Pathogenesis and treatment options for hemophilic synovitis

ABSTRACT

Introduction: Hemophilia is characterized by recurrent bleeding episodes, most commonly in the knees, elbows and ankles. Repeated hemarthroses lead to synovial hypertrophy and a vicious cycle of chronic synovitis arises, leading to destruction of the joint.

Areas covered: This article covers the pathogenesis of chronic hemophilic synovitis and its treatment by means of different types of synovectomy.

Expert opinion: Both radiosynovectomy (RS) and arthroscopic synovectomy considerably improve the frequency of bleeding episodes. RS is the best option for patients with synovitis unresponsive to a three-month trial of hematological prophylaxis. If the bleeding is refractory to three successive episodes of RS at six monthly intervals, arthroscopic synovectomy is indicated. Open synovectomy should be reserved for adults with elbow synovitis requiring radial head removal and synovectomy in the same surgical session. RS is effective and safe, and particularly helpful in patients with inhibitors as they are at greatest risk of bleeding episodes and have the highest risk of complications of surgery.

KEYWORDS:

• Hemophilia
• synovitis
• pathogenesis
• treatment
• radiosynovectomy
• arthroscopic synovectomy

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Article highlights

• The pathogenesis of hemophilic synovitis is multifactorial, but is initiated by the presence of blood within the joint. As a result, hemarthroses must be prevented by means of primary hematological prophylaxis.

• Once the synovium is hypertrophic due to recurrent hemarthroses, a vicious cycle of hemarthrosis-synovitis-hemarthrosis will develop.

• The only way we have to break this vicious cycle is synovectomy (removal of the hypertrophic synovium).

• There three types of synovectomy: radiosynovectomy (RS), chemical synovectomy and surgical (generally arthroscopic) synovectomy.

• RS is an efficacious, safe, minimally invasive, well tolerated technique for the management of chronic hemophilic synovitis and is very straightforward to perform.

• RS of the knee requires more injections than the elbow or the ankle as do more severe cases.

• The last surgical resort is arthroscopic synovectomy. Arterial embolization is the last nonsurgical resort.

• Open synovectomy is indicated in cases of elbow synovitis with severe loss of pronation and supination range. In these patients radial head excision and open synovectomy can be performed simultaneously.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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Funding

This paper was not funded.