1
|
Lu W, Yon DK, Lee SW, Koyanagi A, Smith L, Shin JI, Rahmati M, Xiao W, Li Y. Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:1374-1383.e3. [PMID: 37972664 DOI: 10.1016/j.arth.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin. METHODS A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents. RESULTS Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators. CONCLUSIONS Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.
Collapse
Affiliation(s)
- Wenhao Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Seung Won Lee
- Department of Precision Medicine, Sungkyunkwan University College of Medicine, Suwon, Republic of Korea
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Masoud Rahmati
- Department of Physical Education and Sport Sciences, Faculty of Literature and Human Sciences, Lorestan University, Khoramabad, Iran; Department of Physical Education and Sport Sciences, Faculty of Literature and Humanities, Vali-E-Asr University of Rafsanjan, Rafsanjan, Iran
| | - Wenfeng Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yusheng Li
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
2
|
Pant N, Miranda-Hernandez S, Rush C, Warner J, Eisen DP. Non-Antimicrobial Adjuvant Therapy Using Ticagrelor Reduced Biofilm-Related Staphylococcus aureus Prosthetic Joint Infection. Front Pharmacol 2022; 13:927783. [PMID: 35846990 PMCID: PMC9284533 DOI: 10.3389/fphar.2022.927783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Prosthetic joint infection (PJI), frequently caused by Staphylococcus aureus, leads to a significant arthroplasty failure rate. Biofilm is a crucial virulence factor of S. aureus that is intrinsic to the pathogenesis of PJI. Biofilm-related infections are recalcitrant to antibiotic treatment. Surgical and antibiotic therapy could be combined with non-antibacterial adjuvants to improve overall treatment success. Ticagrelor, a P2Y12 receptor inhibitor antiplatelet drug, is known to have anti-staphylococcal antibacterial and antibiofilm activity. However, the molecular mechanism for ticagrelor’s antibiofilm activity and its efficacy in the treatment of S. aureus PJI are unknown.Methods: To study the in vitro antibacterial and antibiofilm activity of ticagrelor, broth microdilution and crystal violet staining method were used. Ticagrelor’s effect on the expression of S. aureus biofilm genes (icaA, icaD, ebps, fib, eno, and agr) was studied using the relative quantification method. To test ticagrelor’s in vivo efficacy to treat S. aureus PJI, mice were randomized into five groups (n = 8/group): infected femoral implants treated with ticagrelor alone; infected implants treated with cefazolin alone; infected implants treated with ticagrelor and cefazolin; infected implants treated with phosphate buffer solution (PBS)-positive controls, and sterile implants-negative controls. Ticagrelor was administered orally from day 4 to day 7 post-surgery, while cefazolin was injected intravenously on day 7.Results: Ticagrelor, alone and with selected antibiotics, showed in vitro antibacterial and antibiofilm activity against S. aureus. Strain-specific downregulation of biofilm-related genes, fib, icaD, ebps, and eno, was shown. In an animal model of biofilm-related S. aureus PJI, ticagrelor alone and combined with cefazolin significantly reduced bacterial concentrations on the implants compared with the positive control group. Ticagrelor significantly reduced bacterial dissemination to periprosthetic tissue compared with the positive controls.Conclusion: Ticagrelor adjuvant therapy reduced S. aureus PJI in an animal model. However, this study is very preliminary to make a conclusion on the clinical implication of the findings. Based on the current results, more studies are recommended to better understand its implication.
