Elsevier

The Journal of Arthroplasty

Volume 26, Issue 8, December 2011, Pages 1357-1361.e1
The Journal of Arthroplasty

Magnetic Resonance Angiography in the Management of Recurrent Hemarthrosis After Total Knee Arthroplasty

https://doi.org/10.1016/j.arth.2011.01.010Get rights and content

Abstract

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.

Section snippets

Patients

This study is a retrospective case series. From March 2003 to June 2010, 18 patients referred for MRA to evaluate recurrent hemarthrosis after TKA unexplained by trauma, instability, anticoagulation, or bleeding diathesis were retrospectively identified, and their imaging and records were reviewed. All patients gave informed consent for the imaging studies. This study was approved by our institutional review board, which does not require informed consent for retrospective analysis of clinical

Results

Arteriovenous malformationIn 13 (of 18 total) cases, MRA identified mild to marked prominence/hypertrophy of at least one artery supplying hypervascular synovium (Table 1; available online at www.arthroplastyjournal.org). Of those 13 patients, 9 had moderate to marked staining in a specific arterial distribution. All of these 9 patients underwent embolization (Fig. 1, Fig. 2). Seven of these 9 patients had no recurrent hemarthrosis. Two patients (patients 3 and 14 in Table 1; available online

Discussion

Recurrent hemarthrosis after TKA is incompletely understood and often difficult to manage. In the largest study to date, the onset of hemarthrosis averaged 2 years after TKA, with a range of 2 weeks to 12 years [3]. Most cases of hemarthrosis presenting late after TKA are due to hypervascular, proliferative synovium, excluding those due to a coagulopathy [1]. Cases due to iatrogenic vascular injury (eg, pseudoaneurysm or arteriovenous fistula) present most frequently within 6 months after TKA.

Acknowledgments

The authors thank Stephen J. O'Brien, MD, Edwin P. Su, MD, Scott A. Rodeo, MD, and Russell F. Warren, MD, Department of Orthopaedic Surgery, Hospital for Special Surgery, for contributing additional cases for this study.

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Supplementary material available at www.arthroplastyjournal.org.

The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.01.010.

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