Chronic
synovitis is a common finding in people with
haemophilia. It regularly appears after recurrent episodes of intra-articular
bleeding. The
bleeding originates from the subsynovial venous plexus underlying the
capsule where a lack of thromboplastic activity has been demonstrated. Therefore, the changed synovium appears to be a treatment target. There are several methods which can be used to remove the synovial layer from the joint. The aim of our study was to asses the efficacy of different treatment approaches used in a group of haemophiliacs between 1985 and 2005 in our hospital.
MATERIAL AND METHODS: DISCUSSION: In 1994 Merchan presented seven excellent or good results in a group of 10 knees evaluated 1 year
after treatment with
methylprednisolone. Six years later he reported that "five years after completion of treatment, all results of the observed patients were poor". Generally,
corticosteroids will reduce
synovitis in the majority of patients but the effect is temporary. A complete remission is a very rare situation under
corticosteroid treatment. The experience with surgical
synovectomies is not recent and this method is described as carrying a high risk of complications and requiring a high amount of coagulating factor consumption. There are several recent reports on the application of
Yttrium-90: in Madrid they evaluated treated joints (knees, ankles and elbows, n = 66) in 44 patients aged from 9 to 39 years. The results were good in less than half of the knees and ankles. The treatment of elbows was more successful. It was recommended to perform synoviorthesis at the early stages of
synovitis. In Israel, they reported that a decrease in the number of
bleeding episodes was achieved in 80% of 115 patients treated with
Yttrium-90; in 15% of them,
bleeding in the treated joints stopped completely. In Izmir,
Yttrium was used in the treatment of knees, elbows, ankles and also shoulders in children and young adults (3-25 years). The method was found to be safe and effective. Brazilian authors have experience with the treatment of knees, ankles, elbows and shoulders too; they have concluded that this method represents an important resource for the treatment of chronic haemophilic
synovitis and markedly reduces joint
bleeding frequency and
pain, irrespective of the radiographic stage and inhibitor status. While the European Association of Nuclear Medicine (EANM) recommend using 186Re-sulfide for treatment in medium-sized joints, Chinese authors have published a study comparing the effect of using three different doses of 186Re-sulfide in the treatment of chronic
synovitis in knees. Their patients have received an amount of
radionuclide according to the thickness of their synovial layer measured on MRI, with the result that 22 patients exhibited significant reduction in synovial thickness. A reduction in the number of
bleeding episodes was reached in 71% of the patients within an 18-month period. No significant differences were found among the groups receiving different radioactivity doses. In Turkey, 35 elbows, 26 ankles and two shoulders in 49 patients aged between 3 and 30 years were treated with 186Re. The patients were followed up from 6 months to 3 years. At 6 months after the procedure, 81% of the elbows and 86% of the ankles with grade II
synovitis were free from
bleeding, as well as 53% and 44% of the elbows and ankles with grade III
synovitis, respectively.
CONCLUSIONS: Radiation
synovectomy appears to be the method of choice in the treatment of recurrent
bleeding in the joint cavity in people with
haemophilia. The efficacy of surgical
synovectomy is lower in comparison with radiation
synovectomy. Risks associated with surgery and anaesthesia, the need of hospitalisation and a prolonged period of rehabilitation are bothering. On the contrary, the application of
corticosteroids cannot be recommended as a good method to treat recurrent haemarthroses.