Acute Hemarthrosis Research Articles

Optimizing outcomes for patients with severe haemophilia A

Haemophilia A is an inherited, sex-linked disorder inwhich coagulation factor VIII (FVIII) is deficient orabsent [1]. The hallmark of the severe form of thedisease, defined as plasma FVIII level of <1% ofnormal [2], is early, recurrent bleeding into softtissues and joints [3]. Intra-articular bleeding (haem-arthrosis) accounts for more than 90% of all seriousbleeding events in patients with severe haemophilia,and 80% of these bleeds involve the knees, elbowsand ankles [1]. An acute haemarthrosis is typified byrapid joint swelling that may be preceded by aprodrome of tingling, stiffness and pain (Fig. 1)[4,5]. Recurrent bleeding over time into the samejoint (a target joint) results in progressive jointdamage and the development of haemophilicarthropathy, characterized by synovial hypertrophy,cartilage damage, loss of joint space and bonychanges (Fig. 2) [6,7]. Decreased use of a target jointleads to ongoing muscle atrophy, ankylosis, osteo-porosis, bone cysts, and eventually, crippling arthri-tis by young adulthood [3,7].Thedevelopmentofarthropathyisdirectlylinkedtothe number of joint bleeding episodes [8,9]. In thelandmark Orthopaedic Outcome Study, which en-rolled 378 patients with severe haemophilia A,Aledortet al.reportedthePetterssonradiologicscoresincreased 1 point for every 40 joint bleeds [8]. Asubsequent evaluation by Fischer et al. of 117 severehaemophiliapatientsfoundthatfarfewerbleeds–just13 – were necessary to cause a 1 point increase in thePettersson score [9]. Yet even this lower number maybe an overestimate. A major limitation to the use ofplain film radiographs as a tool for assessing arthro-pathy is their ability to visualize only gross arthriticalterations [1]. When magnetic resonance imaging(MRI) was performed on children with haemophiliawho had no obvious clinical signs of arthropathy,early changes in the soft tissues (e.g., synovium andcartilage) were demonstrated [1]. These MRI findingsindicate that incipient joint damage may occur aftervery few bleeding episodes.On-demand therapy (episodic factor replacementin response to acute bleeding events), while effectivein controlling acute haemorrhage, cannot halt theongoing joint destruction many patients with severehaemophilia A experience [10]. An epidemiologicsurvey conducted by the French Study Group of 116haemophilia patients treated almost exclusively frombirth with on-demand therapy found that at a meanage of 23 years, only 3.7% had normal joints byradiographic examination and 54.3% had undergoneorthopaedic procedures [11]. Similarly dismal long-term outcomes were reported by Blanchette. Amongpatients with severe haemophilia managed in Canadawith on-demand therapy, approximately 50% hadevidence of joint disease by age 13 years; and by age18, 24% of the 54 patients had undergone surgicalsynovectomy of at least 1 joint [12].For children with severe haemophilia A and noevidence of inhibitors, the musculoskeletal compli-cations that follow repeated joint bleeding can beeffectively prevented with the early initiation ofprophylaxis, the routine scheduled replacement ofFVIII with the goal of maintaining FVIII trough

The impact of joint bleeding and synovitis on physical ability and joint function in a murine model of haemophilic synovitis

Haemophilia is a congenital disorder that commonly results in musculoskeletal bleeding and orthopaedic complications. After an acute joint haemorrhage, an increase in intra-articular pressure and inflammation cause pain, swelling and limited motion. Blood in the joint space provokes a proliferative disorder known as haemophilic synovitis. Overgrowth of the synovial membrane causes mechanical dysfunction. Eventually, there is destruction of the articular surface and underlying bone. The aim of this project was to test the hypothesis that a minimum number of haemarthroses negatively impacts on joint function and that this would be reflected by decreased physical performance of experimental animals. Mice deficient in factor VIII coagulant activity were trained to ambulate on a rotating rod then injured three times at weekly intervals. Their ability to walk was then compared to a group of uninjured mice. Cohorts of mice were killed after 1, 2 or 3 months and the knee joints examined by gross and histological methods. The results supported the following conclusions: (i) haemophilic mice can be trained to ambulate on a rotating rod; (ii) acute hemarthrosis temporarily impairs their ability to ambulate and (iii) following recovery from acute injury, mice developing synovitis demonstrated inferior physical ability compared to mice not developing synovitis. This is the first description of a quantitative assay to monitor joint function in experimental animals and should be useful to evaluate the efficacy of new therapies developed to prevent and treat bleeding and to test strategies to counter the devastating effects of synovitis.

