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Torres-Lugo NJ, Serrano-Boett PS, Acosta-Julbe J, Otero-Lopez A, Bibiloni-Rodríguez J. Pseudotumor in total knee revision arthroplasty resembling heterotopic ossification: A case report. Int J Surg Case Rep 2024; 124:110479. [PMID: 39437502 PMCID: PMC11532899 DOI: 10.1016/j.ijscr.2024.110479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 10/15/2024] [Accepted: 10/16/2024] [Indexed: 10/25/2024] Open
Abstract
INTRODUCTION Pseudotumors are well-known complications following total hip arthroplasty (THA), usually attributed to debris-induced inflammation from direct metal-on-metal contact between implants. In total knee arthroplasty (TKA), the traditional use of polyethylene as a bearing surface prevents direct metal articulation. Thus, pseudotumor formation in TKA usually suggests atypical metal interaction between the prosthetic components. PRESENTATION OF CASE We presented the case of a 65-year-old male who developed a progressively growing mass in the left posterior knee after revision TKA, debuting as heterotopic ossification (HO) based on the radiographic assessment. Subsequent histopathological examination establishes the diagnosis of a pseudotumor. DISCUSSION Pseudotumors impose a diagnostic challenge in TKA due to their non-specific presentation and imaging, which may overlap with other etiologies. Currently, there are no standardized guidelines for pseudotumor assessment in TKA, and each case should be approached individually without relying on a simple diagnostic tool. CONCLUSION Physicians should consider a comprehensive approach supported by a high index of suspicion to include pseudotumors within the differential diagnosis of knee periprosthetic masses.
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Affiliation(s)
- Norberto J Torres-Lugo
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan 00936-5067, Puerto Rico.
| | - Patricia S Serrano-Boett
- Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan 00936-5067, Puerto Rico
| | - Jose Acosta-Julbe
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan 00936-5067, Puerto Rico.
| | - Antonio Otero-Lopez
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan 00936-5067, Puerto Rico.
| | - Juan Bibiloni-Rodríguez
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan 00936-5067, Puerto Rico
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Melian CM, Giannopoulos S, Tsouknidas I, Volteas P, Virvilis D, Nicholson J, Koullias GJ. Endovascular Repair Of Popliteal Artery Injury Post-Total Knee Arthroplasty is Safe and Effective: A Case Report And Systematic Review Of the Literature. Ann Vasc Surg 2023:S0890-5096(23)00105-X. [PMID: 36868455 DOI: 10.1016/j.avsg.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Objective: Popliteal artery pseudoaneurysms are a rare but serious complication following total knee arthroplasty (TKA) that have been traditionally managed with open surgical repair. Endovascular stenting, while relatively new, offers a promising alternative that is less invasive and may reduce the risk of peri-operative complications. 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. Additionally, we present a case of a patient with a popliteal pseudoaneurysm treated with a covered endovascular stent. RESULTS A total of 14 studies (12 case reports, 2 case series; n= 17) were included for review. In all cases a stent-graft was placed across the popliteal artery lesion. In 5 out of 11 cases popliteal artery thrombus was present and treated with adjacent modalities (i.e. mechanical thrombectomy, balloon angioplasty, etc). Procedure success was reported in all cases without perioperative adverse events. Stents remained patent over a median follow up of 32 weeks (Interquartile range IQR: 36). In all but one case the patients experienced immediate symptom relief and had an uneventful recovery. For our case, at 12 months follow up the patient was asymptomatic, and ultrasound demonstrated vessel patency. CONCLUSION Endovascular stenting is a safe and effective treatment for popliteal pseudoaneurysms. Future studies should be aimed at evaluating the long-term outcomes of such minimally invasive techniques.
