Procedure

Radiographs of the joints to be treated should be obtained and reviewed prior to undertaking radiosynoviorthesis. Weightbearing views of lower limb joints should be requested specifically. Symptoms largely or exclusively attributable to cartilage damage are unlikely to benefit from radiosynoviorthesis.

Joint puncture for radiosynovectomy carries the same risk as any joint puncture and should follow the rules of strict asepsis.

Local skin anaesthesia is advisable.

Correct deposition and homogeneous distribution of the radiopharmaceutical agent in the joint space is essential. Puncture of all joints should be performed under fluoroscopic (X-ray screening) or ultrasound guidance. Additional contrast medium administration is necessary to control homogeneous distribution, especially when treating the knee. If the contrast medium is not distributed evenly, but is instead localised intra-articularly, you may be able to locate the needle in a synovial villus or septation within the joint. If there is no response after treatment, you should change the needle's location. 

A particle size of at least 5-10 nm is essential to avoid leakage.

Absolute immobilization of the treated joint(s) for 48 h using splints or bed rest is recommended as this will reduce transport of particles through the lymphatics to the regional lymph nodes.

Where possible, simultaneous administration of intraarticular long-acting glucocorticoids (e.g. methylprednisolone or triamcinolone) is recommended to reduce the risk/severity of acute synovitis and to improve treatment response. 

For Erbium-169 10 mg of triamcinolone acetonide can be administered if there is enough joint space for a pressure-free injection.

The needle through which the radiopharmaceutical has been injected should be flushed before and during withdrawal with 0.9% saline or directly through the glucorticoids administration.

The importance of joint immobilization following treatment should be emphasized.