The value of ultrasonography in detecting early arthropathic changes and contribution to the clinical approach in patients of hemophilia

Hemophilic arthropathy: how to diagnose subclinical bleeding early and how to orthopedically treat a damaged joint

INTRODUCTION

It is important to know the current status of hemophilic arthropathy diagnoses, treatments, complications, and outcomes in developed countries.

AREAS COVERED

A bibliographic search in PubMed for articles published from 1 January 2019 through 12 June 2023 was performed.

EXPERT OPINION

In developed countries with specialized hemophilia treatment centers, primary hematological prophylaxis (started before the age of 2 years and after no more than one joint bleed) has almost completely eliminated the joint-related problems of the disease. The ideal goal of zero hemarthroses can be achieved only with intense and well-dosed prophylaxis: intravenous infusion of coagulation factor - standard half-life or extended half-life; periodic or subcutaneous injections of nonfactor products (emicizumab or fitusiran). However, hemophilic arthropathy continues to occur due to subclinical joint hemorrhages. In one study, 16% of the joints without reported hemarthroses showed signs of previous subclinical bleeding (hemosiderin deposits with/without synovial hypertrophy on magnetic resonance imaging were deemed signs of previous subclinical bleeding), rendering evidence for subclinical bleeding in people with severe hemophilia with lifelong prophylaxis treatment. Subclinical joint hemorrhages can be averted only by employing accurate and tailored prophylaxis.

Synovitis in hemophilia: preventing, detecting, and treating joint bleeds

INTRODUCTION

Most bleeding events in individuals with hemophilia occur within the ankle, knee, and elbow joints. Should the bleeding persist, the synovial membrane starts to hypertrophy and a vicious cycle of chronic hemophilic synovitis (CHS) occurs, leading to joint destruction.

AREAS COVERED

This article covers the prompt diagnosis of CHS by point-of-care ultrasonography (POC-US) and its treatment by means of several types of synovectomy.

EXPERT OPINION

It is essential to prevent, detect and treat hemophilic synovitis, because it indicates that the joint has bled and is at risk of bleeding further. Prophylaxis with standard half life (SHL) factor VIII (FVIII) concentrate is the standard of care for individuals with severe hemophilia A and can also be considered for selected patients with moderate disease. Several years of real-world experience with extended half life (EHL) FVIII, emicizumab, and other drugs in development will be needed to ascertain their final effect on bleeding and its complications. We must look for synovitis in individuals declaring joint pain and in asymptomatic patients, and POC-US is the most reasonable imaging instrument with which to carry out periodic joint screening. Radiosynovectomy, chemical synovectomy, and arthroscopic synovectomy markedly reduce bleeding events.

The role of point-of-Care Musculoskeletal Ultrasound for Routine Joint evaluation and management in the Hemophilia Clinic - A Real World Experience

BACKGROUND

The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown.

METHODS

We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint _TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and "medical" (joint injections/aspirations, referrals to orthopedics, changes/adjustments of hemostatic plans, and use of oral anti-inflammatory medications) were recorded in relation to POC-MSKUS.

RESULTS

Forty-four persons [median age 37 years (IQR 29, 51)], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 (IQR 18, 42)] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were "medical". Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of "medical" decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education.

CONCLUSION

Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes.