Recurrent hemarthrosis after total knee arthroplasty

Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature

PURPOSE

To provide an updated systematic review on the use of geniculate artery embolization (GAE) in the management of recurrent hemarthrosis post-total knee arthroplasty (TKA).

MATERIALS AND METHODS

A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications, and follow-up data were extracted and analyzed using STATA 14.1.

RESULTS

A total of 20 studies (9 case reports, 11 case series; n= 214) were included for review. In all cases, patients underwent coil embolization of one or more geniculate arteries. Procedure success was reported in 94.8% (n=203/214) of cases without perioperative adverse events. Improvement of symptoms was seen in 72.6% (n=119/164) of cases, with 30.7% (n=58/189) of cases requiring repeat embolization. Recurrent hemarthrosis occurred in 22.2% (n=22/99) of cases over a mean follow-up of 48 months.

CONCLUSION

GAE appears to be a safe and effective treatment for recurrent hemarthrosis following TKA. Future studies in the form of randomized controlled trials should be conducted to further evaluate such embolization techniques and compare outcomes between GAE and standard techniques.

CLINICAL IMPACT

Conservative management of post total knee arthroplasty (TKA) hemarthrosis is successful in only one third of cases. Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive nature compared to open or arthroscopic synovectomy promising faster rehabilitation, decreased infection rates and less additional surgeries. The purpose of this article was to summarize current literature, provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA and describe immediate and long-term outcomes in an effort to help optimize current treatment algorithms.

A Pseudoaneurysm of the Inferior Lateral Geniculate Artery Following Total Knee Arthroplasty

Vascular complications after total knee arthroplasty are rare. We present a case of an inferior lateral geniculate artery pseudoaneurysm which became symptomatic 10 days after total knee arthroplasty in a patient with a cardiac comorbidity and using dabigatran. The pseudoaneurysm was most likely caused by iatrogenic injury during surgery. Fourteen days after the index surgery, the patient was seen with a painful but normal post-total knee arthroplasty effused knee, with a maximum flexion angle of 80 degrees. No signs of infection, hemarthrosis, or neurovascular deficit were present. Radiographic imaging included ultrasonography and computed tomography angiography. The pseudoaneurysm was successfully treated with coil embolization. The etiology, presentation, diagnosis, and treatment of a geniculate artery pseudoaneurysm are discussed in this case report.

Predictive Variables for Interventional Angiography among Patients with Knee Hemarthrosis

Studies regarding the variables that could predict the success of conservative treatment for knee hemarthrosis are lacking. This retrospective study evaluated the laboratory variables of patients who had unsatisfactory results from conservative treatment for knee hemarthrosis. Twenty-nine patients conservatively treated for knee hemarthrosis were included and divided into two groups: group A comprised 14 patients who underwent interventional angiography and selective embolization due to failed conservative treatment, and group B comprised 15 patients with successful results after conservative treatment. The results of the serological and synovial fluid tests were evaluated. The mean number of synovial red blood cells (RBCs) was 1,905,857 cells/µL and 7730 cells/µL in groups A and B, respectively (p = 0.01), while the mean number of RBCs per high-power field (HPF) was 68.9 and 3.2, respectively (p < 0.01). Patients who underwent interventional angiography and selective embolization after failed conservative treatment for knee hemarthrosis had higher synovial RBC counts and RBC counts per HPF than those with successful outcomes after conservative treatment. It is necessary to carefully interpret the results of the synovial fluid analysis in patients with knee hemarthrosis; if the synovial fluid analysis shows a synovial RBC count greater than 81,500 and RBC count per HPF greater than 16.3, we recommend immediate interventional angiography rather than continuing conservative treatment.

Treatment of Recurrent Hemarthrosis Following Total Knee Arthroplasty Using Surgical Interventions

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.

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.

Traditional investigation and management for recurrent hemarthrosis after total knee arthroplasty: A case report

BACKGROUND

Recurrent hemarthrosis is a rare complication of total knee arthroplasty, and only a few cases have been reported; hence, it is hard to establish comprehensive diagnosis and treatment guidelines. We here report a case of recurrent hemarthrosis after total knee arthroplasty, and briefly review the literature.

CASE SUMMARY

A 50-year-old man, with a history of hypertension, presented to the Orthopedic Department of our hospital for non-traumatic acute left knee pain and swelling associated with a warmth sensation 14 mo after total knee arthroplasty. Investigations (ultrasound, aspiration, and arthroscopy) and managements (non-surgical, arthroscopy and open exploration) were performed, and the clinical effects of these interventions were analyzed separately. Clinical evidence indicates that the cause of this case was rupture of a pseudoaneurysm of the medial superior genicular artery.

