What is the management of a postoperative hematoma/seroma after a right direct anterior total hip arthroplasty?

From the Guidelines

The management of a postoperative hematoma or seroma after a right direct anterior total hip arthroplasty should prioritize a conservative approach, with observation and close monitoring for small, asymptomatic collections, as there is no strong evidence to support the routine use of drains to improve outcomes 1.

Key Considerations

• The use of postoperative drains vs. no drains has been shown to have similar pain scores in both groups, with one study reporting higher pain scores in patients with a drain 1.
• The direct anterior surgical approach, used in this case, has been associated with less postoperative pain than a posterolateral approach, but with a longer duration of surgery 1.
• For symptomatic or large collections, aspiration under sterile conditions may be necessary, typically using an 18-gauge needle after local anesthetic administration, with ultrasound guidance to improve accuracy and safety.
• If aspiration reveals purulent fluid or infection is suspected, samples should be sent for culture and sensitivity testing, and empiric antibiotics should be initiated.

Management Approach

• Small, asymptomatic collections: observation with close monitoring
• Symptomatic or large collections: aspiration under sterile conditions with ultrasound guidance
• Recurrent or persistent collections: surgical evacuation and debridement may be required
• Compression dressings or garments can help prevent reaccumulation after drainage

Important Considerations

• Monitor for signs of infection (fever, increasing pain, erythema, drainage) and deep vein thrombosis
• Prophylactic antibiotics are typically not needed for simple aspiration unless the patient is immunocompromised
• These collections require attention as they can increase infection risk, delay wound healing, and potentially compromise the prosthesis if left untreated.

From the Research

Management of Postoperative Hematoma/Seroma

The management of a postoperative hematoma/seroma after a right direct anterior total hip arthroplasty is crucial to prevent further complications.

• The use of tranexamic acid has been shown to decrease the risk of haematomas after total hip arthroplasty (THA) 2.
• Risk factors for postoperative hematomas requiring reoperation after primary THA include body mass index (BMI) ≥ 35, American Society of Anesthesiologists (ASA) class ≥3, and history of bleeding disorder 3.
• Patients developing a hematoma requiring reoperation are at higher risk of subsequent deep wound infection, sepsis, and pneumonia 3.

Prevention and Treatment

• Effective risk stratification strategies and prevention measures can be applied to minimize morbidity and mortality after THA 4.
• Hematoma following primary THA can require a return to the operating room, and risk factors include blood loss, administration of fresh frozen plasma and Vitamin K, perioperative anticoagulation, and hormonal therapy 5.
• Postoperative intraarticular haematoma and remaining seroma fluid and/or weakened posterior soft tissue wall may be contributing factors to dislocation after total hip replacement 6.

Key Considerations

• The incidence of postoperative hematomas requiring reoperation after primary THA is relatively low, at 0.12% 3.
• Surgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA 3.
• Hematoma itself is an independent risk factor for adverse outcomes, increasing morbidity and mortality, despite adequate treatment 5.