Recurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization

Angiosarcoma after revision total knee arthroplasty

BACKGROUND

Hemarthrosis after total knee arthroplasty (TKA) is a relatively rare complication. Although most cases are effectively treated with conservative therapy, some cases require angiographic embolization or surgical intervention. Angiosarcoma is a rare malignant tumor derived from the vascular endothelium with neovascular hyperplasia and mainly arises in the skin and superficial soft tissue, and less frequently in deep soft tissue and bone. Although malignant neoplasms such as angiosarcoma in the vicinity of orthopedic implants were reported, the causal relationship between development of the malignant tumor and the orthopedic implant is widely debated in the literature.

CASE PRESENTATION

We report the case of a 68-year-old female with angiosarcoma that developed in the knee joint 2 years after revision TKA. The patient exhibited severe persistent bleeding, which reached 1000-1400 ml per day for 4 months. Histological analysis of the synovial tissue in the knee joint showed large cells with nuclear atypia. Immunohistochemical staining showed cells that were positive for CD31, CD34, and D2-40, and she was diagnosed with angiosarcoma. The patient underwent an amputation at the level of the thigh, and her general condition immediately improved after the operation. The patient did not exhibit bleeding from the site of amputation, and no local recurrence or distant metastases were detected 1 year after the amputation.

CONCLUSIONS

To the best of our knowledge, this represents the first report of angiosarcoma 2 years after revision TKA. Further careful follow up is needed, given the high-grade malignancy.

The role of knee arthroscopy in managing common soft tissue complications after total knee arthroplasty: a retrospective case series study

Background

To investigate the feasibility, safety and therapeutic efficacy of arthroscopy in managing the 3 most common soft tissue complications, peripatellar impingement (PI), arthrofibrosis (AF) and generalized synovitis (GS), after total knee arthroplasty (TKA).

Methods

A retrospective review of patients undertaking arthroscopy for PI, AF and GS was conducted. Outcome measures included complications, postoperative range of motion (ROM), Knee Society Score (KSS) and rates of symptom recurrence, prosthesis revision. Intraoperative findings and surgical procedures were also recorded. Paired t test, Fisher’s exact test, Kruskal-Wallis test and post hoc analysis with Bonferroni correction were used for statistical evaluation.

Results

A total of 74 patients, including 35 patients with peripatellar impingement, 25 patients with arthrofibrosis and 14 patients with generalized synovitis, with a mean age of 66.1 ± 7.9 years, were analysed. The mean follow-up (FU) duration was 81.3 ± 40.6 months. All patients underwent arthroscopic surgery safely without intraoperative complications. However, there were 4 postoperative complications, including 1 acute myocardial infarction and 3 periprosthetic joint infections. Overall, patients acquired improvements in ROM from 81.7 ± 23.1° to 96.8 ± 20.5° (p < 0.05), in KSS knee score from 64.2 ± 9.6 to 78.7 ± 12.1 (p < 0.05) and in KSS function score from 61.1 ± 7.4 to 77.3 ± 12.2 (p < 0.05) postoperatively. Patients in all 3 groups had improvements in ROM (p < 0.05), KSS knee score (p < 0.05) and KSS function score (p < 0.05). The overall recurrence rate was 22.9% (95% confidence interval (CI) 15.1–34.9%), and the overall revision rate was 14.9% (95% CI 8.6–25.6%). There were significant differences in both the symptom recurrence and prosthesis revision rates among the groups (p < 0.05). The PI group had a significantly lower symptom recurrence rate (11.4%, 95% CI 4.5–28.7%) and revision rate (8.6%, 95% CI 2.9–25.3%) (p < 0.017), while the GS group had a significantly higher recurrence rate (42.9%, 95% CI 23.4–78.5%) and revision rate (35.7%, 95% CI 17.6–72.1%) (p < 0.017).

Conclusions

In the setting of symptomatic TKA, although carrying certain risks for PJI and other complications, arthroscopic intervention could be feasible and provide clinical improvement in most cases at an average of 81.3 months follow-up. Patients with PI had the best outcomes, while patients with GS had the worst outcomes.

