Radiologist-Performed Musculoskeletal Ultrasound (MSKUS) for Evaluation of Joint and Soft Tissue Pain Episodes in Patients with Bleeding Disorders
Authors: Mahajan Anjlee , Tobase Patricia , Phelps Andrew , Phelan Darcy , Lesh Mary B. , Giermasz Adam 
Published: October 2019

Abstract
Background: Joint and soft tissue bleeds are a significant cause of morbidity in patients with bleeding disorders leading to disabling arthropathy and significant economic burden related to treatment. In clinical practice, due to the lack of readily available imaging, providers often diagnose bleeds based on patient's symptoms and empirically prescribe clotting factor concentrate. Point of care musculoskeletal ultrasound (MSKUS) has been shown to be a valuable tool in evaluation of painful episodes in patients with bleeding disorders (Ceponis et al. 2013; Kidder et al. 2015). However, operator error and existing pathologies, excluding acute intra-articular or intramuscular bleed, can be challenging for non-radiologist trained providers. In this study we evaluate the use of radiologist-performed MSKUS for the diagnosis and follow up of joint and soft tissue pain episodes in pediatric and adult patients with bleeding disorders.
Methods: Retrospective chart review was performed for patients with bleeding disorders who presented with pain symptoms suspicious for joint or soft tissue bleeds at the University of California, San Francisco Hemophilia Treatment Center between April 2012 and June 2015. All sonography was performed by radiologists trained in musculoskeletal imaging. Data was abstracted and placed in a secure web-based database that includes demographic, laboratory, imaging and clinical information for each patient.
Results: Forty-eight individual patients (44 with Hemophilia, 4 with von Willebrand Disease or other platelet disorders) and 69 musculoskeletal ultrasounds (40 joint and 29 soft tissue) were included in this study. Sixty-four ultrasounds were done to evaluate acute episodes of pain and five were done for chronic pain. Of the 69 evaluations, 28 (40.6%) were radiologist confirmed bleeding episodes. Forty-one (59.4%) ultrasounds did not confirm bleeds and of these, 10 (24%) showed other findings related to inflammation including synovitis, arthritis, tendonitis, bursitis, and cellulitis. The application of other interventions (antibiotics, systemic steroids or steroid injections, non steroidal anti-inflammatory medication, physical therapy and orthopedics referrals) occurred in 19 of the 41 (46%) patients. Serial ultrasounds were performed in 12 patients with confirmed bleeds; this series included 6 serial MSKUS evaluations of a patient with a large intramuscular bleed of the thigh (Figure 1).
Conclusion: This is the first study to our knowledge to evaluate the use of radiologist-performed musculoskeletal ultrasound imaging in the diagnosis and treatment of painful joint and soft tissue episodes in pediatric and adult patients with bleeding disorders. Our study highlights the importance of ultrasound in the evaluation of patients with bleeding disorders as it is often a more accessible imaging modality as compared to MRI or CT. By collaborating with our Radiology Department we were able to not only verify bleeds and mitigate the cost of treatment, but also discover unexpected pathology that changed management of painful episodes. A prospective study is planned to better characterize the duration of painful episodes as correlated with ultrasound findings. Future studies are necessary to evaluate the economic and quality of life impact of the clinical use of MSKUS in patients with bleeding disorders.
Figure 1. Hematoma volume measured by serial MSKUS for a patient with severe hemophilia A. Figure 1. Hematoma volume measured by serial MSKUS for a patient with severe hemophilia A.

Disclosures
Tobase: Bayer Health: Consultancy, Honoraria. Lesh:Biogen: Membership on an entity's Board of Directors or advisory committees. Giermasz:Bayer Health: Membership on an entity's Board of Directors or advisory committees; Biogen: Membership on an entity's Board of Directors or advisory committees; Alexion: Membership on an entity's Board of Directors or advisory committees; BaxAlta: Membership on an entity's Board of Directors or advisory committees.