The efforts to stop the articular bleeds should be complemented by a physiotherapy program oriented toward the recuperation of dorsiflexion and propioception of the foot and ankle[2]. Repetitive

bleeding into the ankle will produce a marginal osteophyte on the anterior portion of the tibia in the ankle [3]. It may be associated with chronic active synovitis, or be a vestige of previous articular inflammation that has subsided. The prominence of the osteophyte produces impingement of the synovium during dorsiflexion of the ankle which constitutes a mechanical impediment, therefore, Smoothened Agonist the treatment of this condition requires the removal of the osteophyte, by arthroscopic or open arthrotomy. As with plantar flexion deformities due to chronic synovitis, the focus of the physiotherapy effort in this condition should be on elongating the posterior ankle capsule and the retraction of the achilles tendon. Advanced hemophilic arthropathy of the ankle may also result in a plantar flexion deformity. The deformity results from a combination Lapatinib price of the contracture of the posterior capsule of the ankle and retraction of the achilles tendon and collapse of the dome of the talus, due to osteonecrosis and cartilage deterioration [4]. Ribbans and Phillips developed

a combined clinical and radiographic scoring system, specifically for hemophilic ankle arthropathy, which is helpful in deciding definitive treatment [5]. Severe arthropathy of the ankle with plantar flexion deformity and intractable pain has been treated exclusively, until recently, with a tibio-talar fusion. When severe plantarflexion deformity is present a high degree of technical difficulty will be encountered during surgery when bringing the foot to a neutral position. The contracture of the posterior capsule of the tibio-talar joint as well as that of the subtalar joint and the retraction of the achilles tendon may impede dorsiflexion

of the foot even after sufficient bone medchemexpress has been removed from the tibio-talar joint for the purpose of fusion. Recently, considerable progress in ankle arthroplasty has been obtained, anticipating a potential role for this procedure in primary hemophilic arthropathy of the ankle, and perhaps in reversion of fused ankles to a total ankle arthroplasty [6,7]. The current indication for these procedures in arthropathy of the ankle due to hemophilia remains to be defined. Contracture of the gastro-soleous muscle due to overlooked compartment syndrome of the calf due to muscle bleeds will lead to muscle scarring, contracture, often paresis, and ultimately, to a plantar flexion deformity of the ankle. Treatment of the contracture of the gastro-soleous unit requires lengthening of the achuilles tendon and often posterior capsulotomy of the tibio-talar joint and frequently of the subtalar joint.