Level of evidence

Level IV

Endovascular management of recurrent hemarthrosis of the knee: a case series

Background

Recurrent hemarthrosis of the knee is an uncommon but potentially debilitating occurrence with multiple etiologies, including previous total knee replacement. The purpose of this study is to present data of a group of patients undergoing angiography and embolization for recurrent hemarthrosis of the knee. Patient characteristics, angiographic findings, safety and efficacy of the procedure are reported.

Methods

A retrospective single centre review of patients undergoing angiography and embolization at a tertiary referral centre in Sydney, Australia from March 2006 to April 2018 was performed. A total of 25 patients undergoing a total of 29 procedures were identified (20 female, 5 male; mean age 67), the majority of which (23/25, 92%) had a history of total knee arthroplasty. Embolization was performed in 28 of the 29 procedures (97%). The embolic agent used was either polyvinyl alcohol particles (23/28), gelatin foam (3/28), detachable microcoils (1/28) or a combination of particles and coils (1/28).

Results

The most commonly identified dominant vascular abnormality was periarticular synovial hypervascularity (23/25, 92%). A pseudoaneurysm was demonstrated in two patients (8%). Technical success (elimination of angiographic abnormalities) was achieved in 27 of 29 procedures (93%). There were 6 episodes of recurrence (25%) following a single embolization procedure, three of which were managed successfully with repeat embolization. There were no complications relating to skin or periarticular ischemia.

Conclusion

Angiography and embolization is a safe and effective tool for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first line treatment following failure of conservative management.

Level of evidence

Level 4, Case Series.

Genicular Artery Embolization for Recurrent Hemarthrosis of the Knee Following Total Knee Arthroplasty: A Single Centre Experience

PURPOSE

To retrospectively review the safety and efficacy of genicular artery embolization procedures performed at our institution in patients presenting with recurrent knee hemarthrosis following total knee arthroplasty (TKA).

MATERIALS AND METHODS

A total of 13 consecutive patients (average age: 68; range 51-84, 62% female) were identified who underwent 14 genicular artery embolization procedures after presenting with recurrent hemarthrosis after TKA. Patient charts were retrospectively reviewed for demographic information, pre-embolization investigations, and details of embolization procedure including complications, technical success, and clinical success. Each patient had failed initial conservative therapy and all patients had a diagnostic aspiration performed by the referring physician prior to the procedure. The average time between TKA and embolization in our cohort was 21 months.

RESULTS

All procedures performed were technically successful, defined as elimination of periprosthetic hypervascular blush. An average of 3.6 genicular vessels were embolized in each patient; 355 to 500 µm polyvinyl alcohol (PVA) particles were used in each case. There were no cases of transient cutaneous ischemia, skin erythema, or skin necrosis. Clinical success was obtained in 85.7% of cases, defined by elimination of the presenting clinical symptoms (knee pain and swelling) during continued follow-up by the referring clinician.

CONCLUSION

Particle embolization is a safe and effective treatment for recurrent hemarthrosis after arthroplasty and our experience suggests that utilizing particle sizes of greater than 300 µm appears to be important in order to avoid cutaneous ischemic complications.

Recurrent Hemarthrosis After Total Knee Arthroplasty: Evaluation and Treatment

Recurrent hemarthrosis (RH) is a rare complication (∼1%) after total knee arthroplasty (TKA). It is a complex and particularly frustrating problem for both patient and surgeon. Typically, patients present several months to years after their index TKA surgery with a painful and swollen joint. Although conservative management may provide temporary relief, the rate of recurrence is high. Despite extensive case series in the literature, no consensus was made on the criteria needed to establish this diagnosis, or how to best provide treatment. Several management strategies have been described for RH, including immobilization, arthroscopic versus open synovectomy, angiographic embolization, and revision arthroplasty. All of these have demonstrated variable effectiveness, with limited evidence for their use in specific situations. This review synthesizes the available literature and suggests an algorithm for the diagnosis and treatment of RH after TKA.

Recurrent Hemarthrosis due to Iatrogenic AVF Treated With Onyx Embolization

A 78-year-old gentleman presented with recurrent symptomatic hemarthrosis after total knee arthroplasty. His workup revealed an iatrogenic arteriovenous fistula (iAVF). The iAVF was embolized with the Onyx Liquid Embolization System with resolution of his symptoms up to 10 months of follow-up. This is the first description to our knowledge of an iatrogenic hemarthrosis after total knee arthroplasty successfully treated with Onyx solution embolization.

