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

Abstract

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 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.

Haemophilic arthropathy: Diagnosis, management, and aging patient considerations

“…Patients should not undergo more than three RS within a 6-month interval. 52,53 Non-surgical synovectomy is effective in decreasing the number of joint bleeds, controlling pain, and improving range of motion, but RS appears to be more effective than chemical synovectomy in larger joints with a mid-and long-term efficacy of 75%-80%. 52 A rehabilitation program should be put in place after the first 48 hours to regain strength and mobility.…”

“…The shortest interval for repeating RS is at least 6 months. 49,[52][53][54] Five decades of data show that RS is cost-effective, minimally invasive, safe, and well-tolerated. It should be considered early and first when conservative measures fail at preventing progression of haemophilic arthropathy in PwH with or without inhibitors.…”

“…It should be considered early and first when conservative measures fail at preventing progression of haemophilic arthropathy in PwH with or without inhibitors. 50,52,53,55 This is important to prevent irreversible osteochondral damage. A review of the American Thrombosis and Haemostasis Network dataset shows no increase in prevalence of malignancy in PwH who had undergone no more than three early consecutive RS within a 6-month interval.…”

“…Non‐surgical synovectomy : Chemical synovectomy 51 is safe, inexpensive, and Rifampicin and oxytetracycline continue to be used in developing countries as a good alternative to radioactive synovectomy (RS), which uses a beta‐emitting radioisotope Yttrium‐90 ( 90 Y) for the knees, and Rhenium ( 185 Re) for elbows and ankles coupled with a carrier particle. Patients should not undergo more than three RS within a 6‐month interval 52,53 . Non‐surgical synovectomy is effective in decreasing the number of joint bleeds, controlling pain, and improving range of motion, but RS appears to be more effective than chemical synovectomy in larger joints with a mid‐ and long‐term efficacy of 75%–80% 52 .…”

“…Patients should be reassessed closely every 3–6 months documenting haemarthrosis, synovial thickness and inflammation, and functional joint status. The shortest interval for repeating RS is at least 6 months 49,52–54 …”