title: Is Embolization an Effective Treatment for Recurrent Hemorrhage After Hip or Knee Arthroplasty?
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria. peter.kalmar@medunigraz.at.
authors.forename: Peter I
authors.identifier: http://orcid.org/0000-0002-5742-3026
authors.initials: PI
authors.lastname: Kalmar
authors.affiliation: Department of Orthopedics, Medical University of Graz, Graz, Austria.
authors.forename: Andreas
authors.initials: A
authors.lastname: Leithner
authors.affiliation: Department of Orthopedics, State Hospital Bad Radkersburg, Bad Radkersburg, Austria.
authors.forename: Reinhard
authors.initials: R
authors.lastname: Ehall
authors.affiliation: Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria.
authors.forename: Rupert Horst
authors.initials: RH
authors.lastname: Portugaller
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D004621:Embolization, Therapeutic / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D011859:Radiography; D012008:Recurrence; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome