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van Leeuwen FHP, Timmer MA, de Jong PA, Fischer K, Foppen W. Screening for subclinical synovial proliferation in haemophilia: A systematic review and meta-analysis comparing physical examination and ultrasound. Haemophilia 2023; 29:445-455. [PMID: 36595617 DOI: 10.1111/hae.14737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Ultrasound is increasingly used as addition to physical examination for detection of subclinical joint changes in haemophilia. However, the added value of ultrasound to physical examination for detecting synovial proliferation is not fully established. AIM To determine the diagnostic accuracy of swelling at physical examination for ultrasound-detected synovial proliferation in haemophilia. METHODS PubMed and EMBASE were searched up to 2 August 2022. Studies reporting original data on occurrence of swelling at physical examination and synovial proliferation on ultrasound of index joints in persons with haemophilia were included. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Diagnostic accuracy parameters of swelling at physical examination for ultrasound-detected synovial proliferation were determined. Summary sensitivity and specificity were calculated using a bivariate random-effects model. RESULTS Fifteen studies reporting on swelling at physical examination and synovial proliferation on ultrasound in 2890 joints of 627 patients were included. Prevalence of subclinical synovial proliferation ranged between 0% and 55%. Sensitivity of swelling was low [summary estimate .34; 95% confidence interval (CI) .24-.46], while specificity was high (summary estimate .97; CI .92-.99). Predictive values varied widely due to inter-study differences in prevalence of synovial proliferation. CONCLUSION Joint swelling has low sensitivity for presence of ultrasound-detected synovial proliferation in haemophilia, suggesting underestimation of synovial proliferation by physical examination alone. Consequently, ultrasound screening may generate important information on synovial changes which would otherwise remain undetected.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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2
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Mancuso ME, Holstein K, O'Donnell JS, Lobet S, Klamroth R. Synovitis and joint health in patients with haemophilia: Statements from a European e-Delphi consensus study. Haemophilia 2023; 29:619-628. [PMID: 36622258 DOI: 10.1111/hae.14734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Synovitis, a common feature in haemophilia, is triggered by the presence of blood in joints, and represents the first step towards the development of chronic arthropathy. Synovitis may be detected early by means of ultrasound or magnetic resonance imaging scan; clinical joint scores are less sensitive in this setting. Regular long-term prophylaxis with clotting factor concentrates, as primary prophylaxis and tailored to individual needs, has high efficacy in preventing synovitis. In general, higher factor levels lower bleeding risk, but no direct correlation between factor levels and synovitis incidence has been demonstrated. AIM This study aimed to develop an expert consensus relating to the definition, pathophysiology, diagnosis, prevention, follow-up and treatment of synovitis, recognising its relevance for joint health and taking into account existing knowledge gaps. METHODS A Delphi consensus study was designed and performed. An expert group prepared 22 statements based on existing literature; a wider expert panel subsequently voted on these. RESULTS Retention of panellists was high. Four statements required amending and consensus on all statements was achieved after three rounds of voting. CONCLUSION This e-Delphi consensus study addressed the importance of synovitis in joint health of people with haemophilia and highlighted knowledge gaps in this field. Studies on the natural course of synovitis are lacking and the biological mechanisms underlying this process are not yet fully elucidated. While basic and clinical research proceeds in this field, expert consensus can help guide clinicians in their routine clinical practice, and Delphi methodology is often used to produce best-practice guidelines.
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Affiliation(s)
- Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
| | - Katharina Holstein
- Department of Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - James S O'Donnell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland
| | - Sébastien Lobet
- Hematology department, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Institute for Experimental and Clinical, Catholic University of Louvain, Avenue Hippocrate, Woluwe-Saint-Lambert, Belgium.,Physical Medicine and Rehabilitation Service, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium
| | - Robert Klamroth
- Vivantes Hospital, Friedrichshain, Berlin, Germany.,Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
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3
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Di Minno MND, Napolitano M, Giuffrida AC, Baldacci E, Carulli C, Boccalandro E, Bruno C, Forneris E, Ricca I, Passeri W, Martinelli M, Rivolta GF, Solimeno LP, Martinoli C, Rocino A, Pasta G. Diagnosis and treatment of chronic synovitis in patients with haemophilia: consensus statements from the Italian Association of Haemophilia Centres. Br J Haematol 2021; 196:871-883. [PMID: 34923621 PMCID: PMC9299781 DOI: 10.1111/bjh.17919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023]
Abstract
Although synovitis is recognized as a marker of joint disease activity, its periodic assessment is not included in routine clinical surveillance of patients with haemophilia (PwH). In order to evaluate the current knowledge and to identify controversial issues, a preliminary literature search by the Musculoskeletal Committee of the Italian Association of Haemophilia Centres (AICE) has been conducted. Statements have been established and sent to the Italian AICE members to collect their level of agreement or disagreement by a Delphi process. Thirty‐seven consensus recommendations have been drafted. We found a general agreement on the indication to consider the presence of synovitis as a marker of joint disease activity in PwH. Accordingly, there was agreement on the indication to search for synovitis both in patients reporting joint pain and in asymptomatic ones, recognizing ultrasound as the most practical imaging technique to perform periodic joint screening. Interestingly, after detection of synovitis, there was agreement on the indication to modify the therapeutic approach, suggesting prophylaxis in patients treated on demand and tailoring treatment in patients already under prophylaxis. Whereas the need of an early consultation with a physiotherapist is recommended for PwH affected by chronic synovitis, the exact timing for an orthopaedic surgeon consultation is currently unknown.
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Affiliation(s)
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | | | - Erminia Baldacci
- Hematology, University Hospital Policlinico Umberto I, Rome, Italy
| | - Christian Carulli
- Department of Health Sciences, Orthopaedic Clinic, University of Florence, Florence, Italy
| | - Elena Boccalandro
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy
| | - Clarissa Bruno
- Haemophilia Center and Thrombosis, Policlinico, Bari, Italy
| | - Eleonora Forneris
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Irene Ricca
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Walter Passeri
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Marco Martinelli
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Gianna Franca Rivolta
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Luigi Piero Solimeno
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Traumatology and Orthopaedic Unit, Milan, Italy
| | - Carlo Martinoli
- Department of Health Science (DISSAL), University of Genoa, Unit of Radiology and IRCCS San Martino Hospital, Genoa, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy
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4
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Gualtierotti R, Solimeno LP, Peyvandi F. Hemophilic arthropathy: Current knowledge and future perspectives. J Thromb Haemost 2021; 19:2112-2121. [PMID: 34197690 PMCID: PMC8456897 DOI: 10.1111/jth.15444] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/15/2021] [Accepted: 06/30/2021] [Indexed: 02/06/2023]
Abstract
Hemophilia A and B are rare X-linked inherited bleeding disorders caused by complete or partial deficiency in or the absence of coagulation factors VIII and IX. Recurrent joint bleeding (hemarthrosis) is the most frequent clinical manifestation of severe hemophilia. Unless appropriately managed, even subclinical hemarthrosis can lead to the development of hemophilic arthropathy, a disabling condition characterized by joint remodelling, chronic pain, and a reduced quality of life, and eventually requires joint replacement. Given the lack of specific treatments to reduce blood-induced synovitis, the prevention of bleeding is pivotal to the maintenance of joint health. Prophylactic coagulation factor replacement therapy using extended half-life recombinant drugs has significantly improved patients' quality of life by reducing the burden of intravenous injections, and the more recent introduction of nonreplacement therapies such as subcutaneous emicizumab injections has improved treatment adherence and led to the greater protection of patients with hemophilia A. However, despite these advances, chronic arthropathy is still a significant problem. The introduction of point-of-care ultrasound imaging has improved the diagnosis of acute hemarthrosis and early hemophilic arthropathy, and allowed the better monitoring of progressive joint damage, but further research into the underlying mechanisms of the disease is required to allow the development of more targeted treatment. In the meantime, patient management should be based on the risk factors for the onset and progression of arthropathy of each individual patient, and all patients should be collaboratively cared for by multidisciplinary teams of hematologists, rheumatologists, orthopedic surgeons, and physiotherapists at comprehensive hemophilia treatment centers.
