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Background: Hemophilia type A and B is associated with spontaneous bleeding in muscle tissues and joints. Acute hemarthrosis, representing 70–80% of all bleedings in severe hemophilia patients, is extremely painful. When surgical procedures are needed in hemophiliac patients, perioperative management should be planned with a multidisciplinary team. Our narrative review, through a rigorous analysis of the current literature, focuses on pain management in hemophiliac patients. Methods: The report synthesizes a literature review on hemophilia, adapting PRISMA guidelines. It identifies a research question on surgical procedures and perioperative pain management. Various sources, including electronic databases, are utilized. Study inclusion criteria are defined based on the research question. Forty studies are included. A detailed study selection is illustrated. Results: Guidelines for managing acute postoperative pain in the general population advocate for a multimodal analgesic administration to enhance synergistic benefits, reduce opioid requirements, and minimize side effects. Recent recommendations from the World Federation of Hemophilia (WFH) for postoperative pain management in hemophilia patients suggest tailoring treatment based on pain levels, in coordination with anesthesiologists. Conclusions: Pain management in hemophiliac patients undergoing orthopedic interventions requires a multidisciplinary approach, with further research needed to define a reliable global standard of treatment. [ABSTRACT FROM AUTHOR]

We aim (a) to introduce an easy-to-perform multi-echo gradient-echo sequence (mGRE) for the detection of hemosiderin deposition in the ankle joints of boys with haemophilia (b) to explore the associations between the presence and severity of hemosiderin deposition and the other components of haemophilic arthropathy, the clinical score, and the number and chronicity of joint bleeds. An MRI of 41 ankle joints of 21 haemophilic boys was performed on a 3 T MRI system using an mGRE sequence in addition to the conventional protocol. Conventional MRI and mGRE were separately and independently assessed by three readers, namely, two musculoskeletal radiologists and a general radiologist for joint hemosiderin. We set as a reference the consensus reading of the two musculoskeletal radiologists, who also evaluated the presence of synovial thickening, effusion, and osteochondral changes. Excellent inter-reader agreement was obtained using the mGRE sequence compared to the conventional protocol (ICC: 0.95–0.97 versus 0.48–0.89), with superior sensitivity (90–95% versus 50–85%), specificity (95.2–100% versus 76.2–95.2%), and positive (95–100% versus 71–94.4%) and negative predictive value (91.3–95.5% versus 87–63%). Hemosiderin deposition was associated with osteochondral changes, synovial thickening, clinical score, and the total number of ankle bleeds, while it was inversely related with the time elapsed between the last joint bleed and MRI. (p < 0.05). The application of an mGRE sequence significantly improved hemosiderin detection, even when performed by the less experienced reader. Joint hemosiderin deposition was associated with the other components of haemophilic arthropathy and was mostly apparent in recent joint bleeds. [ABSTRACT FROM AUTHOR]

To explore how plyometric-based hydro-kinesiotherapy (Plyo-HKT) would affect pain, muscle strength, postural stability, and functional performance in a convenience sample of children with hemophilic knee arthropathy (HKA). Forty-eight children with HKA (age: 8–16 years) were randomly allocated to the Plyo-HKT group (n = 24; underwent the Plyo-HKT for 45 min, twice/week over 12 wk in succession) or the comparison group (n = 24; performed the standard exercise rehabilitation at an equivalent frequency and duration). Pain, peak concentric torque of quadriceps and hamstring (produced at two angular velocities: 120 and 180 o/sec), dynamic limits of postural stability (DLPS), and functional performance [Functional Independence Score in Hemophilia (FISH) and 6-Minute Walk Test (6-MWT)] were assessed pre- and post-intervention. In contrast with the comparison group, the Plyo-HKT group achieved more favorable pre-to-post changes in pain (p =.028, η2p = 0.10), peak torque of quadriceps [120°/sec (p =.007, η2P = 0.15); 180°/sec (p =.011, η2P = 0.13)] and hamstring [120°/sec (p =.024, η2P = 0.11); 180°/sec (p =.036, η2P = 0.09)], DLPSdirectional [forward (p =.007, η2P = 0.15); backward (p =.013, η2P = 0.12); affected side (p =.008, η2P = 0.14); non-affected side (p =.002, η2P = 0.20)], DLPSoverall (p <.001, η2P = 0.32), and functional performance [FISH (p <.001, η2p = 0.26); 6-MWT (p =.002, η2p = 0.19)]. Plyo-HKT is likely helpful for reducing pain, improving strength, enhancing postural stability, and boosting functional capabilities in children with HKA. Physical rehabilitation practitioners should, therefore, consider this intervention strategy. [ABSTRACT FROM AUTHOR]

BackgroundMechanisms of iron clearance from hemophilic joints are unknown.ObjectivesTo better understand mechanisms of iron clearance following joint bleeding in a mouse model of hemophilia.MethodsHemarthrosis was induced by subpatellar puncture in factor VIII (FVIII)-deficient (FVII-/-) mice, +/- periprocedural recombinant human FVIII, and hypocoagulable (HypoBALB/c) mice. HypoBALB/c mice experienced transient FVIII deficiency (anti-FVIII antibody) at the time of injury combined with warfarin-induced hypocoagulability. Synovial tissue was harvested weekly up to 6 weeks after injury for histological analysis, ferric iron and macrophage accumulation (CD68), blood and lymphatic vessel remodeling (αSMA; LYVE1). Synovial RNA sequencing was performed for FVIII-/- mice at days 0, 3, and 14 after injury to quantify expression changes of iron regulators and lymphatic markers.ResultsBleed volumes were similar in FVIII-/- and HypoBALB/c mice. However, pronounced and prolonged synovial iron accumulation colocalizing with macrophages and impaired lymphangiogenesis were detected only in FVIII-/- mice and were prevented by periprocedural FVIII. Gene expression changes involved in iron handling (some genes with dual roles in inflammation) and lymphatic markers supported proinflammatory milieu with iron retention and disturbed lymphangiogenesis.ConclusionAccumulation and delayed clearance of iron-laden macrophages were associated with defective lymphangiogenesis after hemarthrosis in FVIII-/- mice. The absence of such findings in HypoBALB/c mice suggests that intact lymphatics are required for removal of iron-laden macrophages and that these processes depend on FVIII availability. Studies to elucidate the biological mechanisms of disturbed lymphangiogenesis in hemophilia appear critical to develop new therapeutic targets.

