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Successful radiosynoviorthesis of an olecranon bursitis in psoriatic arthritis
  1. M N Berliner1,
  2. R G Bretzel1,
  3. R Klett2
  1. 13rd Department of Internal Medicine, University Hospital Giessen, Germany
  2. 2Department of Nuclear Medicine, University Hospital Giessen, Germany
  1. Correspondence to:
    Dr M N Berliner, Universitätsklinikum Giessen, Medizinische Klinik, III - Rheumatologie, Rodthohl 6, D-35392 Giessen, Germany;
    michael.berliner{at}rheuma.med.uni-giessen.de

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We describe the case of a 45 year old male patient who for more than 10 years had had psoriasis with typical manifestations at knees and elbows. The family recalled psoriasis of the grandfather. Without any trauma or special straining, an olecranon bursitis and an arthritis of the left elbow developed in 1999 as the initial manifestation of psoriatic arthritis. Three months after developing the bursitis, the patient came to the rheumatological outpatient clinic for his first visit.

The clinical findings showed a patient with good general condition (height 186 cm, weight 93 kg), blood pressure 120/80 mm Hg, rhythmic pulse rate 68 beats/min; psoriatic skin lesions at knees and elbows; no reduction of spine mobility. The left elbow showed an olecranon bursitis with a diameter of 50 mm. The remaining musculoskeletal system was not affected.

The laboratory results were within the normal ranges, HLA-B27 was negative, antinuclear antibodies negative, functional tests of liver and kidney were normal.

Radiographic findings showed that sacroiliac joints and the left elbow joint were normal. Sonography showed an olecranon bursitis with a large effusion (fig 1A).

Diclofenac 100 mg twice daily was given for the first two weeks but did not produce any effect. After that, the olecranon bursa was punctured aseptically, and a crystal suspension of 10 mg triamcinolone hexacetonide was injected. Two days later, the bursitis relapsed completely. Further therapeutical options were surgical bursectomy or, alternatively, radiation synovectomy. After having received complete information, the patient gave his consent to treatment by radiosynoviorthesis. After aspiration of 9 ml of a serous effusion, 55 MBq rhenium-186 was instilled into the olecranon bursa, and then, to avoid radiosynovitis, 5 mg triamcinolone was injected. Radioisotope scanning immediately after the injection and three days later showed that the radionuclide was distributed uniformly in the bursa. There were no local signs of an infection.

A physical examination three months after radiation synovectomy of the olecranon bursitis showed regular clinical findings. Arthrosonographic results had also normalised (fig 1B). Even six months later the bursitis was not reactivated.

Radiation synovectomy is often used as an alternative, or in addition to, surgical synovectomy. Definite indications are chronic persisting synovitis, intermittent hydrops, relapsing synovitis after surgical synovectomy, haemophilic arthropathy, and activated osteoarthritis resistant to other treatments. Some studies have reported successful concomitant treatment of Baker's cysts in the treatment of gonarthritis,1 but radiosynoviorthesis solely for the treatment of Baker's cysts is not usual. It is possible, however, by infusion of a radioisotope into the knee joint, but the popliteal cyst must not be punctured directly. Due notice should be taken of contraindications.2 Other reports disagree about the success rates of radiosynoviorthesis in treating psoriatic arthritis compared with rheumatoid arthritis.3,4 A few years ago, only patients aged over 40 were treated with radiosynoviorthesis. Today, this treatment is used in an increasing number of younger patients. The success rate for radiosynoviorthesis of olecranon bursitis is between 50 and 80%, depending on the localisation and the amount of inflammatory activity.5–7

Up to now, no studies of the treatment of chronic inflammation of the bursa by radiosynoviorthesis have been reported. In our patient, neither the treatment with a non-steroidal anti-inflammatory drug (200 mg diclofenac daily) nor the local treatment with triamcinolone hexacetonide after a decompression aspiration led to improvement. As an alternative to surgical bursectomy, radiosynoviorthesis with rhenium-186 was performed. The patient improved quickly and started working again the following day. The follow up examinations, after intervals of three and nine months, confirmed the continuing success.

As far as we know this is one of the first reports on radiosynovectomy in an isolated bursitis. This case gives cause for hope that radiosynoviorthesis represents a successful alternative treatment to operational intervention for chronic inflammation of the bursa.

Figure 1

Sonography of the left elbow (A) showing an olecranon bursitis (58.1 mm; 17.7 mm; 3.3 mm; 2.5 mm) and (B) three months after radiation synovectomy.

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