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Affiliation(s)
- Roberta Gualtierotti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Luigi Piero Solimeno
- Traumatology and Orthopedic UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
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5
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Bakeer N, Dover S, Babyn P, Feldman BM, von Drygalski A, Doria AS, Ignas DM, Abad A, Bailey C, Beggs I, Chang EY, Dunn A, Funk S, Gibikote S, Goddard N, Hilliard P, Keshava SN, Kruse-Jarres R, Li Y, Lobet S, Manco-Johnson M, Martinoli C, O'Donnell JS, Papakonstantinou O, Pergantou H, Poonnoose P, Querol F, Srivastava A, Steiner B, Strike K, Timmer M, Tyrrell PN, Vidarsson L, Blanchette VS. Musculoskeletal ultrasound in hemophilia: Results and recommendations from a global survey and consensus meeting. Res Pract Thromb Haemost 2021; 5:e12531. [PMID: 34268464 PMCID: PMC8271584 DOI: 10.1002/rth2.12531] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/18/2021] [Accepted: 04/24/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction For persons with hemophilia, optimization of joint outcomes is an important unmet need. The aim of this initiative was to determine use of ultrasound in evaluating arthropathy in persons with hemophilia, and to move toward consensus among hemophilia care providers regarding the preferred ultrasound protocols for global adaptation. Methods A global survey of hemophilia treatment centers was conducted that focused on understanding how and why ultrasound was being used and endeavored to move toward consensus definitions of both point‐of‐care musculoskeletal ultrasound (POC‐MSKUS) and full diagnostic ultrasound, terminology to describe structures being assessed by ultrasound, and how these assessments should be interpreted. Next, an in‐person meeting of an international group of hemophilia health care professionals and patient representatives was held, with the objective of achieving consensus regarding the acquisition and interpretation of POC‐MSKUS and full diagnostic ultrasound for use in the assessment of musculoskeletal (MSK) pathologies in persons with hemophilia. Results The recommendations were that clear definitions of the types of ultrasound examinations should be adopted and that a standardized ultrasound scoring/measurement system should be developed, tested, and implemented. The scoring/measurement system should be tiered to allow for a range of complexity yet maintain the ability for comparison across levels. Conclusion Ultrasound is an evolving technology increasingly used for the assessment of MSK outcomes in persons with hemophilia. As adoption increases globally for clinical care and research, it will become increasingly important to establish clear guidelines for image acquisition, interpretation, and reporting to ensure accuracy, consistency, and comparability across groups.
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Affiliation(s)
- Nihal Bakeer
- Indiana Hemophilia & Thrombosis Center Indianapolis IN USA
| | - Saunya Dover
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Paul Babyn
- Department of Medical Imaging University of Saskatchewan and Saskatchewan Health Authority Saskatoon City Hospital SK Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada.,Department of Pediatrics Faculty of Medicine University of Toronto Toronto ON Canada.,Institute of Health Policy, Management and Evaluation The Dalla Lana School of Public Health University of Toronto Toronto ON Canada.,Division of Rheumatology The Hospital for Sick Children Toronto ON Canada
| | | | - Andrea S Doria
- Department of Medical Imaging University of Toronto The Hospital for Sick Children Toronto ON Canada
| | - Danial M Ignas
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Audrey Abad
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Cindy Bailey
- Los Angeles Orthopaedic Treatment Centre Los Angeles CA USA
| | - Ian Beggs
- Department of Radiology Royal Infirmary of Edinburgh NHS Lothian Edinburgh UK
| | - Eric Y Chang
- University of California San Diego Medical Center San Diego CA USA
| | - Amy Dunn
- Division of Pediatric Hematology, Oncology & Marrow Transplant Department of Pediatrics Nationwide Children's Hospital The Ohio State University College of Medicine Columbus OH USA
| | - Sharon Funk
- Hemophilia and Thrombosis Center University of Colorado Anschutz Medical Campus Aurora CO USA
| | - Sridhar Gibikote
- Division of Clinical Radiology Christian Medical College Vellore India
| | - Nicholas Goddard
- Katherine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pamela Hilliard
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | | | - Rebecca Kruse-Jarres
- University of Washington and Washington Center for Bleeding Disorders Seattle WA USA
| | - Yingjia Li
- Ultrasound Department Manfang Hospital Guangzhou China
| | - Sébastien Lobet
- Haemostasis and Thrombosis Unit Division of Haematology Cliniques Universitaires Saint-Luc Brussels Belgium
| | - Marilyn Manco-Johnson
- Hemophilia & Thrombosis Center Department of Pediatrics University of Colorado Anschutz Medical Center Aurora CO USA
| | - Carlo Martinoli
- Department of Health Sciences (DISSAL) Università di Genova IRCCS Ospedale Policlinico San Martino Genova Italy
| | - James S O'Donnell
- Irish Centre for Vascular Biology Royal College of Surgeons in Ireland Dublin Ireland
| | | | - Helen Pergantou
- Pediatric Hemophilia Centre/Haemostatis and Thrombosis Unit Aghia Sophia Children's Hospital Athens Greece
| | - Pradeep Poonnoose
- Department of Orthopedics Unit 2 Christian Medical College Vellore India
| | - Felipe Querol
- Haemostasis and Thrombosis Unit Hospital LA FE Universidad de Valencia Valencia Spain
| | - Alok Srivastava
- Department of Hematology Christian Medical College Vellore India
| | - Bruno Steiner
- Department of Rehabilitation Medicine Physical Therapy and MSKUS Program Washington Center for Bleeding Disorders University of Washington Seattle WA USA
| | - Karen Strike
- School of Rehabilitation Science Faculty of Health Science Hamilton Niagara Regional Hemophilia Program Hamilton Health Sciences McMaster University Hamilton ON Canada
| | - Merel Timmer
- van Creveldkliniek University Medical Center Utrecht Utrecht The Netherlands
| | - Pascal N Tyrrell
- Department of Medical Imaging Institute of Medical Science Toronto ON Canada.,Department of Statistical Sciences University of Toronto Toronto ON Canada
| | - Logi Vidarsson
- Diagnostic Imaging The Hospital for Sick Children Toronto ON Canada
| | - Victor S Blanchette
- Department of Pediatrics Division of Hematology/Oncology University of Toronto The Hospital for Sick Children Toronto ON Canada
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6
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Prasetyo M, Moniqa R, Tulaar A, Prihartono J, Setiawan SI. Correlation between Hemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score and Hemophilia Joint Health Score (HJHS) in patients with hemophilic arthropathy. PLoS One 2021; 16:e0248952. [PMID: 33826621 PMCID: PMC8026024 DOI: 10.1371/journal.pone.0248952] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/09/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hemophilic arthropathy, a condition manifested as joint destruction due to spontaneous joint bleeding, is one complication of hemophiliac patients. Early detection and intervention may improve the outcome, in which ultrasonography can be an ideal modality with the introduction of HEAD-US (Hemophilia Early Arthropathy Detection with Ultrasound) protocol. Studies have shown US benefit in hemophiliac patients, including its potential as an alternative for the Hemophiliac Joint Health Score (HJHS) system. However, many of the studies were conducted in countries with better management of hemophilia using prophylaxis treatment. It is unclear whether HEAD-US has a correlation with HJHS in countries using episodic treatment only, like in Indonesia. PURPOSE This study aimed to explore the correlation between HEAD-US and HJHS in hemophiliac patients with joint problems in Indonesia. MATERIALS AND METHODS A cross-sectional correlation study between HEAD-US and HJHS was performed with primary data collected from 120 hemophilic patients. US examination was performed on elbow, knee and ankle joints using the HEAD-US scoring method by a musculoskeletal radiologist. HJHS examination was conducted by a trained physiotherapist and a medical rehabilitation specialist. All examiner is member of multidisciplinary Hemophiliac Management Team in Cipto Mangunkusumo General Hospital in Jakarta, Indonesia. RESULTS The mean age of the participant was 9.3 (5-14) years old. The median score of HEAD-US was 8 (1-28) with most of the joint abnormalities found on the ankles. The median score of HJHS was 3 (0-35), with most joint abnormalities found on the knees. There was a moderate correlation between HEAD-US and HJHS score (p < 0.05, r = 0.65). CONCLUSION HEAD-US shows a moderate correlation to HJHS in hemophiliac patients who received episodic treatment. HEAD-US can provide additional value in the anatomical evaluation of the joint and could be complementary to HJHS in assessing the joint status in hemophilic patient.