A 44-year-old otherwise healthy male with a history of trauma and surgical interventions in his right knee presented to the emergency department with repeated hemarthrosis of the right knee. The patient underwent blood tests, X-rays, and magnetic resonance imaging of the knee. A computed tomography angiography revealed blushing of the synovium of the knee. The patient underwent successful embolization of the genicular artery branches. Hemarthrosis did not recur. The use of genicular artery embolization, in our case, not only successfully addressed recurrent hemarthrosis but also underscores its emerging role in comprehensive patient management. This minimally invasive approach, precisely targeting the vascular supply to the affected synovium, offers an effective alternative where conventional therapies may fall short. Beyond symptom relief, it holds promise for preventing hemarthrosis recurrence, a valuable addition to clinicians' interventions for challenging knee joint bleeding cases. Further investigation in larger cohorts and comparative studies may reveal its broader applicability and long-term efficacy, shaping treatment options for recurrent hemarthrosis.

Recurrent bleeding in the synovial joint, such as the knee, can give rise to chronic synovitis and degenerative arthritis, which are major causes of morbidity. Whereas chronic arthropathy affects one-fifth of hemophiliacs, conditions such as rheumatoid arthritis (RA), periarticular and articular fractures, osteochondral autograft transplantation surgery, and anterior cruciate ligament (ACL) injury are also associated with joint bleeding. Synovial joint trauma is associated with inflammation, acute pain, bloody joint effusion, and knee instability. Clinically, some physicians have advocated for blood aspiration from the joint post-injury to mitigate the harmful effects of bleeding. Despite the significant potential clinical impact of joint bleeding, the mechanism(s) by which joint bleeding, acute or microbleeds, leads to deleterious changes to the synovial joint remains understudied. This review will address the impact of blood on synovial joint tissues observed from in vitro and in vivo studies. While the deleterious effects of blood on cartilage and synovium are well-described, there are much fewer reports describing the negative effects of blood on the meniscus, cruciate ligaments, and subchondral bone. Based on our studies of blood in co-culture with chondrocytes/cartilage, we raise the possibility that ferroptosis, an iron-dependent, nonapoptotic form of regulated cell death, plays a contributing role in mediating hemophilic arthropathy (HA) and may represent a therapeutic target in reducing the negative impact of joint bleeds. [ABSTRACT FROM AUTHOR]

Rupture of the anterior cruciate ligament (ACL) disturbs the stability of the knee, and increases the risk of subsequent meniscal damage and the risk of developing degenerative joint disease. Surgical ACL reconstruction (ACLR) is one of the most common orthopedic surgeries. This study aimed to investigate the effective factors on the rehabilitation rate in ACLR with hamstring autograft based on the Tegner activity scale (TAS) and Lysholm knee scoring scale (LKS) one year after the operation. In this descriptive-analytical study, 140 patients who underwent ACLR surgery with hamstring autograft were evaluated. Patients were evaluated based on TAS and LKS scores before and after the surgery and their responses were recorded. Then, the rehabilitation rate was calculated based on these two scales, and the association between the rehabilitation rate and pre-operative and post-operative parameters was investigated. Based on the findings, LKS scores after surgery were significantly associated with age, gender, education, injury mechanism, loss of full flexion ROM, analgesic consumption after surgery, surgical site infection, and BMI. Also, the LKS score was higher in people whose Tegner activity scale score was 8 before the injury. There was no significant association with smoking before surgery, hematoma at the graft site after surgery, knee meniscal lesions, and hemarthrosis formation during the first six hours of ACL injury. Determining the effective factors before and after surgery on the rehabilitation rate of patients undergoing ACLR who were treated with hamstring autograft may be useful in evaluating the rehabilitation rate of patients. [ABSTRACT FROM AUTHOR]

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Synovial hemangioma is a rare vascular issue that can lead to persistent knee swelling and bleeding within the joint. It is typically seen in children and young adults but can also affect those in older age groups. Because the symptoms and x-ray results are not specific, it is often diagnosed late. Magnetic Resonance Imaging (MRI) is the best process for identifying and understanding the characteristics of synovial hemangioma. The recommended treatments are surgical removal and partial synovectomy, both of which offer good outcomes and minimal chance of recurrence. We discuss a case of a 48-year-old man with synovial hemangioma in the knee joint. His symptoms included swelling, pain, and restricted movement. His medical history included regular drainage of persistent knee swelling. An MRI highlighted typical features of synovial hemangioma, such as enlarged veins, looped or linear patterns, and greater visibility under gadolinium. He underwent a successful open surgery with partial synovectomy and mass removal. The pathology report confirmed the diagnosis of synovial hemangioma. Post-surgery, the patient had no complications and showed significant symptom reduction and better movement range 6 months later. [ABSTRACT FROM AUTHOR]

Background: Hemophilia is an inherited bleeding disorder that could cause many complications one of them is hemarthrosis. Neutrophils are the predominant immune cells that infiltrate joints after hemorrhage. Tissue injury is often accompanied by the productions of neutrophil extracellular traps (NETs), which are DNA constructs containing attached granular enzymes. Aims of Study: Measuring the circulating NETs, neutrophil elastase (NE), and myeloperoxidase (MPO) in the plasma of hemophilia A patients with hemarthrosis, for an understanding of hemarthrosis’ underlying pathology. Subjects and Methods: Fifty persons were recruited in this study, during a period of 8 months from November 2022 to June 2023: 25 patients were diagnosed as hemophilia A with hemarthrosis and another 25 individuals served as a control group who were unrelated, apparently healthy, and were age and sex matched. Plasma NE and MPO were measured by ELIZA technique. Results: The plasma MPO and NE levels were significantly higher in hemophilia A patients than controls: 12.714 ± 19.439 and 1535.34 ± 2059.87 ng/mL, respectively, at (P < 0.05) compared to control group 3.672 ± 3.623 and 235.26 ± 274.61 ng/mL. Conclusions and Recommendations: Patients with hemarthrosis had a considerably higher level of NETs in their plasma than healthy individuals. These findings may indicate the function of NETs in the pathology of hemophilia A with hemarthrosis, and the identification of high NETs might serve as a biomarker, as well as a possible prognostic and therapeutic target for such individuals.

