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

Pseudomeniscus after knee arthroplasty: A case series for arthroscopic management of this problem and systematic review of literature

Introduction

Most patients undergoing total knee arthroplasty (TKA) experience favorable outcomes. Some patients, however, experience prolonged post-operative knee pain and tenderness at the joint line. This has been attributed in some cases to soft tissue impingement due to pseudomeniscus. The purpose of this study is to evaluate patient outcomes for arthroscopic excision of pseudomeniscus for persistent knee pain after TKA and to perform a review of literature for pseudomeniscus after knee arthroplasty.

Methods

A retrospective analysis of patients undergoing arthroscopy to remove soft tissue causing persistent knee pain after previous TKA was performed. Outcome scores were asked at three time points: prior to knee arthroplasty, prior to arthroscopy, and post-arthroscopy at final follow-up. Subjective satisfaction with surgery and willingness to repeat procedures were also recorded. A two-tailed distribution paired t-test was used to determine statistical significance (p < 0.05). We also performed a review of the literature for pseudomeniscus complications for comparison.

Results

Nine out of eleven patients were considered eligible to be assessed for post-operative satisfaction. Seven out of nine patients reported complete satisfaction and eight participants stated they would undergo the procedures again if they have to. Among 9 included patients, five patients have successfully completed the clinical score evaluation survey. The mean age of the patients with clinical score evaluation at the time of TKA was 61 years (range, 53-72) and the time between TKA and undergoing arthroscopy was 8 months (range, 5-13). The average follow-up period for patient-determined assessment after the arthroscopic procedure was 71 months (range, 16-115). All 5 patients reported improved Oxford Knee Scores (p=0.017), Western Ontario and McMaster Universities Osteoarthritis Index (p=0.023), and pain scores (p=0.018) comparing pre-arthroscopy to post-arthroscopy at follow-up.

Conclusion

Arthroscopic removal of pseudomeniscus after TKA provides promising results in patients who experience persistent knee joint line pain and tenderness. Considering our results and review of literature, we recommend including pseudomeniscus in the differential for post arthroplasty knee pain.

Study design

Case series with a review of literature.

Selective Embolization Is Safe and Effective for Total Knee Arthroplasty-Associated Recurrent Hemarthroses: A Systematic Review and Meta-Analysis

Total knee arthroplasty (TKA)-associated hemarthroses are infrequent and often respond to nonoperative therapy. Geniculate artery embolization may provide symptomatic relief in cases recalcitrant to needle aspiration, although no meta-analysis exists regarding this therapy. This meta-analysis aims to assess the rate of symptom relief, the number of embolizations needed to achieve relief, and the rate of complications associated with embolization. Public databases were queried from 1998 until 2018 for TKA-associated recurrent hemarthroses treated with embolization. Eight studies met inclusion and exclusion criteria. Major complications were defined as those requiring readmission or nonelective reoperation; minor complications were defined as those not requiring readmission or reoperation. Pooled statistics were calculated utilizing the method of inverse variance. Fifty-nine patients with a mean follow-up of 30 months (range, 1-50 months) were evaluated. The pooled proportion of patients with symptom improvement following embolization was 86% (95% confidence interval [CI]: 74-93%, I ²: 0%, p = 0.97). The average number of embolization procedures was 1.30 (95% CI: 1.03-1.63, I ²: 0%, p = 0.66). The pooled proportion of patients who required a second embolization procedure was 26% (95% CI: 15-40%, I ²: 0%, p = 0.43), while those requiring three or more procedures was 13% (95% CI: 6-25%, I ²: 0%, p = 0.87). The rate of complications were as follows: any complication - 19% (95% CI: 11-32%, I ²: 0%, p = 0.81); major complications-8% (95% CI: 3-19%, I ²: 0%, p = 0.96); minor complications-18% (95% CI: 10-31%, I ²: 0%, p = 0.79); inguinal hematoma-9% (95% CI: 4-19%, I ²: 0%, p = 1.00); skin necrosis-15% (95% CI: 7-29%, I ²: 0%, p = 0.62); and incision breakdown-7% (95% CI: 3-17%, I ²: 0%, p = 1.00). Previous literature on selective artery embolization following TKA is relatively limited. This meta-analysis supports embolization as a potentially safe and effective treatment for recurrent hemarthroses after TKA. Other correctable causes of recurrent hemarthrosis, such as instability or malalignment, must be diligently ruled out prior to utilizing embolization. Surgeons should be aware of embolization's potential role in the postoperative period following TKA.

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.

Arthroscopic treatment of total knee arthroplasty complications

The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments.

When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint.

Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out.

Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA.

The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections.

More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy.

Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.

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.