Joint injection in patient with hemophilia

[Creflo]

I have a patient with moderate to severe hemophilia A who has severe ankle arthritis. Any thoughts on risk of hemarthrosis after ankle joint injection of hyalgan?

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[air bud]

I have a patient with moderate to severe hemophilia A who has severe ankle arthritis. Any thoughts on risk of hemarthrosis after ankle joint injection of hyalgan?

Why are you injecting hyalgen into an ankle? What literature do you have to support this?
Also, shouldn't you know how patient responded to the steroid injections that have already failed? I don't see anyway you could use hyaluronic acid as a first line treatment for OA of ankle.

 

[Creflo]

It's off label for this condition. My main concern is any type of injection into an ankle for a patient with hemophilia and the risk of hemarthrosis and potential negative consequences.

 

[ExperiencedDPM]

It's off label for this condition. My main concern is any type of injection into an ankle for a patient with hemophilia and the risk of hemarthrosis and potential negative consequences.

Why don’t you discuss your concerns with the patient’s hematologist? And if you do use a product for an off label use, AND there is a complication, make sure you have your attorney and malpractice carrier on speed dial.

 

[Creflo]

A quick literature search will show the evidence for hyaluronic acid in the ankle. For a patient with hemophilia who can't have surgery, who is at risk of addiction to narcotics for ankle pain, and who can't take nsaids, it's actually a defendable option. Of course I will call the hematologist, but in the interest of being careful just looking for some friendly pods who may share their opinion regarding their experience in treating patients with this coagulopathy disorder. And I have plenty of personal experience injecting hyalgan into ankles, it actually works well for arthritis just as it does in the knee, and has a much lower side effect profile vs corticosteroids.

 

[hematosis]

i've scoped these patients and they do well. I've never tried the HA injection. There is an old ortho guy in our practice that injects these in the knee when other options are exhausted/contraindicated.

 

[dtrack22]

I believe the literature shows that risks of intra-articular injections in these patients is low, at least when looking at corticosteroid injections. I don’t see why HA would be different.

I would talk to the hematologist if for no other reason than to pick his/her brain

 

[spo01]

I came from a residency where my head attending was very cautious, like he would probably get permission from the OB doctor before prescribing a pregnant woman ammonium lactate lol. Thing is you're probably fine, but it's 2018 and we live in a litigious society and you gotta protect yourself.

I had a similar situation yesterday actually. Patient had 10/10 plantar fasciitis pain and was going to cancel work the next day because of it. She wanted a steroid injection because she had them before with great relief, however this time she was on humira for psoriasis. I had no problem giving it at first but as I was walking to the room with the syringe that little voice in the back of my head got the best of me. I told the patient to call her dermatologist and get the ok first. Then I went back to my office and out of pure curiosity I texted another podiatrist who has been practicing 25 years and my buddy who is an internal medicine doctor. The podiatrist said sure just use half the dose, the internist said he wouldn't, and the dermatologist said it was fine and in 5 minutes he faxed me a letter stating it was ok. It was as easy as that and I protected myself.

Bottom line is if there is any doubt you should get permission from the doctor giving her the medicine just to cover yourself (either verbal or written consent though the latter is always better and document it).