Spontaneous recurrent haemarthrosis following unicompartmental knee arthroplasty and its successful treatment by coil embolisation

Relationship between the location of the popliteal artery and the tibial osteotomy plane in patients with medial and lateral unicompartmental knee arthroplasty: A retrospective analysis of preoperative magnetic resonance imaging and intraoperative findings

PURPOSE

To clarify the location of the popliteal artery (PA) is relative to the tibial osteotomy plane in patients with medial and lateral unicompartmental knee osteoarthritis (KOA) undergoing UKA.

METHODS

Preoperative MRI and postoperative radiographs obtained from 50 patients with unicompartmental KOA who underwent fixed-bearing UKA were analyzed. The amount of tibial resection was determined from the surgical records, and a line was drawn parallel to the tibial posterior tilt angle on the sagittal MR image to create a virtual tibial cut line. The tibial resection width measured from the anteroposterior image of the postoperative radiograph was projected onto the transverse plane containing the intersection between the virtual tibial cut line and the posterior tibial cortex, after which a line was drawn parallel to the medial or lateral intercondylar ridge. We then determined whether the PA was within an extension of the osteotomy area. The shortest distance (Distance 1) between the posterior tibial cortex and the PA within the osteotomy area was measured. In addition, the shortest distance between the line extending the osteotomy posteriorly and the PA was measured (Distance 2).

RESULTS

The medial UKA (group M) and lateral UKA (group L) group comprised 41 and 9 cases. The percentage of PA located behind the osteotomy plane was significantly higher in group L than in group M [6/9 knees (66.7%) vs. 2/41 knees (4.9%); P < 0.001]. The distance 1 was 12.6 (4.3) mm in group M and 7.9 (3.7) mm in group L (P = 0.004). The distance2 was 11.1 (4.9) mm in group M and 2.6 (3.5) mm in group L (P < 0.001).

CONCLUSION

During lateral UKA, the PA was often located behind the tibial osteotomy plane and close to the posterior tibial cortex. Nearly 5% of medial UKAs, the artery was located behind the osteotomy plane.

LEVEL OF EVIDENCE

Retrospective comparative LEVEL III study.

Treating recurrent hemarthrosis after knee arthroplasty with selective embolization: a cohort study of 56 patients

BACKGROUND AND PURPOSE

 Recurrent hemarthrosis (RH) is a rare late complication of knee arthroplasty, with an unknown etiology. We aimed to evaluate the effectiveness of arterial embolization (AE) on resolution of hemarthrosis following knee arthroplasty. Additionally, we investigated pain management requirements after the procedure and related complications.

METHODS

 56 patients underwent AE for recurrent hemarthrosis between 2015 and 2023. The prevalence of hemarthrosis was 0.6%. The median age of the patients was 70 years (range 42-88), with 41 females and 15 males. 70 embolizations were performed, consisting of 56 initial procedures and 14 repeat procedures. Clinical success was defined as the resolution of hemarthroses.

RESULTS

 Technical success was achieved in 93% of cases. Clinical success improved from 64% to 79% after the second treatment; subsequent sessions did not yield further improvement. 12 patients (21%) required 1 or more reoperations. The majority of patients (86%) relied solely on analgesics for post-treatment pain management. Complications occurred in 7% of treatments, most of which resolved spontaneously.

CONCLUSION

 AE is effective in the treatment of recurrent hemarthrosis but 21% had reoccurance. Oral analgesics are generally sufficient for managing post-embolization pain. 7% had complications.

A structured evaluation of the symptomatic medial Oxford unicompartmental knee arthroplasty (UKA)

Unicompartmental knee arthroplasty (UKA) has several advantages over total knee arthroplasty; however, in many reports, the risk of revision remains higher after UKA.Many reasons for failure of UKA exist.Successful treatment starts with accurate assessment of the symptomatic UKA as a specific mode of failure requires a specific solution.A structured and comprehensive evaluation aids assessment of the symptomatic UKA.This review provides an overview of the causes for a symptomatic medial UKA, its risk factors, diagnostic modalities that can be used, and briefly discusses treatment options. Cite this article: EFORT Open Rev 2021;6:850-860. DOI: 10.1302/2058-5241.6.200105.

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.

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.

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.

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.

Quantitative analysis of the perimeniscal position of the inferior lateral genicular artery (ILGA): magnetic resonance imaging study

PURPOSE

The inferior lateral genicular artery (ILGA) passes around the lateral knee joint, adjacent to the lateral meniscus (LM). ILGA injuries in total knee arthroplasty or arthroscopic surgery can result in recurrent hemarthrosis or painful pseudoaneurysms. Detailed information about the perimeniscal position of the ILGA relative to the LM is necessary to avoid these complications.

METHODS

3-T MR images of 100 knees (mean age 36.3 ± 11.2 years) were retrospectively reviewed. The perimeniscal area was divided into four regions: the anterior, middle, popliteal hiatus, and posterior zones. In each zone, the ILGA diameter, superoinferior position (assessed as the height of the ILGA from the LM base), and distance between the meniscocapsular junction and the ILGA were measured.

