Hyaluronic acid, a major constituent of connective tissue, can be delivered transdermally when it is Rucaparib hydrolysed by the positive-charged enzyme hyaluronidase [49]. A single study including 500 patients with haemophilia concluded that hyaluronidase iontophoresis was a useful adjunctive treatment of both haemarthrosis and haematomas [50]. Caution is, however, recommended until further studies demonstrate the safety of this technique, because hyaluronidase is indiscriminate in breaking down the intercellular ground substance matrix and may therefore damage cartilage by opening a path for infection and other toxins [51]. Rest and splinting.  The World Federation

of Haemophilia Guidelines for lower limb bleeding episodes recommend bed rest (1 day) followed by avoidance of weight-bearing and the use of crutches when ambulating, and elevation when sitting (3–4 days). For the knee, a compressive bandage is adequate, although in very painful cases the bandage should be supplemented with a long-leg posterior plaster splint. For

the ankle, a short-leg posterior plaster splint is recommended. For the upper limb, usually a sling (for the shoulder) or a long-arm posterior plaster splint (for the elbow) will provide sufficient rest, support and protection. Lifting and carrying heavy items should be avoided until the bleeding has resolved (4–5 days) [52]. There is no Ruxolitinib datasheet literature supporting a role for arthroscopy in the acute management of haemarthrosis in haemophiliacs, and it is not recommended by current consensus guidelines. There is no consensus about the role of arthroscopy

in patients with normal haemostasis presenting with haemarthrosis following trauma. Although arthroscopy may contribute to accurate diagnosis, 上海皓元 it does not influence acute management in adults [53,54] or in children [53]. The technique of aspiration of an acute haemarthrosis in patients with haemophilia has been described since 1963 [55]. Protagonists of the procedure suggest that removal of blood may provide immediate pain relief and may lower the risk of haemophilic arthropathy by reducing the duration of synovial exposure to blood and iron. There is very limited literature addressing this area of management in patients with haemophilia, and, except for selected cases, it is not generally recommended in consensus guidelines. A single randomized control trial included 22 adults with intermediate swelling of the knee joint, 11 of whom underwent aspiration under local anaesthesia and intravenous analgesia [56]. The knee was then bandaged, and neither splinting nor intra-articular steroid injection were used. At day 1, there was a statistically significant improved range of movement in patients who had undergone aspiration, but by day 5 there was no difference between the groups. Aspiration was painful in a subset of patients.