Type:
Educational Exhibit
Keywords:
Education and training, Radionuclide therapy, Ultrasound, Fluoroscopy, Musculoskeletal joint, Interventional non-vascular
Authors:
S. Carbullanca Toledo, J. Ares, I. García Duitama, A. Agustí, A. Solano, I. Espallargas Giménez, E. martinez miralles; Barcelona/ES
DOI:
10.26044/ecr2019/C-0985
Findings and procedure details
Previous study
- It is advisable to have an RX or MRI of the last 6 months in patients candidates for an radiosynoviorthesis
- Joint ultrasonography may be useful to evaluate the presence of synovial effusion and / or thickening / synovitis,
or to exclude rupture of a Baker's cyst or massive hemarthrosis.
- It may be useful to have a osseus gammagraphy (2 or 3 phase) to evaluate the severity of soft tissue and joint inflammation,
particularly if multiple joints are affected (8) and for post-treatment assessment (10)
- The characteristics of the synovial fluid,
obtained by arthrocentesis of the joint,
must be analyzed in order to rule out the presence of infection (10)
- Interdisciplinary collaboration with responsible physicians (rheumatologists or orthopedic surgeons) is recommended for the indication of the test and the general management of these patients.
Informed consent
Informed consent is required,
stating the procedure to be performed,
the benefits and risks (8).
- They must be informed of the radioactive nature of the treatment
- It is advisable that you receive the information orally and in writing
- Patients should be informed that the response is not immediat and may take more than 2 weeks to 1 month,
with improvement up to 6 months.
- Initially,
there may be a temporary increase in synovitis and pain
- Risk of fever or allergy after injection (very rare)
- Risks related to joint puncture (infection,
local hemorrhage or extravasation)
- Risk of radionecrosis if the injection is not strictly intraarticular (very rare)
- Future risk of malignancy (theoretical)
- Risk of a thromboembolic event after immobilization of the lower extremity for 48 hours after treatment (antithromboembolic precautions should be taken).
- The patient should also be informed that the procedure is 60% to 80% effective and can be repeated after at least 6 months.
Technique (1) Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6
- Adequate room
- Sterile procedure
- Adequate support of the syringe containing the radiopharmaceutical (The adequate protection for the emission of β radiation is made of acrylic plastic)
- Special precaution in the handling of radionuclides due to extremely high doses in cases of contamination (9)
Technique (2)
- Local skin anesthesia (optional)
- Puncture and intra-articular injection should be ensured.
(In the knee it is easier to aspirate synovial fluid)
- In smaller joints,
puncture can be controlled with ultrasound or under fluoroscopic guidance.
The administration of contrast allows to document the correct intra-articular situation of the needle (The iodinated contrast should not contain EDTA or other chelating agents that could eliminate the radiopharmaceutical from the colloid medium)
- If there is an abundant joint effusion,
it is advisable to empty it beforehand
- In small joints it may be difficult or almost impossible to perform the needle rinse due to the very small intra-articular volume
- Compression and immobilization of the joint should be applied for 48 hours using the appropriate methods (for example,
splints).
Example of fluoroscopic guidance Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11
Example of ultrasound guidance Fig. 12 Fig. 13 Fig. 14 Fig. 15 Fig. 16
It is advisable to obtain post-injection scintigraphic images to assess the distribution within the joint (186Re or adding an isotope Υ (1-2mCi of 99mTc colloidal sulfide or 99mTc pertechnetate) that is usually obtained after 2h (10)
Fig. 17
Indications
Indications for radiosinovectomy include several inflammatory diseases and degenerative joints:
- AR (initially used for it)
- Seronegative spondyloarthropathies (reactive,
psoriatic arthritis)
- Articular inflammatory diseases (Lyme,
Behçet)
- Pigmented villonodular synovitis
- Hemophilic arthritis (not in active bleeding phase)
- Arthropathy by calcium pyrophosphate (CPPD)
- Undifferentiated arthritis
- Osteoarthritis (activated) (OA)
- It can also be done to remove residual inflammatory tissue after incomplete arthroscopic synovectomy
- Chronic persistent effusions after placement of joint prostheses.
- Some authors include Baker's cyst (10)
- Treatment of chronic or persistent inflammatory pathology,
refractory to both systemic treatment and intra-articular infiltration with corticosteroids and in hemophilia.
Contraindications
Absolute (according to the current guidelines):
- Pregnancy Lactation
- Local infection,
joint or sepsis Intra-articular fracture (10)
- Broken Baker's Cyst
- Massive hemarthrosis (8)
Relative:
- Marked joint instability
- Advanced erosive joint involvement or other forms of bone destruction
- Significant loss of articular cartilage
- Patients under 20 years of age (the benefit of the treatment must be greater than the potential risk of the radionuclide)
Side effects / Complications
- Temporary increase in pain (synovitis)
- Lymphoedema,
fever,
radiotracer allergy (1,8)
- Radiological necrosis of the injection site Joint infection
- Thrombosis due to immobilization
In a large study these complications were estimated in approximately 1 % and most were treated with conventional therapy (1,5).
- Radioactive leak,
through the lymphatic circulation; regional lymph nodes proximal lymph nodes blood flow reticuloendothelial system.
- Unwanted extra-articular radiation levels have been shown to be negligible with these agents.
- Biological effect: Chromosomal alterations.
There is no evidence that they increase,
in a statistically significant way (1)
- Risk of malignancy: No case of local or systemic malignancy related to treatment has been established (6,10)
Post treatment instructions
- Immobilization of the joint for at least 48 h
- If early aggravation of pain,
it can be treated with simple anti-inflammatory measures
- A review of 4 to 6 days (or sooner) after the injection is recommended to detect possible side effects
- Women should avoid pregnancy for at least 4 months after treatment
- Avoid unnecessary exposure to family members and the public to radiation.
Several country-specific rules can be applied in this regard
- Radiopharmaceutical excretion is not a concern in these patients because the application is local
Follow up
- After 3-4 months,
the nuclear medicine specialist can (in accordance with national regulations) reevaluate the inflammatory activity of the synovial membrane and the therapeutic response
- Ultrasound,
osseus gammagraphy (2-phase or 3-phase) or MRI can be valuable in documenting the condition
- The reevaluation can also be interdisciplinary,
involving the rheumatologist or orthopedic surgeon since they are the ones that deal mainly with these patients
Post treatment control
- The reduction of the pain manifests habitually from 3 weeks post-treatment,
although some authors indicate that the benefit is not obtained until 3 months (11)
- Treatment is considered ineffective when there is no response at six weeks post injection.
In these cases,
or when the response is only partial,
SR can be repeated after six months
- There is no evidence that increasing the dose in the second treatment results better
- If there is no improvement after the 2nd,
some authors consider that it is not usually indicated to perform more (10)
Results
- A complete reduction of swelling of the knee joint by more than 40% and of pain relief have been reported in 88% of patients (11)
- In the joints of the wrist,
elbow,
shoulder,
ankle and hip has shown a significant improvement of 50-60% (11)
- Restoration of normal function and long-term pain relief in approximately 70% of the small finger joints (11)
- In hemophilic arthropathies,
complete cessation of hemorrhage has been observed in approximately 60% and better mobility in 75% of patients (11)