Treatment of Recurrent Hemarthrosis Following Total Knee Arthroplasty Using Surgical Interventions

Abstract

Backgroud: Recurrent hemarthrosis following total knee arthroplasty (TKA) is a rare complication. Its pathophysiology and standard treatments have not yet been established. In this study, we report 7 cases of recurrent hemarthrosis after TKA in which failure of the initial conservative treatment was followed by angiographic embolization; in 1 of the 7 cases, arthroscopic electrocauterization was also performed after treatment failure with selective embolization.

Methods: From January 2015 to May 2018, 7 patients visited our hospital due to recurrent hemarthrosis after TKA. Their medical records and serologic test results were reviewed to check for the presence of any bleeding disorder and history of anticoagulant use. Implant malalignment and instability were checked using X-ray. In all cases, the conservative treatment failed, so interventional angiography with selective embolization was performed, which was also followed by arthroscopic electrocauterization if the outcome was unsatisfactory.

Results: The interval between TKA and the onset of hemarthrosis ranged from 3 to 76 months (average, 34.1 months). There was no coagulopathy and instability. All patients underwent conservative treatment at an interval of 4.3 months and the rate of relapse was 3.1 on average. On the interventional angiography, 6 cases showed vascular blush, and 1 case had pulsatile bleeding. The average duration for interventional angiography was 90.9 minutes. The average length of follow-up was 38.8 months. Embolization was successfully performed in 4 cases. In 2 of 3 failed cases, the symptoms improved without further treatment. In the remaining 1 failed case, the patient had a relapse of hemarthrosis, so an arthroscopic procedure was performed, which led to identification of the suspicious bleeding point by using preoperative angiographic findings. Electrocauterization was performed and active bleeding was stopped. All cases with recurrent hemarthrosis achieved improvement.

Conclusions: Interventional angiography was used to aid in the diagnosis of recurrent hemarthrosis, and therapeutic selective embolization provided satisfactory clinical results. Even if selective embolization fails, interventional angiography may be helpful for further surgical procedures because it reveals vascular blush of a bleeding site. Therefore, interventional angiography and selective embolization should be considered to be a useful treatment for recurrent hemarthrosis after TKA.

Keywords: Angiography; Embolization; Hemarthrosis; Total knee arthroplasty.

Fig. 1. (A) Interventional angiography demonstrating vascular blush with haziness in the right inferior lateral genicular artery (arrow). (B) Selective embolization using Gel-foam led to the immediate absence of the vascular blush and resolution of haziness.

Fig. 2. (A) Pulsatile active bleeding was observed in the terminal branch of the middle genicular artery connected to the posterior superior aspect of the knee joint (arrow). (B) Selective embolization using Gel-foam was performed for the terminal branch of the middle genicular artery (arrow). (C) After selective embolization of the middle genicular artery, active bleeding stopped.

Fig. 3. In angiography, vascular blush was observed in the left inferior lateral genicular artery (arrow).

Fig. 4. (A) Hemosiderin pigmented hypertrophic synovium was observed, but there were no active bleeding sites. (B) We tried to find a suspicious bleeding point in preoperative angiography. To check the inferior lateral genicular artery by arthroscopy, a posteromedial viewing portal was used and the posterolateral corner was observed through a transseptal portal with a 70° scope (black arrow). (C) After cauterization using Arthrocare, active bleeding stopped (black arrow).

Fig. 5. In general, there are several areas of vascular blush on interventional angiography in patients with recurrent hemarthrosis after total knee arthroplasty, but we approached the vascular blush around the joint as the main focus of hemarthrosis. Black arrows: blush around the intra-articular area, White arrows: blush in the extra-articular area.