What are the management and treatment options for a patient with a hematoma following hip surgery?

Management of Hematoma Following Hip Surgery

Hematoma following hip surgery requires urgent surgical evacuation when symptomatic or expanding, as it significantly increases the risk of deep wound infection (21.6-fold), sepsis, and mortality, making it a grave complication that demands aggressive management. 1, 2

Immediate Recognition and Assessment

Clinical Presentation

• Monitor for groin pain, expanding mass, and signs of femoral nerve compression (weakness of knee extension, sensory loss over anterior thigh), particularly in patients on anticoagulation therapy 3
• Assess for systemic signs including progressive anemia, tachycardia, hypotension, and signs of hypovolemia 2
• Evaluate wound appearance for excessive swelling, tension, or drainage 1

Diagnostic Workup

• Obtain immediate imaging with CT or MRI to confirm hematoma size, location (superficial vs. deep iliopsoas), and extent of compression on neurovascular structures 3
• Check hemoglobin levels using point-of-care analyzers to assess degree of anemia and guide transfusion 4
• Review coagulation parameters (INR, aPTT, platelet count) especially in anticoagulated patients 4
• Rule out infection through clinical assessment and laboratory markers, as hematomas dramatically increase subsequent deep wound infection risk 1

Surgical Management

Indications for Operative Intervention

Proceed with urgent surgical drainage when:

• Symptoms are severe and disabling (significant pain, nerve compression, functional impairment) 3
• Hematoma is expanding or causing neurovascular compromise 3
• Clinical suspicion of infection exists, as hematomas increase deep infection risk 21.6-fold 1

Surgical Technique

• Perform complete evacuation and irrigation of the hematoma cavity 3
• Achieve meticulous hemostasis and identify any bleeding sources 2
• Consider drain placement to prevent reaccumulation, though balance against bleeding risk 2
• Send tissue for culture and pathology to rule out infection and rare complications like chronic expanding hematoma 5

Perioperative Anticoagulation Management

Reversal Strategy

• For warfarin (INR >2): Administer small doses of vitamin K; target INR <1.5 for surgery 4
• Prothrombin complex concentrates can rapidly reverse warfarin but are expensive and rarely indicated 4
• For patients on LMWH: Time surgery appropriately based on last dose (typically 18-24 hours) 4
• Consult hematology for patients on novel anticoagulants or complex anticoagulation regimens 4

Resumption of Anticoagulation

• Restart warfarin 24 hours after surgical evacuation in most cases, though some centers restart on day of surgery 4
• Use supplemental perioperative anticoagulation with heparins as indicated for high-risk patients 4
• Balance thromboembolism risk (37% DVT prevalence, 6% PE prevalence in hip fracture patients) against bleeding risk 4

Risk Factor Modification

Identified Risk Factors

Nonmodifiable factors:

• BMI ≥35 (RR 1.83) 1
• ASA class ≥3 (RR 2.11) 1
• History of bleeding disorder (RR 2.71) 1

Modifiable factors:

• Operative time ≥100 minutes (RR 2.03) - optimize surgical efficiency 1
• General anesthesia (RR 1.41) - consider regional techniques when appropriate 1
• Perioperative anticoagulation timing and hormonal therapy 2
• Blood loss and FFP/Vitamin K administration 2

Postoperative Monitoring and Complications

Enhanced Surveillance

• Monitor high-risk patients closely for signs of infection, as hematoma increases deep wound infection risk 21.6-fold 1
• Watch for sepsis (4.3-fold increased risk) and pneumonia (3.69-fold increased risk) 1
• Serial hemoglobin checks to detect ongoing bleeding 4
• Assess for nerve recovery if femoral neuropathy was present; recovery may be only partial even after drainage 3

Fluid and Hemodynamic Management

• Transfuse packed red blood cells for symptomatic anemia 6
• Encourage early oral fluid intake rather than routine IV fluids postoperatively 4
• Monitor for hypovolemia, which is common after hip surgery 4

Critical Pitfalls to Avoid

• Do not delay surgical evacuation in symptomatic patients, as hematoma is an independent risk factor for increased morbidity and mortality despite adequate treatment 2
• Do not overlook iliopsoas hematoma in patients presenting with groin pain and femoral nerve palsy, especially those on anticoagulation 3
• Do not assume improvement without intervention - surgical drainage can immediately relieve pain and drastically improve quality of life 3
• Do not restart anticoagulation too aggressively without ensuring adequate hemostasis 4
• Do not miss the diagnosis of chronic expanding hematoma in cases with progressive osteolysis and "mosaic sign" on MRI, which may present years after surgery 5

Long-term Outcomes

• Expect improved quality of life after surgical drainage, with immediate pain relief, though nerve recovery may be incomplete 3
• Recognize increased mortality risk associated with hematoma formation, independent of other factors 2
• Monitor for recurrence and ensure adequate rehabilitation with interdisciplinary support 6