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Affiliation(s)
- Christina M Melian
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Ioannis Tsouknidas
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Dimitrios Virvilis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - James Nicholson
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY; Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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Sundaram K, Udo-Inyang I, Mont MA, Molloy R, Higuera-Rueda C, Piuzzi NS. Vascular Injuries in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev 2021; 8:e0051. [PMID: 32105241 DOI: 10.2106/jbjs.rvw.19.00051] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Vascular injuries associated with total knee arthroplasty can have limb and life-threatening consequences. The aims of this study were to conduct a meta-analysis of the overall rate of vascular injuries after total knee arthroplasty and to conduct a systematic review of specific major and minor vessel injuries. METHODS All English-language literature published from January 1, 1998, to November 30, 2018, was queried in 4 unique databases using a common search term. This yielded 404 results, of which 270 were unique. Two reviewers then assessed studies for eligibility. All non-human studies, cadaver studies, studies describing only human images, and human studies with non-acute pathology were excluded. The final study included 10 large epidemiological studies and 68 case series or studies. Data from the literature were abstracted into a comma-separated database spreadsheet using Microsoft Excel. A meta-analysis was then performed. Pooled statistics were calculated with weighting by inverse variance assuming a random effect model. I was calculated as a quantifier of heterogeneity and interpreted according to the Cochrane manual. All data analysis was performed using R software. RESULTS Among the 1,419,557 total knee arthroplasties reported in 10 studies, there were 767 major vascular injuries (0.05% [54 per 100,000 total knee arthroplasties]). Amputation or long-term neurological complications occurred in approximately 21% of patients after major vascular injury. Presentation after 24 hours occurred in 36% of cases. The most frequently injured vessels were the geniculate arteries, popliteal artery, superficial femoral artery, and anterior tibial artery. The injuries that were most likely to result in amputation were femoral artery occlusion, popliteal artery transection, and popliteal artery arteriovenous fistula. CONCLUSIONS Amputation and long-term neurological complications are common complications after a vascular injury associated with a total knee arthroplasty. Preoperative consultation with vascular surgery physicians may be a prudent approach before a surgical procedure for patients with known peripheral vascular disease, diabetes, hypertension, or smoking; however, more data on risk factors are needed. Awareness by the surgical team and implementation of specific strategies during a surgical procedure such as gentle manipulation of the knee and careful retraction may further reduce the rate of injuries. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Robert Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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The role of interventional radiology in the treatment of lower limb vascular injuries after orthopaedic surgery. Pol J Radiol 2020; 84:e504-e510. [PMID: 32082447 PMCID: PMC7016496 DOI: 10.5114/pjr.2019.91204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose This paper focuses on the role of interventional radiology embolisations in a series of patients presenting with iatrogenic vascular injuries of the lower limbs following orthopaedic interventions. Material and methods Fourteen patients (mean age: 64 years, range 23-90 years) were retrospectively analysed. Clinical presentation consisted of palpable pulsatile mass, pain, reduced lower limb motion, or visible haematoma; 11 patients had also anaemia (haemoglobin < 7 g/dl). Results The time between orthopaedic surgery and embolisation ranged between 0 and 67 days (mean: 15 days). Injured arterial vessels were as follows: inferior gluteal artery (2), superficial external pudendal artery (2), deep femoral artery (1), lateral circumflex femoral artery (3), medial circumflex femoral artery (2), articular branch of descending genicular artery (1), perforating femoral arteries (3), posterior tibial recurrent artery (1), and anterior tibial artery (1). The typologies of vascular lesion were: pseudoaneurysm 57%, bleeding with extraluminal contrast agent blush of the terminal arterial segment 36%, and laceration and bleeding with extraluminal contrast agent blush of the arterial main trunk 7%. Embolising agents adopted were microcoils 57%, glue 14%, microplug 7%, particles 14%, and covered stent 7%. In all cases clinical and procedural technical successes were obtained (100%). Conclusions For the management of vascular injuries occurring after different orthopaedic interventions of the lower limbs, endovascular embolisations have proven to be safe and effective; orthopaedic surgeons should be aware of the support that interventional radiology could provide in the case of iatrogenic vascular complications.
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Daniels SP, Sneag DB, Berkowitz JL, Trost D, Endo Y. Pseudoaneurysm after total knee arthroplasty: imaging findings in 7 patients. Skeletal Radiol 2019; 48:699-706. [PMID: 30306198 DOI: 10.1007/s00256-018-3084-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/29/2018] [Accepted: 09/23/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 East 68th Street, Box 141, New York, NY, 10065, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | - Jennifer L Berkowitz
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | - David Trost
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 East 68th Street, Box 141, New York, NY, 10065, USA
| | - Yoshimi Endo
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA.
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Abstract
Arterial complications following total knee arthroplasty are rare but carry a high risk of significant morbidity and mortality. Herein, the authors report a case of pseudoaneurysm in a branch of a high-division anterior tibial artery caused by laceration by the retractor following primary total knee arthroplasty in a 72-year-old woman. The patient presented with an unexplained hematoma and an enlarging swelling, with pallor and acute hemorrhage on the first postoperative day. The diagnosis was confirmed by arteriography and the patient was successfully treated using endovascular embolization without long-term complications. Because of the high risk of progression to a potentially limb- or life-threatening condition, it is important to discuss the risk factors for this complication, as well as its early diagnosis and treatment methods.
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