Collapse
Affiliation(s)
- Narayan Pant
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
- *Correspondence: Narayan Pant,
| | | | - Catherine Rush
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
| | - Jeffrey Warner
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
| | - Damon P. Eisen
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| |
Collapse
|
3
|
Wu CT, Lien TH, Chen IL, Wang JW, Ko JY, Lee MS. The Risk of Bleeding and Adverse Events with Clopidogrel in Elective Hip and Knee Arthroplasty Patients. J Clin Med 2022; 11:jcm11071754. [PMID: 35407361 PMCID: PMC8999348 DOI: 10.3390/jcm11071754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/19/2022] [Indexed: 12/07/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Tzu-Hsien Lien
- Department of Family Medicine, E-Da Hospital, Kaohsiung 824, Taiwan;
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Jih-Yang Ko
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
- Correspondence: ; Tel.: +886-7-731-7123
| |
Collapse
|
4
|
|
5
|
Lieberman JR, Bell JA. Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty. J Bone Joint Surg Am 2021; 103:1556-1564. [PMID: 34133395 DOI: 10.2106/jbjs.20.02250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The selection of an agent for prophylaxis against venous thromboembolism (VTE) is a balance between efficacy and safety. The goal is to prevent symptomatic VTE while limiting the risk of bleeding. ➤ The optimal agent for VTE prophylaxis has not been identified. The American College of Chest Physicians guidelines recommend that, after total hip or total knee arthroplasty, patients receive at least 10 to 14 days of 1 of the following prophylaxis agents: aspirin, adjusted-dose vitamin K antagonist, apixaban, dabigatran, fondaparinux, low-molecular-weight heparin, low-dose unfractionated heparin, rivaroxaban, or portable home mechanical compression. ➤ The use of aspirin for VTE prophylaxis has increased in popularity over the past decade because it is effective, and it is an oral agent that does not require monitoring. The true efficacy of aspirin needs to be determined in multicenter randomized clinical trials. ➤ Validated risk stratification protocols are essential to identify the safest and most effective regimen for VTE prophylaxis for individual patients. There is no consensus regarding the optimal method for risk stratification; the selection of a prophylaxis agent should be determined by shared decision-making with the patient to balance the risk of thrombosis versus bleeding. ➤ Patients with atrial fibrillation being treated with chronic warfarin therapy or direct oral anticoagulants should stop the agent 3 to 5 days prior to surgery. Patients do not typically require bridging therapy prior to surgery.
Collapse
Affiliation(s)
- Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | |
Collapse
|
6
|
Kugelman D, Teo G, Doran M, Buchalter D, Long WJ. The Association Between Clopidogrel and Gastrointestinal Bleeding After Primary Total Joint Arthroplasty. Arthroplast Today 2021; 9:61-64. [PMID: 34041330 PMCID: PMC8141600 DOI: 10.1016/j.artd.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/10/2021] [Accepted: 04/03/2021] [Indexed: 11/26/2022] Open
Abstract
Background Anticoagulation after total joint arthroplasty has been demonstrated to reduce venous thromboembolism. However, anticoagulation can lead to adverse bleeding events. The purpose of this study was to assess if an association exists between specific anticoagulation modalities, such as clopidogrel, and postoperative gastrointestinal (GI) bleeding. Methods A prospective cohort of Medicare patients undergoing total joint arthroplasty from 2017 to 2019 (3535 patients) was retrospectively reviewed. The baseline characteristics and anticoagulation methods were compared between the “GI bleed” cohort and the “non-GI bleed cohort.” Independent t-tests were conducted for continuous variables, while chi-squared analysis was conducted for dichotomous variables. Results Thirteen patients (0.42%) sustained a postoperative complication of a GI bleed. The mean age for patients sustaining a GI bleed was 69.23 years compared with 72.30 years for the non-GI bleed cohort (P = .11). Six patients who sustained a GI bleed (46%) were on an anticoagulation therapy other than aspirin, and this trended toward significance (P = .09). Five patients who sustained a GI bleed (38%) were on clopidogrel (P < .01). Seven percent of patients on clopidogrel sustained a postoperative GI bleed (P < .01). None of the patients who sustained a postoperative GI bleed had a history of peptic ulcer disease. Conclusion Patients on clopidogrel in the acute perioperative period demonstrated a strong association with the complication of postoperative GI bleeding. Arthroplasty surgeons should be aware of this association to educate and monitor patients on clopidogrel therapy and to work as part of interdisciplinary teams to assess the risks vs benefits of perioperative clopidogrel.