RESULTS

The distance between the ILGA and meniscocapsular junction was significantly smaller in the middle zone than in the other three zones (anterior 5.3 ± 0.8 mm, middle 1.4 ± 0.4 mm, popliteal hiatus 6.1 ± 1.0 mm, and posterior 5.6 ± 1.5 mm, p < 0.05). In the superoinferior position, the height of the ILGA was 3.4 ± 0.9 mm in the anterior zone, 0.4 ± 1.3 mm in the middle zone, - 1.9 ± 1.8 mm in the popliteal hiatus zone, and - 1.3 ± 4.3 mm in the posterior zone. When the LM bottom is the base, the ILGA was located superiorly in the anterior zone, close to the base in the middle zone, and inferiorly in the popliteal hiatus zone.

CONCLUSIONS

To avoid ILGA injury, close attention is necessary during surgical procedures involving the meniscocapsular junction of the LM, especially at the meniscal base in the middle zone.

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

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.

Recurrent Hemarthrosis Following Knee Arthroplasty Treated with Arterial Embolization

Recurrent hemarthrosis is an uncommon but troublesome complication following knee arthroplasty. This study reports the results for 13 patients with spontaneous recurrent hemarthrosis after knee arthroplasty treated with arterial embolization. The average interval between arthroplasty and embolization was 47 months (range, 2-103 months), and the average time from onset of hemarthrosis to embolization was 4.1 months (range, 1-11 months). Geniculate arterial embolization lead to resolution of hemarthrosis in 12 of 13 patients (92.3%). The one clinical failure likely represented a case of misdiagnosed periprosthetic joint infection. Two patients experienced transient cutaneous ischemia related to distal particulate embolization that resolved spontaneously. Selective geniculate arterial embolization is an effective and safe treatment modality for recurrent hemarthrosis after knee arthroplasty.

Popliteal lesion due to traction during unicompartmental knee revision surgery

Popliteal artery injury is a rare but known complication in knee surgery. Only one article in current literature reports that the risk increases during revision knee surgery. A new case is described in which an injury to the popliteal artery occurred during lateral unicompartmental to total knee arthroplasty revision surgery. This vascular injury occurred 5-10 cm below the tibial resection level in a healthy patient with a history of cruris fracture with plate osteosynthesis and lateral unicompartmental knee arthroplasty. This paper stresses the importance of being aware that trauma and surgery can create fibrosis in which the popliteal artery can get fixated, thus reducing the scope for safe manipulation of the knee during secondary surgery.

Geniculate artery embolization in the management of spontaneous recurrent hemarthrosis of the knee: case series

Spontaneous recurrent hemarthrosis after knee arthroplasty is reported to occur in 0.3%-1% of patients, likely secondary to hypertrophic vascular synovium. Five patients who underwent previous arthroplasty presented with spontaneous hemarthrosis. Selective arterial embolization was performed with spherical embolic particles (diameter range, 100-700 μm). Angiography demonstrated synovial hypervascularity with geniculate artery "tumor blush" appearance in all patients. Average time to resolution of effusion was 2.6 weeks, with no recurrences reported during follow-up (mean, 25.4 mo; range, 16-48 mo). Two patients experienced transient cutaneous ischemia. Selective geniculate artery embolization with spherical embolic particles is an effective treatment for spontaneous recurrent hemarthrosis of the knee.

Arthroscopic observation was useful to detect loosening of the femoral component of unicompartmental knee arthroplasty in a recurrent hemoarthrosis

A case of recurrent hemarthrosis of the knee after a mobile-bearing unicompartmental knee arthroplasty (UKA; Oxford UKA) is described. A 58-year-old man met with a road traffic accident 10 months after UKA. He developed anteromedial pain and hemarthrosis of the knee joint 1 month after the accident, which required multiple aspirations. Physical examination showed no instability. Plain radiograph revealed no signs of loosening. All laboratory data, including bleeding and coagulation times, were within normal limits. Diagnostic arthroscopy demonstrated loosening of the femoral component. Any intraarticular pathology other than nonspecific synovitis was ruled out. The loose femoral component and polyethylene meniscal bearing were revised. Since then, hemarthrosis has not recurred.

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.

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.

Recurrent hemarthrosis after total knee arthroplasty

This report describes a case of spontaneous recurrent hemarthrosis of the knee that presented 4 weeks after total knee arthroplasty. Femoral arteriography showed a false aneurysm of a branch of the inferior lateral geniculate artery. Therapeutic embolization of the arterial branch was performed using three platinum coils with good clinical result and good knee joint function. Hemarthrosis has not recurred since embolization.

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.

Recurrent haemarthrosis of knee joint due to arterio-venous malformation of the superficial femoral artery

Recurrent haemarthrosis involving the knee joint is commonly due to bleeding, a coagulation disorder or previous surgery. We have recently encountered a case of recurrent haemarthrosis involving the left knee joint of a 72 year old man due to arterio-venous malformation of the superficial femoral artery. Vascular malformations in patients with recurrent haemarthrosis without previous history of operation and a normal bleeding and clotting screen, should be considered a possible cause.