Local Complications After Radiation Synovectomy

Local complications after radiation synovectomy are very rare. A transient radiogenic effusion is seen in 2% of the patients several hours after application of the

Table 6 Patient Instructions, Side Effects, and Radiation Safety Considerations

Patients should receive written and verbal information about the procedure and its side effects:

Strict immobilization of the joint is absolutely necessary for treatment efficacy and radiation safety

Patients benefit from the treatment in about 60% to 70% of the cases

Treatment response will be delayed by two to eight weeks in knee and mid-size joints and may be delayed up to three to six months in finger and toe joints Risk of temporary worsening of the symptoms due to radiation-induced inflammation

(cooling with ice packs, over-the-counter anti-inflammatory drugs) Joint puncture is associated with the risks of local bleeding, bruising, and infection Risks associated with application of radionuclides are local tissue necrosis as well as radiation exposure and future malignancy Other risks associated with the procedure are allergic reactions to contrast medium and local anesthetics, hyperglycemia in diabetic patients and flush symptoms from steroids, thyreotoxicosis as a result of iodine-containing contrast medium, and thrombosis due to immobilization Patients should be advised to report any worsening or other uncommon changes in the treated joint, and the patient should be given a contact he can reach at any time

Information about radiation safety considerations should be provided:

Radiosynoviorthesis should not be performed in pregnant or breastfeeding women Pregnancy should be avoided after radiation synovectomy by effective contraception for four to six months Urinary contamination should be avoided by flushing the toilet two or three times and handwashing after every toilet's use, men should urinate sitting down No additional home precautions are required radionuclide (47). Aggravation of local pain and swelling 6 to 48 hours after treatment has been observed in about 15% of our patients, mostly in finger and toe joints which received no steroid application. These symptoms are usually self-limited without further intervention and can be treated simply by cooling the joint with ice packs or, if necessary, with anti-inflammatory drugs such as ibuprofen.

More severe complications are local skin and needle track ulcerations which may occur if drops of the radionuclide flush back out of the needle during retraction from the joint. This can be easily avoided by flushing the needle with steroids or 0.9% saline after application of the radionuclide, as described before. Savaser et al. (48) report on a needle track ulceration after radiation synovectomy of an ankle joint with Re-186, which showed healing by scar formation after a few weeks without any further treatment. Necrosis of periarti-cular tissue is the worst local complication in radiation synovectomy and is caused by accidental para-articular injection of the radionuclide. A very low frequency of two cases of necrosis out of 11,000 treatment procedures was reported by Kolarz and Thumb in 1982 (49). With at least 23,000 radiation synovectomy procedures performed in Europe in 2001, there is only one documented case of radionecrosis in a knee joint after application of Y-90 (50). Apart from these data, very few cases have been reported in literature. Interestingly, there are no reports on radionecrosis for Er-169.

Besides an insufficient technique during joint puncture, the use of an inappropriate radionuclide is another possible reason for radionecrosis. A case of severe necrosis with an open wound was reported after injection of Y-90 into an ankle joint, which should be treated with a radionuclide of lower energy and a lower tissue range such as Re-186 (51). Therapy was performed by immediate surgical excision of the necrotic soft tissue and closure was achieved with a fasciocu-taneous lap. In other cases (unpublished data, personal communications), hyperbaric oxygen was successfully used for treatment of superficial radiogenic ulcers. However, owing to the small number of well-documented cases, no reliable guidelines exist for the treatment of radionecrosis after radiation synovectomy.

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