Recurrent Hemarthroses After TKA Treated With an Intraarticular Injection of Yttrium-90

BACKGROUND

Recurrent hemarthroses after a TKA are uncommon and usually respond to nonoperative treatment or intervention using angiographic embolization or synovectomy. However, in rare circumstances, the problem can be resistant to treatment.

CASE DESCRIPTION

We report the case of a patient who had recurrent hemarthroses after a TKA. During the first 18 months after surgery, the patient experienced 48 episodes consistent with bleeding into the knee. The bleeding episodes recurred despite use of traditional treatments, including arthroscopy, open synovectomy and embolization of a small, false aneurysm. The patient ultimately received an intraarticular injection of yttrium-90 silica/citrate, and the hemarthroses ceased soon after the injection. At last review, 25 months after the injection, the patient had experienced no additional bleeding episodes.

LITERATURE REVIEW

On review of the literature, we found only one other report in which yttrium-90 was used successfully in a similar situation.

CLINICAL RELEVANCE

Yttrium-90 may be considered a treatment option in patients with recurrent hemarthroses after TKA, especially when the condition has not responded to more traditional treatments. The long-term risk of treatment with yttrium-90 for recurrent hemarthroses after a TKA remains unclear.

Geniculate artery embolization for recurrent postarthroplasty hemarthrosis of the knee

Hemarthrosis after total knee arthroplasty is an uncommon condition. We present a unique case of recurrent hemarthrosis in a 93-year-old woman two years after an uneventful total knee arthroplasty and describe how we successfully treated her with selective angiographic embolization of the geniculate arteries.

Recurrent hemarthrosis after unicompartmental knee arthroplasty

Recurrent hemarthrosis after knee arthroplasty can be disabling, requiring adequate and immediate diagnosis and treatment for recovery of symptoms and joint function. The most commonly reported cause is impingement of proliferative synovium between prosthetic components. Although various procedures for hemarthrosis have been reported after knee arthroplasty for patients who do not respond to conservative treatment, the recommended first-line therapy is open surgery or embolization. Although hyperplastic synovium was observed during the first and second arthrotomy, in our case, tissue impingement was not detected. We describe a rare case of recurrent hemarthrosis after unicompartmental knee arthroplasty (UKA) and successful treatment by open synovectomy. A 66-year-old woman presented with spontaneous osteonecrosis of the medial femoral condyle in the right leg. She underwent UKA of the right knee of the medial condyle. Eighteen months after UKA, the patient developed recurrent hemarthrosis. Open arthrotomy was performed 22 months after UKA, revealing only hematoma with no obvious hemorrhage or loosening of the prosthesis. No history of trauma or use of anticoagulant medications was present. After a symptom-free period of 8 months, another 2 episodes of hemarthrosis occurred over the course of 8 months. A second open arthrotomy was performed. Hyperplastic synovium with fibrin and hemosiderin pigmentation was observed, again without hemorrhage or loosening. There were no pathological features of pigmented villonodular synovitis. Synovectomy was performed, and no hemarthrosis has recurred for 2 years.

Causes of failure and etiology of painful primary total knee arthroplasty

The review provides an overview of the causes of failure and the many different aetiologies of a painful primary total knee arthroplasty (TKA). They can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. Whereas biological aetiologies like infections have remained stable over time, other causes of failure have changed. In the early times of knee arthroplasty, they were mainly related to technical insufficiencies. A better understanding of knee arthroplasty, patients' increasing functional demands as well as a continuous development of TKA techniques generated newer problems, which are increasingly related to the functioning of the soft-tissue envelope of the knee. From a therapeutic point of view, three situations can be considered: functional problems not needing reoperations, causes of reoperations not needing an exchange of prosthetic components as well as reoperations with exchange of at least one prosthetic component.

Embolisation for vascular injuries complicating elective orthopaedic surgery

OBJECTIVES

The study aims to present the indications and emphasise the role of embolisation for vascular injuries in orthopaedic surgery.

