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How to manage bleeding of the knee due to haemophilia?

Q: My 9-year-old son has haemophilia [F-VIII deficiency). He has injured his knee several times, due to which it has become very weak. What should we do? Our family doctor advised to inject some fluid in his knee, which will make it secure. Please advise.

A:Bleeding into major joints is seen in 70-80% patients with knee joint being involved in nearly 45% patients. Once a joint develops recurrent bleeding episodes, chronic changes occur. These changes affect all of the tissues within and surrounding the joint including synovium, cartilage, capsule, ligaments, bone and muscles. Chronic synovitis is usually seen in the first and second decades of life while chronic hemophilic arthropathy develops over a period of time. The goal of treatment is to improve joint function and relieve pain and this depends on the stage of the condition, symptoms and cost of procedure. Supervised physiotherapy is a very important part of management of this stage with pain being controlled with appropriate analgesics. It is preferable to avoid narcotics and the use of certain COX-2 inhibitors is advocated. Other conservative techniques include serial casting to assist in correcting deformities and bracing and orthotics to support painful and unstable joints. Surgical intervention is done if pain continues and there is functional impairment. This may include Synoviorthesis, Extra-articular soft tissue release to treat contractures, Arthroscopy to release intra-articular adhesions and correct impingement, Osteotomy to correct an angular deformity and Prosthetic joint replacement for severe disease involving a major joint (knee, hip, shoulder). Total knee replacement in hemophiliacs is quite an anatomical challenge but the mechanical survival is quite good. However, the prevalence of infection after the total knee replacements is high and its prevention substantially improves the long-term outcome of total knee replacements. This surgery is available in most major hospitals in metros but the cost will vary from place to place. You may contact hemophilia federation of India who might be able to help.

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