Clinical outcome of radiosynoviorthesis: a meta-analysis including 2190 treated joints

Radiosynoviorthesis with [90Y] Yttrium citrate in refractory synovitis of the knee: Experience of 2 reference hospitals

INTRODUCTION

To describe the therapeutic efficacy of radiosynoviorthesis with [90Y]Yttrium citrate (90Y), in patients with chronic knee synovitis refractory to systemic treatments and/or infiltrations, correlating the results with the different etiologies and degenerative changes that they showed, in order to optimize the indication of the technique.

MATERIAL AND METHODS

Observational retrospective study with 32 patients (22 men and 10 women) and 34 knees, with refractory chronic knee synovitis, who underwent radiosynoviorthesis between January 2013 and December 2022. Its efficacy was described and analyzed by the subjective improvement referred by the patients and its relationship with the existing etiologies and radiological degenerative changes, expressed by the Kellgren-Lawrence (K-L) scale.

RESULTS

A statistically significant subjective improvement was observed in 70.6% of the cases (p < 0.001). There were 92.3% of cases with absent, doubtful or mild degenerative changes (K-L 0-2) who improved, while only 50% with moderate or severe changes (K-L 3-4) improved, showing statistically significant differences (p = 0.03). Among patients with chronic inflammatory origin of synovitis (spondyloarthropathies and rheumatoid arthritis), 80% improved, while in those with osteoarthritis (degenerative) origin, only 25% improved with statistically significant differences (p = 0.006).

CONCLUSIONS

Radiosynoviorthesis with 90Y is an effective treatment in patients with knee refractory chronic synovitis, especially in the presence of mil degenerative joint changes and chronic inflammatory origin. We must ensure the appropiate selection of patients according to these criteria.

Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

A Pathological Fracture of the Femoral Neck Revealing Villonodular Synovitis

Villonodular synovitis is a rare disease of the synovial tissue occurring most commonly in synovial joints such as the knee and ankle joints. We report the case of a patient presenting with villonodular synovitis of the hip revealed by a pathological fracture of the femoral neck, discussing our diagnostic and therapeutic approach with recent scientific data.

Ultrasound-guided joint procedures in hemophilia: technique, indications and tips

INTRODUCTION

The therapeutic approach to pain in hemophilia should be multimodal. Intra-articular injections are a good option when joint lesions do not respond to hematological treatment or rehabilitation and orthopedic surgery is not yet indicated. Performing these procedures under ultrasound guidance has been shown to improve their accuracy and efficacy.

AREAS COVERED

This article provides a practical overview of the most frequently employed ultrasound-guided intra-articular procedures on the joints of people with hemophilia. The article describes the key elements for performing the technique on the elbow, knee and ankle as the most affected joints. The particularities of the most frequent indications, arthrocentesis, synoviorthesis and analgesic injections with various products are detailed.

EXPERT OPINION

Current hematological treatments have made it possible to incorporate new therapeutic tools for pain relief for people with hemophilia, including ultrasound-guided joint procedures, which offer excellent results.

Safety and Efficacy of Radiosynoviorthesis: A Prospective Canadian Multicenter Study

Radiosynoviorthesis is approved in several European countries and the United States to treat refractory synovitis in many inflammatory joint diseases, such as rheumatoid arthritis, spondyloarthropathies, and other arthritic joint diseases. No radiopharmaceuticals for radiosynoviorthesis are currently approved in Canada. The aim of this Health Canada-approved trial was to demonstrate the safety and efficacy of radiosynoviorthesis. Methods: Between July 2012 and November 2017, we conducted a multicenter, prospective, interventional Canadian trial. Patients (n = 360) with synovitis refractory to standard treatments after failing 2 intraarticular glucocorticoid injections were included. They were followed up at 3, 6, and 12 mo. Outcome measures included adverse events (AEs) and clinical signs of synovitis (pain, swelling, and joint effusion) measured with the Health Assessment Questionnaire Disability Index, the Disease Activity Score, and the Visual Analog Scale. Results: In total, 392 joints were treated, including those reinjected after 6 mo (n = 34). Of these, 83.4% (327/392) were injected with [90Y]Y-citrate for the knees and 9.9% (39/392) with [186Re]Re-sulfide for medium-sized joints. Of the joints treated, 82.7% (324/392) were knees. Fifty-five AEs, most of them of mild grade, occurred and resolved without sequelae and were not life-threatening. The incidence of radiosynoviorthesis-related AEs was 9.4% (34/360). The proportion of patients showing an improvement in synovitis symptoms after radiosynoviorthesis was significant at 3 mo and was maintained up to 12 mo (P < 0.001). Conclusion: This study confirmed the safety of radiosynoviorthesis in the treatment of patients with synovitis refractory to standard treatments. There is evidence of sustained clinical efficacy at 12 mo, suggesting that radiosynoviorthesis is an effective treatment for improving synovitis symptoms.

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.

[Pain reduction by radiosynoviorthesis in rheumatism-induced synovitis of the elbow : Results of a retrospective multicenter data analysis]

BACKGROUND

Radiosynoviorthesis (RSO) is a nuclear medical local treatment modality for inflammatory joint diseases. It is indicated in patients with rheumatoid arthritis (RA) in joints with persistent synovitis despite adequate pharmacotherapy. Arthritis of the elbow joint occurs in up to 2/3 of patients with RA. Intra-articular radiotherapy using the beta emitter [186Re] rhenium sulfide leads to sclerosis of the inflamed synovial membrane with subsequent pain alleviation. The clinical efficacy in cubital arthritis, however, has so far only been described in small monocentric studies.

OBJECTIVE

The degree of pain alleviation by RSO was analyzed in patients with rheumatoid cubital arthritis, treated in several nuclear medical practices specialized in RSO.

MATERIAL AND METHODS

The subjective pain intensity before and after RSO was documented in a total of 107 patients with rheumatic cubital arthritis using a 10-step numeric rating scale (NRS). A difference of ≥ -2 is rated as a significant improvement. Follow-up examinations were done after a mean interval of 14 months after RSO (at least 3 months, maximum 50 months).

RESULTS

The mean NRS value was 7.3 ± 2.1 before RSO and 2.8 ± 2.2 after RSO. A significant pain alleviation was seen in 78.5% of all patients treated. The subgroup analysis also showed a significant improvement in the pain symptoms in all groups depending on the time interval between the RSO and the control examination. A significant pain progression was not observed. The degree of pain relief was independent of the time of follow-up.

CONCLUSION

Using RSO for local treatment of rheumatoid cubital arthritis leads to a significant and long-lasting pain relief in more than ¾ of the treated patients.

