Point‐of‐care musculoskeletal ultrasound is critical for the diagnosis of hemarthroses, inflammation and soft tissue abnormalities in adult patients with painful haemophilic arthropathy

Abstract

We previously demonstrated in adult patients with haemophilia (PWH) that hemarthrosis is present in only ~1/3rd of acutely painful joints by using point-of-care-musculoskeletal ultrasound (MSKUS). Therefore, other unrecognized tissue abnormalities must contribute to pain. Using high resolution MSKUS, employing grey scale and power Doppler, we sought to retrospectively (i) investigate soft tissue abnormalities in painful haemophilic joints and (ii) to determine to what extent MSKUS findings, functional or radiographic joint scores correlate with biomarkers of inflammation in PWH. Findings were correlated with Hemophilia Joint Health Scores (HJHS), Pettersson scores, high sensitivity C-reactive protein and von Willebrand factor activity and antigen levels. A total of 65 MSKUS examinations for acute and chronic joint pains were performed for 34 adult haemophilia patients, mostly for chronic joint pains (72.3%). The most prominent findings (66.5%) pertained to inflammatory soft tissue changes including synovitis, tendinitis, enthesitis, bursitis and fat pad inflammation. Effusions were present in 55.5% and 46.8% of MSKUS performed for acute and chronic pain, respectively. Of those, 90.0% were bloody during acute and 47.6% during persistent pains. While inflammatory biomarkers correlated well with overall HJHS and total Pettersson scores (P < 0.05), they did not differ between those patients with synovitis and those without. MSKUS is emerging as an important modality to diagnose treatable musculoskeletal abnormalities contributing to pain in haemophilic arthropathy, and therefore seems critical for a personalized approach to haemophilia care. The role of biomarkers in this setting remains less clear and requires further investigation.

The frequency of joint hemorrhages and procedures in nonsevere hemophilia A vs B

“…Because joint bleeding was not objectively measured, the rate of joint bleeding could also be falsely inflated, particularly in the older cohorts, because it is challenging to differentiate synovitis and arthritic pain from hemorrhage. 32 The UDC did not collect measures of physical activity, which conceivably influence bleeding rates. However, we are unaware of systematic differences in activity between hemophilia A and B that could have accounted for the results derived from our self-reported joint hemorrhage rates.…”

Spontaneous elbow hemarthrosis identified by point-of-care ultrasound

“…Hemarthrosis is typically the result of injury or bleeding disorder; other causes include osteoarthritis, septic arthritis, tumor, scurvy, and Charcot joint [2,8]. Spontaneous hemarthrosis may complicate anticoagulant therapy, but typically affects the knee or ankle.…”

Advances and challenges in hemophilic arthropathy

“…The ability to diagnose inflammatory soft tissue changes and synovitis with power Doppler 25, 2633, 35 is important in HA. As in rheumatoid arthritis (RA), synovial hypertrophy is often present and can be accompanied by synovitis characterized by increased synovial blood flow.…”

“…47 The individual percentage increase for CTX-II and CS-846 in response to bleeding ranged from ~25 to 500% and from ~80 to 120%, returning gradually to baseline during the following 10 days. The wide inter-individual initial rise of CTX-II may have been related to imprecision of self-reported bleeding as etiology of painful episodes, 25, 26 bleeding volume or individual joint responses to the blood. For CTX-II, similar findings were noted in a canine model when blood was injected into the joint.…”