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Silva M, Luck JV, Leissinger C. Opinions on radiosynovectomy for chronic haemophilic synovitis: point/counterpoint. Haemophilia 2012; 18:836-42. [PMID: 22762742 DOI: 10.1111/j.1365-2516.2012.02908.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2012] [Indexed: 01/17/2023]
Abstract
Joint bleeding is the hallmark of severe haemophilia and the major cause of disability in patients with this coagulopathy. Repeated bleeding into the same joint can lead to chronic synovitis and progressive arthropathy. Radiosynovectomy is one option for the treatment of chronic haemophilic synovitis, but concerns about the risks of exposure to ionizing radiation have divided clinicians as to the safety and appropriate use of the procedure. This article presents two differing viewpoints, one from a pair of orthopaedic surgeons who collectively have performed more than 300 radiosynovectomies in patients with haemophilia. They maintain that radiosynovectomy is a simple, effective, safe and low-cost technique children and adults with chronic haemophilic synovitis. The other perspective is from an experienced haemophilia treater who directs a major US haemophilia treatment centre. She believes that unresolved questions about the safety of radiation exposure in children argue against the use of radiosynovectomy in paediatric patients with haemophilia.
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Affiliation(s)
- M Silva
- Los Angeles Orthopaedic Hospital, UCLA/Orthopaedic Hospital, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90007, USA.
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Mäkelä OT, Lammi MJ, Uusitalo H, Hyttinen MM, Vuorio E, Helminen HJ, Tulamo RM. Analysis of lapine cartilage matrix after radiosynovectomy with holmium-166 ferric hydroxide macroaggregate. Ann Rheum Dis 2003; 62:43-9. [PMID: 12480668 PMCID: PMC1754287 DOI: 10.1136/ard.62.1.43] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To study the short and long term effects of radiosynovectomy on articular cartilage in growing and mature rabbits. METHODS The articular cartilage of the distal femurs of rabbits was examined four days, two months, and one year after radiosynovectomy with holmium-166 ferric hydroxide macroaggregate ([(166)Ho]FHMA). Arthritic changes were evaluated from histological sections by conventional and polarised light microscopy, and glycosaminoglycan measurements using safranin O staining, digital densitometry, and uronic acid determination. Proteoglycan synthesis was studied by metabolic [(35)]sulphate labelling followed by autoradiography, and electrophoretic analysis of extracted proteoglycans. Northern analyses were performed to determine the mRNA levels of type II collagen, aggrecan, and Sox9 in cartilage samples. RESULTS Radiosynovectomy had no major effect on the histological appearance of articular cartilage in mature rabbits, whereas more fibrillation was seen in [(166)Ho]FHMA radiosynovectomised knee joints of growing rabbits two months after treatment, but not after one year. Radiosynovectomy did not cause changes in the glycosaminoglycan content of cartilage or in the synthesis or chemical structure of proteoglycans. No radiosynovectomy related changes were seen in the mRNA levels of type II collagen, whereas a transient down regulation of aggrecan and Sox9 mRNA levels was seen in young rabbits two months after [(166)Ho]FHMA radiosynovectomy. CONCLUSIONS [(166)Ho]FHMA radiosynovectomy caused no obvious chondrocyte damage or osteoarthritic changes in mature rabbits, but in growing rabbits some transient radiation induced effects were seen--for example, mild cartilage fibrillation and down regulation of cartilage-specific genes.
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Affiliation(s)
- O T Mäkelä
- Department of Clinical Veterinary Sciences, Faculty of Veterinary Medicine, PO Box 57, FIN-00014 University of Helsinki, Finland.
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Mäkelä O, Penttilä P, Kolehmainen E, Sukura A, Sankari S, Tulamo RM. Experimental radiation synovectomy in rabbit knee with holmium-166 ferric hydroxide macroaggregate. Nucl Med Biol 2002; 29:593-8. [PMID: 12088730 DOI: 10.1016/s0969-8051(02)00317-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Holmium-166 ferric hydroxide macroaggregate (Ho-166 FHMA) particles possess two important properties for radiosynovectomy; relatively short half-life of the radioisotope and appropriate carrier size. Both these minimize radioactive leakage from the treated joint. This study was conducted to assess the effects of Ho-166 FHMA on synovium and synovial fluid in rabbit knee joints. Whole-knee autoradiography was utilized to determine distribution of radioactivity after intra-articular Ho-166 FHMA injection. Intra-articular injection of Ho-166 FHMA resulted in focal acute radiation necrosis in synovial lining but no hyperplasia of synoviocytes. Later, subsynovial fibrosis became evident. White blood cell and total protein levels in the joint fluid were elevated because of intra-articular inflammation due to the acute effects of radiation. Whole knee autoradiograms showed uneven distribution of the radionuclide along the synovium and extraarticular leakage on the third day after treatment.