Arthroscopic synovectomy versus intra-articular injection of corticosteroids for the management of refractory psoriatic or rheumatoid arthritis of the wrist: study protocol for a randomized controlled trial (ARCTIC trial)

BACKGROUND

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are inflammatory diseases that often affect the wrist and, when affected, can lead to impaired wrist function and progressive joint destruction if inadequately treated. Standard care consists primarily of disease-modifying anti-rheumatic drugs (DMARDs), often supported by systemic corticosteroids or intra-articular corticosteroid injections (IACSI). IACSI, despite their use worldwide, show poor response in a substantial group of patients. Arthroscopic synovectomy of the wrist is the surgical removal of synovitis with the goal to relieve pain and improve wrist function. The primary objective of this study is to evaluate wrist function following arthroscopic synovectomy compared to IACSI in therapy-resistant patients with rheumatoid or psoriatic arthritis. Secondary objectives include radiologic progress, disease activity, health-related quality of life, work participation and cost-effectiveness during a 1-year follow-up.

METHODS

This protocol describes a prospective, randomized controlled trial. RA and PsA patients are eligible with prominent wrist synovitis objectified by a rheumatologist, not responding to at least 3 months of conventional DMARDs and naïve to biological DMARDs. For 90% power, an expected loss to follow-up of 5%, an expected difference in mean Patient-Rated Wrist Evaluation score (PRWE, range 0-100) of 11 and α = 0.05, a total sample size of 80 patients will be sufficient to detect an effect size. Patients are randomized in a 1:1 ratio for arthroscopic synovectomy with deposition of corticosteroids or for IACSI. Removed synovial tissue will be stored for an ancillary study on disease profiling. The primary outcome is wrist function, measured with the PRWE score after 3 months. Secondary outcomes include wrist mobility and grip strength, pain scores, DAS28, EQ-5D-5L, disease progression on ultrasound and radiographs, complications and secondary treatment. Additionally, a cost-effectiveness analysis will be performed, based on healthcare costs (iMCQ questionnaire) and productivity loss (iPCQ questionnaire). Follow-up will be scheduled at 3, 6 and 12 months. Patient burden is minimized by combining study visits with regular follow-ups.

DISCUSSION

Persistent wrist arthritis continues to be a problem for patients with rheumatic joint disease leading to disability. This is the first randomized controlled trial to evaluate the effect, safety and feasibility of arthroscopic synovectomy of the wrist in these patients compared to IACSI.

TRIAL REGISTRATION

Dutch trial registry (CCMO), NL74744.100.20. Registered on 30 November 2020.

CLINICALTRIALS

gov NCT04755127. Registered after the start of inclusion on 15 February 2021.

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.

Optimizing the anti-inflammatory strategies in (osteo)arthritis: local or systemic?

Arthritis is affecting millions of people globally, involvement and distribution depending on the type of arthritis. The most common arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). Despite the pathogeneses being fundamentally different, both joint diseases share the same need for local treatment of synovitis. No current treatment can stop the progression of OA. Local articulate treatment including glucocorticoid (GC) injections, radiosynoviorthesis (RSO) and surgical synovectomy are the only options to relieve pain and temporally improve movability before surgical intervention. For RA, despite effective systemic treatments, similarly need for local articulate treatment is still present, especially early in the disease, but also in case of recurrent episodes of disease flare. Current evidence supports local GC injection as first line treatment for persistent synovitis in a single or a few joints. RSO provides an evident and effective alternative for GC refractory synovitis, especially in early RA. Surgical synovectomy is an invasive alternative, but with less documented efficacy. Whether one unsuccessful intraarticular GC injection is enough to change of mode of action for local treatment is still unclear and needs to be further investigated. In conclusion persistent single joint synovitis in OA and RA is well treated with local treatment. Intra-articular GC injection is considered as first line of treatment, but RSO provides an additional treatment alternative with less side effects and better evidence of efficacy than surgical synovectomy.

Long-term clinical results from 10 years follow-up after radiosynoviorthesis: a prospective observational study

BACKGROUND

The aim of this study was to assess the long-term anti-inflammatory effect and safety of 90-Yttrium and 166-Holmium radiosynoviorthesis (RSO) for treating chronic knee synovitis of various origins.

METHODS

A total of 820 patients were included in this study and were followed up to 10 years after the procedure for objective and subjective changes in signs and symptoms of inflammation.

RESULTS

Five years after RSO, excellent and good results were seen in 71% (95% CI 67-74%) of patients. Six, seven, eight and nine years following RSO, efficacy did not decrease significantly. Ten years after RSO, the effectiveness of the therapy fell to 65% (95% CI 59-71%). Overall, 64% of patients did not need another joint puncture ten years after RSO. We achieved excellent to good results at 5 years in 79% of patients with rheumatoid arthritis, 59% with ankylosing spondylitis, and 62% with osteoarthritis. Efficacy was mainly affected by the local X-ray stage of the knee joint. A significant association was also found between the diagnosis of the underlying disease and the success of radiosynoviorthesis. Efficacy, however, was not substantially affected by any of the following factors: the duration of synovitis, the number of punctures before radiosynoviorthesis, the number of intraarticular steroid injections before the procedure, or the number of interventions before radiosynoviorthesis (radiotherapy, surgery).

CONCLUSIONS

Radiosynoviorthesis is an effective long-term method of treating chronic synovitis. The treatment showed the most favorable effects in patients with rheumatoid arthritis and those with mild to moderate degenerative osseous changes.

The future of radiosynoviorthesis: bright or bleak?

Radiosynoviorthesis (RSO) is a decades known, effective intra-articular nuclear medicine local therapy, with few rare side-effects, in which inflamed synovial membrane is treated by means of colloidal beta-emitters. There are major variations worldwide in terms of acceptance, frequency of use and approved indications for this procedure. Thus, reliable figures that reflect reality are only available for a few countries. A Europe-wide survey revealed that RSO is carried out most frequently in Germany, where RSO is the most common nuclear medicine therapy with about 70,000 joints treated per year. The main indications include synovitis due to rheumatoid arthritis, hemophilia and pigmented villonodular synovitis (PVNS), and depending on national approvals, osteoarthritis. Despite the many indications, there are very few published scientific studies and therefore, RSO evidence is lacking. Reliable data on the clinical usage of RSO and demographics of RSO specialists are only available in Germany, thus we discuss the future challenges of RSO mainly from a German perspective. In the German healthcare system, RSO is performed primarily on an outpatient basis and plays only a minor role in the university setting. The necessary expertise for RSO is therefore lacking, for the most part, at university training centers. Currently, nearly more than three quarters of the German RSO experts are over fifty years old, illustrating a shortage of young talent. In the future, RSO providers from the non-university or private sector will have to cooperate with universities through networks and will have to intensify their cooperation with referring physicians, such as rheumatologist and orthopedic surgeons, and patients in order to maintain a timely and beneficial exchange of information. In networks of RSO experts, the participants must jointly develop and establish training concepts and facilities for future talents, elaborate on guidelines, if clinically useful expand the range of indications, initiate studies to generate further evidence and finally make the procedure more public. In addition, it is worthwhile to apply this process beyond human medicine to other fields, such as medical physics and veterinary medicine. If these points are implemented, the future of RSO will be bright, if it fails, it looks bleak.