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Affiliation(s)
- Marcel Prasetyo
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Ratna Moniqa
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Angela Tulaar
- Department of Medical Rehabilitation, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Joedo Prihartono
- Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Stefanus Imanuel Setiawan
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
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7
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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8
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Manco-Johnson MJ, Warren BB, Buckner TW, Funk SM, Wang M. Outcome measures in Haemophilia: Beyond ABR (Annualized Bleeding Rate). Haemophilia 2021; 27 Suppl 3:87-95. [PMID: 33398908 DOI: 10.1111/hae.14099] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022]
Abstract
Options for management of haemophilia are increasing rapidly with completely novel therapeutic approaches that cannot be compared using traditional factor assays. In addition, as prophylaxis regimens have improved, bleeding rates have decreased, and consequently, it is difficult to show an impact of novel therapies on rates of spontaneous bleeding. There is currently an urgent need for a panel of outcome measures to compare therapies that are dissimilar in many essential ways. Conventional objective outcome measures including joint physical examination and joint imaging continue to hold a central importance. Factor assays are essential for evaluation of products derived from native factor genes, but are not applicable to some extended half-life factors or non-factor bypassing agents. Global assays including thrombin generation and chromogenic assays of factor X activation are under investigation for their usefulness in haemophilia assessment. Bleeding rate is a conventional subjective patient-reported outcome that, while decreasing in frequency, is indispensable as an outcome given that the primary manifestation of haemophilia is bleeding. Other patient-reported outcomes such as pain intensity and interference, health-related quality of life and activities and participation are increasingly important to distinguish superior outcomes in comparative trials. This review of outcome measures for haemophilia presents examples of existing outcome measures with an emphasis on their strengths and limitations.
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Affiliation(s)
- Marilyn J Manco-Johnson
- Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado and Childrens Hospital Colorado, Aurora, CO, USA
| | - Beth Boulden Warren
- Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado and Childrens Hospital Colorado, Aurora, CO, USA
| | - Tyler W Buckner
- Departments of Medicine and Pediatrics, Hemophilia & Thrombosis Center, University of Colorado and UCHealth, Aurora, CO, USA
| | - Sharon M Funk
- Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado and Childrens Hospital Colorado, Aurora, CO, USA
| | - Michael Wang
- Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado and Childrens Hospital Colorado, Aurora, CO, USA
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9
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Christensen KR, Kjelgaard-Hansen M, Nielsen LN, Wiinberg B, Alexander Althoehn F, Bloksgaard Poulsen N, Kryger Vøls K, Popp Thyme A, Maria Lövgren K, Kornerup Hansen A, Roepstorff K. Rapid inflammation and early degeneration of bone and cartilage revealed in a time-course study of induced haemarthrosis in haemophilic rats. Rheumatology (Oxford) 2020; 58:588-599. [PMID: 29982826 DOI: 10.1093/rheumatology/key186] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/23/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Detailed knowledge of the sequential cell and tissue responses following haemarthrosis is important for a deep understanding of the pathological process initiated upon extensive bleeding into the joint causing haemophilic arthropathy (HA). The underlying pathobiology driving haemarthrosis towards HA has been difficult to establish in detail, although animal models have shed light on some processes. Previous studies have focused on a single or a few distant time points and often only characterizing one tissue type of the joint. The objective of this study was, therefore, to carefully map early onset of synovitis and HA following induced haemarthrosis. METHODS One hundred and thirty haemophilia A rats were subjected to induced haemarthrosis or a sham procedure in full anaesthesia and euthanized from 30 min to 7 days after the procedure. Pathological changes of the joints were visualized using micro-computed tomography, histology and immunohistochemistry. RESULTS Synovitis developed within 24 h and was dominated by myeloid cell infiltrations. Cartilage and bone pathology were evident as early as 48-96 h after haemarthrosis, and the pathology rapidly progressed with extensive periosteal bone formation and formation of subchondral cysts. CONCLUSION Fast, extensive and simultaneous cartilage and bone degeneration developed shortly after haemarthrosis, as shown by the detailed mapping of the early pathogenesis of HA. The almost immediate loss of cartilage and the pathological bone turnover suggest a direct influence of blood on these processes and are unlikely to be attributed simply to an indirect effect of inflammation.
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Affiliation(s)
- Kristine Rothaus Christensen
- Translational Haemophilia Pharmacology, University of Copenhagen, Copenhagen, Denmark.,Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Mads Kjelgaard-Hansen
- Translational Haemophilia Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Lise Nikolic Nielsen
- Veterinary Clinical and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Wiinberg
- Haemophilia Translational Biology, Global Research, Novo Nordisk A/S, Maaloev
| | | | | | - Kåre Kryger Vøls
- Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark.,Histology & Bioimaging, Global Research, Novo Nordisk A/S, Maaloev, Denmark
| | - Anders Popp Thyme
- Translational Haemophilia Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Karin Maria Lövgren
- Translational Haemophilia Pharmacology, University of Copenhagen, Copenhagen, Denmark
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10
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Bakeer N, Shapiro AD. Merging into the mainstream: the evolution of the role of point-of-care musculoskeletal ultrasound in hemophilia. F1000Res 2019; 8. [PMID: 31431824 PMCID: PMC6619375 DOI: 10.12688/f1000research.16039.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 01/19/2023] Open
Abstract
Bleeding with resultant hemophilic arthropathy constitutes the largest cause of morbidity in patients with hemophilia. It results from repeated bleeding episodes in the joint and is characterized by synovial hypertrophy and cartilage and bony destruction. Hemophilic arthropathy assessment is a continually evolving process and is particularly challenging in children and young adults in whom joint disease may be missed or underestimated as obtaining serial "baseline" magnetic resonance imaging scans of multiple clinically asymptomatic or nearly asymptomatic joints may be unjustifiable and cost-ineffective. Musculoskeletal ultrasound-particularly, point-of-care musculoskeletal ultrasound-has emerged as a promising imaging modality for the early detection and management of hemophilic arthropathy, and for the evaluation of hemarthrosis and painful musculoskeletal episodes in patients with hemophilia. This review summarizes currently available data on the emerging role of this new imaging modality, its limitations, and gaps in knowledge. The review also raises unanswered questions, highlights the need for consolidated research efforts, and delineates future directions expected to advance this technology and optimize its use in this patient population.
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Affiliation(s)
- Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
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11
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Volland LM, Zhou JY, Barnes RFW, Kruse-Jarres R, Steiner B, Quon DV, Bailey C, Hughes TH, Moore RE, Chang EY, von Drygalski A. Development and Reliability of the Joint Tissue Activity and Damage Examination for Quantitation of Structural Abnormalities by Musculoskeletal Ultrasound in Hemophilic Joints. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1569-1581. [PMID: 30371941 DOI: 10.1002/jum.14846] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Musculoskeletal ultrasound (US) is used increasingly to examine hemophilic arthropathy. However, quantitative algorithms to document findings are lacking. We developed and sought to validate a protocol quantifying hemophilic joint abnormalities. METHODS Thirty-one patients with hemophilia were examined serially for 2 years with musculoskeletal US (≈600 joint examinations and ≈6000 images). Based on the spectrum of pathologies, a quantitative algorithm, named Joint Tissue Activity and Damage Examination (JADE), was developed for soft tissue and osteochondral measurements, including power Doppler, using nominal group techniques. To study intra- and inter-rater reliability, 8 musculoskeletal US-experienced hemophilia providers performed anatomic landmark recognition and tissue measurements on 86 images with arthropathic changes, with repetition 1 month later. Twenty-three musculoskeletal US-inexperienced providers performed similar assessments. Inter-operator reliability was established by 6 musculoskeletal US-experienced hemophilia providers, each acquiring images and JADE assessments of 3 hemophilic arthropathic joints. A radiologist and musculoskeletal sonographer functioned as adjudicators. The statistical analysis was performed with the intraclass correlation coefficient (ICC), Fleiss κ, and Cohen κ where appropriate. RESULTS The musculoskeletal US-experienced providers showed excellent intra-and inter-rater reliability for tissue measurements (ICCs, 0.94-0.96). Agreement was good to excellent for landmark recognition (Fleiss κ, 0.87-0.94). Inter-operator reliability was excellent for measurements and landmark recognition (ICC, 0.90; Fleiss κ, 1.0). Agreement with adjudicators was mostly good to excellent. Musculoskeletal US-inexperienced providers showed excellent inter-rater reliability for measurements (ICC, 0.96) and moderate agreement for landmark recognition (Fleiss κ, 0.58). CONCLUSIONS The JADE protocol appears feasible for quantifying hemophilic intra-articular abnormalities. Musculoskeletal US-trained hemophilia providers showed high intra-rater, inter-rater, and inter-operator reliability, supporting JADE as a protocol for clinical management and research.