METHODS

Thirty-one patients with vascular injuries complicating elective orthopaedic surgery had embolisation from 2003 to 2010. N-2-butyl cyano-acrylate (NBCA) was used as embolic agent in 28 patients, gelatin sponge in three and coil embolisation in addition to NBCA or gelatin sponge in two patients. The mean follow-up period was 37 months (range, 4-96 months).

RESULTS

The most common orthopaedic operations associated with vascular injuries amenable to embolisation were hip-joint procedures; and the most common injuries were arterial tears of branch vessels or non-critical axial vessels, most commonly of the superior glutaeal artery. In all cases, angiography showed the bleeding point, and a single embolisation session effectively stopped bleeding. Embolisation-related complications were not observed.

CONCLUSIONS

Embolisation should be considered the treatment of choice for vascular injuries of branch vessels or non-critical axial vessels following elective orthopaedic surgery because of the advantages of minimally invasive therapy and the lack of complications.

Recurrent haemarthrosis following total knee replacement

Total knee replacement is a well-established treatment for osteoarthritis with increasing numbers performed each year. Recurrent haemarthrosis is a relatively rare complication following TKR being reported in up to 1.6% of patients. While some causes are related to direct trauma to blood vessels, others are more obscure and may be difficult to diagnose. The purpose of this review is to give an overview of this unusual complication and summarise the current methods of management.

The management of patients with painful total knee replacement

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient's pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Angiographic findings and therapeutic embolization of late hemarthrosis after total joint arthroplasty

OBJECTIVE

The objective of this study was to describe the angiographic findings of late spontaneous hemarthrosis after total joint arthroplasty and to illustrate the therapeutic role of angiography.

MATERIALS AND METHODS

A retrospective multicenter study was performed looking for patients who underwent an angiography for spontaneous hemarthrosis occurring at least 1 month after total joint arthroplasty. Eight patients were included, all suffering from spontaneous hemarthrosis. One patient had an additional large extra-articular hematoma.

RESULTS

Angiography in eight cases revealed hypertrophic vascular synovium in seven patients with an additional false aneurysm in one patient. Hypervascularization with pooling of contrast spots was seen in one patient. Five patients underwent selective arterial particulate embolization. Three patients were successfully embolized after one session, one was successful after two sessions, and one patient needed surgery after two embolization sessions.

CONCLUSION

Angiography for late spontaneous hemarthrosis is very effective to exclude or establish vascular malformations and to establish the diagnosis of hypertrophic vascular synovium. Selective arterial embolization seems to be a good therapeutic option as alternative to open or arthroscopic synovectomy.

Recurrent spontaneous hemarthrosis after total knee arthroplasty successfully treated with synoviorthesis

A case of spontaneous recurrent hemarthrosis--due to developed hypertrophied synovium--after total knee arthroplasty is reported. The patient was successfully treated with radiosynovectomy. The first hemorrhage occurred 18 months after the total knee arthroplasty. Several similar episodes followed over a period of 4 years. Because conservative treatment failed to control the bleeding, an arthroscopic lavage was performed, which revealed the existence of proliferative synovium. A significant part of the hypertrophic tissue was excised with the use of a thermocoagulator. However, 1 month later, another episode of hemarthrosis occurred. As a final step before reoperation, the patient was treated with intra-articular injection of ytrium 90. Eighteen months later, she remains symptom-free, is very satisfied with the result, and reports no new episode of hemarthrosis.

Therapeutic embolization for the treatment of recurrent hemarthrosis after total knee arthroplasty due to an arteriovenous fistula

We describe the case of a 79-year-old woman who presented with recurrent hemarthrosis 8 years after primary total knee arthroplasty. An arteriovenous fistula of the superior lateral geniculate artery was diagnosed by arteriography after arthroscopy of the knee revealed multiple organized hematomata with minimal synovitis. The arteriovenous fistula was treated by percutaneous coil embolization and the symptoms resolved.

A case of spontaneous hemoarthrosis after a total knee arthroplasty

A 63-year-old woman with osteoarthritis had undergone right total knee arthroplasty. Nineteen months later, the patient presented with a recurrent hemoarthrosis. Open arthrotomy revealed hypertrophic synovium with small clots in the suprapatellar pouch, but entrapment of synovial tissues could not be observed. Histological examination of the extirpated specimen showed fibrous hypertrophy of synovium. The patient has no symptoms 51 months after surgery.