Arthroscopic Synovectomy of the Wrist in Patients With Rheumatoid Arthritis: A Systematic Review of the Current Literature

BACKGROUND

Rheumatoid arthritis (RA) of the wrist can lead to loss of wrist function and progressive joint destruction if inadequately treated. Arthroscopic synovectomy of the wrist may prove a valuable treatment for local inflammation.

OBJECTIVE

The aim of this study was to perform a systematic review evaluating functional outcomes and pain following arthroscopic synovectomy of the wrist in RA patients.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. MEDLINE, EMBASE, The Cochrane Library, Web of Science, and Google Scholar were searched for studies describing pain or functional outcomes following arthroscopic synovectomy of the wrist in RA patients (CRD42021270846). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies. Data collection included patient characteristics, pain scores, wrist function questionnaires, secondary surgery, and complications.

RESULTS

Six noncomparative cohort studies were included, with a total of 153 arthroscopic synovectomies. Disease duration of RA ranged from 32 to 89 months, and radiographic progression was mild to moderate. The Methodological Index for Non-Randomized Studies scores ranged from 8 to 10 out of 16. Mean follow-up ranged from 21 to 95 months. Improvements were seen in pooled mean visual analog scale pain score (from 7.7 to 2.2, p < 0.05), pooled mean Modified Mayo Wrist Score (from 43.3 to 70.4, p < 0.05), and the Disability of the Arm, Shoulder, and Hand (from 67.5 to 36.5, p < 0.05). Two complications occurred, and 5 patients required secondary surgery.

CONCLUSIONS

There is limited evidence suggesting that arthroscopic synovectomy of the wrist improves wrist function and pain in patients with RA, with few complications. In centers with arthroscopic expertise, it can be considered as a treatment option.

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.

Radiosynovectomy is effective in thumb basal joint arthritis

OBJECTIVE

Radiosynovectomy (RSO) describes the internal low-dose radiotherapy of the synovia via intra-articular administration of small radioactive particles. Since the introduction of biologics, the main aetiology of arthritic joints for RSO changed to mostly osteoarthritis with concordant change in typically affected joints. Thus, the effect of RSO in thumb basal joint arthritis (BJTh) with focus on osteoarthritis needs to be explored.

DESIGN

From 2017 to 2020, 219 BJTh were treated in 125 patients, 17 patients with rheumatoid arthritis (RA) and 108 patients with osteoarthritis (OA). The therapeutic effect was assessed using a four-step subjective scoring.

RESULTS

20% of the treated joints were symptom free, 48% had a very good response, 16% slight and 16% no response. RSO was performed in 71 patients singularly and in 54 patients repetitively. The mean response duration was 6.8 months with a maximum of 48 months. 35% of patients had post-therapeutic pain relief followed by relapse after 3 months. Response duration showed no significant difference the between first and repetitive therapy, primary responder and primary non-responder and RA and OA.

CONCLUSION

In thumb basal joint arthritis, RSO leads to response rates from 66 to 79%, mean response duration from 6 to 12 months and individual response duration 48 months. The present results are in line with previously published response rates in smaller joints. In respect to 35% of patients with relapse within 3 months post-therapy, we recommend a primary follow-up after 3-4 months.

177Lu-labeled micro liposomes as a potential radiosynoviorthesis therapeutic agent

Micro-sized multivesicular liposomes were prepared, radiolabeled with ¹⁷⁷Lu, and tested in vitro and in vivo to evaluate the potential of ¹⁷⁷Lu-labeled micro liposomes in radiosynoviorthesis (RSO) therapy. A standard reverse-phase procedure of liposome preparation with a lipid mixture of DPPC: CHOL (80:20%) was used for the synthesis. TEM and fluorescence microscopy imaging were performed to determine the size, shape, and structure of the prepared liposomes. Both measurements are in good agreement while TEM micrographs additionally indicate to a large multivesicular inner structure of prepared liposomes. A simple and straightforward procedure was used for liposome radiolabeling with ¹⁷⁷Lu, a well-known and commonly used radionuclide in radiotherapy with favorable properties, that can be exploited in RSO therapy. Radiolabeled ¹⁷⁷Lu-liposomes were tested in vitro for stability and then injected into the knee joints of Wistar rats where liposome in vivo behavior was followed up to 30 days post injection. Results from both ex vivo biodistribution and in vivo imaging studies presented a high stability and retention (>94 %ID) of ¹⁷⁷Lu-micro liposomes in the synovial liquid for the entire observation period. Leakage of free ¹⁷⁷Lu or ¹⁷⁷Lu-liposomes from the synovial fluid has not been detected, indicating to a possible application of ¹⁷⁷Lu-liposomes in radiosynoviorthesis (RSO) therapy.

The use of radiosynovectomy in patients with juvenile idiopathic arthritis. Assessment of treatment efficacy and safety

Objectives

The aim of the study was to evaluate the usefulness of knee joint radiosynovectomy (RS) in patients suffering from juvenile idiopathic arthritis (JIA).

Material and methods

One hundred RS procedures performed in 58 patients with JIA in average age 10.4 years were evaluated.

Results

After 6 weeks, a decrease in the number of cases with joint pain from 90.3% to 29%, with joint oedema from 100% to 74.5%, with joint exudate from 100% to 60.6%, with gait disorders from 19.4% to 3.2%, with joint mobility disorders from 51.1% to 26.6% in the RS cases was observed. A reduction of the score in the Colorado scale from 10.9 to 4.66, in the pain visual analogue scale (VAS) from 50 to 10, in the illness VAS assessed by the patient/parent from 69.9 to 32.4, in the illness VAS assessed by the physician from 68.8 to 36.9 was observed. Six months after the RS procedure, a reduction in the number of cases with joint pain from 89.5% prior to the procedure to 29.5%, with oedema from 100% to 58.3%, with exudate from 100% to 46.9%, with gait disorders from 20% to 2.1%, with joint motility disorders from 51.1% to 26.1% was achieved. The score in the Colorado scale was reduced from 10.9 to 4.04, in the pain VAS from 40 to 0, in the illness VAS assessed by the patient/parent from 69.7 to 27.9, in the illness VAS assessed by the physician from 68.8 to 32.4. In ultrasound examinations, the greatest improvement compared to the initial condition was recorded in the 6^th month after the RS. Radiosynovectomy was positively evaluated by parents and patients in 34 anonymous surveys. Early and late observations (average 1473 days) did not show lesions at the isotope injection site, and no neoplastic lesions were observed.

