Complications of hip fracture surgery on patients receiving clopidogrel therapy

The Risk of Bleeding and Adverse Events with Clopidogrel in Elective Hip and Knee Arthroplasty Patients

Orthopedic surgeons often face a clinical dilemma on how to manage antiplatelet therapies during the time of surgery. This retrospective study is aimed to investigate the bleeding risk and adverse events in patients who hold or keep clopidogrel during elective major joints arthroplasty. Two hundred and ninety-six patients that were treated with clopidogrel while undergoing total hip or knee joint replacement between January 2009 and December 2018 were studied. Group 1 included 56 patients (18.9%) who kept using clopidogrel preoperatively. Group 2 included 240 patients who hold clopidogrel use ≥5 days preoperatively. Blood transfusion rates, estimated blood loss, complication rates, and adverse cardiocerebral events were collected and analyzed. The mean total blood loss was more in the group 1 patients as compared with that in the group 2 patients (1212.3 mL (685.8 to 2811.8) vs. 1068.9 mL (495.6 to 3294.3), p = 0.03). However, there was no significant difference between the two groups of patients regarding transfusion rates, bleeding-related complications, and infection rates. There was a trend toward a higher incidence of adverse cardiocerebral events in patients withholding clopidogrel for more than 5 days before surgery. The results of this study suggest that clopidogrel continuation could be safe and advisable for patients at thrombotic risk undergoing primary major joint replacement. Acute antiplatelet withdrawal for an extended period of time might be associated with an increased risk of postoperative thromboembolic events. More studies are required in the future to further prove this suggestion.

Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis

Background

Hip fractures are common and account for a large proportion of orthopedic surgical admissions in elderly patients. However, determining the timing for surgery has been controversial for patients who develop hip fractures while on antiplatelet treatment.

Methods

Computerized databases for studies published from the inception date to January 2020, including the Cochrane Library, PubMed (Medline), EMBASE, Web of Science^TM, ClinicalTrials, ClinicalKey, and Google Scholar, were searched using the keywords “Hip AND Fracture”, “Antiplatelet”, “Antithrombocyte”, “Platelet aggregation inhibitors”, “Aspirin”, “Plavix”, and “Clopidogrel”.

Results

In total, 2328 initial articles were identified. Twenty-four studies with 5423 participants were ultimately included in our analysis. Early surgery was associated with an increased transfusion rate in the antiplatelet group compared to the non-antiplatelet group (OR = 1.21; 95% CI, 1.01 to 1.44; p = 0.03). Early surgery for hip fracture patients on antiplatelet therapy was associated with a greater decrease in hemoglobin compared to delayed surgery (WMD = 0.75; 95% CI, 0.50 to 1.00; p < 0.001). However, early surgery appeared to decrease the length of hospitalization (WMD = − 6.05; 95% CI, − 7.06 to − 5.04; p < 0.001) and mortality (OR = 0.43; 95% CI, 0.23 to 0.79; p = 0.006).

Conclusion

It is unnecessary to delay surgery to restore platelet function when patients with hip fractures receive antiplatelet therapy. Furthermore, early surgery can significantly reduce mortality and hospital stay, which is conducive to patient recovery. Future randomized trials should determine whether the results are sustained over time.

Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community

PURPOSE

This retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery.

METHODS

After IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015-2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed.

RESULT

In total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days.

CONCLUSIONS

Remaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.

Effect of Acetylsalicylic Acid Dose and Time Discontinued Preoperatively on Outcomes After Total Knee and Hip Arthroplasty

The purpose of this study was to determine if acetylsalicylic acid (ASA) dose or time discontinued preoperatively affected surgical outcomes in total joint arthroplasty (TJA). The authors hypothesized that ASA worsens surgical outcomes in patients receiving higher doses and in those who discontinue ASA closer to the operative date. A total of 2853 TJAs (1802 primary total knee arthroplasties and 1051 total hip arthroplasties) performed at a tertiary medical center were reviewed. Postoperative outcomes of patients receiving ASA prior to TJA, dosing of ASA (81 mg or 325 mg) preoperatively and postoperatively, and the time of preoperative discontinuation (no ASA, <4 days, <7 days, and 7 or more days) were compared. Preoperative ASA was a risk factor for readmission (odds ratio [OR], 1.86; P<.001) and 90-day postoperative events (OR, 1.26; P=.004). Among patients receiving ASA, the dose was not a risk factor for any of the studied outcomes. Discontinuing ASA 7 or more days prior to TJA was protective for hematomas (OR, 0.64; P=.038), emergency department visits (OR, 0.79; P=.006), readmission (OR, 0.65; P<.001), and 90-day postoperative events (OR, 0.72; P<.001). These outcomes had a time effect: the risk was greater for those who discontinued therapy closer to the operative date. Patients who discontinued ASA 7 or more days prior to TJA had a lower incidence of hematomas, emergency department visits, readmissions, and 90-day postoperative events. This study's findings support discontinuing ASA at least 7 days prior to TJA. [Orthopedics. 2019; 42(5):286-293].

Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review

INTRODUCTION

To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence.

METHODS

We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph.

RESULTS

We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies.

CONCLUSIONS

Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.

Poor prognosis after surgery for intertrochanteric fracture in elderly patients with clopidogrel treatment: A cohort study

Choice of surgical approach in patients under clopidogrel treatment is controversial. Intertrochanteric fractures are common in the elderly, who also suffer from a number of comorbidities.The aim of this study is to assess the prognosis of elderly patients with clopidogrel treatment after surgery for intertrochanteric fracture.This was a cohort study of 238 elderly patients who underwent proximal femur intramedullary nailing for intertrochanteric fracture between January 2012 and December 2013 at the Geriatric Trauma Center of the Beijing Army General Hospital. The patients were divided into the clopidogrel (n = 32) and control (n = 206) groups according to their history of long-term clopidogrel treatment before surgery. Demographic and clinical characteristics, intraoperative parameters, postoperative complications, and 1-year survival were compared between the 2 groups.Preoperative American Society of Anesthesiologists (ASA) grade and the frequency of arterial stenting were different between the 2 groups (P = .002 and P < .001, respectively). The rate of intraoperative blood transfusion, ICU stay, and hospital stay were higher in the clopidogrel group compared with the control group (all P < .001). Postoperative complications were similar in the 2 groups. The 1-year mortality rate after surgery was significantly higher in the clopidogrel group compared with the control group (37.5% vs 20.3%, P = .030).Prognosis after surgery for intertrochanteric fracture was poorer in elderly patients with clopidogrel treatment; these patients had lower 1-year survival, more intraoperative blood transfusion, longer ICU stay, and longer hospital stay. ASA grade, arterial stenting, and anesthesia mode were prognostic factors.

Perioperative complications following preoperative cessation of antithrombotic agents for total knee arthroplasty: A retrospective study

The number of elderly patients undergoing total knee arthroplasty (TKA) has steadily increased. Elderly patients undergoing TKA usually have underlying diseases, and some of them take antithrombotic agents for the prevention or treatment of these co-morbidities, including cardiovascular, cerebrovascular, or thromboembolic diseases. When these patients are scheduled to undergo TKA, preoperative cessation of antithrombotic agents is considered on the basis of its risks and benefits. This study was aimed to evaluate the impact of discontinuing antithrombotic agents for primary total knee arthroplasty (TKA) on perioperative complications.Patients who underwent primary TKA between 2008 and 2012 were identified, and classified into two groups: group A, in whom antithrombotic agents were ceased preoperatively, and group B, in which patients did not receive antithrombotic therapy. Patient characteristics, history of antithrombotic therapy, intraoperative blood loss, perioperative blood transfusion, postoperative 30-day complications, and postoperative hospital stay were recorded.Of 885 patients undergoing primary TKA, 218 (24.6%) patients were included in group A, and 667 (75.4%) in group B. Group A received transfusion more frequently than group B (P < 0.001). However, there was no difference between the two groups in terms of intraoperative blood loss, postoperative 30-day complications, and postoperative hospital stay.Patients who discontinued antithrombotic drugs before primary TKA do not have a higher incidence of postoperative 30-day complications, including cardiovascular, cerebrovascular, or thromboembolic events. Moreover, the estimated intraoperative blood loss was not different compared with patients not receiving antithrombotic agents preoperatively. Larger prospective studies of this issue are required.

Surgical delay as a risk factor for wound infection after a hip fracture

PURPOSE

Analysis of significant risk factors for mortality and for medical and orthopaedic complications.

PATIENTS AND METHODS

Observational study of a prospective consecutive cohort of 697 patients diagnosed of hip fracture from December 2012 to December 2014. Average age was 85±9years and 520 were female (75%). Intracapsular fractures (308, 44%) were treated non-operatively, (19 patients), with cannulated screws (58) or with hip arthroplasty (228 bipolar, 3 total hip atrhoplasty). Extracapsular fractures (389, 56%) were reduced and fixed with 375 trochanteric nails and 14 sliding-hip-screw-plates. Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6 and 12months. Bivariate analysis (Pearson, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Odds Ratio were calculated.

RESULTS

Surgical delay reached 2.1±2.2days, 1.7±1.9 in medically stable patients. Main reason for delay was anticoagulant/anti-platelet therapy. Immediate weight-bearing was begun for 72% of patients. Average time in-hospital was 12±8days and 63% returned to previous environment. Lost-to-follow-up reached 4% after 1month and 8% after 6months. After 1year, 6% of previously-walking patients were unable to walk. Mortality reached 4% while in-hospital and 14% after 1year, with older age as only significant risk factor (p=0.004), OR=1.9. Wound infection developed in 2.3% of the series, and surgical delay longer than 24hours was a significant risk factor (p=0.023), with an OR=3.48 (1.1-10.8). Fixation failed in 7.9% of cannulated screws and 1.9% of trochanteric nails (1.1% cut-out, 0.8% nail fracture), while 2.7% of arthroplasty patients suffered a prosthesis dislocation and 1.3% a periprosthetic fracture. Pyelonephritis appeared in 6.7%, pneumonia in 6.3% and cardiac failure in 2.2% of patients; significant risk factors were previous comorbidity for pneumonia (p=0.007) (OR=2.7) and cardiac failure (p=0.007) (OR=9.7), as well as older age (p=0.006) (OR=2.2) for pneumonia.

CONCLUSIONS

Surgical delay longer than 24hours has been an important risk factor for wound infection, a finding not previously described in literature. Older age is a significant risk factor for mortality and pneumonia, and previous comorbidity for cardiac failure and pneumonia.

In Hospital and 3-Month Mortality and Functional Recovery Rate in Patients Treated for Hip Fracture by a Multidisciplinary Team

Objectives

Medical comorbidities affect outcome in elderly patients with hip fracture. This study was designed to preliminarily evaluate the usefulness of a hip-fracture unit led by an internal medicine specialist.

Methods

In-hospital and 3-month outcomes in patients with hip fracture were prospectively evaluated in 121 consecutive patients assessed before and followed after surgery by a multidisciplinary team led by internal medicine specialist; 337 consecutive patients were recalled from ICD-9 discharge records and considered for comparison regarding in-hospital mortality.

Results

In the intervention period, patients treated within 48 hours were 54% vs. 26% in the historical cohort (P<0.0001). In-hospital mortality remained stable at about 2.3 per 1000 person-days. At 3 months, 10.3% of discharged patients had died, though less than 8% of patients developed postoperative complications (mainly pneumonia and respiratory failure). The presence of more than 2 major comorbidities and the loss of 3 or more BADL were independent predictors of death. 50/105 patients recovered previous functional capacity, but no independent predictor of functional recovery could be identified. Mean length of hospital stay significantly decreased in comparison to the historical cohort (13.6± 4.7 vs 17 ± 5 days, p = 0.0001). Combined end-point of mortality and length of hospitalization < 12 days was significantly lower in study period (27 vs 34%, p <0.0132).

Conclusions

Identification and stabilization of concomitant clinical problems by internal medicine specialists may safely decrease time to surgery in frail subjects with hip fracture. Moreover, integrated perioperative clinical management may shorten hospital stay with no apparent increase in in-hospital mortality and ultimately improve the outcome. These results are to be confirmed by a larger study presently ongoing at our institution.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis

Background

Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel.

Methods

All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I² statistic.

Results

A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures.

Conclusions

On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding.

Trial registration

This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0988-9) contains supplementary material, which is available to authorized users.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons

OBJECTIVE

There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients.

METHODS

A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05.

RESULTS

Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution.

CONCLUSIONS

There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Variability of platelet aggregation in patients with clopidogrel treatment and hip fracture: A retrospective case-control study on 112 patients

AIM: To identify the rate of non-responders to clopidogrel treatment in hip fracture patients and study how non-responders differ from controls.

METHODS: In a retrospective case-control study we included 28 cases of acute proximal femoral fracture with clopidogrel treatment 2011 to 2013. Eighty-four controls from the same time period were included. Data collected included response to clopidogrel measured with multiple electrode aggregometry (MEA), intraoperative bleeding, erythrocyte transfusion, time to surgery and the incidence of adverse events up to 3 mo after surgery.

RESULTS: Eight (29%) of the 28 cases were non-responders. The median intraoperative bleeding was 300 mL (range, 0-1500), and was lower for non-responders (50 mL) but did not reach statistical significance. Erythrocyte transfusions did not differ between responders, non-responders and controls. Forty-five (40%) of 112 patients had adverse events postoperatively but the rate did not differ between patients with and without clopidogrel treatment.

CONCLUSION: Almost one-third of patients with clopidogrel treatment and an acute proximal femoral fracture are non-responders to antiplatelet therapy and can be operated without delay.

Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression

INTRODUCTION

Hip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes?

METHODS

A systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared.

RESULTS

For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58-1.38) or 30-day mortality (OR 1.10 95% CI: 0.48-2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00-1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference -7.09 days (95% CI: -10.14 to -4.04).

DISCUSSION

Early surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings.