Is Embolization an Effective Treatment for Recurrent Hemorrhage After Hip or Knee Arthroplasty?

Abstract

Background: Spontaneous recurrent hemorrhage after arthroplasty of the hip or knee is a rare condition. In patients who do not have coagulopathy, the likeliest etiology for hemarthrosis is hypertrophic vascular synovium. Treatments include arthroscopic or open synovectomy, or angiography with embolization; however, because the condition is rare, seldom reported, and debilitating, small case series characterizing the efficacy of any approach are important to allow a collective experience with this condition to emerge.

Questions/purposes: We attempted to (1) determine whether angiography with embolization can prevent recurrent hemarthrosis after hip or knee arthroplasty in a small series of patients with or without coagulopathy, and (2) evaluate complications associated with this intervention.

Methods: Between 2005 and 2014, seven patients presented with spontaneous, recurrent hemarthroses. One patient had polycythemia vera and factor XIII deficiency as underlying illnesses. All patients were treated with selective transarterial embolization, and all had followup at a minimum of 12 months (range, 12-102 months; median, 74 months). Other treatments during this time included hematoma removals and flap operations in one patient, and indications for transarterial embolization included recurrent hemarthrosis. The patients included six men and one woman with a median age of 72 years (range, 61-78 years). Five patients underwent one or more reoperations before transarterial embolization. A diagnostic workup for coagulopathy was performed in all patients; one patient was identified to have polycythemia ruba vera and factor XIII deficiency, however the patient still was treated with transarterial embolization because it was perceived to be the least invasive of available options. No other patients had a diagnosis of coagulopathy. Angiography showed hypervascularity in all patients and a contrast agent showed extravasation in two. Selective transarterial embolization of branches of the internal iliac artery, common femoral artery, deep femoral artery, or the popliteal artery was performed with polyvinyl alcohol particles, microspheres, and/or coils. Patients were followed clinically during 12 to 102 months (median, 74 months) to determine whether the hemorrhages recurred.

Results: Technical success was achieved in all patients. No procedure-related complications were reported. On followup, recurrent hemorrhage was reported in one patient who had a diagnosis of coagulopathy before the procedure. He underwent three reinterventions and five reoperations. Three months after initial embolization, a flap procedure was performed.

Conclusions: In a small series of patients with a minimum followup of 1 year, we found selective transarterial embolization to be effective in patients without underlying coagulopathy in preventing recurrences of spontaneous recurrent hematoma or hemarthrosis of the hip and the knee. This condition is rare, therefore comparative trials are unlikely to be done. Because transarterial embolization is relatively low risk and generally well tolerated, we consider it to be a reasonable approach for consideration with other options such as arthroscopic or open synovectomy and revision arthroplasty.

Level of evidence: Level IV, therapeutic study.

Fig. 1A–B

A 74-year-old man had recurrent hemorrhage after total knee replacement. The patient had a diagnosis of polycythemia vera and factor XIII deficiency. (A) Owing to ongoing hemarthrosis, digital subtraction angiography was performed 6 days after initial coil embolization (curved arrow). Popliteal angiography showed a large extravasation in the popliteal fossa (arrows). (B) Complete cessation was seen after embolization.