Conclusions

Radiosynovectomy is a valuable therapeutic option for local treatment in patients with JIA.

Prospective Clinical Evaluation of Intra-Articular Injection of Tin-117m (117mSn) Radiosynoviorthesis Agent for Management of Naturally Occurring Elbow Osteoarthritis in Dogs: A Pilot Study

Purpose

To evaluate the clinical effects of an intra-articular injection of ^117mSn-colloid for management of canine grade 1 or 2 elbow osteoarthritis (OA).

Patients and Methods

This was a prospective study in 23 dogs with grade 1 or 2 elbow OA. An orthopedic examination and elbow radiographs were performed to confirm the presence of OA. Dogs were randomly assigned to receive unilateral intra-articular (IA) injection of low-dose (LD: 1.0mCi, n =8), medium-dose (MD: 1.75mCi, n =6), or high-dose (HD: 2.5mCi, n =9) of ^117mSn-colloid. The primary outcome measure was peak vertical force (PVF) from force-plate gait analysis and secondary outcome measures included the Canine Brief Pain Inventory score (CBPI) and elbow goniometry. The CBPI was evaluated at pretreatment and then monthly post treatment for 1 year, and goniometry and PVF were evaluated at pretreatment, and at 1, 3, 6, 9 and 12 months post treatment.

Results

PVF improved at 3, and 9 months compared to pretreatment values in the HD group. CBPI scores improved at most of the time points in all dose groups. There was no significant difference in elbow goniometry between treated and untreated elbows. There were no self-reports of any adverse effects of the injection by the owners and none were noted by the examining veterinarian at the time of regularly scheduled re-evaluations.

Conclusion

^117mSn IA injection was free of any obvious adverse effects, improved CBPI scores, and increased weight bearing in limbs with elbow OA providing preliminary evidence that ^117mSn may be beneficial in the management of elbow OA in dogs. Although ^17mSn appeared to be effective for management of elbow OA in these dogs, this pilot study has inherent limitations; therefore, future studies with larger numbers and with placebo group are needed.

[Joint DGN, OGNMB and SGNM S1 guideline for radiosynoviorthesis]

This recommendation is intended to provide a guideline for radiosynoviorthesis (RSO) in the effective local treatment of chronic inflammatory (non-infectious) joint diseases. It was developed in an interdisciplinary manner and describes the general objectives, definitions, clinical background information, indication and contraindications of this radionuclide therapy. The requirements to be met by a treatment center, the results of pretherapeutic examinations as well as recommendations on how the treatment should be carried out. Here, organizational and technical issues have been considered. Furthermore, information on the surveillance and follow-up of the treated patients can be found. In general, treatment and follow-up should be done in in close cooperation of the participating disciplines.

[RSO in clinical practice: Status in Germany 2020]

BACKGROUND

 Radiosynoviorthesis (RSO) is a local radionuclide therapy of inflammatory joint diseases, successfully performed since several decades mainly as an outpatient-protocol in ambulatory health care centers or nuclear medicine practices. Despite of long-term experience in some centers, only very few valuable or comparable data about the procedure itself and/or the clinical results of this treatment are available.

OBJECTIVES

 The aim of this online survey is to assess reliable data of the current status in Germany.

MATERIALS AND METHODS

 A web-based questionnaire was designed to evaluate the status of RSO in Germany including demographic data, training, pretherapeutic diagnostics, clinical procedures, and follow-up. The survey was distributed via the supplier of RSO-nuclides, national nuclear medicine societies, and personal networks. It was available for 28 days and closed on November 30, 2020.

RESULTS

 A total of 78 specialists in nuclear medicine answered the questionnaire, which corresponds to a response rate of 23 %. Several differences and concordances in pre-therapeutic diagnostics, in the procedure of RSO itself, and follow-up were documented in this survey for the first time. Most important, less than 70 nuclear medicine specialists in Germany perform more than 75 % of all RSO-procedures and most of them are older than 50 years of age. This implies the urgent need of a dedicated advancement of young academics in nuclear medicine and a professional advanced training in RSO to offer this beneficial treatment to future patients.

CONCLUSIONS

 To achieve these goals, an association of RSO experts would be useful, through which, among other things, an RSO training curriculum is developed and theoretical and practical trainings are organized. Moreover, possible cooperation agreements between ambulant and inpatient institutions would foster the education of young nuclear medicine specialists interested in RSO.

90Y Radiosynovectomy in Persistent Synovitis Caused by Knee Replacement: Long-Term Outcome

INTRODUCTION

After knee replacement, therapy resistant, persistent synovitis is a common issue, which causes effusion and pain, and leads to loosing. It has been hypothesized that radiosynovectomy (RSO) is useful in these patients.

MATERIALS AND METHODS

A cohort of 55 patients with 57 knee replacements and persistent synovitis underwent RSO using 4.9 ± 0.24 mCi (182 ± 9 MBq) of Y-citrate. The number of RSOs ranged from 1 to 4. Bone scans before and 3 months after every RSO were performed. Long-term follow-up ranged from 0.8 to 7.6 years with a mean of 23.2 months. For qualitative analysis, an established 4 steps scoring was used. For quantification, the uptake was determined within the Tc-MDP scintigraphy blood pool phase before and after therapy.

RESULTS

Long-term response was in 27% with excellent, 24% good, 30% weak, and 20% no response. The duration of response was 12.0 ± 12.0 months (maximum, 54 months). In patients with repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, 3 months after the last RSO, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated RSOs had a higher effectiveness at similar duration response. In bone scan, 65% of patients showed a reduction of uptake. When comparing subjective and objective response, 78% of patients showed a concordance in both symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles.

CONCLUSIONS

We concluded that RSO is an effective therapy in patients with knee replacement and persistent synovitis with high long-term response. Repeated treatment leads to a stronger long-time response.

Comparison of Lutetium-177 tin colloid and Rhenium-188 tin colloid radiosynovectomy in chronic knee arthritis

OBJECTIVE

To assess the role of Lutetium-177(Lu-177) tin colloid for radiosynovectomy and compare it with Rhenium-188 (Re-188) tin colloid radiosynovectomy for alleviation of pain in patients with chronic inflammatory arthritis of knee.

