The rationale of selecting one reference surface only was based on the evidence that the diffuse establishment of osteochondral damage in haemophilic arthropathy may allow one surface to be considered as representative of the overall status of the joint without significantly reducing the sensitivity

of the method. This also keeps the HEAD-US method reliable, easy and quick to perform. The protocol can be accomplished with portable ultrasound machines without any need for high-end or proprietary technology. An additive scoring scale has also been implemented as part of the HEAD-US method [47]. Generally speaking, MRI scoring scales have been widely used and approved as reference standards in haemophilia arthropathy trials, although rarely applied in clinical practice for diagnosis and outcome because of their complexity and extensive time requirements. In Trametinib concentration addition, it is difficult to harness the large selleck compound amount of information generated by MRI into effective information to influence a patient’s management. Similarly,

the existing ultrasound protocols are somewhat complex, with only trained readers potentially able to get an acceptable level of reproducibility. These existing protocols include the evaluation of poorly relevant structures or give an incomplete estimation of osteochondral damage compared with the potential offered by the HEAD-US technique. The HEAD-US scoring method has been specifically designed to be relatively simple and quick to complete in a busy practice allowing, at the same time, a reliable quantification of the two domains of disease: activity and damage. In contrast to other ultrasound scoring scales available, Doppler imaging has not been included due to the high inter- and intra-observer variability of results expected from inexperienced examiners, the need for high-end machines to get better performance and the lack of any evidence that hyperaemia detection

in chronic synovitis may impact the management of patients with haemophilia. We would expect the use of ultrasound as part of routine clinical examination by haemophilia specialists to optimize the diagnostic workflow, avoiding additional costs and long waiting lists for patients referred to imaging departments. Preliminary clinical experience with the integrated use of ultrasound in routine clinical assessment has made it feasible to screen learn more six joints in a single examination, and has enabled detection of subclinical bleeds and initial asymptomatic damage in an unexpectedly high percentage of cases. Especially in children, who have hyperlax joints and an immature skeleton, ultrasound has proved able to disclose severe joint involvement with high-grade synovitis and chondral abnormalities, despite a normal physical examination. The information on early joint involvement provided by ultrasound could guide the clinical management of haemophilia by influencing prophylaxis regimen decisions on a personalized basis in the future.