Collapse
Affiliation(s)
- David Kugelman
- Investigation Conducted at New York University Langone Orthopaedic Hospital, New York, NY, USA
| | - Greg Teo
- Investigation Conducted at New York University Langone Orthopaedic Hospital, New York, NY, USA
| | - Michael Doran
- Investigation Conducted at New York University Langone Orthopaedic Hospital, New York, NY, USA
| | - Daniel Buchalter
- Investigation Conducted at New York University Langone Orthopaedic Hospital, New York, NY, USA
| | - William J Long
- Investigation Conducted at New York University Langone Orthopaedic Hospital, New York, NY, USA
| |
Collapse
|
7
|
Reducing Risk in Total Joint Arthroplasty: Vascular Status. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
9
|
Triantafyllopoulos GK, Soranoglou VG, Memtsoudis SG, Sculco TP, Poultsides LA. Rate and Risk Factors for Periprosthetic Joint Infection Among 36,494 Primary Total Hip Arthroplasties. J Arthroplasty 2018; 33:1166-1170. [PMID: 29248486 DOI: 10.1016/j.arth.2017.11.040] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/12/2017] [Accepted: 11/16/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As periprosthetic joint infections (PJIs) can have tremendous health and socioeconomic implications, recognizing patients at risk before surgery is of great importance. Therefore, we sought to determine the rate of and risk factors for deep PJI in patients undergoing primary total hip arthroplasty (THA). METHODS Clinical characteristics of patients treated with primary THA between January 1999 and December 2013 were retrospectively reviewed. These included patient demographics, comorbidities (including the Charlson/Deyo comorbidity index), length of stay, primary diagnosis, total/allogeneic transfusion rate, and in-hospital complications, which were grouped into local and systemic (minor and major). We determined the overall deep PJI rate, as well as the rates for early-onset (occurring within 2 years after index surgery) and late-onset PJI (occurring more than 2 years after surgery). A Cox proportional hazards regression model was constructed to identify risk factors for developing deep PJI. Significance level was set at 0.05. RESULTS A deep PJI developed in 154 of 36,494 primary THAs (0.4%) during the study period. Early onset PJI was found in 122 patients (0.3%), whereas late PJI occurred in 32 patients (0.1%). Obesity, coronary artery disease, and pulmonary hypertension were identified as independent risk factors for deep PJI after primary THA. CONCLUSION The rate of deep PJIs of the hip is relatively low, with the majority occurring within 2 years after THA. If the optimization of modifiable risk factors before THA can reduce the rate of this complication remains unknown, but should be attempted as part of good practice.
Collapse
Affiliation(s)
- Georgios K Triantafyllopoulos
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Vasileios G Soranoglou
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Thomas P Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Lazaros A Poultsides
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| |
Collapse
|
10
|
Venous Thromboembolism Prophylaxis in Total Hip Arthroplasty and Total Knee Arthroplasty Patients: From Guidelines to Practice. J Am Acad Orthop Surg 2017; 25:789-798. [PMID: 29176502 DOI: 10.5435/jaaos-d-15-00760] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Venous thromboembolism (VTE) prophylaxis is recommended for all patients undergoing total hip arthroplasty or total knee arthroplasty. The selection of an appropriate prophylaxis regimen represents a balance between efficacy and safety. To help orthopaedic surgeons select an appropriate VTE prophylaxis regimen for their patients, the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have developed guidelines. These guidelines do not recommend an optimal regimen, however. Rather, an individualized prophylaxis regimen that balances efficacy and safety is recommended for each patient, based on various risk factors. Because of a paucity of data and a lack of adequately powered head-to-head trials, implementing these guidelines can be challenging for the orthopaedic surgeon. Knowledge of the prophylaxis options and the VTE risk factors is paramount for developing an effective VTE prophylaxis algorithm for the surgeon's practice.
Collapse
|
11
|
Karmakar B. Impact of health utility after thrombotic complications following total hip and knee arthroplasty. ANZ J Surg 2017; 87:820-824. [PMID: 28759944 DOI: 10.1111/ans.14122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/21/2017] [Accepted: 05/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Medical complications and preexisting conditions frequently place the surgeon in the unenviable position of choosing between the serious and potentially life-threatening effects of thrombosis, or the issue of bleeding and surgical site complications. The aim of this research was to determine if health utility could be a consideration before choosing to therapeutically anticoagulate in the hip and knee arthroplasty patient. METHODS The quantitative risks and effectiveness of treatment options for venous thromboembolism, atrial fibrillation, acute coronary syndromes, ischaemic stroke and mechanical heart valves were evaluated from previously published data. Previously calculated health utility values were obtained from published studies for both thrombotic events and anticoagulant-related complications at the site of arthroplasty. An impact score was generated through a multiplication of 1 - utility with the rate of the event occurring. RESULTS Impact scores associated with revision surgery and deep infection at the arthroplasty site following anticoagulation are higher compared to impact scores in subsets of non-treated venous thromboembolism, low CHADS2 (congestive heart failure, hypertension, age >75, diabetes (1 point each), stroke/transient ischaemic attack (2 points)) atrial fibrillation and potentially some acute coronary syndrome patients. Some anticoagulation strategies in mechanical heart valves are of definite overall patient value due to the significant complications otherwise. CONCLUSION Objective calculation of both the benefit and risks of anticoagulation in the post-operative patient is significantly altered by including the effect on patient's quality of life utility value. Therapeutic anticoagulation in some common situations is probable to be of more detriment than benefit when considering health utility.
