population is controversial, there is some indication that the approach may have a small and short‐lived effect on postoperative pain and function in joint replacement.27, 28 Current data are lacking on the efficacy of preoperative physiotherapy in haemophilia patients with severe joint damage; however, prehabilitation retains value for the importance of rehabilitation education. Developments or decisions that affect the intraoperative or postoperative period are shared with the MDT.

2.2.5 Assessment of comorbidities All patients should be assessed for comorbidities, including cardiopulmonary, renal or liver disease to ensure appropriate anaesthetic management.8, 29 If the patient has hepatitis C, liver function should be assessed before surgery. If positive for HIV, CD4 levels are obtained and requirement for perioperative antibiotic prophylaxis assessed. The type of protease inhibitor the patient is receiving may require suspension of medications prior to anaesthesia to prevent possible interrelated drug toxicity. Special attention should be paid to older patients in whom the rate of viral disease or comorbidities (such as cardiovascular disease or cancer) may be greater than younger patients.30 Also, the risk of venous thromboembolism in older patients is elevated and the potential effects on thrombosis risk of excessive factor (F)VIII replacement during the peri‐operative period are unclear.30

2.2.6 Haemostasis planning After assessment of the patient's underlying factor deficiency, inhibitor status and associated complications or comorbidities are aligned with the planned surgical procedure and the haematology team develops an individualized haemostatic management plan, including the preoperative, intraoperative and rehabilitation periods. Replacement therapy, doses and intervals are established, including method of administration (bolus/continuous infusion), as well as the need for concomitant antifibrinolytic therapy.1, 31, 32 A contingency plan should be in place (eg pharmacy and blood bank support) if unexpected bleeding occurs. The quantity of clotting factor product required for surgery is determined. Patients with mild haemophilia A undergoing surgery may not require clotting factor concentrate and may be treated with non‐specific haemostatic agents (eg desmopressin acetate). Less‐invasive procedures, such as radio‐ and chemical synovectomy, typically require smaller amounts of clotting factor concentrates. Prior to major elective procedures, an in vivo recovery and half‐life study should be considered when the patient is not bleeding, using either a standard or a Bayesian approach to pharmacokinetic analysis.33, 34 Attention to the possibility of inhibitor development during and following surgery requiring replacement therapy is imperative. A factor assay monitoring schedule must be coordinated with the coagulation laboratory to ensure timely and accurate results to permit dosing adjustments. Expertise in inhibitor identification and treatment must be available. Some patients with non‐severe haemophilia A may have mutations that increase their risk of inhibitor development after intensive exposure to FVIII.35 The haemostatic plan must be approved by the haematologist, communicated to all teams involved in the surgery, and a copy filed in the medical records. Patients with existing inhibitors require additional attention, and the quantity and mode of administration of bypassing agents and need for adjunctive therapy (eg antifibrinolytics) agreed upon.31

2.2.7 Laboratory testing Appropriate laboratory testing is needed to confirm patient status. An inhibitor titre measurement should be available within 2 months of scheduled surgery.31 Assessment of other coagulation parameters (eg prothrombin time) is performed to assure an otherwise intact haemostatic system. Baseline laboratory evaluation including complete blood count and chemistries is obtained to determine adequacy of haemoglobin and platelet count, and overall liver/renal function. The MDT should be aware if a patient is immunocompromised, so that proper precautions are taken to prevent infection. The specialized laboratory team is informed by the haematologist in advance of anticipated factor assay samples and need for prioritized results, including capacity to analyse samples during nights and weekends, if required.