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Affiliation(s)
- Lena M Volland
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Jenny Y Zhou
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Richard F W Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Bruno Steiner
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Doris V Quon
- Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | - Cindy Bailey
- Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | - Tudor H Hughes
- Department of Radiology, University of California, San Diego, California, USA
| | - Randy E Moore
- General Musculoskeletal Imaging, Inc, Cincinnati, Ohio, USA
| | - Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, California, USA
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12
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Banchev A, Stoyanova D, Konstantinov D, Ignatova I, Peteva E, Kaleva V, Kostova S, Petkova N, Dineva A, Pavlova A. Beyond the bleeding rates‐ HEAD‐US joint assessment in patients treated by late prophylaxis. Haemophilia 2019; 25:e294-e297. [DOI: 10.1111/hae.13771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 04/15/2019] [Accepted: 04/22/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Atanas Banchev
- Department of Paediatric Haematology and Oncology University Hospital “Tzaritza Giovanna – ISUL” Sofia Bulgaria
| | - Denka Stoyanova
- Department of Paediatric Haematology and Oncology University Hospital “Tzaritza Giovanna – ISUL” Sofia Bulgaria
| | - Dobrin Konstantinov
- Department of Paediatric Haematology and Oncology University Hospital “Tzaritza Giovanna – ISUL” Sofia Bulgaria
| | - Iglika Ignatova
- Centre for Coagulopathies and Rare Anaemias University Hospital “Sv. Marina” Varna Bulgaria
| | - Elina Peteva
- Centre for Coagulopathies and Rare Anaemias University Hospital “Sv. Marina” Varna Bulgaria
| | - Valeria Kaleva
- Centre for Coagulopathies and Rare Anaemias University Hospital “Sv. Marina” Varna Bulgaria
| | - Svetla Kostova
- Department of Paediatrics University Hospital “G. Stranski” Pleven Bulgaria
| | - Nina Petkova
- Department of Haematology Military Hospital Sofia Bulgaria
| | - Antonia Dineva
- Faculty of Statistics Technical University Dortmund Germany
| | - Anna Pavlova
- Institute of Transfusion Medicine and Experimental Haematology Bonn Germany
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13
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Jiménez-Yuste V, Álvarez-Román MT, Martín-Salces M, De la Corte-Rodríguez H, Altisent C, Parra R, Núñez R, Pérez R, García-Candel F, Bonanad S, Querol F, Alonso N, Fernández-Mosteirín N, López-Ansoar E, García-Frade LJ, Bermejo N, Pérez-González N, Gutiérrez-Pimentel MJ, Martinoli C, Fernández-Arias I, Kim HK. Joint status in Spanish haemophilia B patients assessed using the Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score. Haemophilia 2018; 25:144-153. [DOI: 10.1111/hae.13628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 01/05/2023]
Affiliation(s)
| | | | | | | | | | - Rafael Parra
- Hospital Universitario Vall d’Hebron; Barcelona Spain
| | - Ramiro Núñez
- Hospital Universitario Virgen del Rocio; Seville Spain
| | - Rosario Pérez
- Hospital Universitario Virgen del Rocio; Seville Spain
| | | | | | - Felipe Querol
- Hospital Universitario y Politécnico La Fe; Valencia Spain
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14
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Zhang CM, Zhang JF, Xu J, Guo YL, Wang G, Yang LH. Musculoskeletal ultrasonography for arthropathy assessment in patients with hemophilia: A single-center cross-sectional study from Shanxi Province, China. Medicine (Baltimore) 2018; 97:e13230. [PMID: 30431602 PMCID: PMC6257645 DOI: 10.1097/md.0000000000013230] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 10/20/2018] [Indexed: 01/03/2023] Open
Abstract
Magnetic resonance imaging (MRI) is currently considered the gold standard for assessing hemophilic arthropathy (HA) severity; however, MRI is often costly, time-consuming, and difficult to perform in children. In the present study, we evaluated the joint status of hemophilic patients from Shanxi Province, China, using musculoskeletal ultrasonography (MSKUS) and identified the factors that most strongly correlated with disease severity.The study included 104 patients with hemophilia, who underwent MSKUS examination. A total of 1248 joints (including the shoulder, elbow, wrist, hip, knee, and ankle joints on both sides) from these patients were evaluated. Effusion, hypertrophy, cartilage modification, and bone erosion were assessed. The chi-square test was used to analyze categorical variables, and multivariate logistic regression was used to analyze the relationship between joint disease and risk factors.MSKUS allowed clear visualization of synovial lesions, effusion, cartilage modification, and bone surface damage; however, it was unable to identify changes deep within bones. The distribution of damaged joints was as follows: shoulder, 2 (1.0%); elbow, 80 (38.5%); wrist, 4 (1.9%); hip, 4 (1.9%); knee, 126 (60.6%); and ankle, 90 (43.3%). Damage was more common in the knee, elbow, and ankle joints than in the shoulder, wrist, and hip joints (P < .001). Among the 1248 joints, 306 showed lesions, which included effusion in 102 (8.2%) joints, synovium hypertrophy in 176 (14.1%), cartilage modification in 193 (15.5%), and bone damage in 176 (14.1%). Many joints had multiple lesions at the same time. The chi-square test and multivariate logistic analysis showed that age and hemophilia severity were significantly associated with joint disease, while type of hemophilia and treatment categories were not associated with joint disease.MSKUS is a convenient and cost-effective examination that can play an important role in the diagnosis and long-term monitoring of HA.
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Affiliation(s)
- Cui-ming Zhang
- Department of Ultrasound, The Second Hospital of Shanxi Medical University
| | - Jun-feng Zhang
- Department of Health Statistics, Public Health of Shanxi Medical University
| | - Jing Xu
- Department of Pathology, Shanxi Medical University
| | | | - Gang Wang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lin-hua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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15
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Jimenez-Yuste V. Point-of-care Ultrasonography in Orthopedic Management of Hemophilia: Multiple Uses of an Effective Tool. HSS J 2018; 14:307-313. [PMID: 30258338 PMCID: PMC6148577 DOI: 10.1007/s11420-018-9604-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/25/2018] [Indexed: 02/07/2023]
Abstract
Even in our current era of hemophilia prophylaxis, articular complications can arise and there is a growing need for strategies in the prevention, diagnosis, and treatment of hemophilic arthropathy, a significant contributor to disability in patients with hemophilia. One useful tool, point-of-care ultrasonography (POC-US), offers diverse diagnostic and therapeutic possibilities. This article reviews the literature on the uses of POC-US in hemophilia, including early diagnosis of joint damage, differential diagnosis of articular pain, follow-up of joint injury, and guidance for both arthrocentesis and intra-articular injection. Studies show that for patients with hemophilia, POC-US enhances diagnostic accuracy and targeted treatments. Further research is required into the most efficient use of POC-US and the training needed to develop clinicians' skills. The attributes of POC-US should be understood more fully to enable its widespread application.