This article discusses the relevance of magnetic resonance imaging (MRI) findings in individuals with haemophilia. It highlights that most bleeding episodes in haemophilia occur in the large synovial joints, leading to irreversible haemophilic arthropathy. The article emphasizes the importance of detecting subclinical bleeding and inflammation, as they contribute to the development of arthropathy. MRI is considered the gold standard for evaluating early blood-induced joint changes in haemophilia, and the International Prophylaxis Study Group (IPSG) has developed a comprehensive scoring scheme for MRI assessment. The article also discusses the clinical consequences of subclinical bleeding, the evaluation of joint effusions, and the assessment of osteochondral abnormalities using MRI. It concludes by stating that MRI provides a complete overview of joint status in individuals with haemophilia and that the IPSG MRI Scale version 2.0 facilitates standardized MRI scoring for future outcome studies. [Extracted from the article]

We aim (a) to introduce an easy-to-perform multi-echo gradient-echo sequence (mGRE) for the detection of hemosiderin deposition in the ankle joints of boys with haemophilia (b) to explore the associations between the presence and severity of hemosiderin deposition and the other components of haemophilic arthropathy, the clinical score, and the number and chronicity of joint bleeds. An MRI of 41 ankle joints of 21 haemophilic boys was performed on a 3 T MRI system using an mGRE sequence in addition to the conventional protocol. Conventional MRI and mGRE were separately and independently assessed by three readers, namely, two musculoskeletal radiologists and a general radiologist for joint hemosiderin. We set as a reference the consensus reading of the two musculoskeletal radiologists, who also evaluated the presence of synovial thickening, effusion, and osteochondral changes. Excellent inter-reader agreement was obtained using the mGRE sequence compared to the conventional protocol (ICC: 0.95–0.97 versus 0.48–0.89), with superior sensitivity (90–95% versus 50–85%), specificity (95.2–100% versus 76.2–95.2%), and positive (95–100% versus 71–94.4%) and negative predictive value (91.3–95.5% versus 87–63%). Hemosiderin deposition was associated with osteochondral changes, synovial thickening, clinical score, and the total number of ankle bleeds, while it was inversely related with the time elapsed between the last joint bleed and MRI. (p < 0.05). The application of an mGRE sequence significantly improved hemosiderin detection, even when performed by the less experienced reader. Joint hemosiderin deposition was associated with the other components of haemophilic arthropathy and was mostly apparent in recent joint bleeds.

This study aimed to evaluate the viscoelastic properties of lower-extremity muscles in pediatric hemophilia (FVIII-IX) patients. The study included 20 severe- and moderate-type right-dominant hemophilia patients diagnosed with hemophilia A–B and 20 healthy children. Viscoelastic properties (tone, stiffness, elasticity) of the lower-extremity muscles were measured using a MyotonPRO device. The physical characteristics of the pediatric hemophilia patients (mean age: 11.9 ± 3.95 years) and the control group (mean age: 12.6 ± 3.41 years) were found to be similar. A difference was observed only in the elasticity of the right vastus lateralis (p < 0.05) by means of the viscoelastic properties of the lower-extremity muscles. The results were similar in other muscle groups (p > 0.05). The dominant-side vastus lateralis muscle elasticity (the ability of the muscle to regain its original shape after contraction or removal of an external force) of hemophilia patients was found to be lower compared to healthy children. The fact that 45% of hemarthroses occur in the knee joint and that recurrent bleeding may affect the flexibility of the vastus lateralis, which is the main muscle within the quadriceps muscle group and responsible for the stabilization of the patella, can be associated with the study results. [ABSTRACT FROM AUTHOR]

(1) Background: Around 50% of hemophilia patients develop severe arthropathy, with even subclinical hemorrhage in childhood potentially leading to intra-articular iron deposition, synovia proliferation, neoangiogenesis, and eventual damage to articular cartilage and subchondral bone. Treatments typically include coagulation factor substitution, radiosynoviorthesis, and joint replacement for advanced cases. This study aims to elucidate programmed cell death mechanisms in hemophilic arthropathy (HA) to identify novel treatments. (2) Methods: Human chondrocytes were exposed to lysed/non-lysed erythrocytes, ferroptosis inducer ML-162, cytokines (IL-1ß, TNFα), and ferric citrate, then assessed for metabolic activity, DNA content, and cell death using Alamar Blue, cyQUANT, and Sytox assays. Three-dimensional spheroids served as a cartilage model to study the effects of erythrocytes and ML-162. (3) Results: Erythrocytes caused significant cell death in 2D cultures (p < 0.001) and damaged 3D chondrocyte spheroids. Iron citrate and erythrocytes reduced chondrocyte DNA content (p < 0.001). The ferroptosis pathway was implicated in cell death, with no effects from apoptosis and necroptosis inhibitors. (4) Conclusions: This study offers insights into HA's cell death pathway, suggesting ferroptosis inhibitors as potential therapies. Further studies are needed to evaluate their efficacy against the chronic effects of HA. [ABSTRACT FROM AUTHOR]