Identifying and overcoming barriers to prophylaxis in the management of haemophilia

Haemophilia is often characterized by acute haemarthrosis and synovitis arising from spontaneous bleeding episodes, particularly in the muscles and joints of the elbows, knees and ankles. Current treatment for patients with severe haemophilia involves coagulation factor concentrate (CFC) replacement therapy given on demand at the time of bleeding or through long-term prophylaxis aimed at preventing future bleeds and joint disease. Although prophylaxis has many advantages over on-demand therapy (particularly if started before age 2 and prior to any signs of joint disease), its practice varies widely even among developed countries because of several barriers. Such barriers include CFC costs and availability; patient perceptions, lifestyles and bleeding patterns; difficulties and complications arising from the use of intravenous access devices (IVADs); the development of inhibitors; and the lack of randomized clinical trials. These barriers can be overcome by tailoring treatment regimens according to individual patient bleeding patterns and CFC pharmacokinetic profiles, using IVADs selectively and judiciously, helping patients maintain normal weight and physical exercise and providing the families of patients with continuous support from healthcare providers.

A Case Report of Cyclops Syndrome Occurred with Acute Knee Hemarthrosis after ACL Reconstruction

A Case Report of Cyclops Syndrome Occurred with Acute Knee Hemarthrosis after ACL Reconstruction

Short‐term oral corticosteroid therapy for acute haemarthrosis in haemophilia patients with high‐titre inhibitors

Treatment of acute bleeding events is unsatisfactory in patients with haemophilia and high-titre factor VIII (FVIII) inhibitors. In order to determine whether short-term corticosteroid therapy enhances resolution of the signs and symptoms of acute haemarthrosis, we performed a randomized, double-blind, placebo-controlled study in children with FVIII deficiency and high-titre inhibitors receiving Factor Eight Inhibitor Bypass Activity (FEIBA) for acute haemorrhagic events. At each haemarthrosis, patients were randomized to receive either prednisolone 2 mg kg(-1) day(-1) or placebo-divided t.i.d. for 2 days (six doses) in addition to FEIBA. The primary endpoint was the number of subsequent doses of FEIBA required. The effect of the study medication was also assessed subjectively by patients or parents, by physical examination and by repeated haemorrhages into the joint. During the study period, seven patients were enrolled with 45 evaluable events, 24 treated with prednisolone and 21 with placebo. An average of 2.08 and 1.86 doses of FEIBA were infused in the prednisolone- and placebo-treated patients, respectively. By Wilcoxon Rank Sum Test, there was no statistically significant difference in number of additional infusions of FEIBA or duration of symptoms between the corticosteroid and placebo arms. We conclude that there is no significant benefit of a 2-day course of oral corticosteroids as adjunctive therapy for haemarthrosis in patients with haemophilia and a high-titre inhibitor.

In vitro multipotentiality and characterization of human unfractured traumatic hemarthrosis‐derived progenitor cells: A potential cell source for tissue repair

Mesenchymal progenitor cells (MPCs) are a very attractive tool in the context of repair and regeneration of musculoskeletal tissue damaged by trauma. The most common source of MPCs to date has been the bone marrow, but aspirating bone marrow from the patient is an invasive procedure. In an attempt to search for alternative sources of MPCs that could be obtained with minimal invasion, we looked into traumatic hemarthrosis of the knee. In this study, we determined whether a population of multipotent MPCs could be isolated from acute traumatic knee hemarthrosis in the absence of intra-articular fractures. Mononuclear cells were isolated from the aspirated hemarthrosis by density gradient separation, and cultured. We were able to obtain plastic adherent fibroblast-like cells from the mononuclear cell fractions. Flow cytometry analysis revealed that the adherent fibroblast-like cells were consistently positive for CD29, CD44, CD105, and CD166, and were negative for CD14, CD34, and CD45. These were similar to control bone marrow stromal cells. These cells could differentiate in vitro into osteogenic, adipogenic, and chondrogenic cells in the presence of lineage-specific induction factors. In conclusion, acute unfractured traumatic hemarthrosis of the knee contains MPCs with multipotentiality. Because knee hemarthrosis is easy to harvest with minimal pain and without unnecessary invasion, we regard hemarthrosis-derived cells as an additional progenitor cell source for future tissue engineering and cell-based therapy in knee injuries.