Collapse
Affiliation(s)
- Bikram Karmakar
- Department of Orthopaedics, John Hunter Hospital, Newcastle, New South Wales, Australia
| |
Collapse
|
12
|
Ghanem ES, Richard RD, Wingert NCH, Gotoff JR, Graham JH, Bowen TR. Preoperative Use of Clopidogrel Does Not Affect Outcomes for Femoral Neck Fractures Treated With Hemiarthroplasty. J Arthroplasty 2017; 32:2171-2175. [PMID: 28262456 DOI: 10.1016/j.arth.2017.01.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/17/2017] [Accepted: 01/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery. METHODS We conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups. RESULTS The 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P < .001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89). CONCLUSION Patients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside.
Collapse
Affiliation(s)
- Elie S Ghanem
- Department of Orthopedics at Geisinger Medical Center, Danville, Pennsylvania
| | - Raveesh D Richard
- Department of Orthopedics at Geisinger Medical Center, Danville, Pennsylvania
| | | | - James R Gotoff
- Department of Orthopedics at Geisinger Medical Center, Danville, Pennsylvania
| | - Jove H Graham
- Center for Health Research, Henry Hood Research Center, Danville, Pennsylvania
| | - Thomas R Bowen
- Department of Orthopedics at Geisinger Medical Center, Danville, Pennsylvania
| |
Collapse
|
13
|
Von Keudell AG, Thornhill TS, Katz JN, Losina E. Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention. Open Orthop J 2017; 10:706-716. [PMID: 28144380 PMCID: PMC5220172 DOI: 10.2174/1874325001610010706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. METHODS We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. RESULTS If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. CONCLUSION Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.
Collapse
Affiliation(s)
- Arvind G Von Keudell
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Thomas S Thornhill
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Jeffrey N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| |
Collapse
|
14
|
Dundon JM, Trimba R, Bree KJ, Woods CJ, Laughlin RT. Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Rev 2015; 3:01874474-201509000-00002. [PMID: 27490669 DOI: 10.2106/jbjs.rvw.n.00105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John M Dundon
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Boonshoft School of Medicine, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409
| | | | | | | | | |
Collapse
|
15
|
Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
Collapse
Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
16
|
Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
|
17
|
Time spent per patient in lumbar spinal stenosis surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1868-76. [PMID: 23397190 DOI: 10.1007/s00586-013-2691-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/09/2012] [Accepted: 01/25/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To examine the time needed from a surgeon's viewpoint to treat a patient operated for lumbar spinal stenosis. We firstly aimed to give evidence of the wide ranging duration of standardized procedure. Secondly, we investigated factors affecting the time allocated to each patient. METHODS 438 medical records of patients operated on for lumbar decompression without fusion (2005-2011) were retrospectively examined. Primary data were operative time (OT, min), length of stay (LoS, days) and number of postoperative visits. A fourth parameter was calculated, the time spent per patient (TSPP, min) by summing the time spent in surgery, during inpatient and outpatient follow-up visits. Factors that influenced these medical resources were examined. RESULTS Median (5th-95th percentile) LoS was 5 days (2-15), OT 106 min (60-194), number of medical visits 5 (2-11) and TSPP 329 min (206-533). In descending order, factors predicting LoS were age, no. of levels, sex, operative technique, cardiovascular risk index, dural tear and haematoma. Factors predicting OT were number of levels, dural tear, foraminotomy, synovial cyst and body mass index. The statistical model could predict 36% of the TSPP variance. We recommend that surgeons add 35 min for each level, 29 min for patients over 65 years, 30 min for women, 132 min for dural tear and 108 min for epidural haematoma. CONCLUSION TSPP treated for lumbar spinal stenosis is highly variable, yet partially predictable. These data may help individual surgeons or heads of departments to plan their activities.
Collapse
|