Mouhammad J Alawad,1 Mohammad Abu-Tineh,2 Awni Alshurafa,2 Alaa Al-Taie,3 Anil Yousaf,2 Mohamed A Yassin2 1Department of Medical Education, Internal Medicine Residency Program, Hamad Medical Corporation, Doha, Qatar; 2Department of Medical Oncology, Hematology and BMT Section, National Center for Hamad Medical Corporation, Doha, Qatar; 3Clinical Imaging Department, Hamad Medical Corporation, Doha, QatarCorrespondence: Mouhammad J Alawad, Department of Medical Education, Internal Medicine Residency Program, Hamad Medical Corporation, PO Box 3050, Doha, Qatar, Tel +974 33078745, Fax +97444397857, Email www.wad7a123@gmail.comAbstract: Glanzmann thrombasthenia is a bleeding disorder with a low incidence. It typically manifests as superficial bleeding episodes, which tend to be mild. Deep organ involvement is not uncommon but remains rare due to the rarity of the disease itself and the unusual association between platelet disorders and deep organ implications. A 17-year-old boy with Glanzmann thrombasthenia since infancy developed ankle pain after a minor trauma. His initial workup was negative, but he continued to experience ankle pain. A magnetic resonance imaging (MRI) done after four weeks suggested siderotic synovitis. The patient was lost to follow-up after that and returned after two years with recurrent left ankle pain. Imaging and studies have shown evidence of chronic arthropathy. A specialized orthopedic team assessed the patient. The patient underwent intra-articular steroid injection for pain relief and was referred to continue physical therapy. In conclusion, hemarthrosis is more common in hemophilia than in platelet disorders and has potential morbidity and quality-of-life implications.Keywords: Glanzmann thrombasthenia, hemarthrosis, synovitis

Case presentation: A 32-year-old man with a history of hemophilia A presented to the emergency department with right shoulder pain, swelling, and decreased range of motion.Discussion: Emergency physicians can use ultrasound to quickly and accurately identify hemarthrosis at the bedside.

Recurrent bleeding in the synovial joint, such as the knee, can give rise to chronic synovitis and degenerative arthritis, which are major causes of morbidity. Whereas chronic arthropathy affects one-fifth of hemophiliacs, conditions such as rheumatoid arthritis (RA), periarticular and articular fractures, osteochondral autograft transplantation surgery, and anterior cruciate ligament (ACL) injury are also associated with joint bleeding. Synovial joint trauma is associated with inflammation, acute pain, bloody joint effusion, and knee instability. Clinically, some physicians have advocated for blood aspiration from the joint post-injury to mitigate the harmful effects of bleeding. Despite the significant potential clinical impact of joint bleeding, the mechanism(s) by which joint bleeding, acute or microbleeds, leads to deleterious changes to the synovial joint remains understudied. This review will address the impact of blood on synovial joint tissues observed from in vitro and in vivo studies. While the deleterious effects of blood on cartilage and synovium are well-described, there are much fewer reports describing the negative effects of blood on the meniscus, cruciate ligaments, and subchondral bone. Based on our studies of blood in co-culture with chondrocytes/cartilage, we raise the possibility that ferroptosis, an iron-dependent, nonapoptotic form of regulated cell death, plays a contributing role in mediating hemophilic arthropathy (HA) and may represent a therapeutic target in reducing the negative impact of joint bleeds.

IntroductionJoint iron accumulation is the incendiary factor triggering osteochondral destruction, synovial hypertrophy, inflammation, and vascular remodelling in haemophilic arthropathy (HA). Hemosiderin depositions have been described in synovium and, more recently, in cartilage. Clinical observations also suggest hemosiderin accumulation in subchondral cysts, implying cyst bleeding.AimWe explored associations between cystic iron accumulation, vascular remodelling and HA status to determine if cystic bleeding may contribute to HA progression.MethodsThirty-six haemophilic joints (16 knees, 10 ankles, and 10 elbows; 31 adult patients with haemophilia A/B) were evaluated by magnetic resonance imaging (MRI) for subchondral cysts and hemosiderin. Cyst score (WORMS) and hemosiderin presence were compared between haemophilic and osteoarthritic knees, matched for the degree of arthritis (Kellgren-Lawrence score). Cystic iron accumulation, vascular remodelling and macrophage cell counts were also compared by immunohistochemistry in explanted joint tissues. In haemophilic knees, cyst number and extent of hemosiderin deposition were correlated with haemophilia joint health scores (HJHS).ResultsCystic hemosiderin was detected in 78% of haemophilic joints. Cyst score and presence of hemosiderin were significantly higher in haemophilic compared to osteoarthritic knees. Cyst score and presence of hemosiderin strongly correlated with HJHS. Moreover, iron deposition and vascular remodelling were significantly more pronounced within cysts in haemophilic compared to osteoarthritic knees, with similar total cell and macrophage count.ConclusionThese findings suggest the presence of subchondral bleeding in haemophilia, contributing to poor joint health outcomes. Observations of bleeding into osseous structures are novel and should inform investigations of new therapies.

Objective: Compare the surgical treatment options available in our institution and the postoperative outcomes during follow-up. Additionally, assess patient’s perception of their condition and its progression. Methods: This descriptive observational study is a case series with a narrative literature review. All patients who met the inclusion and exclusion criteria and received surgical management for ankle arthropathy due to ankle hemarthrosis between 1999 and 2022 at Hospital San José in Bogotá were included. A perception survey was conducted via teleconsultation to evaluate pain control, functional impact, and capacity for daily activities. Results: Fifteen patients were included in the study, 13 male (86.7%). The mean age at the time of surgical intervention was 33 years (range 25–68). Among the patients, eight (53.3%) were diagnosed with Hemophilia A, four (26.7%) with Hemophilia B, two with Von Willebrand disease (13.3%), and one (6.7%) with Factor VII deficiency. The most common surgical intervention was ankle arthroscopy, with nine cases (50%). No infectious or intraoperative complications were documented, but one case of Hemophilic Pseudotumor developed late. The mean follow-up time was 87.7 months (IQR 60–105, SD 56.17). All patients reported improved pain and resumed their daily activities after the surgical intervention. Conclusion: Surgical management, regardless of the technique used (joint preservation or sacrifice), had a positive impact on patients by reducing pain after conservative management failure and allowing them to regain their daily activities, improving their quality of life. Level of Evidence IV; Therapeutic studies - investigating the results of treatment; Case series.