CONCLUSION

The present case indicated that angiography is essential in cases of hemarthrosis after TKA; arthroscopy may not always be adequate as it may not provide a clear view; and traditional open exploration is still effective and sometimes necessary.

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.

Pseudoaneurysm after total knee arthroplasty: imaging findings in 7 patients

OBJECTIVE

To describe the clinical presentation of arterial pseudoaneurysms following total knee arthroplasty (TKA) and their diagnostic imaging features on ultrasound and magnetic resonance angiography (MRA) in 7 patients.

MATERIALS AND METHODS

A search of our radiology report database from 2007 to 2017 yielded 7 patients with a pseudoaneurysm diagnosed by imaging after TKA. Clinical notes and imaging were reviewed.

RESULTS

All 7 patients were male and ranged in age from 53 to 68 (mean 61) years. All patients presented with a painful swollen knee and hemarthrosis within the first month following surgery. Five patients presented after primary TKA. One patient presented after explantation for septic arthritis and another after partial synovectomy for septic arthritis without explantation. Ultrasound identified the pseudoaneurysm as a hypoechoic or hyperechoic mass with a "yin-yang" appearance of turbulent arterial flow and associated complex joint effusion. On MRA, the pseudoaneurysm was a mass next to a parent artery showing avid contrast enhancement in the arterial phase that persisted into the venous phase and washed out in the late venous phase. Six pseudoaneurysms arose from lateral geniculate arteries and 1 from a medial geniculate artery. There were no popliteal artery pseudoaneurysms. Five patients were treated endovascularly, 1 patient thrombosed without intervention, and 1 patient was treated with open surgery.

CONCLUSION

Pseudoaneurysm is a potential source of a painful swollen knee with hemarthrosis or a drop in hematocrit after TKA and can be identified with either ultrasound or MRA.

Emergency Transarterial Embolization in Postoperative Hip Bleeding: Indications, Techniques, and Results in a Retrospective Cohort

BACKGROUND

The aim of this study is to report the results of transarterial embolization (TAE) in the setting of postoperative bleeding after hip surgery.

METHODS

We retrospectively evaluated 40 patients (male:female = 15:25, median age = 68 years) who underwent TAE from 2006 to 2016: 77.5% underwent total hip arthroplasty, 20% open reduction internal fixation, and 2.5% external fixation. Preangiographic multidetector computed tomography angiography was performed in 20 (49%) cases, and 9 of them showed arterial extravasation. Twenty-seven TAEs were performed within a week from surgery; active bleeding was seen in 33 (80.5%) angiograms. Gelatin sponge, microparticles, coils, n-butyl cyanoacrylate, and combinations of them were used as embolic materials.

RESULTS

Bleeding was controlled in all cases. The most frequently embolized arteries were branches of the deep femoral artery (n = 17). Permanent embolization agents (microparticles, coils, n-2-butyl-cyanoacrylate) were used in 88% of cases; temporary agents (gelfoam) in 12%. One procedure was complicated by arterial dissection. Hospital discharge averaged 20 days post-TAE (median = 17, range = 3-104). One-month survival rate was 97.5%. One patient died of ischemic bowel perforation.

CONCLUSION

TAE is safe and effective in stopping the bleeding of the hip region and should be performed early, to avoid irreversible ischemic damage. Multidetector computed tomography angiography can be used to confirm doubtful evidence of ongoing bleeding. Several embolic materials can be used, each one offering different advantages. Low complication and mortality rates were observed. TAE seems to be the ideal first-line intervention when postoperative bleeding of the operated hip is detected.

Treatment of Recurrent Hemarthrosis after Total Knee Arthroplasty

Purpose

The purpose of this study is to evaluate the incidence and treatment of recurrent hemarthrosis after total knee replacement (TKR).

Materials and Methods

Among a total of 5,510 patients who underwent TKR from March 2000 to October 2016, patients who had two or more bleeding 2 weeks after surgery were studied. Conservative treatments were performed for all cases with symptoms. In patients who did not respond to conservative treatment several times, embolization was performed. We retrospectively evaluated the postoperative bleeding time, bleeding frequency, treatment method, and outcome.

Results

Seventeen (0.3%) of the 5,510 patients developed recurrent hemarthrosis. Bleeding occurred at an average of 2 years 3 months after the operation. Joint aspiration was performed 3.5 times (range, 2 to 10 times) on average, and 14 cases (82.3%) were treated with conservative treatment. In 3 patients with severe bleeding and hemorrhage, embolization was performed.

Conclusions

Recurrent hemarthrosis after TKR is a rare disease with a low incidence of 0.3% and usually could be treated by conservative treatment. If recurrences occur repeatedly, embolization through angiography or surgical treatment may be considered, but the results are not satisfactory and careful selection of treatment modalities is warranted.