METHODS

Patients of chronic inflammatory arthritis of the knee underwent pretherapeutic evaluation in a form of knee ultrasonogram, bone scan and clinical evaluation. Fifty-seven recruited patients were allocated at random to receive either intraarticular injections of Lu-177 tin colloid or Re-188 tin colloid. Eventually, 27 patients received Re-188 tin colloid and 30 patients received Lu-177 tin colloid. The joint was then immobilized for 2 days. Response evaluation was done using knee ultrasound, bone scan and clinical findings.

RESULT

Of 30, 20 patients responded to radiosynovectomy in the Lu-177 tin colloid group compared to 21/27 patients in the Re-188 tin colloid group.

CONCLUSION

Lu-177 tin colloid is an effective alternative to Re-188 tin colloid for radiosynovectomy in patients with chronic inflammatory knee arthritis.

The results of 394 consecutive cases of knee joint radiation synovectomy (radiosynoviorthesis) using 90Y

OBJECTIVE

The aim of this study was to assess the treatment results of ⁹⁰Y radiation synovectomy for chronic exudative synovitis of knee joints.

METHODS

The retrospective data consist of 394 consecutive knee radiation synovectomies performed using 6 mCi (222 MBq) of ⁹⁰Y. The assessment included 3-point custom pain and joint mobility scale, evaluation of joint's circumference, binary joint's temperature evaluation, patellar ballottement test, indications for puncture and its volume in applicable cases. 21 cases had to be forfeited due to missing data regarding follow-up.

RESULTS

The final analysis of 373 treatment procedures performed in 253 patients yielded following results-at 6 months after treatment, 80.9% of the patients reported at least partial pain relief (including 33.3% with complete pain relief), which increased to 86.7% at one year. The pain intensity decreased over time, however, the outcomes were worse in older patients. The probability of pain recurrence was 15% at 6 months, and 28% at one year. It was highest in post-traumatic synovitis, and lowest in pigmented villonodular synovitis. The circumference of the treated knee joints decreased over the course of follow-up, however, the decrease was significantly lower in older patients. The fraction of patients with full knee joint mobility increased from 34.6 to 40.6% at 6 months and 49.2% at one year. The percentage of patients that required articular puncture decreased from 62.8% at baseline to about 35.6% at 6 months, and 32.8% at one year. Positive patellar ballottement was found in 68.5% before treatment and remained at about 40-50% during the course of follow-up. The increased temperature of the joint was reported in 51.2% at baseline and decreased to 33% at 6 months and 28.3% at one year.

CONCLUSIONS

(1) Radiation synovectomy is a safe and effective method of treatment in patients with exudative synovitis, however, the pain recurrence rate is significantly higher in post-traumatic exudative synovitis compared to pigmented villonodular, undifferentiated, and rheumatoid arthritis. (2) Our results suggest that older patients have worse treatment results with radiation synovectomy compared to younger patients.

Long-term outcome of pigmented villonodular synovitis of the hip after joint preserving therapy

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare, destructive synovial disease that affects the hip joint the second most common after the knee. However, in contrast, joint preserving surgery in the hip joint is considered to be significantly more difficult or even impossible due to earlier occurrence of osteochondral dissemination and surgical difficulties. Today, earlier diagnosis due to the generous use of MRI and modern surgical strategies raise hope for improved outcomes.

METHODS

Since 2005, six patients with PVNS of the hip and a minimal follow-up of 2 years underwent joint preserving surgery in our institution (mean age 20.5 years, range 14-27). After PVNS was suspected in the MRI and confirmed by arthroscopic biopsy (four diffuse, two focal forms), synovectomy was carried out in 5 patients via surgical hip dislocation and in one focal case via arthroscopy. In diffuse forms, adjuvant radiosynoviorthesis (RSO) was conducted 6-8 week postoperatively. MRI and clinical examinations were performed during follow-up.

RESULTS

After a mean follow-up of 8 years (range 35-141 months), five of six patients did not show recurrence or secondary osteoarthritis. Clinical outcome evaluation resulted in a mean modified Harris Hip Score of 91 points (range 67-100 points). A 21-year-old patient with a diffuse form and advanced osteochondral involvement at the time of diagnosis was eventually treated by total hip arthroplasty.

CONCLUSION

In cases without osteochondral involvement, recurrence-free long-term results without progression of joint degeneration can be achieved by joint preserving therapy.

Treatment Response Evaluation using Yttrium-90 in Patients with Rheumatoid Arthritis of Knee Joint

For radiosynovectomy, we have measured the retention time of yttrium-90 (⁹⁰Y) hydroxyapatite (particle size 1-10 μm) within the knee joint space and evaluated the treatment responses in knees with rheumatoid arthritis. Radioactive measurements in the region of knee after injection of ⁹⁰Y hydroxyapatite into the joint space were made with a single prove system designed to monitor radioactivity and showed retention of ⁹⁰Y in the knee ranged 76.6% ±5.4% after 4 days of injection. The clinical improvements in rheumatoid arthritis of knee joint with steinbroker Stages I and II were increased as time goes by, the improvement ratio is in 72% at 6^th months and 76% at 12^th months after injection of ⁹⁰Y 185 MBq (5 mCi) per joint.

[Indications and contraindications for radiosynoviorthesis]

BACKGROUND

Radiosynoviorthesis (RSO) provides a simple method for the treatment of patients with chronic synovitis and has only few side effects.

OBJECTIVES

Evidence-based indications and contraindications for performing RSO based on the current literature are presented.

MATERIAL AND METHODS

Published information on the indications and contraindications for performing RSO in chronic synovitis were analyzed and summarized.

RESULTS

According to the guideline recommendations of the German Society of Rheumatology indications for RSO are given in patients with rheumatoid arthritis, seronegative spondyloarthropathy, crystal arthropathy, villonodular synovitis and hemophilia with recurrent joint bleeding. Osteoarthritis with documented reactive synovitis is also regarded as an indication in the guidelines of the nuclear medicine societies. The European League Against Rheumatism (EULAR) and the German Society of Rheumatology (DGRh) have given no recommendations for using RSO in osteoarthritis. Given the correct indications RSO shows high success rates.

CONCLUSION

The effects of RSO with the named secondary side effects last on average for 5 years. Crucial for the success of RSO are the correct indications, the correct timing and combination with other therapeutic procedures, such as surgical synovectomy.

Radionuclide synovectomy - essentials for rheumatologists

Radionuclide synovectomy is a minimally invasive method of treating persistent joint inflammation. It involves intra-articular injection of radioactive colloids which induce necrosis and fibrosis of hypertrophic synovial membrane. The most common indication for radiosynovectomy is rheumatoid arthritis, although patients with seronegative spondyloarthropathies, unclassified arthritis, haemophilic arthropathy and other less common arthropathies can also benefit from this method. Radiosynovectomy is safe, well tolerated and efficacious. About 70–80% of patients respond well to the therapy. However, the therapeutic effects are considerably worse in patients with co-existent osteoarthritis and advanced joint degeneration. Despite its advantages, radionuclide synovectomy is not performed as often as it could be, so greater knowledge and understanding of this method are needed. The authors present the most important facts about radiosynovectomy that may help rheumatologists in their daily clinical practice.