Rapid leukocyte activation following intraarticular bleeding

The study aims at elucidating the leukocyte activation in the joint fluid of patients with acute traumatic hemarthrosis. Paired samples of peripheral blood and articular effusions after an acute hemorrhage were obtained from 22 patients. Leukocytes were separated and stained with fluorescein isothiocyanate (FITC)-conjugated mouse anti-human CD11a, CD18, and CD97 monoclonal antibodies for flow cytometry. The reactive oxygen species (ROS) production of leukocytes in corresponding samples of peripheral blood and joint effusion was measured via luminol dependent whole blood chemiluminometry. Significant decrease of CD11a density on monocytes, but markedly enhanced expression of CD97 and CD18 on polymorphonuclear neutrophil granulocytes (PMN), and significantly increased proportion of CD97 positive lymphocytes were found in the joint fluids as compared to the corresponding peripheral blood samples. Moreover, significantly decreased lag time and elevated rate of ROS production were revealed by chemiluminometry in case of joint derived leukocytes. Our results provide good evidence for intraarticular leukocyte activation during acute hemarthrosis. Since the activation precedes synovial inflammation, it is suggested that the leukocytes play an important role as an initiator in the pathogenesis of acute hemarthrosis.

Impact of Joint Bleeding on Joint Function in a Murine Model of Hemophilia A.

Hemophilia is a congenital bleeding disorder that commonly results in musculoskeletal complications due to recurrent bleeding into joints. After an acute joint bleed, there is pain, swelling and limited motion due to the increase in intra-articular pressure and inflammation. Blood in the joint space provokes a proliferative and inflammatory disorder known as hemophilic synovitis (HS), which causes mechanical dysfunction and eventually destruction of the articular surface and bone. Among persons in the USA with severe hemophilia, nearly half have some restriction in activity (Evatt 2004) and it is estimated that 73% of boys enter adolescence with arthropathy and between 13–16 years of age, two or more major joints are affected (Brackmann,1992). Detail examination of the earliest changes in joint function following 1–3 joint hemorrhages is difficult to perform in patients. In this project, a murine model of HS (Valentino,2004) was used to examine the impact of a minimum number of hemarthrosis on joint function. The hypothesis tested was that there is a relationship between hemarthrosis and joint dysfunction. It was expected that joint dysfunction would be observed following few bleeds. Also, it was expected that a single hemarthrosis will result in permanent joint dysfunction. To test these hypotheses, 25 mice deficient in factor VIII coagulant activity were injured, times three, at weekly intervals to induce hemarthrosis then their ability to ambulate monitored using a Rotorod: Economex apparatus, which is intended for testing coordination and impairment of locomotor agility of laboratory animals. Mice were trained to ambulate on the rotating rod then injured and retested 2, 4 and 7 days after each hemarthrosis. A 2nd group of 25 mice was not injured and served as controls. At the conclusion of the experiment, mice were sacrificed and the knee joints examined by gross and histological methods. Correlations were drawn between the ambulatory dysfunction and the pathological changes observed. Preliminary data showed:mice can be trained to ambulate on the Rotarod,acute hemarthrosis temporarily impairs their ability to ambulate, andafter mice recover from acute injury they regain their lost ability to ambulate to the point that their performance is better than previous.

Rofecoxib as adjunctive therapy for haemophilic arthropathy

Joint haemorrhage and subsequent haemophilic arthropathy are significant complications in haemophilia. The pathophysiology involves inflammation and angiogenesis. Cyclooxygenase-2 (COX-2) inhibitors are anti-inflammatory agents, which have potent anti-inflammatory, anti-angiogenic and analgesic properties yet do not affect platelet function in the manner of traditional non-steroidal anti-inflammatory drugs. These properties make such agents potentially useful as adjunctive therapy in haemophilia. There is only one prior report describing rofecoxib treatment in a single haemophilia patient. Our objectives were to determine the safety and efficacy of rofecoxib in treating acute haemarthrosis, chronic synovitis, target joints and pain. We conducted a retrospective medical record review of patients treated with rofecoxib for acute haemarthrosis, chronic synovitis, target joint or pain. The safety and efficacy of rofecoxib treatment were determined based on subjective patient reports and physical examinations during follow-up clinic visits. A total of 28 patients between 3 and 37 years of age were treated for a total of 42 courses of rofecoxib treatment. All courses were evaluated for safety and 31 for efficacy. Rofecoxib was used for eight acute haemarthrosis, four target joints, seven cases of synovitis and 12 episodes of pain. Efficacy was demonstrated particularly for chronic synovitis and pain and no serious adverse events occurred. This is the largest study to date evaluating COX-2 inhibitors as adjunctive therapy in haemophilia and suggests that these agents may be an important adjunctive therapy in the management of haemophilia.

