Drs Asanuma (Kunihiro), Ito, Ogawa, Asanuma (Yumiko), Yoshikawa, Hasegawa, and Sudo are from Mie University School of Medicine, Tsu City, Mie, Japan.
Drs Asanuma (Kunihiro), Ito, Ogawa, Asanuma (Yumiko), Yoshikawa, Hasegawa, and Sudo have no relevant financial relationships to disclose.
Correspondence should be addressed to: Kunihiro Asanuma, MD, PhD, Mie University School of Medicine, 2-174 Edobashi, Tsu City, Mie, Japan (email@example.com).
Knee arthroplasty is a common procedure for elderly patients showing deleterious cartilaginous changes. Major complications include deep venous thrombosis (DVT), pulmonary embolism, infection, nerve palsy, periprosthetic fractures, joint instability, problems with wound healing, component loosening, and component failure.1 Recurrent spontaneous hemarthrosis after knee arthroplasty in the absence of anticoagulant medications or a bleeding disorder is rare, with a reported incidence of .1% to 1.6%.1–4 Recurrent hemarthrosis 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. This article describes a rare case of recurrent hemarthrosis after unicompartmental knee arthroplasty (UKA) and successful treatment by open synovectomy.
A 66-year-old woman underwent UKA of the right knee for spontaneous osteonecrosis of the medial femoral condyle. No postoperative complications were identified. However, 18 months after the primary operation, her knee was swollen with acute spontaneous pain. A large amount of blood was aspirated from the knee joint, with immediate relief of pain. She could not recall any cause of acute swelling or pain. Despite conservative therapy, such as aspiration, rest, and cooling, another 2 episodes of spontaneous hemarthrosis occurred during the following 4 months. No history of trauma or use of anticoagulant medications was present.
Laboratory testing showed no abnormalities. A coagulation study, including bleeding time, coagulation time, prothrombin time, and activated partial thromboplastin time, yielded normal results. The Lumpel-Reede test was negative. A second operation was performed 21 months after UKA. After thorough lavage of the knee joint, no visible bleeding source was identified. Likewise, no signs of loosening of the prosthesis were apparent. The hyperplastic synovium appeared brown in color. A few microbleeds from capillary vessels were coagulated using a bipolar coagulator.
After a symptom-free period of 8 months, another 2 episodes of hemarthrosis occurred over the course of 8 months. A third operation was therefore performed. As in the second operation, no visible bleeding source or signs of prosthesis loosening were identified. The synovium was found to be hyperplastic, and synovectomy was performed (Figure). Pathological testing revealed the chronic synovitis with fibrosis and hemosiderin staining. There were no pathological features of pigmented villonodular synovitis. As of 24 months after synovectomy, the patient remains symptom-free.
Figure: Arrows indicate hyperplastic synovium.
Recurrent hemarthrosis has been attributed to synovial hyperplasia,5 vascular abnormality,6,7 anticoagulant therapy8,9 and metal particles in the joint.7 Although reported cases of hemarthrosis after arthroplasty have most often occurred with total knee arthroplasty (TKA), several cases of hemarthrosis after UKA have been described.2,10,11 Similar to TKA, causes of hemarthrosis after UKA are thought to involve synovitis, probably due to the presence of metallic debris and hyperplastic blush of the descending genicular artery.10,11 No relationships to the type of prosthesis or use of cement have been identified.12
The most distinctive source of hemarthrosis is thought to be impingement of the proliferative synovium between articulating prosthetic components. Reported causes of hemarthrosis have included pieces of synovial tissue or fat pad in 9 of 21 patients,13 a polypoid mass of vascular and hyperplastic synovium in 1 case,1 and proliferative synovial tissue in 4 of 7 patients4 and 2 of 6 patients.2 Meanwhile, 4 of 6 patients who underwent arthroscopic synovectomy for hemarthrosis showed recurrent hemarthrosis.2
Although detecting tissue impingement is difficult, open synovectomy is recommended as a curative procedure when symptoms do not resolve after conservative treatment. Despite the risk of infection and delayed rehabilitation, open surgery is worthwhile because open synovectomy shows a high recovery rate, and components are sometimes a cause of hemarthrosis. Revision of loose or failed components can thus resolve symptoms without requiring synovectomy.13 In addition, no recurrence of hemarthrosis was seen in 1 case after revision of components despite no obvious abnormal motion of the components.2 Open surgery targets synovectomy and allows revision of prosthetic components for hemarthrosis therapy.
In contrast, some recent reports have described the embolization of hemarthrosis after TKA. Angiography is a useful investigation for the identification of vascular blush or hypervascularization of the genicular artery.6,9,11,14,15 Pseudoaneurysms from the popliteal artery16 and genicular artery16,17 or arteriovenous fistula12 have also been reported. Ultrasonography is helpful to detect hypoechoic masses in the popliteal fossa with bidirectional Doppler flow consistent with popliteal artery aneurysm or pseudoaneurysm.16 Embolization of these vascular abnormalities results in immediate improvement of symptoms in most cases. In only 1 case, hemarthrosis recurred after first embolization. Second embolization was successfully performed.6 Despite risks of skin or tissue necrosis or allergic reaction to contrast dye, angiography and embolization are curative treatments that avoid major surgery. Pham et al14 performed arthroscopy and noted only hyperplastic synovial membrane 2 weeks after successful embolization.