Effect of single dose radiation therapy on weight-bearing lameness in dogs with elbow osteoarthritis

OBJECTIVES

To determine if a single low dose of radiation therapy in dogs with osteoarthritis of the elbow joint was associated with a detectable improvement in their lameness and pain as documented by force platform gait analysis.

METHODS

In this cohort longitudinal observational study, five Labrador Retrievers with lameness due to elbow osteoarthritis that was unresponsive to medical treatment were removed from all non-steroidal anti-inflammatory and analgesic medications. A single treatment of radiation therapy delivering 10 Gray was performed on the affected elbow joint(s). Force platform gait analysis was used to assess the ground reaction forces of a limb affected with elbow osteoarthritis both before and after radiation therapy.

RESULTS

Significant differences occurred in the weight-bearing on an affected limb with elbow osteoarthritis after radiation therapy at weeks six and 14. Change due to treatment was particularly apparent in dogs with unilateral elbow osteoarthritis.

CLINICAL SIGNIFICANCE

Administering a single low dose of radiation therapy may have a short-term benefit in dogs with elbow osteoarthritis, which is similar to the evidence supporting the use of radiation therapy in horses with orthopaedic disease.

Radiosynovectomy in haemophilic synovitis of elbows and ankles: Is the effectiveness of yttrium-90 and rhenium-186 different?

BACKGROUND

Radiosynovectomy (RS) reduces the number of haemarthroses and the synovial size in chronic haemophilic synovitis. The purpose of this study was to quantitatively compare the effectiveness of two types of RS (yttrium-90 vs. rhenium-186) in terms of the objective improvement of haemarthroses and synovial size.

METHODS

Seventy RSs were performed in 70 joints (44 elbows, 26 ankles) of 70 haemophiliacs diagnosed with chronic synovitis. Yttrium-90 was used in 21 joints and rhenium-186 was used in 49 joints. The mean patient age was 20.61 years.

RESULTS

RS resulted in significant improvement in the three variables studied (six months before RS vs. six months after RS), namely in the number of episodes of haemarthrosis (67.8% improvement); the size of the synovium as measured by means of a clinical scale (43.8% improvement) and imaging techniques in millimetres (26.7% improvement). We did not find significant statistical differences between yttrium-90 and rhenium-186 regarding their efficacy. No correlation was found between the results and other variables: age, joint (ankle or elbow), presence or absence of radiological involvement, type of haemophilia (A or B), grade of haemophilia (mild, moderate or severe), previous haematological treatment (on demand or prophylaxis), and the presence or absence of inhibitor

CONCLUSIONS

Yttrium-90 RS and rhenium-186 RS were equally effective in reducing the number of haemarthroses and the size of the synovium in ankles and elbows in the short-term (6 months). No correlation was found between the results and other patients' characteristics.

Efficacy of radiation synovectomy (radiosynovectomy or radiosynoviorthesis) with yttrium-90 in exudative inflammation of synovial membrane of knee joints in patients with rheumatic diseases - preliminary report

OBJECTIVES

Hypertrophic and exudative synovitis of the knee is one of the earliest symptoms in rheumatic diseases. In the case of pharmacotherapy failure, other methods which directly remove the inflamed synovial membrane are used - synovectomies. Radiosynovectomy (RSV) is the radiopharmaceutical application of colloidal solution to joint cavities. In this study, the authors assessed the efficacy of knee radiosynovectomy with yttrium-90 (Y-90) in several groups of patients divided into certain rheumatic diseases.

MATERIAL AND METHODS

The study group consisted of 70 patients aged from 29 to 65 years with hypertrophic and exudative synovitis of the knee in rheumatic diseases such as rheumatoid arthritis, osteoarthrosis and spondyloarthropathies. Radiopharmaceutical colloid of Y-90, with a radiation dose of 185-222 MBq in a volume of 2-3 ml, was administered to joint. Then the knee joint was immobilized for 72 h. During visits V1, V2, V3 and V4, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured and ultrasound of the knee was performed. Disease activity was evaluated by the WOMAC scale, HAQ and 100-mm visual analog scale (VAS).

RESULTS

The most significant difference of synovial hypertrophy, before and after the procedure, was obtained in patients with rheumatoid arthritis. Variability of effusion before and after the procedure in all groups was comparable and statistically significant. The greatest improvement in variability of inflammatory parameters, before and 4 weeks after radiosynovectomy, was observed in patients with rheumatoid arthritis.

CONCLUSIONS

In the therapeutic algorithm radiosynovectomy should be located between conservative treatment and operative procedures. Radiosynovectomy does not require hospitalization or prolonged rehabilitation. Radiosynoviorthesis affects the patient's general condition, which is associated with eliminating pain and restoring joint function.

Radiosynovectomy of Painful Synovitis of Knee Joints Due to Rheumatoid Arthritis by Intra-Articular Administration of (177)Lu-Labeled Hydroxyapatite Particulates: First Human Study and Initial Indian Experience