The Use of Rofecoxib (Vioxx) in the Treatment of Hemophilia.

BACKGROUND: Joint hemorrhage and subsequent hemophilic arthropathy are significant complications in hemophilia. The pathophysiology of joint damage in such patients involves inflammation and angiogenesis. Cyclooxygenase 2 (COX-2) inhibitors are anti-inflammatory agents approved for use in osteoarthritis and rheumatoid arthritis and have potent anti-inflammatory, anti-angiogenic and analgesic properties yet do not affect platelet function in the manner of traditional NSAIDs. These properties make such agents potentially useful as adjunctive therapy in hemophiliacs. There is only one prior report of rofecoxib treatment in a single hemophiliac patient.METHODS: A retrospective chart review was conducted of all patients with hemophilia A or B seen at the Children's Hospital of Orange County and treated with rofecoxib for acute hemarthrosis, chronic synovitis, target joint or pain. The safety and efficacy of rofecoxib treatment was determined based on information gathered from follow-up clinic visits, physical therapy examinations and nursing notes. Efficacy in hemarthrosis was determined by comparing consecutive bleeds treated without and with rofecoxib and judged subjectively as effective, partially effective or ineffective. Efficacy for chronic synovitis and pain was judged subjectively as above. Efficacy in resolution of target joints was judged as effective if the target joint resolved or ineffective if it did not resolve.RESULTS: A total of 30 patients between 3–40 years of age (26 FVIII deficiency, 4 FIX deficiency, 4 inhibitor patients) were treated for a total of 42 courses of rofecoxib treatment. All courses were evaluated for safety and 31 for efficacy. Rofecoxib was used for 8 acute hemarthroses, 4 target joints, 7 patients with chronic synovitis and 12 episodes of pain (see tables). Dosing regimens were chosen empirically. In most cases patients ≥ 10 years received 25 mg dose and children < 10 years were given 12.5 mg. For pain, patients were treated as needed and for acute hemarthrosis, patients were treated for 5 days. For chronic synovitis, patients were treated daily for 30 days and continued indefinitely if improvement was noted. For target joints, patients were treated until resolution or until no response was noted. A total of 2 bleeding events were noted including a mouth bleed and an episode of hematuria. None of the events led to significant complications and all resolved.Treatment of acute hemarthrosis with factor alone versus factor and rofecoxibEfficacyFactor AloneFactor + rofecoxibIneffective1 (8%)0 (0%)Partially Effective3 (23%)2 (25%)Effective9 (69%)6 (75%)Efficacy of rofecoxib in the management of target joints (along with factor therapy), chronic arthritis and pain in hemophilia patientsEfficacyTarget JointChronic SynovitisPainIneffective2 (50%)0 (0%)0 (0%)Partially EffectiveN/A2 (28.5%)1 (8%)Effective2 (50%)5 (71.5%)11 (92%)Note: Efficacy judged subjectively by patient and physicians as ineffective, partially effective or effective. Target joints judged subjectively as ineffective or effective.CONCLUSION: This is the largest study to date evaluating COX-2 inhibitors as adjunctive therapy in hemophilia. This study demonstrates that rofecoxib is safe and resulted in only 2 bleeding events that were mild and not definitively related to the medication. Importantly, it was found to be very effective in the management of chronic synovitis and joint pain. It may be useful as adjunctive therapy in the management of acute hemarthrosis and target joints. Further studies are needed to confirm both safety and efficacy.

Isolated ruptures of the supraspinatus muscle.

