الفهرس 
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Abstract
Hemophilia is an X-linked congenital bleeding disorder, with hemophilia A (reduced or absent levels of factor VIII) and hemophilia B (reduced or absent levels of factor IX). The disease is classified on bases of the residual circulating factor activity level as: severe (<1%), moderate (1-5%) or mild (5-40%). Severe form of the disease is characterized by spontaneous hemoarthrosis and the resultant hemophilic arthropathy (HA). HA is characterized by soft tissue changes such as synovial hypertrophy and effusion as well as cartilage and bony damage which ultimately result from repeated joint bleeding episodes. It was found that even a single episode of bleeding may impact long-term outcomes of the joints function, and HA still remains a critical research focus as it’s a debilitating disease that negatively impacts quality of life, physical activity as well as bone health of the aging group in PwH. (Bakeer and Shapiro, 2019).
MSK-US has many advantages over MRI as its accessibility, wider availability, safety, lower cost of examination and lack of interference of susceptibility artifacts in joints with hemosiderin deposition, including the “blooming” artifact. Therefore, MSK-US has now emerged has emerged as a promising imaging modality for the early detection and management of HA (Di Minno et al., 2016) and for the evaluation of hemarthrosis and painful MSK episodes in hemophilic patients. (Kidder et al., 2015, Ceponis et al., 2013).
MSK-US has been proven to provide a detailed and dynamic assessment of synovial joints as well as periarticular structures including tendons, ligaments, and muscles, and it has proven its efficacy in assessment of the soft tissue abnormalities such as synovial hypertrophy, vascularity and joint effusion, as well as late-onset degenerative cartilage and bone changes, using high-resolution, high-frequency transducers with power Doppler imaging. (Bakeer and Shapiro, 2019) Some authors denoted that US has been used to identify pathological changes in joints with normal X-ray imaging and normal clinical examination. (Pannoose et al., 2016).
Despite MRI was reported to be the gold standard for detection of HA, its higher cost, need for duration of examination for the paediatric age group, susceptibility artefacts in cases of hemosiderin deposition as well as the need for contrast injection in some cases, made ultrasound a more feasible method especially in serial follow ups of the joint status. (Di Minno et al., 2017, Nag et al., 2018)
Limitations of ultrasound include its operator-dependability, difficulty to detect the articular surfaces in cases of younger age group, its inability to detect deeper structures as subchondral cysts and erosions as well as its imprecise nature in detection of different soft tissue pathologies. (von Drygalski et al., 2018)
There are different scanning/scoring protocols which have become widely available for use however, no one has been globally standardized or validated yet, therefore limiting their widespread use and implementation. A consensus is needed regarding which US parameters should be included in the MSK US scoring systems and clear definitions of certain pathologies are demanded as well. (von Drygalski et al., 2018) Well-designed, longitudinal, cohort studies are now needed with larger study samples in order to accurately evaluate the role of ultrasound in HA early detection and its clinical impact on treatment and prophylaxis strategy. (Ligocki et al., 2017) Besides, guidelines and MSK US training practice should be available in order to appropriately use the MSK US for diagnostic purposes.
(Bakeer and Shapiro, 2019 In the paediatrics age group, the MSK US has been underutilized due to the paucity of available literature coupled with the needed specialized sophisticated training and the challenges in image acquisition, as well as the less cooperative children, hence, awareness of the differences between the child’s and adult’s joints and through understanding of the pediatric immature skeleton, growth plates appearances, secondary ossification centres and areas of abundant periarticular fat are key. (Soliman et al., 2017).