The aim of this study is to assess the effectiveness of Radiosynovectomy (RSV) using ¹⁷⁷Lu-labeled hydroxyapatite (¹⁷⁷Lu-HA) in the treatment of painful synovitis and recurrent joint effusion of knee joints in rheumatoid arthritis (RA). Ten patients, diagnosed with RA and suffering from chronic painful resistant synovitis of the knee joints were referred for RSV. The joints were treated with 333 ± 46 MBq of ¹⁷⁷Lu-HA particles administered intra-articularly. Monitoring of activity distribution was performed by static imaging of knee joint and whole-body gamma imaging. The patients were evaluated clinically before RSV and at 6 months after the treatment by considering the pain improvement from baseline values in terms of a 100-point visual analog scale (VAS), the improvement of knee flexibility and the pain remission during the night. RSV response was classified as poor (VAS < 25), fair (VAS ≥ 25-50), good (VAS ≥ 50-75) and excellent (VAS ≥ 75), with excellent and good results considered to be success, while fair and poor as failure and also by range of motion. Three phase bone scan (BS) was repeated after 6 months and changes in the second phase of BS3 were assessed visually, using a four-degree scale and in the third phase, semiquantitatively with J/B ratio to see the response. Biochemical analysis of C-reactive protein (CRP) and fibrinogen was repeated after 48 h, 4 and 24 weeks. In all 10 patients, no leakage of administered activity to nontarget organs was visible in the whole-body scan. Static scans of the joint at 1 month revealed complete retention of ¹⁷⁷Lu-HA in the joints. All patients showed decreased joint swelling and pains, resulting in increased joint motion after 6 months. The percentage of VAS improvement from baseline values was 79.5 ± 20.0% 6 months after RS and found to be significantly related to patients' age (P = 0.01) and duration of the disease (P = 0.03). Knees with Steinbrocker's Grades 0 and I responded better than those with more advanced changes (Steinbrocker's Grades III and IV) in terms of VAS improvement (75% vs. 45.8%) (P < 0.001). The overall success rate (VAS ≥ 50) was 80%. Remission of pain during the night was achieved in 100%, and knee flexibility was improved in 80%. The changes in the blood pool phase before RSV were 3.2 ± 0.7 and after the therapy 1.4 ± 0.7 (P < 0.001). The J/B ratio was: Before RSV 2.4 ± 0.3; after treatment 1.0 ± 0.2 (P < 0.05). CRP concentration 4 and 24 weeks after the therapy was significantly lower than before treatment. The fibrinogen level was not different before and after RSV. RSV side-effects assessed for the whole follow-up period were minor and not significant. RSV with ¹⁷⁷Lu-HA was safe and effective in patients with knee joint chronic painful synovitis of rheumatoid origin. It exhibited significant therapeutic effect after 6 months follow-up period with no significant side-effects. The preliminary investigations reveal that ¹⁷⁷Lu-labeled HA particles hold considerable promise as a cost-effective agent for RSV. More elaborate and controlled clinical trials are necessary to evaluate the therapeutic efficacy and safety of the agent compared with the treatment with other radionuclides and glucocorticosteroids.

Radiosynovectomy in the therapeutic management of arthritis

Radiosynovectomy is a well-established therapy in arthritis and involves an intra-articular injection of small radioactive particles to treat a synovitis. In Europe, frequent indications are rheumatoid and poly-arthritis. Especially in Germany radiosynovectomy is the second common therapy in Nuclear Medicine with about 40,000–60,000 treated joints per year. In Spain, USA, Turkey, Argentines and Philippines the therapy is more use in hemophilic arthritis with excellent results. Especially in developing countries with low availability of clotting factors, the radiosynovectomy represent a cost effective therapeutic option for repeated bleedings in hemophilic arthropathy. The special focus in these countries is maintaining of mobility and work ability. Often only the knee and medium joints (ankle, elbow and shoulder) are treated using yttrium-90, rhenium-186 or phosphorus-32. However, in rheumatoid arthritis most common affected joints are the fingers. For the treatment in these small joints, erbium-169 is necessary. Unfortunately, erbium-169 is only available in Europe. Further indications for radiosynovectomy are osteoarthritis and the articular effusion after joint replacement. The reported response rates in rheumatoid and poly-arthritis range from 60% to 80% depends from the stage of previous arthrosis. The best effectiveness of therapy was observed in hemophilic arthritis with response rate of 90% and significant reducing of bleeding frequency. The therapy is well-tolerated with low rate of side effects. In respect of the specific uptake of particles in the synovia and short range of beta radiation, the radiation exposure outside the joint is very low. The radiosynovectomy has efforts in comparison to surgical synovectomy: it's a minor intervention with low costs; and simultaneous treatments of multiple joints or treatment in short intervals are possible. The presented paper summarized the published papers and reports our own experiences in >15,000 treated joints.

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.

Radiosynovectomy in rheumatic diseases

Radiosynovectomy is a safe and repeatable treatment method of chronic synovitis with synovial overgrowth and refractory chronic or acute inflammatory joint effusion. It consist in the intraarticular administration of a radioactive isotope in the form of a colloid causing the extinguishing of active synovitis. The radiocolloid causes permanent irradiation of the synovium with beta ray electron beams, which ultimately leads to its fibrosis and extinguishes the inflammatory process destroying the joint.

The main indications for radiosynovectomy include chronic and acute arthritis in the course of systemic diseases, intraarticular bleeding in hemorrhagic diatheses (hemophilia), selected cases of osteoarthritis, recurrent effusions following surgery, e.g. arthroplasty, or other iatrogenic post-surgery complications causing arthritis. Radiosynovectomy is also performed in pigmented villonodular synovitis and crystal synovitis. The most common method used to determine the eligibility for radiosynovectomy is an ultrasound, which shows the location and activity of the thickened synovium. The administration of a radiocolloid into the joint, sheath or bursa should also be performed under the control of the ultrasound image, as this ensures a precise location of the puncture needle and full control of the isotope administration process. Clinical efficacy of radiosynovectomy depends on the proper qualification of patients for the procedure. The success rate of radiosynovectomy in common indications is 65–80%. It is confirmed by the visualization of avascular (fibrotic) synovium in follow-up ultrasound tests. The aim of this article is to present techniques and indications for the radiosynovectomy treatment.

Comparison of arthroscopic, radioactive and combined synovectomy in the treatment of chronic non-specific knee synovitis

OBJECTIVE

To compare the outcomes of arthroscopic, radioactive and combined synovectomies in patients with chronic non-specific recurrent synovitis who did not respond to conservative therapy.

SUBJECTS AND METHODS

Twenty-nine patients enrolled between 2007 and 2011 were divided into 3 groups: group 1 was treated with arthroscopy, group 2 received a radioactive drug and group 3 received a combined (radioactive and arthroscopic) synovectomy. Treatment efficacy was evaluated by comparing pre- and post-operative Lysholm knee scores (LKS), night pain, resting pain, activity pain and effusions using visual analogue scales (VAS). Patient satisfaction was assessed using the visual analogue patient satisfaction scale (VAPSS).

RESULTS

The mean age of the study participants was 41.5 ± 5.2 years (range 14-76), and the mean follow-up period was 33.6 ± 3.2 months (range 17-78). Before treatment, the mean LKS was 41.4 ± 3.4 in group 1, 39.6 ± 3.3 in group 2 and 37.1 ± 4.6 in group 3. After treatment, the corresponding mean LKS were 77.7 ± 2.1, 81.6 ± 2.8 and 91.3 ± 2.7 in groups 1, 2 and 3, respectively; the increase was statistically significant (p < 0.05). The VAS scores before and after treatment decreased significantly (p < 0.05). The mean VAPSS score, a measure of patient satisfaction, was 5.1 ± 1.7, 5.8 ± 1.5 and 7.4 ± 1.8 in groups 1, 2 and 3, respectively, and the difference between groups 1 and 2 was not statistically significant, while that between group 3 and the other two groups was significant (p < 0.05).

CONCLUSION

This study showed that the three methods used in individuals with chronic non-specific recurrent synovitis were effective; however, arthroscopic synovectomy in combination with radioactive synovectomy was more effective than the other methods and superior in terms of patient satisfaction.