ABSTRACT Objective: To describe the efficacy of using viscosupplementation in patients with hemophilic arthropathy (HA), on pain, limb functionality, and quality of life. Methods: A systematic review of the literature was performed following the PRISMA guidelines without limitations of language or year of publication. The search was performed on the following medical databases: PubMed, Cochrane Library, EMBASE, BVS/BIREME, Scopus, Web of Science, EBSCOhost, and PROQUEST in April 2020. The search used the following word: (hemophilia AND joint diseases) OR (haemophilic arthropathy OR hemophilic arthropathy) AND viscosupplementation. Results: The systematic review identified 127 articles, 10 of which were selected for data extraction and qualitative analysis. The 10 selected articles included 297 joints with HA in 177 hemophilic subjects. Our review showed positive results in alleviating pain and improving functional capacity, and quality of life. No major adverse effects were observed. Conclusion: There is a lack of scientific evidence regarding viscosupplementation with hyaluronic acid, but the results presented in this research suggest that it is an effective and safe therapeutic option to alleviate pain and improve functional capacity in patients with HA. Level of Evidence II, Systematic Review.

The detrimental effects of blood exposure on articular tissues are well characterized, but the individual contributions of specific whole blood components are yet to be fully elucidated. Better understanding of mechanisms that drive cell and tissue damage in hemophilic arthropathy will inform novel therapeutic strategies. The studies here aimed to identify the specific contributions of intact and lysed red blood cells (RBCs) on cartilage and the therapeutic potential of Ferrostatin-1 in the context of lipid changes, oxidative stress, and ferroptosis. Changes to biochemical and mechanical properties following intact RBC treatment were assessed in human chondrocyte-based tissue-engineered cartilage constructs and validated against human cartilage explants. Chondrocyte monolayers were assayed for changes to intracellular lipid profiles and the presence of oxidative and ferroptotic mechanisms. Markers of tissue breakdown were observed in cartilage constructs without parallel losses in DNA (control: 786.3 (102.2) ng/mg; RBC INT : 751 (126.4) ng/mg; P = 0.6279), implicating nonlethal chondrocyte responses to intact RBCs. Dose-dependent loss of viability in response to intact and lysed RBCs was observed in chondrocyte monolayers, with greater toxicity observed with lysates. Intact RBCs induced changes to chondrocyte lipid profiles, upregulating highly oxidizable fatty acids (e.g., FA 18:2) and matrix disrupting ceramides. RBC lysates induced cell death via oxidative mechanisms that resemble ferroptosis. Intact RBCs induce intracellular phenotypic changes to chondrocytes that increase vulnerability to tissue damage while lysed RBCs have a more direct influence on chondrocyte death by mechanisms that are representative of ferroptosis. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine whether there are any differences in morphology between temporomandibular joint ankylosis (TMJA) of traumatic and infective origin. Cone beam computed tomography (CBCT) scans of 25 patients (28 joints) with TMJA of traumatic origin (trauma group) and 15 patients (15 joints) with TMJA of infectious origin (infection group) were included. The following morphological parameters were evaluated on multiple sections of the CBCT scans: lateral juxta-articular bone growth, residual condyle, residual glenoid fossa, ramus thickening, ankylotic mass fusion line, sclerosis of the ankylosed condyle and spongiosa of the glenoid fossa, and mastoid and glenoid fossa air cell obliteration. Lateral juxta-articular bone growth, juxta-articular extension of fusion, and the presence of normal medial residual condyle and residual glenoid fossa were exclusively found in post-traumatic TMJA. There were differences in ramus thickening (82.1% in trauma vs 53.3% in infection), sclerosis of the ankylosed condyle (100% in trauma vs 60% in infection), and sclerosis of the spongiosa of the glenoid fossa (100% in trauma vs 46.7% in infection) between the trauma and infection groups. Mastoid and glenoid fossa air cell obliteration was found more frequently in the infection group (mastoid obliteration: 23.1% in infection vs 4% in trauma; glenoid obliteration: 66.7% in infection vs 55.6% in trauma). CBCT imaging can be helpful in differentiating between TMJA of traumatic and infectious origin. [ABSTRACT FROM AUTHOR]

Aim: Haemophilia is characterized by recurrent joint bleeding caused by a lack of clotting factor VIII or IX. Due to repeated joint bleeding, end‐stage arthropathy occurs in relatively young patients. A total knee replacement (TKR) can be a solution. However, TKR may be complicated by perioperative and postoperative bleeds despite clotting factor therapy. The aim of this study was to evaluate the prevalence of pre‐operative synovial hyperaemia and the effects of Genicular Artery Embolization on synovial hyperaemia and 3‐month postoperative joint bleeding. Methods: In this retrospective cohort study, all patients with haemophilia who underwent periarticular catheter angiography between 2009 and 2020 were evaluated after written informed consent. Synovial hyperaemia on angiography was scored by an interventional radiologist. Results: Thirty‐three angiography procedures in 24 patients were evaluated. Median age was 54.4 years (IQR 48.4–65.9). Preoperative synovial hyperaemia was observed in 21/33 joints (64%). Moderate and severe synovial hyperaemia was observed in 10/33 joints (30%). Synovial hyperaemia decreased in 13/15 (87%) joints after embolization. Three‐month postoperative joint bleeding occurred in 5/32 joints: in 2/18 joints (11%) without synovial hyperaemia and in 3/14 joints (21%) with mild synovial hypertrophy. Non‐embolized and embolized joints did not differ regarding 3‐month postoperative bleeding (P =.425). No complications were observed after embolization. Conclusion: One‐third of patients with haemophilia requiring a TKR had moderate or severe synovial hyperaemia which can be reduced safely by Genicular Artery Embolization prior to TKR. Three‐month postoperative bleeding appears to occur independently of the presence of residual mild synovial hyperaemia. [ABSTRACT FROM AUTHOR]

Abstract Objectives The Joint tissueActivity and Damage Exam (JADE) is a point-of-care (POC) musculoskeletal ultrasound (MSKUS) protocol for non-radiologists to evaluate hemophilic arthopathy. Our aim was to determine the consistency of cross-sectional analyses of direct tissue measurements (JADE protocol) and clinical Hemophilia Joint Health Score [HJHS] and functional joint assessments (arc) at three clinic visits. Methods We prospectively studied adults (n = 44) with hemophilia (A or B) of any severity and arthropathy at 3 North American sites. We assessed HJHS, total arc, and JADE parameters (bilateral elbows, ankles, and knees) at study entry, at ≈12–18 months, and at ≈24–36 months, and used MSKUS to evaluate painful episodes between study visits. JADE measurements included osteochondral alterations, cartilage thickness, and soft tissue expansion at sentinel positions. Associations between joint HJHS and total arc with each JADE variable were examined with random intercept models. Results At each visit increasing HJHS and decreasing total arc were associated in the expected direction with increasing length of OAs and soft tissue expansion in all joints, and decreasing cartilage thickness in the knee. However, HJHS associations with cartilage thickness were U-shaped for elbow and ankle (i.e. cartilage thinning and thickening). Associations between total arc and cartilage thickness followed a similar curve. (Near) normal levels of both joint parameters (HJHS and total arc) were associated with normal ranges of cartilage thickness. JADE views were also helpful to detect hemarthrosis in association with joint pains. Conclusions POC MSKUS applying direct tissue measurements using the JADE protocol provided reproducible cross-sectional associations with joint health outcomes on three visits. These findings advance protocol validation and enable iterative adaptations resulting in JADE protocol version 2.