We rarely encounter isolated ruptures of the supraspinatus muscle. At the Clinic of Orthopedics at the Faculty Hospital in Olomouc, we encountered only 21 cases out of 385 arthroscopic operation cases from October 1998 to October 2003. The patients were examined by USG, 5 patients were examined arthrographically and 3 patients underwent MRI examination. Of these 21 patients, only 3 were operated for acute post-injury haemarthrosis of the shoulder joint. During arthroscopic operation, an isolated rupture of the supraspinatus muscle was discovered in all these patients. The remaining 40 patients were only treated at our clinic for problems associated with impingement syndrome after an interval of 3-11 months and were indicated for operational therapy for the rupture of the supraspinatus muscle, verified sonographically and by MRI. Surgically we performed end to end sutures in 12 patients, in 9 cases we performed refixation using 1-2 titanium MITEK anchors. We supplemented the work by a detailed anatomical study of the supraspinatus muscle on 27 cadaverous anatomical preparations. It was noted that the supraspinatus muscle may be divided into three parts, with a superficial and deep layer of muscle fascicles. An aponeurotic insertion tendon runs through the center, to which part of the superficial muscle fascicles are attached. The muscle fascicles, including the central attachment tendon, run across the superior margin of the shoulder joint and by broad tendon are attached to the superior surface of the greater tubercle of the humerus. Together with the long head of the biceps muscle, they act as a significant shoulder stabiliser. The authors believe that due to the course of the muscle fascicles, this muscle acts as a significant shoulder stabiliser and a powerful abductor and elevator in the shoulder joint. The inferior portion of the muscle fascicles acts as an external rotator of the shoulder.

Desmopressin (DDAVP) and factor VIII

Desmopressin (DDAVP) and factor VIII

Acute traumatic hemarthrosis of the knee. Is routine arthroscopic examination necessary? A study of 320 consecutive patients.

Distortions and contusions of the knee are common. Fairly often they will result in hemarthrosis. The purpose of this study was to evaluate the findings in patients with acute traumatic hemarthrosis of the knee and based on these findings estimate the necessity of acute arthroscopic examination. A total of 320 patients were examined arthroscopically between the years 1994 to 96 in the Turku University Hospital. Patients with other than chondral or osteochondral fractures were excluded. The most common arthroscopic findings were rupture of the ACL (45%), dislocation of the patella (23%) and meniscal tear (21%). In only 113 (35%) cases an immediate therapeutic procedure was performed in addition to the arthroscopic examination. Based on our findings we believe that routine arthroscopic examination is not necessary in patients with acute traumatic hemarthrosis of the knee. In our opinion the patient should be examined and followed by an orthopedic surgeon and if a lesion requiring operative treatment is diagnosed or suspected, an arthroscopic examination should be scheduled. The timing of the procedure should be such that all possible lesions encountered can be treated in the same operation.

Partial tears of the anterior cruciate ligament in children and adolescents.

The functional outcome after partial anterior cruciate ligament tears in children and adolescents treated without reconstruction has not been established. Nonreconstructive management of partial anterior cruciate ligament tears can be effective in certain pediatric patients. Prospective cohort study. We studied 45 skeletally mature and immature patients 17 years of age or less who had an acute hemarthrosis, magnetic resonance imaging signal changes, grade A or B Lachman and pivot shift result, and an arthroscopically documented partial anterior cruciate ligament tears. All patients were treated without reconstruction, underwent a structured rehabilitation program, and were followed up for a minimum of 2 years. Fourteen patients (31%) underwent subsequent reconstruction. Significant associations with subsequent reconstruction included tears that were greater than 50%, predominantly posterolateral tears, a grade B pivot shift test result, and older chronologic and skeletal age. Among patients who did not require reconstruction, those with tears that were greater than 50% or predominantly posterolateral had significantly lower Lysholm, satisfaction, and Cincinnati Knee Scale scores. Nonreconstructive management is recommended for partial anterior cruciate ligament tears in children and adolescents 14 years of skeletal age or younger with normal or near-normal Lachman and pivot shift results. Reconstruction is recommended in older athletes or in those with greater than 50% or predominantly posterolateral tears.