The all-inside meniscal repair technique has less risk of injury to the lateral geniculate artery than the inside-out repair technique when suturing the lateral meniscus

PURPOSE

To evaluate the risk of injury to the inferior lateral geniculate artery with two different techniques for lateral meniscus repair.

METHODS

Eight cadaveric knees were used. Inside-out sutures and an all-inside suture device were placed at the most lateral edge of the popliteal hiatus, and 15 and 30 mm anterior to this point. The minimum distances between the sutures and the inferior lateral geniculate artery were measured through a limited lateral arthrotomy. Artery penetration or collapse due to the sutures was also evaluated.

RESULTS

The median distance between the sutures and the artery when inserted at the lateral edge of the popliteal hiatus was 1.5 mm (interquartile range: 1.3) for the inside-out technique and 1.5 mm (1.3) for the all-inside technique (differences not significant, n.s.). When the sutures were inserted 15 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.1) and 1.3 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). When the sutures were inserted 30 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.0) and 1.5 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). The artery was punctured with two of the inside-out sutures placed 15 mm from the popliteal hiatus, no puncturing occurred in the all-inside technique (n.s.). Tying of the inside-out sutures resulted in obliteration of the artery in four of eight sutures placed at 15 mm from the popliteal hiatus and three of eight sutures at 30 mm; no obliteration of the artery was found using the all-inside device (significant differences, p = 0.002).

CONCLUSIONS

Although both all-inside and inside-out lateral meniscal repair techniques place sutures very close to the lateral geniculate artery, the inside-out technique is riskier as extra-articular knot tying can cause artery obliteration when suturing the part of the meniscus immediately lateral to the popliteal hiatus. Therefore, all-inside meniscal repair technique shows less risk of injury to the major blood supply of the lateral meniscus.

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.

The results of Oxford unicompartmental knee arthroplasty in the United States: a mean ten-year survival analysis

Aims

Approved by the Food and Drug Administration in 2004, the Phase III Oxford Medial Partial Knee is used to treat anteromedial osteoarthritis (AMOA) in patients with an intact anterior cruciate ligament. This unicompartmental knee arthroplasty (UKA) is relatively new in the United States, and therefore long-term American results are lacking.

Patients and Methods

This is a single surgeon, retrospective study based on prospectively collected data, analysing a consecutive series of primary UKAs using the Phase III mobile-bearing Oxford Knee and Phase III instrumentation.

Between July 2004 and December 2006, the senior author (RHE) carried out a medial UKA in 173 patients (213 knees) for anteromedial osteoarthritis or avascular necrosis (AVN).

A total of 95 patients were men and 78 were women. Their mean age at surgery was 67 years (38 to 89) and mean body mass index 29.87 kg/m2 (17 to 62).

The mean follow-up was ten years (4 to 11).

Results

Survivorship of the Oxford UKA at ten years was 88%, using life table analysis. Implant survivorship at ten years was 95%. The most common cause for revision was the progression of osteoarthritis in the lateral compartment. The mean knee score element of the American Knee Society Score (AKSS) was 50 pre-operatively and increased to 93 post-operatively. The mean AKSS function score was 56 pre-operatively rising to 78 post-operatively

Conclusion

This ten-year follow-up study of the Oxford UKA undertaken in the United States shows good survivorship and excellent function in a wide selection of patients with AMOA and AVN.

Cite this article: Bone Joint J 2016;98-B(10 Suppl B):34–40.

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.

Severe vascular complications and intervention following elective total hip and knee replacement: A 16-year retrospective analysis

INTRODUCTION

Iatrogenic vascular injuries associated with elective orthopaedic joint procedures are relatively rare, however when they do occur they carry a risk of significant morbidity and mortality. The aim of this study was to investigate the incidence of vascular complications and resultant need for specialist intervention following elective total hip replacement (THR) and total knee replacement(TKR).

METHODS

This was a retrospective analysis of prospectively collected data. The primary outcome measure was vascular complication requiring an interventional radiology procedures or vascular surgery. As a secondary outcome measure postoperative Modified Knee Society Scores and Harris Hip Scores were analysed to assess long term clinical outcome.

RESULTS

Six cases of vascular injury requiring specialist intervention were identified. From 2073 total TKRs there were one cases of popliteal artery injury, one case of venous injury and two case of lateral geniculate artery injury (0.19%). From 1601 THRs there were two cases (0.12%) of arterial injury. All patients were treated successfully by a vascular surgeon or an interventional radiologist. Patient outcome varied considerably with the poorest results seen in the THR group.

CONCLUSIONS

Iatrogenic vascular complications following elective THR and TKR carry a risk of significant morbidity and mortality. It is important that surgeons and trainees performing these procedures are conscious of these risks and able to identify vascular injuries promptly when they occur. Detailed preoperative assessment, an awareness of anatomical variants and close liaison with a vascular surgeon may all help to reduce the number and severity of adverse outcomes.

Recurrent hemarthrosis after total knee arthroplasty caused by the impingement of a remnant lateral meniscus: a case report

A case of recurrent hemarthrosis initially presenting after the fifth postoperative month is described. Because of recurrent pain and swelling, the patient underwent an arthroscopy 14 months after total knee arthroplasty (TKA). A remnant posterior lateral meniscus was found to be impinged between the femoral component and the tibial liner, and there was oozing from the hypertrophied synovium around the remnant meniscus. The remnant meniscus and the synovium were carefully cauterized and completely excised. Following the arthroscopy, hemarthrosis has not recurred. A remnant lateral meniscus may be a cause of recurrent hemarthrosis after TKA. Accordingly, in cases of recurrent hemarthrosis after TKA, exploration by arthroscopy should be considered.

A case of the geniculate artery pseudoaneurysm after total knee arthroplasty: search for preventive measures by evaluation of arterial anatomy of cadaver knees

This article presents an 80-year-old man with pseudoaneurysm of the inferolateral geniculate artery after total knee arthroplasty (TKA). The aim is to report this case and review possible preventive methods of pseudoaneurysm formation after TKA by investigating the relationship between knee arterial anatomy and the TKA procedure. Cadaveric evaluation demonstrates that the superomedial and inferomedial geniculate arteries are difficult to visualize. The anatomical position of the inferolateral artery makes it vulnerable to the surgical procedure during cutting of the tibia or while retracting soft tissue from the tibial edge, especially with minimal invasive surgery. In conclusion, careful subperiosteal release around the geniculate arteries is recommended. However, early recognition of pseudoaneurysm formation is even more essential than prevention.

A case of bilateral hemarthrosis due to pseudoaneurysms in a patient on anticoagulation therapy

Hemarthrosis can occur in patients with a predisposition to hemorrhage, such as hemophiliacs or patients on anticoagulation therapy. If hemarthrosis recurs after supportive treatment, however, other etiologies such as anatomical abnormalities should be considered. Spontaneous articular pseudoaneurysm associated with anticoagulation treatment has not been reported previously. We describe a patient on anticoagulation therapy with bilateral hemarthrosis due to pseudoaneurysms. After failing to respond to the correction of over-anticoagulation, magnetic resonance imaging led to the diagnosis of articular pseudoaneurysm. The patient was treated successfully by transarterial embolization.

Pseudoaneurysm of the superior lateral genicular artery: case report of a rare complication after total knee arthroplasty

Background

Pseudoaneurysm of superior lateral genicular artery following total knee arthroplasty is a rare complication and has been reported following lateral release performed for eversion of patella in a knee with tight lateral structures.

Case presentation

This report describes a case of pseudo aneurysm of superior lateral geniculate artery that developed after primary Total knee arthroplasty for a stiff knee in a 68 year old patient. Patient presented with pain and rapidly increasing swelling in early post operative period. Diagnosis was made on duplex ultrasound and confirmed by angiography. Angiographic coil embolisation of the pseudoaneurysm was performed. Since no lateral release was performed in this case, the probable mechanism was shear injury to the vessel.

Conclusion

Pseudoaneurysm of superior lateral genicular artery can occur in absence of lateral release by shear injury to an atherosclerotic vessel. Angiographic coil embolisation appears to be the best method for treating such post arthroplasty pseudoaneurysm because of less chance of infection, non interference with rehabilitation and diagnosis and treatment during same procedure.

Magnetic resonance angiography in the management of recurrent hemarthrosis after total knee arthroplasty

Spontaneous hemarthrosis is an infrequent but disabling complication after total knee arthroplasty. The purpose of this case series is to demonstrate the utility of magnetic resonance angiography (MRA) in the evaluation of hemarthrosis after total knee arthroplasty. Patients presenting with hemarthrosis unexplained by trauma, anticoagulation, or a bleeding diathesis were retrospectively identified. Eighteen patients were referred for MRA to evaluate recurrent hemarthrosis after failing conservative therapy (n = 16) or synovectomy (n = 2). Despite artifact caused by the metallic components, diagnostic evaluation of regional vessels was made. In 12 of 13 cases that underwent embolization or synovectomy, a hypertrophic feeding artery (or arteries) was visualized on MRA. One case of negative MRA did not have subsequent surgery, and we are unable to comment on the rate of false-positives because all patients in this case series had evidence of bleeding. By characterizing the vascular anatomy and identifying a dominant artery (or arteries) supplying the hypervascular synovium, MRA can serve as a guide for subsequent embolization or synovectomy, as indicated.

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.