CHAPTER OUTLINE
Etiology 414
Dissection Technique 414
Closed Wound Drainage 414
Anticoagulation 415
Diagnosis 415
Management 415
Summary 416
Hematoma formation is a common complication after total hip arthroplasty (THA). Its reported incidence after elective THA is 0.8% to 1.7%, and most postoperative hematomas occur in the first 2 weeks after surgery. A hematoma impairs wound healing by increasing wound tension and reducing tissue perfusion. The chronically draining hematoma serves as a culture medium that can lead to deep infection. In addition, a large, tense hematoma can cause neurologic impairment by creating a mass effect on surrounding nerves. It is an important cause of early neurologic impairment and late, permanent nerve injury in the THA patient. Early vigilance is important in the diagnosis and treatment of hematomas.
DISSECTION TECHNIQUE
Meticulous surgical technique with careful handling of tissues and expeditious surgical technique cannot be overemphasized. Adequate exposure is necessary to perform a satisfactory THA, but extensive unnecessary dissection should be avoided. Careful hemostasis during surgery and just before closure should be performed to decrease wound hematoma and seroma formation.
CLOSED WOUND DRAINAGE
Closed wound drainage, once standard, has become rather controversial. The routine use of suction drainage theoretically can reduce the incidence of wound hematomas, therefore decreasing the incidence of postoperative wound drainage and possibly infection. However, multiple studies have shown that postoperative wound drainage offers no distinct advantages. Walmsley and colleagues performed a clinical trial on 552 patients (577 hips) undergoing THA who were randomized to either drain usage for 24 hours or no drain usage. One patient in the undrained group had a hematoma that did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than in the undrained group ( P < .042). The authors concluded that drains provide no clear advantage in THA, representing an additional cost, and exposing patients to a higher risk of transfusion. Parker and colleagues found similar results in a meta-analysis that included 18 studies involving 3495 patients with 3689 wounds. The occurrence of wound hematomas was 1.7% in wounds treated with a drain compared with 0.8% in wounds treated without a drain. Transfusion was required for 40.0% patients managed with a drain compared with 28.1% managed without a drain. The researchers concluded that these studies have indicated that closed suction drainage increases the transfusion requirements after elective THA and has no major benefits.
ANTICOAGULATION
Anticoagulation plays a significant role in the development of hematomas. The prevention of deep vein thrombosis and pulmonary embolism requires the use of anticoagulation after THA. Unfortunately, significant bleeding may occur even though the anticoagulation therapy has been properly administered. Hematocrit and coagulation parameters should be carefully monitored in the postoperative period to prevent hematoma formation. Wound pain and buttock and thigh swelling coupled with low hematocrit and abnormal coagulation profile should suggest the presence of an expanding hematoma. A mean international normalized ratio (INR) of greater than 1.5 is found to be more prevalent in patients who develop postoperative wound complications and subsequent periprosthetic infection. Cautious anticoagulation to prevent hematoma formation and/or wound drainage is critical to prevent periprosthetic infection and its undesirable consequences.
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