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Affiliation(s)
- Olli Mäkelä
- Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, FIN-00014 University of Helsinki, Helsinki, Finland.
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Trauner K, Gandour-Edwards R, Bamberg M, Nishioka NS, Flotte T, Autry S, Hasan T. Influence of light delivery on photodynamic synovectomy in an antigen-induced arthritis model for rheumatoid arthritis. Lasers Surg Med Suppl 2000; 22:147-56. [PMID: 9510098 DOI: 10.1002/(sici)1096-9101(1998)22:3<147::aid-lsm1>3.0.co;2-p] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Minimally invasive synovectomy techniques have been unsuccessful due to lack of selectivity. The purpose of this study was to evaluate the potential of photodynamic therapy to destroy diseased synovium in an antigen-induced arthritis model. STUDY DESIGN/MATERIALS AND METHODS Three sets of experiments evaluated the biodistribution and treatment effects of Photofrin (PF) in rabbits with bilateral knee antigen-induced arthritis. The first set of experiments evaluated the biodistribution of PF in articular tissues of 30 rabbits from 6-72 hours after systemic injection of 2 mg/kg. In the second series of experiments, light was delivered to the knee joint via cleaved optical fibers, whereas for the third, light was delivered via a 600 microm diffusion tip fiber. Tissues were harvested at 2 and 4 weeks posttreatment. RESULTS The biodistribution experiments demonstrated maximal uptake in inflamed synovium at 48 hours and a lack of uptake in normal tissues. With bare cleaved fibers, necrosis was observed in one specimen at 2 weeks and was absent in all specimens at 4 weeks. In the third experiment, synovial necrosis was observed in 3 of 7 specimens at 2 weeks and 3 of 8 at 4 weeks. No damage to articular cartilage or periarticular tissues was seen with either mode of light delivery. CONCLUSION These studies indicate that selective destruction of synovium can be achieved with PF and suggest that optimization of light delivery techniques will play an important role in development of this new technique.
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Affiliation(s)
- K Trauner
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California 95819, USA
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Foldes K, Hynynen K, Shortkroff S, Winalski CS, Collucci V, Koskinen SK, McDannold N, Jolesz F. Magnetic resonance imaging-guided focused ultrasound synovectomy. Scand J Rheumatol 1999; 28:233-7. [PMID: 10503560 DOI: 10.1080/03009749950155607] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To investigate the feasibility of magnetic resonance imaging (MRI)-guided high power focused ultrasound (FUS) to perform synovectomy noninvasively. METHODS Five New Zealand white male rabbit knees with experimentally induced arthritis underwent MRI-guided thermal surgery by high power (60 W/10 s) sonication. Evidence of tissue coagulation was monitored during the procedure and confirmed by gross and microscopic evaluation and MRI. RESULTS Partial synovectomy was performed in five animals. Necrotized synovial tissue was observed on gross and microscopic evaluation. Visible signal intensity alterations including high signal intensity on T2-weighted (T2W) images and lack of contrast-enhancement on T1-weighted (T1W) post-contrast, post-sonication images were characteristic and reproducible. CONCLUSION Our results demonstrate the ability of high power sonication to destroy synovial tissue in vivo.
