Læknablaðið : fylgirit - 01.05.1978, Page 82

Erika Szanto
Department of Rheumatology, Karolinska Bjukhuset,
Stockholm, Sweden
Introduction:
Since 1963, when Barbara Ansell and her
coUeagues reported satisfactory results in the
treatment of persistent knee effusions by intra-
articular injection of colloidal gold,19®Au, radio-
isotopes have piayed an established role in the
treatment and chronic synovitis. 90Yttrium is
preferred to colloidal198Au because of its favour-
able radiophysical characteristics (5) namely
absence of gamma radiation which gives un-
wanted whole-body radiation to the patient and a
considerably greater penetration (4). At the
vmth European Rheumatology Congress in
Helsinki in 1975 it was suggested by Bridgman
et al. that radio-active gold should not be used
any longer. Delbarre and co-workers, in 1970,
reported 417 patients treated by "synoviorthése".
They obtained good results in 807o of the cases,
with a lasting effect in 5f%. Chromosomal
abberrations in circulating lymphocytes have been
observed after intra-articular application of 90Y
which were comparable with those seen in the
treatment of hyperthyreoidism with 131Iodine (2).
No reports of an increased cancer incidence have
appeared since synovial irradiation was introduced
in 1963. Gumpel and Craley (8) determined
which of the four 90Y radio-colloids is best
retained in the knee and result in least irradiation
of the lymph nodes. 90Y silicate showed best
retention in the knee but was associated with
more lymph node uptake than 90Y Fe (OH)3.
90Y Fe (OH)3 and 90Y citrate were both less
well retained in the knee, and 90Y citrate was
associated with most uptake in lymph nodes.
90Y resin - no longer available, was well
retained in the knee, and had least lymph node
uptake. To reduce leakage, immobiUsation of
the treated joint was recommended (9). The
rate of relapse after 90Y treatment was compar-
able with that after surgical synovectomy in
patients followed up for an average of 2 years
(7). No important changes were noted in the
synovial fluid ceU count, viscosity, transaminases,
or acid and alkaline phosphotases (1). Others
(12) found normalisation of the synovial fluid, a
decrease of the number of leucocytes, acid
phosphatases, and lysozyme. It has been shown
(14) that injection of/3-emitters, 109Erbium and
LONG-TERM FOLLOW-UP
OF 90YTTRIUM-TREATED
KNEE-JOINT ARTHRITIS
90Yttrium into the joints of young rabbits slows
down the bone growth in proportion to the amount
of injected radioactivity. In arthritic rabbits the
effect of radiation on the bone growth is reduced.
Patients and methods:
33 patients with long-standing synovitis aixi
effusion of the knee were included in the study
(Table I), 18 of them had rheumatoid arthritis
(RA), 5 seronegative chronic polyarthritis, 6
psoriatic arthropathy (PSA), and 4 pelvospondylitis
(PSP), 3 of whom had also RA. 19 of the patients
were females and 14 males. Their mean age was
56 (range 36 - 76) years. The mean duration of
disease was 10 (2 -31) vears. The patients had
knee effusions lasting for an average of 4 (range
1 - 17) years. They had failed to respond with
durable improvement to earlier general medical
treatment plus aspirations and intra-articular
injections of methyl-prednisolone-acetate
(DepomedronejW as well as nitrogen mustard in
6, radioactive phosphorus (32P) in 2, streptokinase
in 2, and osmic acid in 8; surgical synovectomy
was performed in 6 of the cases. The number
of aspirations of synovial fluid plus intra-articular
steroid injections averaged 5 (range 3-12) per
year. Local joint status was studied with respect
to knee circumference, the presence of effusion,
range of movement, and pain on walking before
treatment, at one week, one month, and then
monthly up to 9 month after treatment and there-
after every 3 months up to 3.5 years.
X-ray of knee joints was performed before the
treatment and at the last check-up. The criteria
of radiological assessment were narrowing of
joint-space and erosions. The disease activity
was estimated with the aid of the activity index
(10). 25 of the 33 patients had bilateral knee
effusions. They were given 90Y into one knee
and the result of the treatment was compared
with the effect of repeated injections of methyl-
prednisolone-acetate (Depomedrone)^) into the
other knee. Eight of the patients had imilateral
knee effusions and were treated with 90Y alone.
Employing full aseptic precautions, all available
synovial fluid was aspirated and 2 ml of
prilocainchloride (Citanest)(R) and 3-4 mC of
90Y resin colloid (Radiochemical Centre,
30