CHAPTER 56 Management of Postoperative Hematomas
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.1 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.
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.2 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.1
