Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review

Are Process Changes Measurable? An Analysis of 4136 Proximal Femur Fractures over 16 Year

Prozessänderungen im perioperativen Setting werden selten analysiert, weil ihre Ergebnisse nicht unmittelbar fassbar sind und es einer hohen Fallzahl bedarf. Primäres Ziel war es, Prozessänderungen retrospektiv anhand proximaler Femurfrakturen (PF) zu evaluieren und deren Effekt mit verschiedenen Zielkriterien zu überprüfen. Sekundäres Ziel war die Definition möglicher Qualitätskriterien für die Versorgung von PF.Retrospektive Analyse der Datenbank eines Level-1-Traumazentrums zu PF. Eingeschlossen wurden alle osteosynthetisch und endoprothetisch versorgten PF im Behandlungszeitraum vom 01.01.2006 bis 31.12.2021. Der Zeitraum von 16 Jahren wurde für die Statistik trichotom aufgeteilt und die ersten 6 Jahre als Ausgangsbasis verwendet. Insgesamt 10 Prozessänderungen wurden in den folgenden 10 Jahren vorgenommen. Die Auswirkungen dieser Änderungen wurden anhand 1. der operativen Revisionsrate, 2. der Infektionsrate, 3. der perioperativen Transfusionsrate sowie 4. der 1-Jahres-Letalität überprüft.Insgesamt 4163 PF wurden analysiert. Hinsichtlich der Zielkriterien zeigten die Änderungen der ersten 5 Jahre (2012-2016; intramedulläres Verfahren für Osteosynthesen sowie Einwegabdeckung und Einwegkittel) den stärksten Effekt mit einer erstmaligen Senkung der operativen Revisionsrate unter 10% auf Dauer. Weitere Prozessoptimierungen der letzten 5 Jahre (2017-2021) erbrachten ebenfalls messbare Verbesserungen (Senkung der Infektions- und Transfusionsrate). Die 1-Jahres-Letalität blieb unverändert, auch während der COVID-19-Pandemie.Prozessänderungen bei PF führen nicht unmittelbar zu objektiv messbaren Verbesserungen. Rückblickend erscheint der Paradigmenwechsel von extra- auf intramedulläre Osteosynthese den höchsten Effekt erzielt zu haben, wenngleich über die letzten 10 Jahre eine schrittweise Besserung aller Zielkriterien eintrat - mit Ausnahme der Letalität. Als objektive Qualitätskontrolle sollte eine 1-Jahres-Revisionsrate unter 10% angestrebt sein.

Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND

Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS

Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

PATIENTS AND METHODS

This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION

Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anticoagulation drug use and rehabilitation outcomes in post-acute hip fractured patients

PURPOSE

To assess the relationship between anticoagulant use and rehabilitation outcomes in post-acute hip fracture patients.

METHODS

A retrospective study (1/2017 to 5/2019) of 299 hip fractured patients.

OUTCOME MEASURES

Functional Independence Measure (FIM) and the motor FIM's effectiveness.

RESULTS

Patients treated with anticoagulation drugs exhibited a significant longer latency time from fracture to surgery (U = -4.37, p < 0.001) and from surgery to rehabilitation (U=-2.27, p = 0.023), and a significantly higher rate of cardiovascular diseases (χ2=0.15, p= 0.023) compared with untreated patients. No significant differences between the two patient groups were found regarding the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures.

CONCLUSIONS

Oral anticoagulants are not associated with rehabilitation outcomes of hip fracture patients.Implications rehabilitationAnticoagulation drug use is not associated with functional outcome of post-acute hip fracture patients.It is recommended to renew oral anticoagulants for patients on chronic treatment after surgery since no negative outcomes were found during rehabilitation under anticoagulant treatment and in light of the importance of these drugs in preventing thromboembolic complications.

