In 1975, a retrospective study of 27 cases of children and adults with haemophilia and a knee haemarthrosis concluded that aspiration was safe and effective in restoring early joint function in established severe haemarthrosis [57]. The authors noted a gain of extension and an overall increase in range of motion learn more by day 4. Patients who had undergone aspiration returned to normal school and employment within 48 h of the procedure, compared with an average of 3–7 days in-patient hospitalization for cast or traction immobilization in descriptive historical controls. There have been no recent studies of aspiration of haemophilic knee bleeds.

A case report found symptomatic improvement in all five patients who underwent AZD2014 ultrasound aspiration of hip haemarthrosis that failed to resolve on factor

replacement. Factor VIII replacement was given to cover the aspiration, and the authors recommended aspiration of haemarthrosis in this group of patients [58]. Most consensus guidelines recommend physiotherapy following acute haemarthrosis in patients with haemophilia (Table 3). There is, however, no significant evidence to support recommendations for specific interventions. In 1964, Greg outlined the need for rest, elevation, application of an ice pack and immobilization of the joint by positioning on foam, rubber or light plaster of Paris shells [59]. Immobilization was recommended for no more than 5 days, and early active movement was advised to assist in the see more absorption of any residual blood. Skin traction to the lower leg was recommended if the ankle affliction was not too great. The paper advised very careful physiotherapy, initiated

after the end of immobilization and including early quadriceps drill and resistance exercises. The final recommendation was to protect the knee joint for several weeks by crutch walking until the quadriceps muscle was strong enough to stabilize the joint. The application of ice is recommended by consensus guidelines (Table 4) but little is known regarding the safe periods of application, or the relative safety of cryotherapy devices such as the Cryo Cuff™ (DJO, Vista, CA, USA) when used in the home setting by patients suffering from severe haemophilia and related bleeding disorders. There is one observational study providing some evidence that cooling procedures provide symptomatic and possibly therapeutic benefit in treating haemarthrosis. In the study, 12 selected patients with severe haemophilia A or B or type 3 von Willebrand’s disease (VWD, age 5–45 years) used Cryo Cuff™ as part of a PRICE (protection, rest, ice, compression and elevation) regimen [60]. The device was applied for 15 min, repeated every 1–2 h as tolerated.