A Tincture of Time Is Not Always the Best Answer for Partial Tears of the Anterior Cruciate Ligament

Injury of the anterior cruciate ligament (ACL) is found in 10% to 65% of children with acute hemarthrosis of the knee. Investigators evaluated functional outcomes in 45 skeletally mature and immature patients aged 17 or younger who had arthroscopically documented partial ACL tears and who were medically managed without reconstruction. The patients had acute …

Anterior cruciate ligament rupture and management

Anterior cruciate ligament rupture is a common knee injury in young people. It is the commonest cause of an acute haemarthrosis following trauma. Acute management involves aspiration, the restoration of full movement, followed by muscle rehabilitation. The long-term natural history of non-operative management is usually a failure to return to high level sports and in most, symptomatic instability with secondary meniscal and chondral injury. The late outcome is that of premature degenerative arthritis. Reconstructive techniques are now advanced and minimally invasive. However, considerable technical skill and experience is required to avoid complications. Physiotherapy guided rehabilitation over 4-6 months is vital prior to a return to sport. The stabilised knee should reduce secondary injury and progressive degenerative disease. In the future an increased number of reconstructions, tissue engineered grafts and accelerated healing will probably be seen.

Management of injuries to the anterior cruciate ligament: results of a survey of orthopaedic surgeons in Canada.

To identify the approaches to management of anterior cruciate ligament (ACL) injury by Canadian orthopedic surgeons. A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following information: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how patients in any of three common ACL injury scenarios would be managed; 3) what variations exist in surgical technique; and 4) how patient variables such as age, gender, and alignment influence the decision-making process. The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely managed by 80% of the respondents. The diagnosis of acute hemarthrosis is predominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competitive athlete with a complete ACL tear, 64% would recommend reconstruction and 33% would recommend bracing and rehabilitation. For reconstruction, 59% would use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use hamstring tendon autograft; 40% would incorporate the ACL stump during reconstruction. Of the respondents, 77% would advocate ACL reconstruction for competitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B autograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synthetic augmentation would be used by 12% in chronic cases and by 16% in acute cases. In making the decision to perform ACL reconstruction, 53% consider limb alignment to be important and 67% consider moderate patellofemoral pain to be important. Seventy-one percent are influenced by patellofemoral pain when choosing a surgical technique, with a trend toward semitendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old child with an acute ACL injury, 63% of the respondents would recommend rehabilitation and bracing. For the 14-year-old, 45% would recommend rehabilitation and bracing and 37% would recommend ACL reconstruction after physeal closure. The results of the survey indicate that, with respect to some of the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and randomized, controlled clinical trials should be directed toward these areas.

Anterior cruciate injuries in the skeletally immature athlete: a review of treatment outcomes.

The documentation of anterior cruciate ligament (ACL) injuries in the skeletally immature athlete has significantly increased over the past decade, primarily due to increased awareness of these injuries within this younger athletic population. The evaluation of these injuries are similar to that in the adult population. Diagnostic studies such as plain radiographs, as well as magnetic resonance imaging, can delineate the location of the ACL failure. Physical presentation most commonly includes an acute haemarthrosis and ligamentous insufficiency. Several studies have demonstrated that the diagnostic reliability of the physical examination is poor in children, especially in patients less than 12 years old. The site of ACL failure in this adolescent population is most commonly at the tibial insertion. We recommend arthroscopic or arthroscopically assisted open reduction and internal fixation with nonabsorbable sutures for all displaced tibial eminence fractures. Mid-substance ACL failures also occur in this athletic age group. The association of meniscal injuries with these ACL failures appears to be greater than 50%. Historically, poor subjective and objective outcomes have been associated with primary and extra-articular repairs. Intra-articular reconstruction is the gold standard. The issue of placing the graft across open physeal plates is under investigation. Recent animal studies as well as human clinical series have demonstrated safety in placing soft tissue, i.e. hamstring grafts, across open growth plates without subsequent angular or leg length discrepancy. Historically, non-operatively treated ACL failures are associated with poor functional outcomes as well as a high incidence of meniscal re-injury. If the treatment of an adolescent athlete with an ACL failure is to be rehabilitation until skeletal maturity, close follow-up is essential to detect functional instability, which may prompt earlier surgical reconstruction.

#408 Short-term oral corticosteroid therapy for acute hemarthrosis in hemophiliacs with high titer inhibitors

#408 Short-term oral corticosteroid therapy for acute hemarthrosis in hemophiliacs with high titer inhibitors

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Magnetic resonance imaging in acute knee haemarthrosis.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Magnetic resonance imaging in acute knee haemarthrosis.