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Affiliation(s)
| | - E. Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital–IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain
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16
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Stephensen D, Classey S, Harbidge H, Patel V, Taylor S, Wells A. Physiotherapist inter-rater reliability of the Haemophilia Early Arthropathy Detection with Ultrasound protocol. Haemophilia 2018; 24:471-476. [DOI: 10.1111/hae.13440] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- D. Stephensen
- Kent Haemophilia Centre; East Kent Hospitals NHS Trust Canterbury; Canterbury UK
- Haemophilia Centre; Royal London Hospital; Barts Health NHS Trust; London UK
| | - S. Classey
- Haemophilia Centre; St Thomas’ Hospital; Guys & St Thomas’ NHS Trust; London UK
| | - H. Harbidge
- Bristol Haemophilia Centre; Bristol Children's Hospital; University Hospitals Bristol NHS Trust; Bristol UK
| | - V. Patel
- Haemophilia Centre; Royal London Hospital; Barts Health NHS Trust; London UK
| | - S. Taylor
- Oxford Haemophilia Centre; Churchill Hospital; Oxford University Hospitals NHS Trust; Oxford UK
| | - A. Wells
- Basingstoke Haemophilia Centre; Hampshire Hospitals NHS Foundation Trust; Basingstoke UK
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17
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Shi W, Tian D, Liu D, Yin J, Huang Y. The comparison of measurement between ultrasound and computed tomography for abnormal degenerative facet joints: A STROBE-compliant article. Medicine (Baltimore) 2017; 96:e7680. [PMID: 28767595 PMCID: PMC5626149 DOI: 10.1097/md.0000000000007680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Besides the study on examining facet joints of lumbar spine by ultrasound in normal population, there has not been any related report about examining normal facet joints of lumbar spine by ultrasound so far. This study was aimed to explore the feasibility of ultrasound assessment of lumber spine facet joints by comparing ultrasound measure values of normal and degenerative lumber spine facet joints, and by comparing measure values of ultrasound and computed tomography (CT) of degenerative lumber spine facet joints.This study included 15 patients who had chronic low back pain because of degenerative change in lumbar vertebrae, and 19 volunteers who did not have low back pain or pain in the lower limb. The ultrasound measure values (height [H] and width [W]) of normal and degenerative lumber spine facet joints were compared. And the differentiation between measure values (H and W) of ultrasound and CT of degenerative lumber spine facet joints was also analyzed.The ultrasound clearly showed abnormal facet joints lesion, which was characterized by hyperostosis on the edge of joints, bone destruction under joints, and thinner or thicker articular cartilage. There were significant differences between the ultrasound measure values of the normal (H: 1.26 ± 0.03 cm, W: 0.18 ± 0.01 cm) and abnormal facet joints (H: 1.43 ± 0.05 cm, W: 0.15 ± 0.02 cm) (all P < .05). However, there were no significant differences between the measure values of the ultrasound (H: 1.43 ± 0.17 cm, W: 0.15 ± 0.03 cm) and CT (H: 1.42 ± 0.16, W: 0.14 ± 0.03) of the degenerative lumber spine facet joints (all P > .05).Ultrasound can clearly show the structure of facet joints of lumbar spine. It is precise and feasible to assess facet joints of lumbar spine by ultrasound. This study has important significance for the diagnosis of lumbar facet joint degeneration.
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Affiliation(s)
| | | | - Da Liu
- Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang, China
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18
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Di Minno MND, Pasta G, Airaldi S, Zaottini F, Storino A, Cimino E, Martinoli C. Ultrasound for Early Detection of Joint Disease in Patients with Hemophilic Arthropathy. J Clin Med 2017; 6:E77. [PMID: 28758960 PMCID: PMC5575579 DOI: 10.3390/jcm6080077] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/12/2017] [Accepted: 07/24/2017] [Indexed: 11/16/2022] Open
Abstract
Joint bleeding represents the most commonly reported type of hemorrhage in patients affected by hemophilia. Although the widespread use of prophylaxis has been able to significantly reduce the onset of arthropathy, it has been shown that a non-negligible percentage of patients develop degenerative changes in their joints despite this type of treatment. Thus, periodic monitoring of the joint status in hemophilia patients has been recommended to identify early arthropathic changes and prevent the development or progression of hemophilic arthropathy. Ultrasound (US) has proven able to detect and quantify the most relevant biomarkers of disease activity (i.e., joint effusion and synovial hypertrophy) and degenerative damages (i.e., osteo-chondral changes) by means of scoring scales of increasing disease severity. In the present review, we have detailed major literature evidence about the use of US to assess joint status in hemophilia patients, focusing on signs of disease activity and degenerative damages. In particular, we have discussed recent evidence about "point-of-care" use patients with hemophilia.
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Affiliation(s)
| | - Gianluigi Pasta
- Dipartimento di Ortopedia-Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Sonia Airaldi
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Federico Zaottini
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Antonio Storino
- Department of Public Health, Federico II University, 80131 Naples, Italy.
| | - Ernesto Cimino
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy.
| | - Carlo Martinoli
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
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19
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Soliman M, Daruge P, Dertkigil SSJ, De Avila Fernandes E, Negrao JR, de Aguiar Vilela Mitraud S, Sakuma ETI, Fernandes ARC, Zhang N, Huo A, Li YJ, Zhou F, Rodrigues BM, Mohanta A, Blanchette VS, Doria AS. Imaging of haemophilic arthropathy in growing joints: pitfalls in ultrasound and MRI. Haemophilia 2017; 23:660-672. [PMID: 28574216 DOI: 10.1111/hae.13249] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/28/2022]
Abstract
The purpose of this review was to summarize the current knowledge on the utilization of magnetic resonance imaging (MRI) and ultrasound (US) for assessing arthropathy in children and adolescents with haemophilia and to recognize the limitations of each imaging modality and pitfalls in the diagnosis of soft tissue and osteochondral abnormalities. Awareness of MRI and US limitations and pitfalls in the assessment of joints in persons with haemophilia is essential for accurate diagnosis and optimal management of haemophilic arthropathy.
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Affiliation(s)
- M Soliman
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - P Daruge
- Institute of Radiology, Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil
| | - S S J Dertkigil
- Department of Radiology, Universidade de Campinas (UNICAMP), Campinas, SP, Brazil
| | - E De Avila Fernandes
- Department of Radiology, Universidade de Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil
| | - J R Negrao
- Department of Radiology, Universidade de Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil
| | | | - E T I Sakuma
- Department of Radiology, Universidade de Campinas (UNICAMP), Campinas, SP, Brazil
| | - A R C Fernandes
- Department of Radiology, Universidade de Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil
| | - N Zhang
- Department of Radiology, Beijing Children's Hospital, Beijing, China
| | - A Huo
- Department of Radiology, Beijing Children's Hospital, Beijing, China
| | - Y-J Li
- Department of Radiology, Nanfang Hospital, Guangzhou, China
| | - F Zhou
- Department of Radiology, Nanfang Hospital, Guangzhou, China
| | - B M Rodrigues
- Institute of Radiology, Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil
| | - A Mohanta
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - V S Blanchette
- Department of Hematology & Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - A S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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20
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Ligocki CC, Abadeh A, Wang KC, Adams-Webber T, Blanchette VS, Doria AS. A systematic review of ultrasound imaging as a tool for evaluating haemophilic arthropathy in children and adults. Haemophilia 2017; 23:598-612. [PMID: 28429878 DOI: 10.1111/hae.13163] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to semi-quantitatively assess the evidence on the value of ultrasound (US) for assessment of haemophilic arthropathy (HA) in children and adults based on the following questions: (1) Does early diagnosis of pathological findings, using available US techniques, impact the functional status of the joint? (2) Do current available US techniques have the ability to accurately detect pathological changes in target joints in haemophilic patients? (3) Does treatment (prophylaxis) improve US evidence of haemophilic arthropathy in children and adults? (4) Is there any association between various US scoring systems and other clinical/radiological constructs? Of the 6880 citations identified searching databases such as MEDLINE, Embase, CENTRAL and Web of Science, 20 articles investigating either the diagnostic accuracy of US and/or US scanning protocols and scoring systems for assessment of HA met the inclusion criteria for the study. Of these, 14 articles evaluating the diagnostic accuracy of US were assessed by two independent reviewers for reporting quality using the Standards for Reporting of Diagnostic Accuracy (STARD) tool and for methodological quality using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Using STARD, 1/14 studies (7%) was scored as of high reporting quality and 8/14 (57%), of moderate quality. Assessment with QUADAS-2 reported 2/14 (14%) studies as having high methodological quality and 6/14 (43%) as having moderate quality. There is fair evidence (Grade B) to recommend US as an accurate technique for early diagnosis of HA, to demonstrate that US scores correlate with clinical/US constructs and to prove an association between US findings and functional status of the joint. However, there is insufficient evidence (Grade I) to conclude that US-detectable findings in HA are sensitive to changes in therapy.
