Objective:
Using point-of-care musculoskeletal ultrasound (MSKUS), we previously demonstrated that patient and physician assessments were unreliable in determining bleeding during acute painful joint episodes. Here we delineated by MSKUS pathophysiological soft tissue changes that may contribute to pain, and investigated to what extent MSKUS findings and functional or radiographic joint status correlate with markers of inflammation.
Methods:
We used the GE Logiq e BT11 US-module with high frequency 8-13 MHz linear transducer and real time spatial compound imaging capability for grey scale and Power Doppler examinations. We analyzed all MSKUS examinations performed between 05/2012 and 08/2013 in 34 adult hemophilia patients (mean age 39.3 years) seen at our Hemophilia Treatment Center. Findings were correlated with Hemophilia Joint Health Scores (HJHS), Pettersson Scores, hsCRP, and von Willebrand Factor (VWF) activity and antigen levels. Spearman correlation coefficient and Wilcoxon Mann-Whitney tests were used. P-values ≤0.05 were considered significant. Acute and persistent pain was defined as lasting ≤7 days and >7 days, respectively.
Results:
Sixty-five examinations were performed. Seventy percent of patients had severe hemophilia. Mean Pettersson scores were 22 of 78 and HJHS were 22 of 124. Joints most commonly examined were knees and ankles (72%), with most examinations (72%) performed for persistent pain. Effusions were present in 48% of painful joints. Of those effusions, 90% were bloody during acute and ~50% during persistent pain episodes. Synovitis (+/-tendinitis, enthesitis or bursitis) was observed in 66% of all MSKUS examinations. Synovitis and hemarthrosis coincided in 20% of examinations. In exams revealing hemarthrosis, synovitis was present in 68%. In acute hemarthrosis, synovitis was present in 55% and, with persistent pain, synovitis was present in 80%. Although total and joint-specific HJHS and Pettersson scores were higher in patients with synovitis, only the joint-specific Pettersson score was significantly higher (mean score 3 vs 6.5). HsCRP, VWF activity and VWF antigen levels correlated significantly with joint-specific Pettersson scores (Cr ~0.4) and total HJHS (Cr ~0.6), but not consistently with synovitis.
Conclusion:
Inflammation and bleeding were prominent findings in painful hemophilic arthropathy. One-fifth of persistently painful joints were diagnosed with hemarthroses, which were almost always associated with synovitis. Inflammatory markers correlated to some extent with joint findings, but were diagnostically not helpful. We conclude that sensitive imaging technology such as MSKUS is critical to precisely diagnose causes of pain in hemophilic arthropathy with a need for personalized care that includes tailored clotting factor replacement and/or novel anti-inflammatory strategies.