Is radiosynovectomy (RS) effective for joints damaged by haemophilia with articular degeneration in simple radiography (ADSR)?

Radiosynovectomy in haemophilic synovitis and arthropathy of the knee: A scoping review

INTRODUCTION

Radiosynovectomy is an established treatment for chronic synovitis in patients with haemophilia. Although its role in rheumatological diseases has diminished, it remains an accepted therapy for haemophilic synovitis.

AIM

The aim of this scoping review was to map and summarise the evidence surrounding radiosynovectomy in haemophilic knees, identify gaps in the literature and inform future research.

RESULTS

Forty-three manuscripts and abstracts were identified for this review. Evidence was limited to observational studies and Yttrium-90 was the most studied licensed radioisotope. Radiosynovectomy was associated with a reduction in bleeding frequency and pain, improvements in range of motion and a reduction in the use of factor replacement.

CONCLUSION

The literature reviewed lacks studies of sufficient methodological quality to permit systematic review and meta-analysis. Systematic review using risk of bias assessment for observational studies should be undertaken to better evaluate the efficacy and safety of radiosynovectomy. A causal relationship between RSV and key clinical outcomes remains undetermined.

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.

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.

Haemosiderotic Synovitis Secondary to Anticoagulant Use: An Unusual Mechanism of Failure of a Unicompartmental Knee Replacement

Haemosiderotic synovitis is a rare condition caused by recurrent or chronic haemarthroses. This may lead to intra-articular destruction, a painful joint, and, if untreated, ankylosis of the joint. We highlight a case of an elderly lady who presented to an orthopaedic clinic with left knee pain, following recurrent left knee atraumatic haemarthroses secondary to oral anticoagulant use. At her presentation, she had a left medial unicompartmental knee prosthesis in situ. Weight bearing radiographs of the left knee showed marked loss of lateral joint space with valgus alignment. These radiographic findings were not present on the radiographs taken at her first presentation with haemarthrosis nine months previously. A left revision total knee arthroplasty was performed, and a diagnosis of haemosiderotic synovitis was made following histological analysis of intraoperative tissue samples. This case highlights an unusual mechanism of failure of a unicompartmental knee replacement. Though haemosiderotic synovitis is an exceedingly rare condition, it must be considered following recurrent haemarthrosis as, due to its destructive nature, prompt recognition and treatment is paramount.

Intra-articular corticosteroid injections in haemophilic arthropathy: are they recommended?

INTRODUCTION

Intra-articular (IA) corticosteroid (CS) injections are commonly used in the treatment of osteoarthritis. However, they are rarely utilized in haemophilic arthropathy. In fact, the efficacy of this method in haemophilic arthropathy is frequently discussed and debated in clinical practice.

AIM

To investigate the effectiveness of IA CS injections in patients with painful haemophilic arthropathy.

METHODS

A review of the literature on the topic was performed.

RESULTS

In osteoarthritis, reports with a high level of evidence state that the efficacy of IA injections of CS is controversial. In haemophilic arthropathy, some low-level evidence reports seem to indicate that short-term pain alleviation can be achieved.

CONCLUSIONS

Considering that pain relief after IA injections of CS is controversial and that the cost of the haematologic treatment required to perform the procedure is high in haemophilic arthropathy, we do not recommend the routine use of CS IS injections in haemophilia. Moreover, point of care (POC) ultrasound (US)-guided injections are not advised, because the injection procedure is so simple that the use of POC-US will unnecessarily prolong the duration of the procedure.

Effect of radiosynoviorthesis on the progression of arthropathy and haemarthrosis reduction in haemophilic patients

INTRODUCTION

Repeated haemarthrosis is widely accepted as the triggering cause of synovitis and haemophilic arthropathy. A first-line treatment of chronic synovitis is radiosynoviorthesis (RS). The aim of this study was to evaluate the RS effects on the progression of arthropathy and on a reduction in bleeding in patients with haemophilia.

METHODS

An observational-retrospective study was performed. Bleeding episodes in the 12 months following and in the 12 months preceding RS was compared. The arthropathy was clinically and radiologically analysed by age range, joint and subject, comparing those undergoing RS (Radiosynoviorthesis Group, RSG) against those not undergoing this treatment (Non-Radiosynoviorthesis Group, Non-RSG).

RESULTS

One hundred and seventy-four RS were performed in 71 patients (⁹⁰ Y in Knees and ¹⁸⁶ Re in elbows/ankles/shoulder). RS resulted in significant reduction in bleeding (582 preintervention and 168 postintervention, P < .001). In general, the level of arthropathy measured clinically and radiologically was greater with age increase in both groups (RSG and Non-RSG), especially in the 25-40 age range. A significant increase (P < .05) in the progression of arthropathy was also observed, both globally by patient and specifically for each joint, in non-RSG and RSG group.

CONCLUSION

RS is an effective method to reduce the number of haemarthrosis episodes in chronic synovitis. Moreover, RS can positively affect arthropathy by slowing down its progression. However, the results obtained suggest that arthropathy may be conditioned by the subject's age, regardless of whether or not the joint has undergone RS.

Radiosynovectomy in haemophilia: long-term results of 500 procedures performed in a 38-year period

BACKGROUND

Radiosynovectomy (RS) can reduce the number of haemarthroses in chronic haemophilic synovitis. The purpose of this study was to assess the effectiveness of RS in terms of the objective improvement of five parameters (number haemarthroses, articular pain, degree of clinical synovitis, clinical score of the World Federation of Haemophilia (WFH), and radiological score of the WFH.

METHODS

In a 38-year period (1976-2013), five hundred radiosynovectomies were performed in 443 joints of 345 patients with haemophilia diagnosed with chronic synovitis. The mean patient age was 23.7 years (range, 6-53). The mean follow-up was 18.5 years (range: 6 months-38 years). The RS was carried out with either yttrium-90 or rhenium-186. We performed 1 to 3 injections (RS-1, RS-2, RS-3), with a 6-month interval between them.

RESULTS

RS resulted in significant improvement in all the parameters studied, except in the WFH radiologic score that showed no improvement. On average, the number of haemarthroses decreased by 64.1% and articular pain decreased by 69.4%. The degree of synovitis showed a reduction of 31.3%. The WFH clinical score revealed an improvement of 19%. The WFH radiological score showed no improvement. There were four complications (0.9%) of RS. Twenty-eight (6.3%) joints eventually had to be subjected to arthroscopic synovectomy or total knee replacement (TKR). No cancer was observed in this group of patients during the 38-year period.

CONCLUSIONS

Radiosynovectomy (RS) is an effective, safe, minimally invasive, well tolerated procedure in the long-term for the treatment of chronic haemophilic synovitis. Moreover, it is very easy to perform. The knee required more injections than the elbow or the ankle and more severe synoviums required a higher number of RS procedures.