Radiosynovectomy in haemophilia

Outcome measures analysis following total knee arthroplasty in patients with severe haemophilic arthropathy of the knee

Total knee arthroplasty (TKA) has been the gold standard for treating severe haemophilic arthropathy of the knee when all conservative measures fail. However, performing a TKA in patients with haemophilic arthropathy is difficult due to severe joint deformity and destruction, and poor bone quality. The aim of the present study was to evaluate the short-term results of TKA in the treatment of knee haemophilic arthropathy in a tertiary referral centre, with an emphasis on health-related quality of life and knee function. A prospective study was conducted that included 19 male patients with end-stage haemophilic knee arthropathy who underwent TKA in a tertiary referral centre. Clinical outcome and health-related quality of life were assessed by the Western Ontario and McMaster Universities Arthritis (WOMAC) index and the Short Form-36 (SF-36) both pre-operatively and at 1-year post-operatively. The mean age of the patients was 50.37±7.63 years (range, 40-65 years). Pre-operative health-related quality of life was impaired in all patients in all SF-36 domains but was markedly improved after TKA. Knee function in all dimensions (pain, stiffness and physical function), as measured by the WOMAC questionnaire, significantly improved after TKA. Pre-operative pain, stiffness and function, along with total WOMAC score, were strongly and negatively correlated with pre-operative SF-36. Overall, the present study indicated a significant improvement in quality of life and clinical outcome after TKA in patients with advanced haemophilic arthropathy. More studies with longer follow-up periods in a larger population are needed to fully elucidate the mid- and long-term values of TKA in haemophilic patients.

Recurrence-Free Survival after Synovectomy and Subsequent Radiosynoviorthesis in Patients with Synovitis of the Knee-A Retrospective Data Analysis

BACKGROUND

Persistent knee synovitis leads to joint discomfort, incapacitating inflammation, and functional limitations. The conventional approach has involved surgical procedures to eliminate the actively inflamed synovial membrane. This study aims to investigate the recurrence-free survival and functional outcome after synovectomy and subsequent radiosynoviorthesis (RSO) in patients with knee synovitis.

METHODS

Thirty-seven knees diagnosed with pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), and peripheral spondyloarthritis underwent synovectomy and subsequent RSO between May 2005 and October 2016. The mean age was 34.9 ± 15.1 years, and the mean follow-up period was 84 ± 36.4 months. Clinical outcomes were assessed using the Oxford Knee Score and the presence of swelling and pain at the last follow-up. Recurrence-free survival denotes the duration from synovectomy to surgical re-synovectomy.

RESULTS

In general, twelve knees underwent re-synovectomy after a mean follow-up of 34.8 ± 24.9 months. The recurrence-free survival was 83.8% at two years, 71.3% at five years, and 61.7% at ten years. The subgroup analysis revealed recurrence-free survival at two years in 63.6% of patients with PVNS, 86.7% of those with RA, and 100% of individuals with peripheral spondyloarthritis.

CONCLUSIONS

This study demonstrates that combined therapy for synovitis is an effective approach, significantly improving clinical outcomes.

Synovitis in hemophilia: preventing, detecting, and treating joint bleeds

INTRODUCTION

Most bleeding events in individuals with hemophilia occur within the ankle, knee, and elbow joints. Should the bleeding persist, the synovial membrane starts to hypertrophy and a vicious cycle of chronic hemophilic synovitis (CHS) occurs, leading to joint destruction.

AREAS COVERED

This article covers the prompt diagnosis of CHS by point-of-care ultrasonography (POC-US) and its treatment by means of several types of synovectomy.

EXPERT OPINION

It is essential to prevent, detect and treat hemophilic synovitis, because it indicates that the joint has bled and is at risk of bleeding further. Prophylaxis with standard half life (SHL) factor VIII (FVIII) concentrate is the standard of care for individuals with severe hemophilia A and can also be considered for selected patients with moderate disease. Several years of real-world experience with extended half life (EHL) FVIII, emicizumab, and other drugs in development will be needed to ascertain their final effect on bleeding and its complications. We must look for synovitis in individuals declaring joint pain and in asymptomatic patients, and POC-US is the most reasonable imaging instrument with which to carry out periodic joint screening. Radiosynovectomy, chemical synovectomy, and arthroscopic synovectomy markedly reduce bleeding events.