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

BACKGROUND

Radiosynovectomy (RS) is known to be effective in the treatment of chronic haemophiliac synovitis. Its effectiveness may, however, be different when the joint treated shows articular degeneration in simple radiography (ADSR).

PURPOSE

The purpose of this study was to investigate the effectiveness or otherwise of RS in the presence of ADSR. To this end, the objective improvement in five joint parameters (haemarthrosis, joint pain, range of motion, muscle strength and synovial size) has been analysed with respect to the pre-existence or otherwise of ADSR in the articulation treated.

MATERIALS AND METHODS

An observational retrospective cohort study was conducted. Between January 1993 and December 2006, RS was performed on 78 people with haemophilia. Their average age was 18 (range 7-51). RS procedures were performed on 104 different joints; some joints required more than one injection (a maximum of 3 were given, with a 6-month interval between them), which we refer to respectively as RS-1, RS-2, RS-3, resulting in a total of 156 procedures. The isotopes used were (90)Y on 107 occasions and (186)Re in 49 injections.

RESULTS

RS treatment reduced the frequency of haemarthroses, reduced joint pain and reduced synovial size, and resulted in improved muscle strength and range of motion both in joints with ADSR (N=86) and in those without ADSR (N=18). However, no articulation without ADSR required RS-3.

CONCLUSION

The five parameters studied improved to an equal degree in joints with ADSR and without ADSR. No joint without ADSR required RS-3; this was the only difference our study found between joints without ADSR and those with ADSR at the time of the RS.

Combined arthroscopic synovectomy and radiosynoviorthesis in the treatment of chronic non-specific synovitis of the knee

INTRODUCTION

Chronic non-specific synovitis has a higher recurrence rate with arthroscopic synovectomy due to the insufficient removal of all pathological tissues. Neither has radiosynoviorthesis been sufficiently effective in treatment in contrast to cases of chronic specific synovitis such as rheumatoid arthritis. This study aimed to investigate the efficiency of combined arthroscopic and radionuclide synovectomy in chronic non-specific synovitis of the knee with the evaluation of clinical and radiological results.

MATERIALS AND METHODS

14 knees of 14 patients (11 female, 3 male) diagnosed as chronic non-specific synovitis were treated with arthroscopic subtotal synovectomy combined with radiosynoviorthesis. The efficiency was evaluated retrospectively by comparing preoperative and postoperative modified cincinnati knee score, Visual Analogue Scale, joint USG and MRI. The mean age was 29.2 ± 10.3 years and the mean follow-up period was 30.3 ± 3.7 months.

RESULTS

Clinical parameters such as pain, limitation of motion and effusion were regressed. Daily activities at the final follow-up were significantly better than in the preoperative period. The mean modified cincinnati knee score of the patients increased from 25.8 ± 8.7 preoperatively to 67.8 ± 13.4 postoperatively (p = 0.002). The mean VAS score was 7.2 ± 1.1 preoperatively and 1.3 ± 0.8 postoperatively (p = 0.003). Clinically and radiologically on MRI there was no recurrence. Mean synovial membrane thickness was 4.5 ± 2.4 mm in the preoperative period. At the final follow-up, noticeable regression of synovial membrane thickness (2.1 ± 0.5 mm) was recorded in the knee joint USG (p = 0.015). No complications were observed.

CONCLUSION

The combination of arthroscopic subtotal synovectomy and radiosynoviorthesis can be an effective treatment modality for chronic non-specific synovitis of the knee.

Consecutive radiosynovectomy procedures at 6-monthly intervals behave independently in haemophilic synovitis

BACKGROUND

Previous studies on the same group of patients investigated here demonstrated the effectiveness of radiosynovectomy in the treatment of chronic haemophilic synovitis even if one, two or three radiosynovectomy procedures (RS-1, RS-2, RS-3) may be necessary. The purpose of this study was to determine whether the joints' response to each radiosynovectomy procedure behaved independently or not.

MATERIALS AND METHODS

One hundred and fifty-six radiosynovectomies were performed in 104 joints of 78 people diagnosed with chronic haemophilic synovitis. The patient's mean age was 18 years. Fifty-eight patients required radiosynovectomy in a single joint, whereas 20 received treatment in more than one joint. Of the 104 joints subjected to radiosynovectomy, 33 were elbows, 47 knees and 24 ankles. Radiosynovectomy was carried out with either yttrium-90 or rhenium-186 (1-3 injections with 6-month intervals between them). Of the 104 joints, 68 required a single injection of the radioisotope (RS-1), 20 required two injections (RS-2) and 16 required three injections (RS-3). In eight cases (7.6%), the affected joints eventually required surgery.

RESULTS

An analysis of seven variables (number of bleeding episodes, articular pain, range of motion in flexion and extension, muscle strength in flexion and extension, and synovial thickness by imaging) demonstrated that each consecutive radiosynovectomy behaves independently in haemophilic synovitis.

DISCUSSION

Each consecutive radiosynovectomy behaves independently in haemophilic synovitis. This finding had not been documented in the literature before the present study.

Radioactive synovectomy with (90) yttrium and (153) samarium hydroxyapatite in haemophilic joints: preliminary study on radiation safety

Most countries still do not achieve 1 IU of factor VIII/capita sufficient for survival. Although primary prophylaxis prevents synovitis, is not universally used. Chronic synovitis is treated with arthroscopy at expense of considerable amount of coagulation factors, and specialized surgeons. Radioactive synovectomy (RS) is a minimally invasive and cost effective alternative to arthroscopy, often considered first the option for persistent synovitis. Even without established causation with cancer, RS is avoided by some, due to this concern. We aim contributing to the understanding of RS safety regarding malignancy, presenting a large number of treated patients, and a single case of cancer. Three centres in Brazil applied RS with (90) Yttrium Citrate, (90) Yttrium hydroxyapatite or (153) Samarium hydroxyapatite in haemophilic joints and performed a survey addressing cancer in these patients. Four hundred and eighty eight patients (ages 3-51) received 1-3 RS (total 842) and follow-up was 6 months to 9 years. One patient aged 14 years presented Ewing sarcoma, 11 months after RS. The tumour was treated successfully with surgery and chemotherapy. Causality of cancer by RS is improbable in this case. Accordingly, latency here is far below minimum 5-10 years for radio-induction of solid tumours. Moreover, ES is not a typically radio-induced tumour, even at high doses. In agreement with others, though recognizing limitations, this study suggests RS is safe regarding cancer induction. Synovitis is a known burden for patients. The decision of making reasonable usage of RS should be outweighed with the risks of leaving synovitis untreated.