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Affiliation(s)
- K Foldes
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Yanch JC, Shortkroff S, Shefer RE, Johnson S, Binello E, Gierga D, Jones AG, Young G, Vivieros C, Davison A, Sledge C. Boron neutron capture synovectomy: Treatment of rheumatoid arthritis based on the 10B(n,α)7Li nuclear reaction. Med Phys 1999. [DOI: 10.1118/1.598527] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Palmer JL, Bertone AL, Malemud CJ, Mansour J. Changes in third carpal bone articular cartilage after synovectomy in normal and inflamed joints. Vet Surg 1998; 27:321-30. [PMID: 9662774 DOI: 10.1111/j.1532-950x.1998.tb00134.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine if arthroscopic synovectomy in normal and inflamed joints had temporal or site-related effects on articular cartilage. STUDY DESIGN Alterations in equine third carpal bone articular cartilage were studied at two time periods: groups 1 and 2 (6 weeks) and groups 3 and 4 (2 weeks) after synovectomy in normal (groups 2 and 4) and inflamed carpi (groups 1 and 3). ANIMAL POPULATION 16 carpi from eight horses. METHODS Biochemical and biomechanical properties of dorsal and palmar articular cartilage were determined by radioloabeling, proteoglycan (PG) extraction, chromatography, electrophoresis, and indentation testing. RESULTS Synovectomy in inflamed joints produced the greatest concentration of newly synthesized PG in articular cartilage by 2 weeks. Synovectomy in normal joints produced significantly greater newly synthesized PG in articular cartilage by 6 weeks. Dorsal sites had greater newly synthesized and endogenous PG in some groups. Chromatographic profiles of newly synthesized PG demonstrated early and late PG peaks. Electrophoresis of late PG peak showed a toluidine blue-positive band that comigrated with human A1D1 PG monomer in the two groups with the most newly synthesized PG> This band was reactive with monoclonal antibody 1C6 specific for the hyaluronic acid-binding region of aggrecan. For the material properties evaluated, only Poisson's ratio was significantly decreased between groups as a function of time (6 weeks < 2 weeks). and this was most pronounced in the thicker dorsal sites. CONCLUSIONS Synovectomy in inflamed joints produced site-specific, significantly greater responses in articular cartilage as compared with synovectomy in normal joints. CLINICAL RELEVANCE Synovectomy may not be beneficial to the articular cartilage in inflamed joints.
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Affiliation(s)
- J L Palmer
- Department of Veterinary Clinical Sciences, Ohio State University, Columbus, USA
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Ratkay LG, Chowdhary RK, Iamaroon A, Richter AM, Neyndorff HC, Keystone EC, Waterfield JD, Levy JG. Amelioration of antigen-induced arthritis in rabbits by induction of apoptosis of inflammatory cells with local application of transdermal photodynamic therapy. ARTHRITIS AND RHEUMATISM 1998; 41:525-34. [PMID: 9506581 DOI: 10.1002/1529-0131(199803)41:3<525::aid-art19>3.0.co;2-i] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To study the efficacy and mechanism of local transdermal photodynamic therapy (tPDT) in rabbits with antigen-induced arthritis (AIA). METHODS AIA in rabbits on day 14 postinduction was treated with an intravenous injection of benzoporphyrin-derivative monoacid ring A (BPD; Verteporfin) and subsequent transdermal exposure of the knee joint to light. BPD uptake and PDT-induced apoptosis of the synovium was studied applying fluorescence confocal microscopy and immunohistochemistry. The (histo)pathology of the joints was assessed at day 28. RESULTS Treatment with tPDT resulted in significant amelioration of synovial inflammation and an almost complete prevention of pannus formation and bone and cartilage destruction. BPD uptake was detectable in activated T cells and macrophages, and there was significant PDT-induced increase in the number of apoptotic cells in the synovium. CONCLUSION Because photodynamic therapy is both specific and noninvasive, our findings suggest that it could be used for treating arthritic joints in humans.
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Affiliation(s)
- L G Ratkay
- University of British Columbia, Vancouver, Canada
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Trauner KB, Gandour-Edwards R, Bamberg M, Shortkroff S, Sledge C, Hasan T. Photodynamic Synovectomy Using Benzoporphyrin Derivative in an Antigen-induced Arthritis Model for Rheumatoid Arthritis. Photochem Photobiol 1998. [DOI: 10.1111/j.1751-1097.1998.tb05176.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chinol M, Vallabhajosula S, Goldsmith SJ, Paganelli G, Palestro CJ. Evaluation of four radiopharmaceuticals for imaging inflammation in a rabbit model of arthritis. Ann Nucl Med 1996; 10:287-91. [PMID: 8883703 DOI: 10.1007/bf03164734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We compared the utility of four radiopharmaceuticals; 111In-chloride, 67Ga-citrate, 111In labeled leukocytes (WBCs) and 99mTc-MDP for assessing the inflammatory response in antigen induced arthritis in a rabbit model. A total of 20 rabbits, divided into four equal groups, were included in this study. Each group was studied twice with a single radiotracer; a baseline study and a follow-up study after induction of the arthritis. Knee to knee, knee to whole body, and knee to liver (except for the group studied with 99mTc-MDP) ratios were generated. Knee to knee ratios showed no significant change from baseline to arthritis studies in any of the four groups. Significantly increased knee to total body ratios were seen in all of the groups, except for the group studied with 99mTc-MDP. The greatest increase was seen in the group studied with 111In-chloride. Significantly increased knee to liver ratios were observed in all three groups for which these ratios were generated and again the greatest increase was observed in the group studied with 111In-chloride. In summary, based on the higher uptake observed in this group, of the four radiotracers evaluated, 111In-chloride is probably the most useful for monitoring the inflammatory response in antigen induced arthritis. The symmetry of the response suggests that it may also be useful in monitoring the response to therapy.
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Affiliation(s)
- M Chinol
- Division of Nuclear Medicine, European Institute of Oncology, Milan, Italy
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Cruz-Esteban C, Wilke WS. Innovative treatment approaches for rheumatoid arthritis. Non-surgical synovectomy. BAILLIERE'S CLINICAL RHEUMATOLOGY 1995; 9:787-801. [PMID: 8591654 DOI: 10.1016/s0950-3579(05)80314-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Rheumatoid patients with intractable knee effusions may benefit from medical or radio-isotopic synoviorthesis. These offer more convenient, less costly alternatives to surgery with similar long-term outcome. Temporary symptomatic relief may be obtained, but disease progression is unaffected. Potential adverse effects include development of osteoarthrosis with osmic acid and teratogenicity and mutagenicity with alkylating agents and radioisotopes.
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Barnes CL, Shortkroff S, Wilson M, Sledge CB. Intra-articular radiation treatment of rheumatoid synovitis of the ankle with dysprosium-165 ferric hydroxide macroaggregates. Foot Ankle Int 1994; 15:306-10. [PMID: 8075761 DOI: 10.1177/107110079401500605] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Intra-articular radiation treatment using dysprosium-165 ferric hydroxide macroaggregate has been performed on eight patients with refractory synovitis of the ankle. Seventy-five percent (six patients) responded well to the treatment, and there were no complications from the injection. Although ankle synovectomy is not often indicated, those patients with rheumatoid synovitis without significant joint destruction respond favorably to radiation treatment.
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Affiliation(s)
- C L Barnes
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
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Chinol M, Vallabhajosula S, Zuckerman JD, Goldsmith SJ. In vivo stability of ferric hydroxide macroaggregates (FHMA). Is it a suitable carrier for radionuclides used in synovectomy? INTERNATIONAL JOURNAL OF RADIATION APPLICATIONS AND INSTRUMENTATION. PART B, NUCLEAR MEDICINE AND BIOLOGY 1990; 17:479-86. [PMID: 2391243 DOI: 10.1016/0883-2897(90)90167-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ferric hydroxide macroaggregates (FHMA) have been widely used as a carrier for several radionuclides used in radiation synovectomy. Different rates of extra-articular leakage of radioactivity have been observed with 90Y and 165Dy. In order to understand the mechanism(s) involved in the extra-articular leakage of radioactivity, the in vivo stability of FHMA carrier was studied. Following an injection of [59Fe]Fe-FHMA into the knees of normal rabbits, the cumulative leakage of [59Fe]Fe-FHMA was 2.9% at 5 days and 12.3% at 14 days. More than 60% of this activity was in the blood. But when FHMA was double labeled with 59Fe and 166Ho, the 59Fe leakage significantly increased to 18.5% at 5 days and 27% by 14 days. The instability of FHMA is accelerated when it is complexed with 166Ho and may be due to the "mass effect" of 166Ho or due to radiolysis induced by high energy beta particles from 166Ho. These results suggest that FHMA is a suitable carrier only for the short lived radionuclides used in synovectomy.
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Affiliation(s)
- M Chinol
- Department of Physics-Nuclear Medicine, Mount Sinai Medical Center, New York, NY 10029
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