Synovitis and joint health in patients with haemophilia: Statements from a European e-Delphi consensus study

INTRODUCTION

Synovitis, a common feature in haemophilia, is triggered by the presence of blood in joints, and represents the first step towards the development of chronic arthropathy. Synovitis may be detected early by means of ultrasound or magnetic resonance imaging scan; clinical joint scores are less sensitive in this setting. Regular long-term prophylaxis with clotting factor concentrates, as primary prophylaxis and tailored to individual needs, has high efficacy in preventing synovitis. In general, higher factor levels lower bleeding risk, but no direct correlation between factor levels and synovitis incidence has been demonstrated.

AIM

This study aimed to develop an expert consensus relating to the definition, pathophysiology, diagnosis, prevention, follow-up and treatment of synovitis, recognising its relevance for joint health and taking into account existing knowledge gaps.

METHODS

A Delphi consensus study was designed and performed. An expert group prepared 22 statements based on existing literature; a wider expert panel subsequently voted on these.

RESULTS

Retention of panellists was high. Four statements required amending and consensus on all statements was achieved after three rounds of voting.

CONCLUSION

This e-Delphi consensus study addressed the importance of synovitis in joint health of people with haemophilia and highlighted knowledge gaps in this field. Studies on the natural course of synovitis are lacking and the biological mechanisms underlying this process are not yet fully elucidated. While basic and clinical research proceeds in this field, expert consensus can help guide clinicians in their routine clinical practice, and Delphi methodology is often used to produce best-practice guidelines.

Radiosynovectomy for the Treatment of Chronic Hemophilic Synovitis: An Old Technique, but Still Very Effective

A radiosynovectomy (RS) should be indicated when recurrent articular bleeds related to chronic hemophilia synovitis (CHS) exist, established by clinical examination, and confirmed by imaging techniques that cannot be constrained with hematological prophylaxis. RS can be performed at any point in life, mainly in adolescents (>13−14 years) and adults. Intraarticular injection (IAI) of a radioactive material in children might be arduous since we need child collaboration which might include general anesthesia. RS is our initial option for management of CHS. For the knee joint we prescribe Yttrium-90, while for the elbow and ankle we prescribe Rhenium-186 (1 to 3 IAIs every 6 months). The procedure is greatly cost efficient when compared to surgical synovectomy. Chemical synovectomy with rifampicin has been reported to be efficacious, inexpensive, simple, and especially practical in developing countries where radioactive materials are not easily available. Rifampicin seems to be more efficacious when it is utilized in small joints (elbows and ankles), than when utilized in bigger ones (knees). When RS and/or chemical synovectomy fail, arthroscopic synovectomy (or open synovectomy in some cases) should be indicated. For us, surgery must be performed after the failure of 3 RSs with 6-month interims. RS is an effective and minimally invasive intervention for treatment of repeated articular bleeds due to CHS. Although it has been published that the risk of cancer does not increase, and that the amount of radioactive material used in RS is insignificant, the issue of chromosomal and/or deoxyribonucleic acid (DNA) changes remains a concern and continued surveillance is critical. As child and adulthood prophylaxis becomes more global, RS might become obsolete in the long-term.

Radiosynoviorthesis: almost seventy years of experience but still somewhat fameless

Radiosynoviorthesis (RSO) or radiation synovectomy has been practiced for more than half a century, but in many parts of the world, it is still relatively unknown and not used to its full potential in the standard care for chronic, persistent or recurrent synovitis. The working mechanism of RSO is simple yet elegant. Radiopharmaceutical particles are, after injection in the affected synovial joint, gobbled up by phagocytizing subsynovial inflammatory cells. As a consequence, the synovium will be irradiated locally resulting in synovial cell necrosis and inhibition of cell proliferation, which eventually leads to a decrease in the inflammatory response in the joint cavity. In this review RSO is once again brought to the attention and common indications for RSO are discussed. Also, appropriate activities of the administrated radiopharmaceuticals and coadministrated glucocorticoids are provided. Furthermore, a detailed database-assisted chronological overview of published literature of RSO in inflammatory and non-inflammatory diseases, like rheumatoid arthritis, psoriatic arthritis, osteoarthritis and osteochrondomatosis, hemophilic hemarthrosis and pigmented villonodular synovitis (PVNS) is provided. Based upon the published literature an indication of level of evidence of RSO is discussed. There is evidence that RSO is effective in persistent synovitis in patients with a variety of causes for synovitis, although the effectiveness seems to decrease over time. In these patients, RSO may not be used to its full potential in many parts of the world. Results in of RSO in hemophilia patients with hemarthrosis are favourable, however the evidence for the effectiveness of RSO in these patients is less firm and mainly based on case series. The evidence for the efficacy of RSO as adjuvant therapy in PVNS is, at best, of very low quality.

Contrasting Patterns of Hemarthroses in Different Joints After Development of Hemophilic Arthropathy in a Severe Type A Hemophiliac: An Autobiographical Case Report

Hemophilic arthropathy is a very common complication in patients suffering from severe hemophilia A (factor VIII activity level <1%). It is the most common cause of long-term joint damage and reduced mobility in people with hemophilia A. This case report describes the author's experience with different and contrasting changes in hemarthroses (bleeding episodes in joints) after developing arthropathies in said joints. While both the knees and the right elbow have severe arthropathy and arthritic changes, the hemarthroses in the knees have decreased while they have increased in the right elbow. This contrast can be attributed to changes in musculature and vasculature around the joint.

The EANM guideline for radiosynoviorthesis

Purpose

Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain.

Methods

The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed.

Conclusion

These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

Hemophilic arthropathy: a teaching approach devoted to hemophilia treaters in under-development countries

INTRODUCTION

Arthropathy is the characteristic injury of hemophilia, primarily occurring in the elbows, knees, and ankles. The aim of this review is a teaching approach devoted to hemophilia treaters in under-development countries.

AREAS COVERED

Current major challenges include the absence of the following therapeutic tools for all people with hemophilia (PWH) worldwide: hematological prophylaxis; well-coordinated multidisciplinary teams in specialized centers; joint aspiration of acute hemarthrosis; point-of-care ultrasonography (POC-US); exercise; treatment of synovitis by means of radiosynovectomy; treatment of mild hemophilic arthropathy with analgesics, anti-inflammatory agents, and rehabilitation medicine; intra-articular injections of corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells; and treatment of severe hemophilic arthropathy by surgical treatment. The future scenario in under-development countries should include all the aforementioned treatment tools plus the possibility of performing total joint arthroplasty in PWH with inhibitors; concomitant use of bypassing agents with emicizumab for PWH with inhibitors undergoing orthopedic surgery; and telemedicine.

EXPERT OPINION

Primary hematological prophylaxis is now the gold standard for the management of hemophilia. Acute hemarthrosis needs intense hematological management and articular aspiration; the articular situation should be scrutinized by POC-US. Synovitis can be controlled by radiosynovectomy. In cases of severe articular degeneration, surgical procedures might be required.

Haemophilia

Haemophilia A and B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of levels of FVIII or FIX, which are determined by the type of the causative mutation in the genes encoding the factors (F8 and F9, respectively). The hallmark clinical characteristic, especially in untreated severe forms, is bleeding (spontaneous or after trauma) into major joints such as ankles, knees and elbows, which can result in the development of arthropathy. Intracranial bleeds and bleeds into internal organs may be life-threatening. The median life expectancy was ~30 years until the 1960s, but improved understanding of the disorder and development of efficacious therapy based on prophylactic replacement of the missing factor has caused a paradigm shift, and today individuals with haemophilia can look forward to a virtually normal life expectancy and quality of life. Nevertheless, the potential development of inhibitory antibodies to infused factor is still a major hurdle to overcome in a substantial proportion of patients. Finally, gene therapy for both types of haemophilia has progressed remarkably and could soon become a reality.

Pain management in people with hemophilia in childhood and young adulthood

Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).

Management of musculoskeletal complications in patients with hemophilia: literature review and expert recommendations

In people with hemophilia, hematological prophylaxis during childhood and adolescence could elude the occurrence of musculoskeletal complications (in joints and muscles) if the concentration of the defective factor is averted from decreasing under 1% of normal. Prompt management is of capital significance as the juvenile skeleton is hypersensitive to the adverse events of the disease; intense structural defects might appear rapidly. Important articular bleeds and inveterate hypertrophy of the articular synovial membrane must be treated vigorously to preclude joint degeneration (hemophilic arthropathy). At the moment that extreme joint disease is in place with intense affliction, the goal must be to reestablish activity whilst at the same time reducing the peril to the patient. Articular debridement is an efficacious surgical technique to accomplish this goal, particularly around the knee or ankle, and may be contemplated to be a backup to ankle arthrodesis or ankle or knee replacement in patients of younger age. Eventually joint replacement can commonly reestablish both articular mobility and function in an unhealthy articulation.