Suggest remedy for recurrent hemarthrosis after knee replacement surgery

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Posted on Tue, 21 Jul 2015 in Bones, Muscles and Joints
Question: Hello. I am 57 and in fairly good health. 2 years ago I had a total knee replacement. I had a DVT 10 days after surgery which resolved with anticoagulants. I did very well and resumed full activity with no pain or swelling until this past November when suddenly and without provocation my knee developed a hemarthrosis. Twice it had to be drained with 800-900 cc of blood. No infection. This continued, though to a lesser degree every 8-10 days for the past 6 months. Finally, we decided to have an arthroscopy to remove synovial tissue and take out scar tissue on and under my patella. That was three weeks ago. I did really well after the arthroscopy, but this morning, the knee swelled up again, hot, squishy feeling, and very painful. No trigger that I can identify. Seems as if the arthroscopy did not help. I don't know what to do next...a vascular doctor? A hematologist?
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Answered by Dr. Aashish Raghu 2 hours later
Brief Answer:
Post replacement infection

Detailed Answer:
Hi there.

I have read your query and understood your problem.

Do you have any history of bleeding disorders ?

Do you have Diabetes or Hypertension ?

Do you have recurrent or chronic fever ?

Since you had blood collection or haemarthrosis in your knee, the knee was drained multiple times and scar tissue and possibly arthroscopic biopsy tissue was taken from your synovium and from the cartilage of the Patella. Wasn't it done?

If it was done, then any chronic knee condition like Pigmented villonodular synovitis which may run across families can be confirmed or ruled out. Pigmented villonodular synovitis can cause multiple recurrent episodes of rust coloured blood like fluid collection and thick synovial lining.

Also your Doctor needs to rule out infection which is a common complication by sending the aspirate for culture and sensitivity testing for bacteria.

You can consult your Orthopaedician about the possibility of Pigmented villonodular synovitis. Also consult a Haematologist for possibility of bleeding disorders or clotting disorders. You may need a laboratory test panel Like Bleeding time, Clotting time, Prothrombin time, aPTT etc.

I hope I have answered your query.

Thanking you.

Regards,

Dr. Aashish Raghu
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Aashish Raghu 14 hours later
There was no infection. Aspirate was sent in for culture and it was negative. Blood markers for infection were also negative.

Synovectomy 3 weeks ago did not resolve the recurrent bleeding episodes. The surgeon said he removed the inflamed synovium and left what looked normal.

I have no history of bleeding disorder, no recurrent fevers, no diabetes, blood pressure is 130/84.

To my knowledge, no biopsy was performed of synovium or scar tissue. Should there have been a biopsy?

It is important to mention that this recent surgery was the 5th surgery on this knee. Medial Menisectomy at age 17. Reconstruction with cadaver ACL and Meniscus at age 36 (resulting in a torn Popliteal vein needing emergency vascular surgery), Arthroscopy for torn meniscus at age 50, Knee replacement at age 55 (with DVT 10-days post-op) , and most recent Arthroscopic Synovectomy with patellar scar tissue removal. Doppler studies show that I have small veins in my lower legs.

Is there anything more that can be done with my Orthopedic Surgeon? Should I consult with both a haematologist (for bleeding disorder) and a vascular specialist?
doctor
Answered by Dr. Aashish Raghu 1 hour later
Brief Answer:
Reactive synovium

Detailed Answer:
Hi there.

Thanks for the follow up query.

According to the information you provided, it appears that the is no post op infection in the joint. This is good news because Post joint replacement infection is very dangerous and usually difficult to treat.

During the diagnostic arthroscopic procedure, a piece of the synovium was taken. This is the biopsy specimen. It is possible that the synovium would have done vascular anomaly or also Reactive synovium that could produce haemorrhage like fluid in post op cases.

Other possibility is arthrofibrosis which can cause tissue contain which makes it prone to rupture on mild movement or stretch. This comes across as scar tissue. You could repeat an MRI to look for any other such causes of this problem.

The small veins in the knee could be varicose veins which could bleed on mild pressure. You could get a Doppler venous study to confirm the same after discussing with your doctor. Using elastic stocking and limb elevation would help in varicose veins.

I hope I answered your query.

Thanking you.

Regards,

Dr. Aashish Raghu
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Answered by
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Dr. Aashish Raghu

Orthopaedic Surgeon

Practicing since :2011

Answered : 5184 Questions

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