Early Surgical Care of Anticoagulated Hip Fracture Patients Is Feasible-A Retrospective Chart Review of Hip Fracture Patients Treated with Hip Arthroplasty within 24 Hours

Anticoagulative medication such as antiplatelet drugs (PAI, acetylsalicylic acid and direct platelet aggregation inhibitors), vitamin-K-antagonist Warfarin (VKA) or direct oral anticoagulants (DOAC) are common among hip fracture patients, and the perioperative management of these patients is a rising challenge in orthopaedic trauma. Our objective was to determine the effect of oral anticoagulation in patients receiving early endoprosthetic treatment within 24 h after their admission. For the period from 2016 to 2020, a retrospective chart review of 221 patients (mean age 83 ± 7 years; 161 women and 60 men) who were treated either with hemi- (n = 209) or total hip arthroplasty (n = 12) within 24 h after their admission was performed. We identified 68 patients who took PAI, 34 who took DOAC and 9 who took VKA medications. The primary outcome measures were the transfusion rate and the pre- and postoperative haemoglobin (Hb) difference. The secondary outcome measures were the in-patient mortality and the rate of postoperative haematomas that needed operative treatment. A logistic/ordinal regression was performed considering the related variables to prevent cofounding occurring. The mean time to surgery was significantly longer for the DOAC and VKA groups when they were compared to the controls (none 14.7 ± 7.0 h; PAI 12.9 ± 6.7 h; DOAC 18.6 ± 6.3 h; VKA 19.4 ± 5.5 h; p < 0.05). There was no difference in the preoperative Hb level between the groups. Overall, 62 patients (28%) needed blood transfusions during the in-patient stay with an ASA classification (p = 0.022), but the type of anticoagulative medication was not a significant predictor in the logistic regression. Anticoagulation with DOAC and grouped surgery times were positive predictors for a higher Hb difference in the patients who did not undergo an intraoperative blood transfusion (n = 159). Postoperative haematomas only occurred in patients taking anticoagulative medication (four cases in PAI group, and three cases in DOAC group), but the logistic regression showed that the anticoagulative medication had no effect. The in-patient mortality was significantly influenced by a high ASA grade (p = 0.008), but not by the type of anticoagulative medication in patients who were treated within 24 h. We conclude that the early endoprosthetic treatment of the anticoagulated hip fracture patient is safe, and a delayed surgical treatment is no longer justifiable.

Risk Factors Associated With Postoperative Pulmonary Infection in Elderly Patients With Hip Fracture: A Longitudinal Study

This study aimed to conduct a longitudinal study to explore the influencing factors of pulmonary infection in elderly patients with hip fracture after surgery, to provide evidence and reference for the early identification and nursing care of patients at high risk of postoperative pulmonary infection.A secondary analysis was conducted of electronic medical record data from elderly patients with hip fractures treated in a tertiary hospital from January 1, 2020 to June 30, 2021.A total of 526 patients were included. Age ≥70 years (odd ratio [OR] 2.042, 95% confidence interval [CI] [1.516-4.022]), history of smoking (OR 2.755, 95% CI [2.009-3.175]), time from fracture to operation ≥5 days (OR 3.117, 95% CI [1.925-3.911]), American Society of Anesthesiologists grade ≥II (OR 1.254, 95% CI [1.053-1.921]), chronic obstructive pulmonary disease (OR 2.832, 95% CI [1.775-3.808]), hypoproteinemia (OR 1.395, 95% CI [1.022-1.841]), red blood cell distribution width >15% (OR 3.142, 95% CI [2.104-4.172]), intensive care unit stay (OR 2.174, 95% CI [1.083-3.718]) and duration of mechanical ventilation ≥180 minutes (OR 3.117, 95% CI [2.199-4.807]) were the independent risk factors (all p < .05).Early nursing care should be taken for patients with risk factors to reduce the pulmonary infection.

Systemic Anticoagulation and Reversal

An increasing number of patients are on anticoagulation for a variety of indications. Patients on anticoagulation who present to the hospital with life-threatening hemorrhage, whether trauma related or not, must be assessed for the reversal of anticoagulation. Identification of the type of anticoagulation, the timing of the most recent usage of anticoagulation, and the efficacy of the anticoagulation all have an impact on whether reversal agents should be used. There are a variety of reversal agents, both nonspecific and specific, that could be used for reversal; however, not all reversal agents work for all anticoagulation medication. As more anticoagulation medications are used and indications expand, providers must be aware of the reversal agents available and the efficacy and indications for these reversal agents.