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Affiliation(s)
- C C Ligocki
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - A Abadeh
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - K C Wang
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - T Adams-Webber
- Hospital Library & Archive Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - V S Blanchette
- Department of Hematology & Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - A S Doria
- Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq, Curitiba, Brazil
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21
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Rodriguez-Merchan EC, Valentino LA. Orthopedic disorders of the knee in hemophilia: A current concept review. World J Orthop 2016; 7:370-375. [PMID: 27335812 PMCID: PMC4911520 DOI: 10.5312/wjo.v7.i6.370] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/10/2016] [Accepted: 04/22/2016] [Indexed: 02/06/2023] Open
Abstract
The knee is frequently affected by severe orthopedic changes known as hemophilic arthropathy (HA) in patients with deficiency of coagulation factor VIII or IX and thus this manuscript seeks to present a current perspective of the role of the orthopedic surgeon in the management of these problems. Lifelong factor replacement therapy (FRT) is optimal to prevent HA, however adherence to this regerous treatment is challenging leading to breakthrough bleeding. In patients with chronic hemophilic synovitis, the prelude to HA, radiosynovectomy (RS) is the optimal to ameliorate bleeding. Surgery in people with hemophilia (PWH) is associated with a high risk of bleeding and infection, and must be performed with FRT. A coordinated effort including orthopedic surgeons, hematologists, physical medicine and rehabilitation physicians, physiotherapists and other team members is key to optimal outcomes. Ideally, orthopedic procedures should be performed in specialized hospitals with experienced teams. Until we are able to prevent orthopedic problems of the knee in PWH will have to continue performing orthopedic procedures (arthrocentesis, RS, arthroscopic synovectomy, hamstring release, arthroscopic debridement, alignment osteotomy, and total knee arthroplasty). By using the aforementioned procedures, the quality of life of PWH will be improved.
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22
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Foppen W, van der Schaaf IC, Fischer K. Value of routine ultrasound in detecting early joint changes in children with haemophilia using the ‘Haemophilia Early Arthropathy Detection with UltraSound’ protocol. Haemophilia 2015; 22:121-5. [DOI: 10.1111/hae.12769] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- W. Foppen
- Department of Radiology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
| | - I. C. van der Schaaf
- Department of Radiology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
| | - K. Fischer
- Van Creveldkliniek; Department of Hematology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
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23
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Stephensen D, Drechsler WI, Scott OM. Outcome measures monitoring physical function in children with haemophilia: a systematic review. Haemophilia 2013; 20:306-21. [PMID: 24252123 DOI: 10.1111/hae.12299] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2013] [Indexed: 12/13/2022]
Abstract
Our objective was to provide a synthesis of measurement properties for performance-based outcome measures used to evaluate physical function in children with haemophilia. A systematic review of articles published in English using Medline, PEDro, Cinahl and The Cochrane Library electronic databases was conducted. Studies were included if a performance-based method, clinical evaluation or measurement tool was used to record an aspect of physical function in patients with haemophilia aged ≤ 18 years. Recording of self-perceived or patient-reported physical performance, abstracts, unpublished reports, case series reports and studies where the outcome measure was not documented or cross-referenced was excluded. Description of outcome measures, patient characteristics, measurement properties for construct validity, internal consistency, repeatability, responsiveness and feasibility was extracted. Data synthesis of 41 studies evaluating 14 measures is reported. None of the outcome measures demonstrated the requirements for all the measurement properties. Data on validity and test-retest repeatability were most lacking together with studies of sufficient size. Measurement of walking and muscle strength demonstrated good repeatability and discriminative properties; however, correlation with other measures of musculoskeletal impairment requires investigation. The Haemophilia Joint Health Score demonstrated acceptable construct validity, internal consistency and repeatability, but the ability to discriminate changes in physical function is still to be determined. Rigorous evaluation of the measurement properties of performance-based outcome measures used to monitor physical function of children with haemophilia in larger collaborative studies is required.
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Affiliation(s)
- D Stephensen
- School of Health, Sport and Bioscience, University of East London, London, UK; Kent Haemophilia Centre, Kent and Canterbury Hospital, Canterbury, UK
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Chen YC, Chen LC, Cheng SN, Pan RY, Chang ST, Li TY. Hemophilic arthropathy of shoulder joints: clinical, radiographic, and ultrasonographic characteristics of seventy patients. J Bone Joint Surg Am 2013; 95:e43. [PMID: 23553306 DOI: 10.2106/jbjs.k.01646] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although shoulder problems frequently occur in patients with hemophilia, systematic evaluation of shoulder joint damage in these patients has only rarely been reported. METHODS The clinical, radiographic, and ultrasonographic characteristics of the shoulder joint were studied in a cohort of seventy consecutive patients with hemophilia. We collected information on age, disease severity, history of shoulder hemarthrosis, prophylaxis therapy, functional Oxford shoulder score, and crutch use. Both shoulders of each patient were evaluated with shoulder motion and visual analog pain scale scores as well as with radiography and ultrasonography. RESULTS Sixty-six patients had hemophilia A, and four had hemophilia B. The median age was thirty-four years (range, ten to sixty-three years). Fifty-six shoulders in thirty-five patients had shoulder bleeds, and twenty-seven patients (38.6%) had shoulder pain or limited motion. As determined with radiographs, eighteen (25.7%) of the seventy patients had hemophilic shoulder arthropathy. A strong correlation between the functional Oxford shoulder score and the radiographic Pettersson score was also noted (r = 0.749, p < 0.001). The ultrasonographic abnormalities in the fifty-six hemarthrotic shoulders included chondromalacia (76.8%), osseous irregularity (60.7%), bicipital tenosynovitis (60%), partial-thickness rotator cuff tear (35.7%), and full-thickness rotator cuff tear (17.9%). Older age, the absence of any previous prophylaxis therapy, and higher frequency of crutch use were the most significant factors associated with shoulder bleeds. CONCLUSIONS Shoulder arthropathy is relatively common in patients with hemophilia. Rotator cuff tears were common in the present study, and there was a strong correlation between shoulder function and the radiographic severity of the arthropathy. Ultrasonography was useful for the evaluation of disorders of the soft tissues of the hemophilic shoulder.
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Affiliation(s)
- Yeu-Chin Chen
- Division of Hematology/Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Di Minno MND, Iervolino S, Soscia E, Tosetto A, Coppola A, Schiavulli M, Marrone E, Ruosi C, Salvatore M, Di Minno G. Magnetic resonance imaging and ultrasound evaluation of “healthy” joints in young subjects with severe haemophilia A. Haemophilia 2013; 19:e167-73. [DOI: 10.1111/hae.12107] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 11/29/2022]
Affiliation(s)
- M. N. D. Di Minno
- Regional Reference Centre for Coagulation Disorders; Federico II University; Naples; Italy
| | - S. Iervolino
- Rheumatology Unit; Federico II University; Naples; Italy
| | - E. Soscia
- Department of Bio-morphological and Functional Sciences; Federico II University; Naples; Italy
| | - A. Tosetto
- Department of Hematology; S. Bortolo Hospital; Vicenza; Italy
| | - A. Coppola
- Regional Reference Centre for Coagulation Disorders; Federico II University; Naples; Italy
| | - M. Schiavulli
- Paediatric Regional Reference Centre for Coagulation Disorders; Santobono-Pausilipon Hospital; Naples; Italy
| | - E. Marrone
- Regional Reference Centre for Coagulation Disorders; Federico II University; Naples; Italy
| | - C. Ruosi
- Department of Orthopedic Surgery; Federico II University; Naples; Italy
| | - M. Salvatore
- Department of Bio-morphological and Functional Sciences; Federico II University; Naples; Italy
| | - G. Di Minno
- Regional Reference Centre for Coagulation Disorders; Federico II University; Naples; Italy
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van Galen K, Mauser-Bunschoten E, Leebeek F. Hemophilic arthropathy in patients with von Willebrand disease. Blood Rev 2012; 26:261-6. [DOI: 10.1016/j.blre.2012.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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27
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van Genderen FR, van Meeteren NLU, Fischer K, Helders PJM. Determinants of participation in patients with severe haemophilia. Haemophilia 2012; 18:860-7. [DOI: 10.1111/j.1365-2516.2012.02884.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - P. J. M. Helders
- Child Development and Exercise Center; University Childrens' Hospital; University Medical Center Utrecht; Utrecht; The Netherlands
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Knobe K, Berntorp E. Haemophilia and joint disease: pathophysiology, evaluation, and management. JOURNAL OF COMORBIDITY 2011; 1:51-59. [PMID: 29090136 PMCID: PMC5556421 DOI: 10.15256/joc.2011.1.2] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/01/2011] [Indexed: 12/25/2022]
Abstract
In patients with haemophilia, regular replacement therapy with clotting factor concentrates (prophylaxis) is effective in preventing recurrent bleeding episodes into joints and muscles. However, despite this success, intra-articular and intramuscular bleeding is still a major clinical manifestation of the disease. Bleeding most commonly occurs in the knees, elbows, and ankles, and is often evident from early childhood. The pathogenesis of haemophilic arthropathy is multifactorial, with changes occurring in the synovium, bone, cartilage, and blood vessels. Recurrent joint bleeding causes synovial proliferation and inflammation (haemophilic synovitis) that contribute to end-stage degeneration (haemophilic arthropathy); with pain and limitation of motion severely affecting patients' quality of life. If joint bleeding is not treated adequately, it tends to recur, resulting in a vicious cycle that must be broken to prevent the development of chronic synovitis and degenerative arthritis. Effective prevention and management of haemophilic arthropathy includes the use of early, aggressive prophylaxis with factor replacement therapies, as well as elective procedures, including restorative physical therapy, analgesia, aspiration, synovectomy, and orthopaedic surgery. Optimal treatment of patients with haemophilia requires a multidisciplinary team comprising a haematologist, physiotherapist, orthopaedic practitioner, rehabilitation physician, occupational therapist, psychologist, social workers, and nurses. Journal of Comorbidity 2011;1:51-59.
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Affiliation(s)
- Karin Knobe
- Lund University, Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Erik Berntorp
- Lund University, Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
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Querol F, Rodriguez-Merchan EC. The role of ultrasonography in the diagnosis of the musculo-skeletal problems of haemophilia. Haemophilia 2011; 18:e215-26. [PMID: 22044728 DOI: 10.1111/j.1365-2516.2011.02680.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Recurrent haemarthrosis is the final cause of haemophilic arthrosic disease in haemophilia patients. Therefore, it is essential to diagnose it early, both clinically and by imaging. In addition, haemophilia patients experience chronic synovitis, joint degeneration, muscle haematoma and pseudotumours. The objective of this article is to highlight the value of ultrasounds in the diagnosis and control of the evolution of musculo-skeletal problems in haemophilia patients. To this end, we have performed a literature search in the PubMed, Web of Science(®) (WOS) and SciVerse bases, using the following keywords: hemophilia or haemophilia and ultrasonography (US), ultrasound, echography and sonography. The search was limited to studies published in English between the years 1991 and 2011, finding a total of 221 references. After reviewing the title or abstract for evidence of the use of US for the diagnosis of musculo-skeletal lesions in haemophilia, we selected 24 of these references. We added data collected from our experience to the most important data found in the references. Our main conclusion is that US is highly valuable for the diagnosis of musculo-skeletal diseases in haemophilia. It is a fast, effective, safe, available, comparative, real-time technique that can help us confirm the clinical examination. It is particularly important in acute haemarthrosis, as it can be used to objectively identify the presence of blood in the joints, measure its size, pinpoint its location, assess its evolution and confirm its complete disappearance.
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Affiliation(s)
- F Querol
- Department of Physiotherapy, Valencia University and La Fe Hospital, Valencia, Spain
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MUÇA-PERJA M, RIVA S, GROCHOWSKA B, MANGIAFICO L, MAGO D, GRINGERI A. Ultrasonography of haemophilic arthropathy. Haemophilia 2011; 18:364-8. [DOI: 10.1111/j.1365-2516.2011.02672.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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RODRIGUEZ-MERCHAN EC, JIMENEZ-YUSTE V, AZNAR JA, HEDNER U, KNOBE K, LEE CA, LJUNG R, QUEROL F, SANTAGOSTINO E, VALENTINO LA, CAFFARINI A. Joint protection in haemophilia. Haemophilia 2011; 17 Suppl 2:1-23. [DOI: 10.1111/j.1365-2516.2011.02615.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aznar JA, Abad-Franch L, Perez-Alenda S, Haya S, Cid AR, Querol F. Ultrasonography in the monitoring of management of haemarthrosis. Haemophilia 2011; 17:826-8. [PMID: 21501338 DOI: 10.1111/j.1365-2516.2011.02538.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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LOBET S, HERMANS C, PASTA G, DETREMBLEUR C. Body structure versus body function in haemophilia: the case of haemophilic ankle arthropathy. Haemophilia 2011; 17:508-15. [DOI: 10.1111/j.1365-2516.2010.02433.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Ravanbod R, Torkaman G, Esteki A. Biotribological and biomechanical changes after experimental haemarthrosis in the rabbit knee. Haemophilia 2010; 17:124-33. [PMID: 20860604 DOI: 10.1111/j.1365-2516.2010.02375.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Changes in articular cartilage after haemarthrosis have not been completely elucidated in haemophilic arthropathy. Insights into the pathophysiological mechanisms of blood-induced joint damage mainly derived from histological, inflammatory and biochemical investigations. A structure-function relationship is another reasonable way to determine the joint overall health status. Cartilage, a viscoelastic connective tissue, is at least a biphasic material that should also work under minimal friction. Pendulum friction tester measures the mechanical aspects of joint lubrication and quantifies the biotribological properties of the joint. Indentation test is an in situ method characterizing the biomechanical properties of the cartilage. Gross, biotribological and biomechanical properties were determined in a rabbit model of experimental haemarthrosis. A sample of 1 mL of fresh autologous blood was injected in the left knee of rabbit's joint twice weekly for four consecutive weeks. The right knee and animals in the control group were left untreated. After 8 days, joint perimeter, biotribological and biomechanical tests were performed. In a consistent manner, all data showed detrimental effects of the blood on the overall cartilage function under loading. Non-weight bearing and early blood aspiration seem wise to be considered after haemarthrosis.
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Affiliation(s)
- R Ravanbod
- Department of Physical Therapy, Biomechanical Research Laboratory, Tarbiat Modares University, Tehran, Tehran, Iran
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35
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SAULYTE TRAKYMIENE S, INGERSLEV J, RAGELIENE L. Utility of the Haemophilia Joint Health Score in study of episodically treated boys with severe haemophilia A and B in Lithuania. Haemophilia 2010; 16:479-86. [DOI: 10.1111/j.1365-2516.2009.02178.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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KHAN U, BOGUE C, UNGAR WJ, HILLIARD P, CARCAO M, MOINEDDIN R, DORIA AS. Cost-effectiveness analysis of different imaging strategies for diagnosis of haemophilic arthropathy. Haemophilia 2009; 16:322-32. [DOI: 10.1111/j.1365-2516.2009.02125.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Maclachlan J, Gough-Palmer A, Hargunani R, Farrant J, Holloway B. Haemophilia imaging: a review. Skeletal Radiol 2009; 38:949-57. [PMID: 18807029 DOI: 10.1007/s00256-008-0586-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 08/16/2008] [Accepted: 08/18/2008] [Indexed: 02/02/2023]
Abstract
Haemophilia disorders are characterised by a blood coagulation anomaly leading to prolonged and excessive bleeding. Imaging provides an essential role in the investigation of both the musculoskeletal and the non-musculoskeletal complications of haemophilia. Our institution is home to a large tertiary referral centre for haemophilia treatment. Using our broad experience, we present a multi-modality pictorial review of the musculoskeletal manifestations of haemophilia, including haemophilic arthropathy, intra-muscular haemorrhage and haemophilic pseudotumour. The main imaging features of haemophilic arthropathy are described, including synovial hypertrophy, haemosiderin deposition, sub-chondral cyst formation and loss of joint space.
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39
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Acharya SS, Schloss R, Dyke JP, Mintz DN, Christos P, DiMichele DM, Adler RS. Power Doppler sonography in the diagnosis of hemophilic synovitis--a promising tool. J Thromb Haemost 2008; 6:2055-61. [PMID: 18823337 DOI: 10.1111/j.1538-7836.2008.03160.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recurrent hemarthroses in hemophilia results in synovitis and joint arthropathy. Primary prophylaxis when universally instituted at current doses can prevent joint deterioration but is expensive. Alternatively, the selective implementation of prophylaxis would require a more sensitive tool for detecting synovitis than possible with clinical surveillance or plain radiographs. Magnetic resonance imaging (MRI) is such a tool and is utilized for the evaluation of hemophilic joint disease (HJD). However, it is expensive, and requires sedation in younger children precluding its utility for monitoring of synovitis. Ultrasonography (USG) with power Doppler (USG-PDS) has been utilized to detect and quantitate synovial vascularity in other arthritides and could provide an equally effective but less costly tool for HJD, particularly in children who would not require sedation. OBJECTIVES To determine whether USG-PDS is comparable to MRI in the evaluation of hemophilic synovitis. PATIENTS A prospective cohort of 31 subjects including 33 joints (knees, elbows, ankles) underwent dynamic contrast enhanced (DCE)-MRI and USG-PDS. RESULTS USG-PDS measurements of synovial thickness(r = 0.70, P < 0.0001) and synovial vascularity (r = 0.73, P < 0.0001) correlated strongly with those obtained with DCE-MRI. A cutoff of PDS intensity of 1.3 decibels (dB) per mm(2) was found to yield a sensitivity of 100% and a specificity of 94.1% in 17 joints with/without a history of hemarthroses. Pettersson radiographic scores correlated significantly with synovial thickness in adults but not children. CONCLUSIONS Our data suggest that USG-PDS may be an inexpensive and easily implemented imaging tool for detecting hemophilic synovitis and could be useful in tailoring effective prophylaxis.
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Affiliation(s)
- S S Acharya
- Pediatrics-Hematology/Oncology, Weill Medical College, New York, NY, USA.
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BOSSARD D, CARRILLON Y, STIELTJES N, LARBRE JP, LAURIAN Y, MOLINA V, DIRAT G. Management of haemophilic arthropathy. Haemophilia 2008; 14 Suppl 4:11-9. [DOI: 10.1111/j.1365-2516.2008.01734.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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41
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Acharya SS. Hemophilic joint disease – current perspective and potential future strategies. Transfus Apher Sci 2008; 38:49-55. [DOI: 10.1016/j.transci.2007.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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42
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Abstract
The pathophysiology of haemophilic synovitis is complex and not as well understood on a molecular level as we have thought. The repeated bleeding episodes and synovial hypertrophy occurring within the joint. Iron and other red-cell debris are phagocytized, and hydrolytic enzymes are produced leading to the destruction of articular cartilage is a simplistic model. However, how iron stimulates this destructive cascade remains speculative and poorly understood. Diagnostic options include radiographic examination using horizontal beam technique, which may reveal a fat blood fluid level, and computed tomography scanning or magnetic resonance imaging.
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Affiliation(s)
- N J Goddard
- Department of Orthopaedics, Royal Free Hospital, London, UK.
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Zukotynski K, Jarrin J, Babyn PS, Carcao M, Pazmino-Canizares J, Stain AM, Doria AS. Sonography for assessment of haemophilic arthropathy in children: a systematic protocol. Haemophilia 2007; 13:293-304. [PMID: 17498079 DOI: 10.1111/j.1365-2516.2006.01414.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiological imaging of joints in children with haemophilia is important to detect abnormalities, grade their severity and monitor the effects of treatment. Scoring systems for staging haemophilic arthropathy have been developed based on plain film or magnetic resonance imaging (MRI) findings. Radiographs alone may be inadequate for evaluating joint disease in children with haemophilia on prophylaxis while MRI may be difficult to access and require the child to be sedated. Sonography can be a useful complementary modality in the evaluation of haemophilic arthropathy that is readily available and does not require the child to be sedated. In this paper, we briefly review the current imaging scales available for the assessment of haemophilic arthropathy and present a systematic protocol for sonographic assessment of the knee and ankle in haemophilic children along with examples of findings in joint effusion/hemarthrosis, synovial hypertrophy and cartilage loss. Also, we correlate the ultrasound findings with the corresponding MRI images demonstrating the anatomic planes used for imaging acquisition. Sonography is a promising technique for the assessment of soft tissue changes which are the earliest findings in haemophilic arthropathy. Further investigation is required for evaluation of osteochondral changes given limitations of sonography in this regard and in minimizing operator dependency, especially if applied in multicentric clinical trials.
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Affiliation(s)
- K Zukotynski
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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van Genderen FR, Westers P, Heijnen L, de Kleijn P, van den Berg HM, Helders PJM, van Meeteren NLU. Measuring patients' perceptions on their functional abilities: validation of the Haemophilia Activities List. Haemophilia 2006; 12:36-46. [PMID: 16409173 DOI: 10.1111/j.1365-2516.2006.01186.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recently, the Haemophilia Activities List (HAL), a haemophilia-specific self-assessment questionnaire to assess a patient's self-perceived functional ability, was introduced and a limited pilot study warranted its further development. The present study finalizes the HAL and assesses the convergent and construct validity, as well as the internal consistency of its definitive version. Three questionnaires (HAL, Dutch-Arthritis Impact Measurement Scales 2 and the Impact on Participation and Autonomy questionnaire) were completed by 127 patients with severe haemophilia (<1% clotting activity), as well as four performance tests (button test, 50 metre walking test, timed-up-and-go test and figure-8 walking test). After removal of 15 non-informative items from the provisional HAL, three components within the questionnaire were identified (upper extremity activities, basic lower extremity activities and complex lower extremity activities). The internal consistency of these components was high (Cronbach's alpha = 0.93-0.95), as was internal consistency for the seven domains of the HAL (alpha = 0.61-0.96). The convergent validity of the HAL when compared to the other two questionnaires was good (r = 0.47-0.84). The construct validity of the HAL when compared to the four performance tests was generally lower (r = 0.23-0.77). The final version of the HAL has good internal consistency and convergent validity and gives the clinician insight into a patient's self-perceived ability to perform activities of daily life. It is likely that self-assessment instruments (questionnaires) and performance tests consider different concepts of functional health status and it is therefore recommended that both types are included when clinicians assess a patient's functional abilities.
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Affiliation(s)
- F R van Genderen
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, The Netherlands.
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45
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Abstract
Treatment of hemophilia aims to minimize structural damage to joints and maximize patients' functional independence and quality of life. From an orthopedic perspective, treatment efficacy can be judged by quantifying the extent of musculoskeletal damage. Joint scores--both clinical and radiologic--have traditionally been measured in patients with hemophilia. However, such scores may lack the sensitivity to detect early changes in the hemophilic joint, and this has prompted the development of more sensitive measures. In addition, scores based on the status of individual joints do not consider the impact of arthropathy on overall musculoskeletal function. It would prove valuable to understand the implications of small differences in clinical/radiologic scores in terms of overall musculoskeletal function and patients' quality of life. The development of functional scores such as the Functional Independence Score for Haemophilia (FISH) and the Haemophilia Activities List (HAL), along with the quality-of-life (QoL) measurement tools, have helped to provide a more comprehensive assessment of health in hemophilia. Such improved understanding should assist with the development of contextually relevant guidelines for the management of hemophilia.
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Dobón M, Lucía JF, Aguilar C, Mayayo E, Roca M, Solano V, Peña A, Giralt M, Ferrández A. Value of magnetic resonance imaging for the diagnosis and follow-up of haemophilic arthropathy. Haemophilia 2003; 9:76-85. [PMID: 12558783 DOI: 10.1046/j.1365-2516.2003.00702.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An orthopaedic assessment of the joint status of seven severe haemophiliacs (mean age 12.5 y - range 8.9-15.5) on prophylactic treatment (PT) by magnetic resonance imaging (MRI) and physical examination was carried out. Median duration of PT of these patients was 84 months (range 32-107). A locally designed MRI joint score considering seven parameters (1 - joint effusion, 2 - synovial membrane thickening, 3 - haemosiderin deposits, 4 - joint cartilage injury, 5 - subchondral bone erosion, 6 - subchondral bone cysts, 7 - osteonecrosis) was used (maximum score = 13 points). MRI scans were performed in 17 joints (nine ankles, seven knees and one elbow): mean MRI scores for the affected joints was 5.1. A poor consistency between physical examination and MRI findings or the real extent of joint damage was found (Cohen kappa index 0.320). MRI is a precise non-invasive tool for the assessment of early joint cartilage and synovium pathological changes still undetectable by physical examination or conventional X-rays in the haemophilic setting.
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Affiliation(s)
- M Dobón
- Department of Haematology, Hospital Miguel Servet, Zaragoza, Spain
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