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) and negative electrocardiogram (EKG)?

From the Guidelines

For a patient with a hip hematoma three months after hip replacement who has mildly elevated troponin levels and a negative EKG, I recommend a comprehensive evaluation to rule out both cardiac issues and potential prosthesis complications, prioritizing consultation with both orthopedic surgery and cardiology teams. The patient's presentation warrants careful consideration of both cardiac and orthopedic aspects due to the potential for significant morbidity and mortality associated with either condition.

Given the mild elevation of troponin and negative EKG, it's crucial to understand that routine postoperative screening with troponin levels in unselected patients without signs or symptoms suggestive of myocardial ischemia or MI is not useful for guiding perioperative management, as stated in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. However, the presence of any troponin elevation, even mild, can associate directly and consistently with increases in 30-day mortality rates, as observed in studies like the VISION trial 1.

The evaluation should include:

• Orthopedic assessment with imaging (ultrasound or CT) to determine the size, location, and whether the hematoma is expanding or infected.
• Cardiology assessment with serial troponin measurements and consideration of an echocardiogram to evaluate cardiac function, given that troponin elevations predicted vascular and nonvascular mortality rates equally in postoperative patients 1.
• Monitoring for symptoms like chest pain, shortness of breath, fever, or increasing hip pain.
• Assessment of hemoglobin levels to evaluate for ongoing blood loss and inflammatory markers like CRP and ESR to assess for infection or inflammation.

A conservative management approach with rest, ice, compression, and elevation may be sufficient if the hematoma is stable and not infected, but surgical evacuation may be necessary if it's expanding or infected. The decision-making process should be guided by the most recent and highest quality evidence available, prioritizing the patient's morbidity, mortality, and quality of life outcomes. In this context, the guidance from the 2014 ACC/AHA guideline 1 emphasizes the importance of selective rather than routine troponin screening postoperatively, highlighting the need for a tailored approach based on clinical judgment and patient-specific factors.

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) and negative electrocardiogram (EKG), the following considerations should be taken into account:

• The patient's history of hip replacement and current presentation of a hematoma may indicate a complication related to the surgery or anticoagulant therapy 2, 3, 4.
• The mild elevation of troponin (TRI) may suggest cardiac involvement, but the negative EKG result indicates that the cardiac issue may not be severe 5, 6.
• The management of the patient should focus on addressing the hematoma and preventing further complications, such as deep vein thrombosis or pulmonary embolism 5, 6.

Risk Factors and Complications

The patient's risk factors for developing a postoperative hematoma include:

• History of bleeding disorder 3
• Use of anticoagulant therapy 2, 4
• Operative time ≥100 minutes 3
• Use of general anesthesia 3 The patient is also at risk for subsequent complications, such as:
• Deep wound infection 3
• Sepsis 3
• Pneumonia 3

Treatment Options

Treatment options for the patient may include:

• Surgical evacuation of the hematoma 2, 3, 4
• Anticoagulant therapy to prevent deep vein thrombosis or pulmonary embolism 5, 6
• Close monitoring for signs of infection or other complications 3