Hemarthrosis secondary to heparin use is a scarce event, especially in patients with no underlying thrombophilia or platelet disorders. Although previously associated with thrombophilia, platelet disorders, or secondary to fibrinolytic therapy, to date, there are very few reported cases in contemporary literature for heparin-induced hemarthrosis. In this article, we report a case of left shoulder joint inferior subluxation secondary to heparin-induced hemarthrosis in an 81-year-old male with an extensive cardiac history and multiple comorbidities. This case report depicts a rare event and discusses its clinical implications aiding healthcare professionals in an early diagnosis and timely management.

Background: High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are well-recognized treatments to address varus and valgus malalignment, respectively, in the setting of symptomatic unicompartmental arthritis of the tibiofemoral joint. The existing literature is limited in its ability to characterize complications after HTO or DFO procedures. Purpose: The objective of this study was to determine the rate of early (≤90 days) postoperative complications and associated variables from the 15-year experience of a single academic institution. Study Design: Case series; Level of evidence, 4. Methods: Patients treated at a single academic institution between 2008 and 2022 who underwent HTO or DFO procedures were identified. All patients with minimum 90-day follow-up were considered for inclusion in the study. Exclusion criteria were inadequate follow-up, unavailable medical records, age <14 years, and revision osteotomy. Patient demographic characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. All intraoperative complications were recorded. Results: A total of 243 knees in 232 patients met eligibility and were included in the final analysis. Three intraoperative complications (1.2%) involving fracture extension of the osteotomy occurred. There were 127 early postoperative complications (121 surgical, 6 medical) in 102 knees (68 with HTO and 34 with DFO). Medical complications included pulmonary embolus in 3 patients (1.2%), urinary tract infection in 2 patients (0.8%), and postoperative ileus requiring prolonged hospitalization in 1 patient (0.4%). The most common complications were stiffness requiring a non–standard of care intervention (17.7%), superficial wound infection or wound dehiscence (13.2%), and hemarthrosis or effusion requiring aspiration (6.6%). The rate of deep infection requiring irrigation and debridement was 4.1%. Variables associated with early postoperative complications included smoking (odds ratio [OR], 3.05; 95% CI, 1.34-6.94; P =.008), concomitant chondroplasty and/or loose body removal (OR, 2.55; 95% CI, 1.50-4.33; P =.001), and concomitant ligament reconstruction (OR, 3.97; 95% CI, 1.37-11.53; P =.011). Conclusion: These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. Surgeons should be aware of the increased postoperative complications associated with smoking, concomitant chondroplasty, and concomitant ligament reconstruction and should use this information to counsel patients regarding appropriate expectations in the postoperative period. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of prophylaxis with rIX‐FP, a fusion protein linking recombinant factor IX (FIX) with human albumin, on joint outcomes. Methods: Joint outcomes were assessed in pediatric (<12 years) and adult/adolescent (≥12 years) patients receiving rIX‐FP prophylaxis every 7, 10, or 14 days; patients (>18 years) well‐controlled on a 14‐day regimen could switch to a 21‐day regimen. Target joints were defined as ≥3 spontaneous bleeds into a single joint within a 6‐month period. Results: For adult/adolescent (n = 63) and pediatric (n = 27) patients, median (Q1, Q3) annualized joint bleeding rate was 0.39 (0.00, 2.31), 0.80 (0.00, 2.85), 0.20 (0.00, 2.58), and 0.00 (0.00, 1.78) when treated with 7‐, 10‐, 14‐, or 21‐day prophylaxis. 50.0%, 38.9%, 45.5%, and 63.6% of adult/adolescent patients had no joint bleeds when treated with 7‐, 10‐, 14‐, or 21‐day prophylaxis, respectively, and 40.7%, 37.5%, and 37.5% of pediatric patients had no joint bleeds when treated with 7‐, 10‐, or 14‐day prophylaxis. Ten adult and two pediatric patients developed target joints; all resolved by the end of the study. Conclusion: Prophylaxis with rIX‐FP produced low joint bleeding rates and provided excellent hemostatic efficacy in the treatment of joint bleeds. All target joints reported resolved with rIX‐FP prophylaxis. [ABSTRACT FROM AUTHOR]

To compare the metabolic profiles of synovial fluid (SF) from patients with anterior cruciate ligament tears and hemarthrosis (HA) with that of normal controls, using 1H NMR spectroscopy (NMRS). Synovial fluid was collected from eleven patients undergoing arthroscopic debridement within 14 days following an anterior cruciate ligament (ACL) tear and hemarthrosis. Ten additional SF samples were obtained from the knees of osteoarthritis-free volunteers to serve as normal controls. The relative concentrations of twenty-eight endogenous SF metabolites (hydroxybutyrate, acetate, acetoacetate, acetone, alanine, arginine, choline, citrate, creatine, creatinine, formate, glucose, glutamate, glutamine, glycerol, glycine, histidine, isoleucine, lactate, leucine, lysine, phenylalanine, proline, pyruvate, threonine, tyrosine, valine, and the mobile components of glycoproteins and lipids) were evaluated using NMRS and quantified using CHENOMX metabolomics analysis software. Mean differences between groups were evaluated with t -tests controlling for multiple comparisons at an overall error rate of 0.10. Statistically significant increases in the levels of glucose, choline, the branched-chain amino acids leucine, isoleucine, and valine, and the mobile components of N -acetyl glycoproteins and lipids were observed in ACL/HA SF as compared with normal controls; lactate levels were reduced. Marked changes occur in the metabolic profiles of human knee fluid following ACL injury and hemarthrosis, suggestive of increased demand and accompanying inflammatory response; potentially increased lipid and glucose metabolism; and possible hyaluronan degradation within the joint following trauma. [ABSTRACT FROM AUTHOR]

