Medical Imaging Analysis Report

I. Radiological Findings

Based on the provided X-ray and MRI images, a large soft tissue mass signal is observed above the left knee joint (distal femur or neighboring area). The boundary is relatively clear, but the interface with adjacent muscle tissue is partially indistinct. The plain radiograph shows a markedly bulging mass with heterogeneous density. Different density layers can be seen within, suggesting septations or various byproducts of blood degradation inside the hematoma. On MRI, the lesion shows inconsistent T1 and T2 signals (mixed signal), with multiple septations and fibrotic boundaries (appearing as low or mixed signal on T1- and T2-weighted images), consistent with chronic or multi-stage hematoma changes.

Overall, the lesion is large and expands into the surrounding soft tissues, potentially involving muscle layers and fascia. No definite disruption of bone continuity is noted, but the possibility of underlying bone destruction or pathological changes cannot be excluded. Considering the five-year history of gradual enlargement, this mass is likely a chronic accumulation of hematoma due to repeated bleeding episodes.

II. Potential Diagnoses

1. Hemophilic Pseudotumor:
   The patient is male, with a confirmed diagnosis of Hemophilia A and notably prolonged APTT indicating coagulation dysfunction. The lesion has slowly enlarged over several years, and the imaging shows mixed density/signal. A hemophilic pseudotumor is an encapsulated, chronic, expanding hematoma caused by recurrent bleeding, consistent with these classic features.
2. Infectious or Inflammatory Granuloma (e.g., Abscess, Tuberculoma):
   Chronic inflammatory lesions may form if there is a history of infection or tuberculosis. However, imaging often shows prominent peripheral enhancement, necrosis, or sinus tract formation. In this case, there is no clear indication of an infectious process.
3. Soft Tissue Tumor or Tumor-like Lesion (e.g., Liposarcoma, Fibrosarcoma):
   A large soft tissue mass could be neoplastic. However, a pseudotumor caused by recurrent hemorrhage in hemophilia is more specific, and the presence of multi-phase blood breakdown products and signs of chronic bleeding are key differential points.

III. Final Diagnosis

Considering the patient’s history of Hemophilia A, clinical presentation (a chronically enlarging localized mass), severe coagulation dysfunction (notably abnormal PT and APTT), and imaging features indicating multi-phase hematomas, the most likely diagnosis is:

Hemophilic Pseudotumor.

For further clarification, any plan should include dynamic monitoring of hematological parameters and follow-up with CT or MRI under controlled conditions. Routine biopsy is generally not recommended due to the risk of bleeding.

IV. Treatment Plan and Rehabilitation

1. Treatment Strategy

• Replacement of Coagulation Factors: For a hemophilic pseudotumor, correcting the coagulation disorder is the first priority. Coagulation function should be closely monitored, and sufficient factor VIII or other necessary preparations should be administered to reduce the risk of re-bleeding.
• Choosing Between Conservative Management and Surgery:
  • For patients with recent active bleeding, when the pseudotumor is not yet large or there are no significant complications, conservative treatment (factor replacement, immobilization, and close follow-up) can achieve some therapeutic effect.
  • If the pseudotumor is very large or causes marked compression, bone destruction, pathological fracture, or soft tissue dysfunction, surgical intervention may be considered. Preoperative embolization can be performed to reduce intraoperative bleeding. During and after surgery, it is essential to maintain elevated and stable coagulation factor levels.
  • In specific cases where surgery is contraindicated or poses a high risk, radiotherapy might be considered (e.g., small doses of 2 Gy per session, totaling 6–23.5 Gy).

2. Rehabilitation/Exercise Prescription

Rehabilitation training should take into account the patient's coagulation dysfunction and the extent of the local lesion, avoiding any excessive load or impact that could lead to re-bleeding. A gradual approach based on the FITT-VP principles can be applied as follows:

• Stage One (Acute Phase or Uncontrolled Bleeding Phase):
  • Frequency: 2–3 sessions of light activity per day.
  • Intensity: Focus on passive joint movement and gentle active movement, avoiding weight-bearing and excessive joint flexion/extension.
  • Time: 5–10 minutes of joint activity each session, together with basic stretching exercises.
  • Type: Mild isometric quadriceps exercises, ankle pump exercises, and other gentle, total-body coordination activities not involving the affected limb in vigorous movement.
  • Progression: Once coagulation function stabilizes, gradually increase range of motion and introduce simple resistance exercises.
• Stage Two (Chronic Repair Phase or After Improving Coagulation Factor Levels):
  • Frequency: 3–4 times per week; as tolerated, it may be increased to once daily.
  • Intensity: Low to moderate intensity. Where possible, incorporate low-load, closed-chain exercises (e.g., seated or supine lower extremity extensions), but avoid pain or discomfort.
  • Time: 20–30 minutes per session, including joint flexibility and muscle strength exercises.
  • Type: Transition from isometric training to low-range isotonic resistance exercises, such as light elastic band workouts, seated active extension/flexion exercises with assistance.
  • Progression: Increase range of motion and resistance under clinical assessment.
• Stage Three (Functional Recovery Phase):
  • Frequency: 3–5 times per week on a regular basis.
  • Intensity: Incrementally increase resistance and lower extremity strength exercises. For example, perform half-squats or standing elastic band exercises with proper protection.
  • Time: 30–45 minutes per session, adjusting to individual capacity.
  • Type: Under professional guidance, gradually introduce balance and stability training, such as simplified balance board exercises or light cycling to minimize joint stress.
  • Progression: Prevent re-bleeding. If any swelling or worsening pain occurs during activities, stop immediately, reduce the load, and seek re-evaluation.

Throughout the rehabilitation process, adjustments should be made based on the patient’s actual condition (e.g., severe anemia, fluctuating coagulation factors, joint status) to ensure safety.

V. Disclaimer

This report is based on the current imaging data and clinical information and is provided for medical reference only. It is not a substitute for in-person consultation or professional medical advice. Patients should follow up with a specialist for further evaluation, treatment, and rehabilitation.