Bleeding into the joints cause major morbidity in haemophilia patients. The clinical hallmark of haemophilia is haemarthrosis especially in knee, ankle and elbow joint. Current literature suggests that aspiration of an acute haemarthrosis in haemophilia may lead to further bleeding and prevent tamponade effect. But the rehabilitation gets delayed, leading to joint stiffness and the function gets deteriorated.
Abhishek Kumar Rai et al conducted a study to evaluate the efficacy of joint aspiration in the management of acute knee haemarthrosis, with regard to pain relief and functional outcome.
A prospective, randomised controlled trial was done in a tertiary care haemophilia treatment centre (Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, India) comprising 120 haemophilic patients with unilateral acute knee haemarthrosis. Factor level was checked and appropriate factor replacement [40%] was done. The patients were randomly allocated in two groups: Group A and Group B, each consisting of 60 patients. All patients received ice application, limb immobilisation, analgesics, physiotherapy and compression bandage as the routine primary management. In addition, study Group A also received therapeutic aspiration of the knee joint at initial presentation, after the first factor infusion.
Under all aseptic precaution, the joint was disinfected with a chlorhexidine-based antiseptic and covered with a sterile drape. A 18 gauge standard intramuscular needle (0.8 × 40 mm) was used with 10 or 20 mL syringes. A lateral suprapatellar approach was selected. The patient was placed in the supine position, with the knee held in extension to relax the extensor mechanism. The needle was inserted 2 cm proximally and 2 cm laterally to the superolateral angle of patella and advanced to the bottom of the suprapatellar pouch, pointing towards the medial malleolus of the opposite limb. The quantity of aspirate varied in all patients as per the age and severity. The aspirated fluid was discarded. In those cases, where it was difficult to aspirate through superolateral approach, other approaches were tried. In cases of fixed flexion deformity of knee, inferomedial and inferolateral approaches were preferred.
All patients were clinically evaluated for pain in terms of Visual Analogue Scale (VAS score) and function in terms of Haemophilic Joint Health Score [HJHS], before and at 4 h, 48 h and 7 days after initial factor administration.
Key findings of the study:
• All patients showed therapeutic improvement in terms of a declining trend in VAS and HJHS scores.
• Pain relief (VAS Score) in Group A, was found to be significantly better compared to Group B at the end of 4 h [4.80±0.49 vs 6.54±1.05; p<0.001],48 h [2.48±0.50 vs 3.30±0.46; p<0.001], and 7 days [2.36±0.48 vs 5.52±0.67; p<0.001].
The authors said – “Our study recommends the use of joint aspiration as a therapeutic tool in the holistic management of acute knee haemarthrosis in addition to usual treatment of ice application, immobilization and physiotherapy in addition to requisite factor correction. Early factor replacement along with therapeutic joint aspiration is a key for better pain relief and a better functional outcome.”
Outcome of Joint Aspiration in Acute Knee Haemarthrosis in a Haemophilic Joint: A Prospective Randomised Controlled Trial in 120 Patients in a Tertiary Haemophilia Care Centre
Abhishek Kumar Rai, Shubhranshu Shekhar Mohanty et al
Indian Journal of Orthopaedics