Background: One of the effective methods to control chronic hemophilic synovitis is radiosynovectomy. Rhenium-188 is a new radionuclide, and its half-life is 0.7 day. This study aimed to investigate the effect of radiosynovectomy with Rhenium-188 on the knee joint of hemophilic patients. Methods: Thirty patients with hemophilic synovitis of the knee visited in the orthopedic clinic in 2019 and 2020, entered the study. They all had at least two bleeding per month; in the supine position with slight knee flexion, after local sterilization, 550 to 750 MBq Rhenium-188 was injected into the knee. A splint was installed for five days. The demographic characteristics, radiography, articular line tenderness, joint line tenderness, flexion and extension restrictions, and joint volume characteristics were evaluated before and six months after injection. Results: The amount of monthly injected factors (VIII and IX) 6 months after injection was decreased from 5260.2±1836 units to 3870.83±1106 units (p<0.001). The radiographic classification has not changed within six months. The average knee pain score decreased from 7.3±1.2 to 2.3±1.1, after six months (p<0.001), and knee flexion increased from 84.6±26.22 to 114±21.58 degrees (p<0.001). None of the patients have experienced complications such as skin necrosis or joint infection. All patients have reported that the pain increases 24 hr after the injection were manageable. Conclusion: The use of Rhenium-188 radiopharmaceutical in radiosynovectomy of 30 hemophilic patients' knees is effective in reducing pain, tenderness of the joint line, and the number of bleeding episodes, and it improved knee range of motion in the short term (6 months). [ABSTRACT FROM AUTHOR]

BACKGROUND: Hemophilia is an inherited bleeding disorder that could cause many complications, one of which is hemarthrosis. Neutrophils are the predominant immune cells that infiltrate joints after hemorrhage. Tissue injury is often accompanied by the production of neutrophil extracellular traps (NETs), which are DNA constructs containing attached granular enzymes. AIMS OF STUDY: The aim of this study was to identify the presence of neutrophil extracellular traps including the neutrophil elastase (NE) and myeloperoxidase (MPO), in patients with hemophilia A presented with hemarthrosis. SUBJECTS AND METHODS: During a period of 8 months from November 2022 to June 2023, 50 persons were recruited cross-sectional study was conducted. In the current study, a sample of 25 individuals with hemophilia A presenting with hemarthrosis were included. Additionally, a control group of 25 unrelated, almost healthy persons,matched in terms of age and sex were also included. NE and MPO levels in blood were measured by flow cytometry technique. RESULTS: The level of MPO and NE in the blood was significantly higher in hemophilia A patients than controls. In the results of hemophilia A patients, the mean and standard deviation of MPO were 3253.36 +_1865.48, while for NE it was 5229.08+_2667.43. These values were found to be statistically significant P

Abstract Background The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown. Methods We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and “medical” (joint injections/aspirations, referrals to orthopedics, changes/adjustments of hemostatic plans, and use of oral anti-inflammatory medications) were recorded in relation to POC-MSKUS. Results Forty-four persons [median age 37 years (IQR 29, 51)], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 (IQR 18, 42)] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were “medical”. Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of “medical” decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education. Conclusion Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes.

Objectives Hemophilic arthropathy is the most common complication of severe hemophilia A. This study aims to investigated joint status and related risk factors in patients with severe hemophilia A (PWSHA). Methods This single-center study included 31 patients. Six index joints (both elbows, knees, and ankles) were evaluated using the Hemophilia Early Arthropathy Detection with UltraSound in China (HEAD-US-C) and Hemophilia Joint Health Score (HJHS). Treatment adherence was measured using the Validated Hemophilia Regimen Treatment Adherence Scale-Prophylaxis (VERITAS-Pro). We analyzed the influence of age, treatment delay (the interval between diagnosis and the initiation of treatment), prophylaxis, and treatment adherence on joint outcomes. Results All patients were male (median age, 22 years). The median age at diagnosis was 1 year; that at initial treatment was 5 years. All patients experienced joint bleeding. HEAD-US-C and HJHS scores were positively correlated (R = 0.70, P 1 year treatment delay was close to significant (P = 0.055). HJHS scores were significantly different between these two groups (P = 0.03). Joint assessment scores were not significantly different between on-demand and low-dose prophylaxis groups. VERITAS-Pro scores were correlated with both HEAD-US-C and HJHS scores (P = 0.046 and P = 0.005, respectively). Conclusions Hemophilic arthropathy was pervasive in PWSHA. Age and poor adherence were significantly correlated with joint damage. Prompt treatment and adherence improvement may reduce severity.

The goal of this study is to study the clinical spectrum of hemophiliac children (age

Abstract Background Hemophilia is an inherited condition that is caused by the deficiency of clotting factors in the blood. The most common presentations of hemophilia are hemarthrosis and muscle hemorrhage. The severity of the bleeding episodes can vary from mild to severe resulting in pain and swelling of the joints and the muscles. Repeated musculoskeletal bleeding can result in hemophilic arthropathies with subsequent joint degeneration and deformity. Our study aims to clinically assess the quality of life in hemophilic patients in terms of disease severity and morbidity in our community using the Functional Independence Score for Hemophilia (FISH). Results Our cross-sectional study which involved 64 hemophilia patients revealed that the most affected joints were the weight-bearing large joints (knees, elbows, ankles) and this was associated with a lower FISH score. While the total FISH score showed a significant positive correlation with the factor activity level, the average FISH score was 21.11 ± 4.5, and the score was slightly lower in severe hemophilia compared to mild-moderate disease. Conclusion We concluded that there is a significant decline in the functional ability of hemophilia patients having disease affecting the knee and elbow joints. Moreover, squatting was significantly reduced in patients with severe hemophilia. The quality of patients’ life can be improved by early and regular physiotherapy and regular administration of the prophylactic factor.