Hyperplastic vascular synovium is usually treated by resection, and may be recognized as vascular blush and embolized.6 This suggests the possibility that indications of embolization for hemarthrosis include not only vascular abnormalities, but also impingement of proliferative synovium that is usually resected by major surgery. However, a case has been reported of a patient who showed no false aneurysm on prerevision angiography and experienced no recurrence of hemarthrosis after component revision despite a lack of obvious abnormal motions of the component.2 Revision of components should be considered for cases in which no abnormality is observed on angiography. Interestingly, defects in the availability of platelet factor 3 in some patients have been attributed to hemarthrosis.18 Routine coagulation profiles were normal, and no patients showed recurrent hemarthrosis after platelet transfusion.18 Furthermore, synoviorthesis by injection of 6.5 mCi of yttrium 90 into the knee joint to diminish the size of the proliferative synovium was a successful treatment.19
Although various procedures for hemarthrosis have been reported after TKA for patients who do not respond to conservative treatment, the recommended first-line therapy is open surgery or embolization. Since these procedures have advantages and disadvantages, treatment should be selected based on the individual patient. In our case, hyperplastic synovium was observed during the first and second surgeries. Although tissue impingement was not detected, we performed open synovectomy, and the patient has since remained symptom-free for 2 years.
- Oishi CS, Elliott ML, Colwell CW Jr., Recurrent hemarthrosis following a total knee arthroplasty. J Arthroplasty. 1995; (10 suppl):56–S58. doi:10.1016/S0883-5403(05)80232-3 [CrossRef]
- Ohdera T, Tokunaga M, Hiroshima S, Yoshimoto E, Matsuda S. Recurrent hemarthrosis after knee joint arthroplasty: etiology and treatment. J Arthroplasty. 2004; 19(2):157–161. doi:10.1016/j.arth.2003.09.009 [CrossRef]
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- Worland RL, Jessup DE. Recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty. 1996; 11(8):977–978. doi:10.1016/S0883-5403(96)80144-6 [CrossRef]
- Ballard WT, Clark CR, Callaghan JJ. Recurrent spontaneous hemarthrosis nine years after a total knee arthroplasty. A presentation with pigmented villonodular synovitis. J Bone Joint Surg Am. 1993; 75(4):764–767.
- Given MF, Smith P, Lyon SM, Robertson D, Thomson KR. Embolization of spontaneous hemarthrosis post total knee replacement. Cardiovasc Intervent Radiol. 2008; 31(5):986–988. doi:10.1007/s00270-007-9257-5 [CrossRef]
- Kitridou RC, Schumacher HR Jr, Sbarbaro JL, Hollander JL. Recurrent hemarthrosis after prosthetic knee arthroplasty: identification of metal particles in the synovial fluid. Arthritis Rheum. 1969; 12(5):520–528. doi:10.1002/art.1780120509 [CrossRef]
- Haddad FS, Prendergast CM, Dorrell JH, Platts AD. Arteriovenous fistula after fibular osteotomy leading to recurrent haemarthroses in a total knee replacement. J Bone Joint Surg Br. 1996; 78(3):458–460.
- Katsimihas M, Robinson D, Thornton M, Langkamer VG. Therapeutic embolization of the genicular arteries for recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty. 2001; 16(7):935–937. doi:10.1054/arth.2001.25555 [CrossRef]
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- Maheshwari R, Kelley SP, Langkamer VG, Loveday E. Spontaneous recurrent haemarthrosis following unicompartmental knee arthroplasty and its successful treatment by coil embolisation. Knee. 2004; 11(5):413–415. doi:10.1016/j.knee.2004.02.007 [CrossRef]
- Kalsi PS, Carrington RJ, Skinner JS. Therapeutic embolization for the treatment of recurrent hemarthrosis after total knee arthroplasty due to an arteriovenous fistula. J Arthroplasty. 2007; 22(8):1223–1225. doi:10.1016/j.arth.2006.11.012 [CrossRef]
- Kindsfater K, Scott R. Recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty. 1995; (10 suppl):S52–S55. doi:10.1016/S0883-5403(05)80231-1 [CrossRef]
- Pham TT, Bouloudian S, Moreau PE, et al. Recurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization. Joint Bone Spine. 2003; 70(1):58–60. doi:10.1016/S1297-319X(02)00012-X [CrossRef]
- Pritsch T, Pritsch M, Halperin N. Therapeutic embolization for late hemarthrosis after total knee arthroplasty. A case report. J Bone Joint Surg Am. 2003; 85(9):1802–1804.
- Ibrahim M, Booth RE Jr, Clark TW. Embolization of traumatic pseudoaneurysms after total knee arthroplasty. J Arthroplasty. 2004; 19(1):123–128. doi:10.1016/j.arth.2003.08.007 [CrossRef]
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- Malhotra R, Bhan S, Kiran EK. Haemarthroses after total knee arthroplasty caused by an isolated platelet factor 3 availability defect. J Bone Joint Surg Br. 2005; 87(11):1549–1552. doi:10.1302/0301-620X.87B11.16836 [CrossRef]
- Kapetanos GA, Papavasiliou KA, Makris V, Nikolaides AP, Kirkos JM, Symeonides PP. Recurrent spontaneous hemarthrosis after total knee arthroplasty successfully treated with synoviorthesis [published online ahead of print March 4, 2008]. J Arthroplasty. 2008; 23(6):931–933. doi:10.1016/j.arth.2007.07.012 [CrossRef]