What to do in a patient with a hematoma of the hip, status post hip replacement 3 months ago, with mild elevation of troponin (TRI) levels?

From the Guidelines

For a patient with a hematoma of the hip three months after hip replacement who has mildly elevated troponin levels, I recommend against routine postoperative screening with troponin levels as it is not useful for guiding perioperative management in asymptomatic patients, as stated in the 2014 ACC/AHA guideline 1.

Patient Management

The patient's management should focus on addressing the hematoma and its potential complications, rather than the mildly elevated troponin levels.

• The patient should undergo ultrasound or CT imaging of the hip to assess the size and characteristics of the hematoma.
• Blood tests including complete blood count, coagulation profile, and serial troponin measurements should be obtained, but the troponin levels should not dictate management unless the patient shows signs or symptoms suggestive of myocardial ischemia or MI.
• While awaiting specialist assessment, the patient should limit weight-bearing on the affected hip and use appropriate pain management with acetaminophen (up to 3000mg daily in divided doses) or NSAIDs if not contraindicated.
• The connection between the hip hematoma and troponin elevation could be related to physiological stress, underlying cardiovascular disease, or potentially a systemic inflammatory response to the hematoma.
• Some patients may require aspiration of the hematoma if it's large, causing significant pain, or if there's concern for infection.
• Anticoagulants should be reviewed and potentially adjusted based on the patient's risk factors and the orthopedic surgeon's recommendations.

Cardiovascular Evaluation

Given the patient's mildly elevated troponin levels, cardiovascular evaluation should be considered, but it should be guided by the patient's symptoms and clinical presentation, rather than the troponin levels alone 1.

• The patient should be monitored for signs and symptoms of cardiac complications, such as chest pain, shortness of breath, or palpitations.
• An ECG and echocardiogram may be considered to rule out cardiac complications, but this should be done on a case-by-case basis, rather than as a routine screening measure.
• The patient's cardiovascular risk factors should be assessed and managed accordingly, but this should not be dictated by the mildly elevated troponin levels alone.

From the Research

Patient Management

In a patient with a hematoma of the hip, status post hip replacement 3 months ago, with mild elevation of troponin (TRI) levels, the following considerations should be taken into account:

• The patient's history of hip replacement and current hematoma may indicate a risk of bleeding or hematoma formation, as seen in studies 2, 3.
• The mild elevation of troponin levels may suggest cardiac involvement or stress, which should be monitored closely.
• Studies have shown that hematoma formation after hip arthroplasty can be a serious complication, increasing the risk of morbidity and mortality 2, 3.
• Risk factors for hematoma formation include blood loss, administration of fresh frozen plasma and Vitamin K, perioperative anticoagulation, and hormonal therapy 2.
• Embolization has been shown to be an effective treatment for recurrent hemorrhage after hip or knee arthroplasty, especially in patients without underlying coagulopathy 4.

Treatment Options

Treatment options for the patient may include:

• Close monitoring of the patient's condition, including troponin levels and hematoma size.
• Consideration of embolization as a treatment option, especially if the patient has recurrent hemorrhage or is at high risk of bleeding 4.
• Management of anticoagulation therapy, as extending prophylaxis up to 4 weeks after discharge has been shown to be safe and cost-effective in preventing deep vein thrombosis and pulmonary embolism 5.
• Surgical evacuation of the hematoma may be necessary in some cases, as seen in study 6.

Risk Factors and Complications

The patient's risk factors and potential complications should be carefully considered, including:

• Risk of deep wound infection, sepsis, and pneumonia, which are increased in patients with hematoma formation after hip arthroplasty 3.
• Risk of bleeding and hematoma formation, which can be increased by anticoagulation therapy and other factors 2, 3.
• Potential complications of embolization, such as procedure-related complications, although these were not reported in study 4.