Background/Aim: Tranexamic acid (TXA) is known to reduce intra-articular bleeding during arthroscopic procedures, which can improve visibility and reduce postoperative pain and knee joint swelling from hemarthrosis. However, insufficient data supports the routine use of TXA in arthroscopic meniscectomy. This study aimed to evaluate the effect of a single dose of intravenous (IV) TXA on visual clarity in arthroscopic meniscectomy without a tourniquet. Methods: A randomized, double-blind, controlled trial was conducted to assess the use of TXA for visibility in routine arthroscopic meniscectomy without a tourniquet. Between January 2021 and February 2022, 53 patients undergoing arthroscopic meniscectomy were randomly assigned to either the TXA group (n=27), who received 1 g IV-TXA, or the control group (n=26), who received 100 ml of normal saline. Visual clarity was evaluated using a Numeric Rating Scale (NRS). Patients were also assessed for the need for a tourniquet, tourniquet time, total operative time, volume of irrigation fluid, postoperative pain, hemarthrosis, and knee function on postoperative day 3 and weeks 1, 2, and 4, using the Lysholm knee scoring scale. Results: There was no significant difference in intra-operative arthroscopic visibility between the TXA and control groups (P=0.394). Tourniquet was required in three cases in the TXA group and four cases in the control group (P=0.646). There was no significant difference between the two groups regarding postoperative pain, grade of postoperative hemarthrosis, knee motion, or the Lysholm Knee Score after the operation. Conclusion: The administration of IV-TXA in arthroscopic meniscectomy without a tourniquet did not provide any benefits such as enhanced surgical visualization, reduction in the need to inflate the tourniquet due to obstructed visibility, or decrease in hemarthrosis, VAS pain score, or improved range of motion of the knee in the postoperative period when compared to the control group. [ABSTRACT FROM AUTHOR]

Objectives: The Joint tissueActivity and Damage Exam (JADE) is a point-of-care (POC) musculoskeletal ultrasound (MSKUS) protocol for non-radiologists to evaluate hemophilic arthopathy. Our aim was to determine the consistency of cross-sectional analyses of direct tissue measurements (JADE protocol) and clinical Hemophilia Joint Health Score [HJHS] and functional joint assessments (arc) at three clinic visits. Methods: We prospectively studied adults (n = 44) with hemophilia (A or B) of any severity and arthropathy at 3 North American sites. We assessed HJHS, total arc, and JADE parameters (bilateral elbows, ankles, and knees) at study entry, at ≈12–18 months, and at ≈24–36 months, and used MSKUS to evaluate painful episodes between study visits. JADE measurements included osteochondral alterations, cartilage thickness, and soft tissue expansion at sentinel positions. Associations between joint HJHS and total arc with each JADE variable were examined with random intercept models. Results: At each visit increasing HJHS and decreasing total arc were associated in the expected direction with increasing length of OAs and soft tissue expansion in all joints, and decreasing cartilage thickness in the knee. However, HJHS associations with cartilage thickness were U-shaped for elbow and ankle (i.e. cartilage thinning and thickening). Associations between total arc and cartilage thickness followed a similar curve. (Near) normal levels of both joint parameters (HJHS and total arc) were associated with normal ranges of cartilage thickness. JADE views were also helpful to detect hemarthrosis in association with joint pains. Conclusions: POC MSKUS applying direct tissue measurements using the JADE protocol provided reproducible cross-sectional associations with joint health outcomes on three visits. These findings advance protocol validation and enable iterative adaptations resulting in JADE protocol version 2. [ABSTRACT FROM AUTHOR]

Introduction: In chronic diseases, disease‐related distress can impact disease outcomes. Distress and haemophilia‐related distress has been demonstrated in people with haemophilia (PwH). The association of haemophilia‐related distress on disease outcomes among PwH is unknown. Aim: To study the association of haemophilia‐related distress with haemophilia specific outcomes, including adherence to prophylactic therapy, the presence of a target joint, healthcare utilization and work‐impairment. Methods: In a cross‐sectional study, adults with haemophilia A or B were enrolled in a study to validate the haemophilia‐related distress questionnaire (HRDq). In this planned analysis, univariate and multivariate associations between the HRDq total score and disease outcomes were explored. Results: The 114 participants in this analysis were male, mostly with haemophilia A (92%) and severe disease (52%) with a median age of 31.9 years. On univariate analysis, HRDq total score (5‐point change) was associated with the presence of a target joint (P =.002), high healthcare utilization (P =.011), poor adherence (P =.033) and work‐impairment (P ≤.001). After adjustment for age, race, severity and other potential confounders, adherence (aβ 0.33, 95% CI.17,.49) and work‐impairment (aβ 4.69, 95% CI 3.27‐6.1) remained statistically significantly associated with HRDq total score. Conclusion: Haemophilia‐related distress is associated with poor adherence to factor prophylaxis and work‐impairment. The direction of the association (causation) is yet to be determined and requires future study. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the viscoelastic properties of lower-extremity muscles in pediatric hemophilia (FVIII-IX) patients. The study included 20 severe- and moderate-type right-dominant hemophilia patients diagnosed with hemophilia A–B and 20 healthy children. Viscoelastic properties (tone, stiffness, elasticity) of the lower-extremity muscles were measured using a MyotonPRO device. The physical characteristics of the pediatric hemophilia patients (mean age: 11.9 ± 3.95 years) and the control group (mean age: 12.6 ± 3.41 years) were found to be similar. A difference was observed only in the elasticity of the right vastus lateralis (p < 0.05) by means of the viscoelastic properties of the lower-extremity muscles. The results were similar in other muscle groups (p > 0.05). The dominant-side vastus lateralis muscle elasticity (the ability of the muscle to regain its original shape after contraction or removal of an external force) of hemophilia patients was found to be lower compared to healthy children. The fact that 45% of hemarthroses occur in the knee joint and that recurrent bleeding may affect the flexibility of the vastus lateralis, which is the main muscle within the quadriceps muscle group and responsible for the stabilization of the patella, can be associated with the study results.