Radiosynovectomy in Hemophilic hemarthropathy

Full text: Eliminating recurrent joint bleeding from early childhood, before the damage occurs, can prevent joint destruction in hemophiliacs. The regular use of systemic factor replacement as a primary prophylaxis is efficacious but expensive. Secondary prophylaxis, which is scheduled Factor 8 replacement, may help, but often times these are delayed causing joint deterioration. Recurrent hemarthrosis causes joint damage that seriously impairs the quality of life of hemophilic patients. Reducing the frequency of hemorrhage appears to be the only possibility to postpone the development and progress of hemarthroses. Several options like intraarticular injections as chemical synovectomy as well as surgical synovectomy continue to produce untoward side effects as pain and bleeding risks respectively. Radionuclide synovectomy has become an increasingly utilized local therapy for several obvious reasons. Radiosynovectomy (RSV) is the local intraarticular injection of radionuclides in colloidal form to create fibrosis of the hypertrophied and highly vascularized synovium. Three radionuclides are in current use: Yttrium- 90, Rhenium 186 sulfide and erbium-169 citrate. Most studies resulted in successful reduction of the frequency of hemorrhage of the joints in around 80% in most reports and up to as high as 94% for the first year and maintained improvement in 63% until long-term follow-up in others. Our experience included 21 hemophiliacs, all males whose age ranged from 4 to 36 years of age. The requirements were the following: that they had at least three bleeding episodes the past 6 months prior to the procedure, an informed consent, at least a 30% coagulopathy at the time of the procedure with no ankylosis or over stage 3 based on Pettersson classification. Exclusion criteria included infection on site of infection, beyond stage 3 and with ankylosis, previous surgery of the involved joint and inability to raise Factor VIII. Baseline knee radiography and two- phase bone scans were done, these being repeated at 6 and 12 months. Clinical evaluation were done at 1, 3, 6 and 12 months wherein pain scoring system through the visual analog scale was done, swelling and measurement of the involved knee joint, ambulation, concurrent medications, as well as the number of bleeds were checked. They were all given Yttrium-90 colloid intrarticularly in the knee with doses ranging from 60 Mbq to 185 Mbq depending on the age of the patient. During the procedure, we aspirated blood and left a few cc for it to be mixed with the Yttrium-90 colloid. We rinsed the intrarticular Yttrium with NSS as we withdraw the needle and applied a splint around the knee for support and asked the patients to immobilize the knee for 48-72 hours to decrease leakage. Imaging for Brehmstrallung radiation on the knee was done and leakage was checked .The coagulation factor was monitored till 48 hours. Ten patients improved 70-100%; nine patients improved 50-70% ;one patient improved 30% and one was status quo. With regards to pain and swelling which was seen only in 40% of the cases, there was 86% improvement; bleeding-86%; bone scan-62% but over-all improvement was seen in 90% of the hemophiliacs after one-year observation. Side effects were mild, ranging from mild discoloration at injection site in one patient, flare in 4 patients and fever in 2 patients. Radiosynovectomy should be the treatment of choice for hemophilic hemarthroses since they are at poor risk for surgery. It likewise prevents sequelae of several bleeds and hence preventing deformities in the joints. There is also less need for future Factor VIII replacement if not at all. It is a minimally invasive procedure that is well tolerated and can be done on an outpatient basis that is cost-effective. (author)