[Anticoagulation medication for proximal femoral fractures: prospective validation study of new institutional guidelines]

Outcome of older hip fracture patients on anticoagulation: a comparison of vitamin K-antagonists and Factor Xa inhibitors

INTRODUCTION

Older hip fracture patients are still challenging in daily clinical practice. Due to the high prevalence of osteoporosis and atrial fibrillation in this age group, the number of fragility fracture patients under oral anticoagulation (OAC) increases. The outcome is still disappointing, short- and long-term mortality and morbidity is high. The impact of pre-existing OAC is not yet clear, especially regarding new OAC drugs like Factor Xa inhibitors (FXa). The purpose of our study was to compare the short-term outcome of older hip fracture patients, without OAC (controls), on Vitamin K antagonists (VKA) and on FXa.

MATERIALS AND METHODS

The study is a retrospective case-control study including patients older than 70 years who sustained hip fractures caused by an inadequate trauma and treated at a level 1 trauma center from February 2017 to June 2018. Patient's information was taken from patient's charts. 102 cases were analysed, 61 controls, 41 on OAC (15 on VKA and 26 on FXa). As outcome parameter we defined mortality, perioperative complications, bleeding, need of blood supplements, delay of surgery, length of stay, and a combined outcome parameter (mortality, myocardial infarction, stroke, thromboembolic events, blood preservations, re-vision surgery, major bleeding and decline of hemoglobin).

RESULTS

Eight patients died during hospital stay, in-hospital mortality was 7.8%. The highest mortality rate was found in patients on VKA (20%), compared to patients on FXa (3.8%) and controls (6.6%). However, mortality rate did not differ significantly within the groups. The combined endpoint was significantly more frequently seen in patients on OAC compared to controls (p = 0.006). No difference was observed between patients on VKA or FXa. Mean time to surgery and LOS was significantly longer in patients on OAC compared to controls. No significant differences were seen between VKA and FXa.

CONCLUSIONS

In our study OAC was significantly associated with worse outcome compared to controls. Marginal differences were observed between patients on FXa or VKA. Further studies involving a higher number of patients are necessary to confirm our results. At that time, some our results have to interpreted carefully and need confirmation.

[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

[Elderly trauma patients with proximal femur fractures : Statistical evaluation of regular process data from a trauma center for the elderly]

BACKGROUND/AIMS

Proximal femoral fractures are one of the most frequently occurring injuries among elderly people. High rates of inpatient treatment indicate the importance of optimized clinical care.

OBJECTIVES

Based on selected outcome parameters in elderly trauma patients with proximal femoral fractures, the current situation of medical care in a trauma center for geriatric patients is presented.

METHODS

For a descriptive evaluation of outcome parameters, 250 patients aged 70 years and older have been included. A clinical register of a trauma center for the elderly served as the database.

RESULTS

The average length of stay was approximately 25 days. Sixty-seven percent of the patients underwent surgical treatment within 24 h of admission to the hospital. More than half of the patients were taking anticoagulant drugs. Around 18 % of patients presented with one or more complications. Mortality rate was 5.2 %. Thirty-two percent of those patients who had been living at home before admission had been discharged to a nursing home.

DISCUSSION AND CONCLUSIONS

Analyzing the data of a trauma registry enables critical reflection upon the clinical outcome of interdisciplinary treatment procedures. The low rate of mortality may be a result of the geriatric co-treatment, starting right from admission. It remains unclear whether the influence of preoperative interdisciplinary treatment outweighs the effect of a timely surgical procedure.

Management of anticoagulation in hip fractures: A pragmatic approach

Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.

The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.

We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.

Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.

The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.

The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.

Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients.

Cite this article: EFORT Open Rev 2017;2:394–402. DOI: 10.1302/2058-5241.2.160083

[Reasons for proximal femoral fracture surgery delays : Analysis of the structured dialog in Rheinland-Pfalz]

BACKGROUND

For the "preoperative stay" quality indicator , which is part of the external quality assurance for proximal femoral fractures (module 17/1), a tolerance range for surgery within 48 h after admission of ≤15 % is given.

MATERIALS AND METHODS

The structured dialog (2014) in Rheinland-Pfalz was analyzed with respect to reasons for delaying surgery for more than 48 h after admission.

RESULTS

A total of 331 cases were analyzed. In 60.7 % patient-related reasons and in 13.3 % administrative reasons were found. In 9.1 % the statements were not feasible. Due to a lack of software-related specifications in 7.3 % a wrong preoperative length of stay was generated. Wrong coding or a computer-related problem was found in 6.6 %. The most common reason for delay was the intake of an anticoagulant (25.7 %).

CONCLUSION

The significance of the quality indicator "Preoperative stay" without division into whether this was administrative or patient-related must be considered critically.

Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study

Introduction:

The use of a multidisciplinary clinical pathway (MCP) for patients with hip fracture tends to be more effective than usual care (UC). The aim of this study was to evaluate the effects of an MCP approach on time to surgery, length of stay, postoperative complications, and 30-day mortality, compared to UC.

Materials and Methods:

This multicenter retrospective cohort study included patients aged 50 years or older with a proximal hip fracture who underwent surgery in one of the 6 hospitals in the Limburg trauma region of the Netherlands in 2012. Data such as demographics, process outcome measures, and clinical outcome were collected.

Results:

This study included a total of 1193 patients (665 and 528 patients in the MCP and UC groups, respectively). There were no differences in patient demographics present. Time to surgery was significantly shorter in the MCP compared to the UC group (19.2 vs 24.4 hours, P < .01). The mean length of stay was 10 versus 12 days (P < .01). In the MCP group, significantly lower rates of postoperative complications were observed and significantly more patients were institutionalized than in the UC group. Mortality within 30 days after admission was comparable between the groups (overall mortality 6%).

Conclusion:

An MCP approach is associated with reduced time to surgery, postoperative complications, and length of stay, without a significant difference in 30-day mortality. The institutionalization rate was significantly higher in the MCP group.

[Early complication rate of fractures close to the hip joint. Dependence on treatment in on-call services and comorbidities]

BACKGROUND

Guidelines advocate early surgery for proximal femoral fractures so that operations are frequently performed in on-call duty times. Multimorbid patients also suffer more frequently from postoperative complications. Does on-call duty or night shift services correlate with higher postoperative complication rates and what influence do comorbidities have?

PATIENTS AND METHODS

In 300 patients (> 65 years) postoperative surgical and non-surgical complications were documented and correlated with comorbidities, on-call duty and night shift service times.

RESULTS

Postoperative complications were observed in 10.7 % of surgical and 62 % of non-surgical cases. Surgery in on-call duty and night shift times did not increase the postoperative complication rate. Comorbidities, age and ASA classification correlated with postoperative complications which significantly prolonged hospital stay.

CONCLUSION

Surgery of proximal femoral fractures in on-call duty and night shift times is justified because postoperative complications are not increased. Comorbidities and higher age correlated with postoperative complications. Postoperative complications should be avoided because they result in prolonged hospital stay.

[Proximal femoral fractures in the elderly]

Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.