The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

Development and validation of models for predicting mortality in intertrochanteric fracture surgery patients with perioperative blood transfusion: a prospective multicenter cohort study

BACKGROUND

The association between allogenic blood transfusions and all-cause mortality in surgically treated hip fracture patients with perioperative transfusion (STHFPT) remained unknown. The authors aim to introduce transfusion-related factors, new variables to develop, and validate models to predict mortality in these patients.

METHODS

A prospective multicenter cohort study was conducted with STHFPT hospitalized during January 2018 and June 2021. The database was divided into training cohort and validation cohort in a ratio of 70-30% using the randomization method. All participants received a minimum of 2-year follow-up and all participants' overall and eight time-specific survival status were recorded. Prediction models were developed using multivariate logistic regression and Cox regression for variable selection. Model performance was measured by determining discrimination, calibration, overall model performance or precision, and utility. Sensitivity analyses were performed to test robustness of the results.

RESULTS

A total of 7074 consecutive patients were prospectively screened and assessed for eligibility to participate. Finally, 2490 patients met our inclusion and exclusion criteria and 1743 (70%) patients were randomized to the training cohort and 747 (30%) to the validation cohort. The median duration of follow-up was 38.4 months (IQR 28.0-62.0). Our novel models highlight that preoperative transfusion is of significance for short-term mortality while mid-term outcomes are predominantly determined by severe complications, pulmonary complications, and advanced age. Our models showed high discriminative power, good calibration, and precision for mortality prediction in both training and validation cohorts, especially in short-term mortality prediction.

CONCLUSIONS

The authors introduce transfusion-related factors, new variables to develop, and validate models to predict mortality with STHFPT. The models can be further tested and updated with the ultimate goal of assisting in optimizing individual transfusion strategy.

Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis

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.

Safety of urgent surgery for the patients with proximal femur fracture treated with platelet aggregation inhibitors: a propensity-score matching analysis

INTRODUCTION

To compare the various perioperative outcomes in an urgent surgery setting among patients with proximal femur fracture (PFF) who received platelet aggregation inhibitors (PAIs) and those who did not.

METHODS

We retrospectively reviewed the data of 1,838 patients who underwent surgery for PFF between January 2011 and January 2021. We conducted 1:1 propensity-score matching and compared the perioperative outcomes, including operation time, postoperative complications, hospital stay, mortality, and variables related to bleeding risk (e.g., number of transfusion profiles, hemoglobin levels, and laboratory data, including coagulation battery).

RESULTS

Of the 492 patients who were treated with PAIs, 484 were 1:1 matched to the untreated control group. The PAI group showed shorter operation time than the matched control group (72.3 min for PAI vs. 77.7 min for control; P = 0.041), and the control group showed more pulmonary thromboembolism (0.2% for PAI vs 1.7% for control; P = 0.046) than the PAI group. The other complications and length of hospital stay, mortality rate, transfusion profile, and the laboratory test (except preoperative international normalized ratio, INR) showed no significant difference between the groups. Subgroup analyses of the patients treated with only aspirin (aspirin: 306, matched control: 306), only clopidogrel (clopidogrel: 100, matched control: 100), and others who were treated with dual anticoagulation (dual anticoagulation: 78, matched control: 78) showed no significant differences in perioperative outcomes among the groups.

CONCLUSION

The patients who were treated with PAI could undergo PFF surgery safely without delay, which led to no significant difference in operation time, postoperative complication risk, perioperative blood transfusion, and variables related to bleeding risk. Therefore, we believe that it is unnecessary to delay surgery for patients with PFF who receive PAI.

Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures

Objective

The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures.

Methods

This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative.

Results

There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28-4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14-1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43).

Conclusion

Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury.

Level of evidence

IV.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion

OBJECTIVE

The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss.

METHODS

DESIGN

Retrospective review.

SETTING

Three level 1 trauma centers at 2 academic institutions.

PATIENT SELECTION CRITERIA

Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures).

OUTCOME MEASURES AND COMPARISONS

Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery.

RESULTS

195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05).

CONCLUSION

There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant.

LEVEL OF EVIDENCE

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

The Role of Endoscopy in Investigating the Causes of Persistent Anaemia in Post-operative Fractured Neck of Femur Patients

Introduction Post-operative anaemia in hip fracture patients has been associated with increased risk of blood transfusion, poorer functional outcomes, increased morbidity and mortality. Patients with persisting drop in haemoglobin after fractured neck of femur with no obvious source of blood loss are often referred for endoscopy to find the cause of anaemia. The reported incidence of perioperative acute upper gastrointestinal bleeding varies from 1 to 15%. Objective The aim of our study is to find out the usefulness of endoscopy in finding gastrointestinal causes leading to the occult loss of blood causing irreversible anaemia in post-operative neck of femur fractures. Material and methods The orthogeriatric unit conducted a study using retrospective data on neck of femur fracture patients from January 2015 to December 2020. Out of 1863 cases, 918 (49.3%) developed post-operative anaemia. Forty-five patients (5%) with refractory anaemia underwent endoscopy referral. Patient demographics, fracture patterns, pre-existing anaemia, and co-morbidities (anaemia, heart disease, chronic kidney disease, oral anticoagulant usage) were recorded. The recorded information also included the type of procedure undergone by each patient. Intra-operative tranexamic acid injections were administered to all patients. Results Male patients accounted for 24% (11) and females for 76% (34). The average age was 82.3 years (range: 73-94). In terms of fracture type, 60% (27) were intracapsular and 40% (18) were extracapsular. Iron deficiency anaemia was present in 24% (11), oral anticoagulants in 20% (9), and systemic malignancy in 12% (6) of patients. The mean post-operative hemoglobin level during endoscopy referral was 7.3 g/dL. Endoscopy revealed normal findings in 60% (27), esophagitis/gastritis in 20% (8), and hiatus hernia in 16% (7) of patients. No patients were diagnosed with active gastrointestinal bleeding or malignancy as the cause of post-operative hemoglobin drop. Conclusion The study did not show evidence of any gastrointestinal bleeding in patients with resistant and refractory post-operative anaemia following fractured neck of femur surgery using endoscopy procedure. The value of such difficult, expensive and time-consuming procedure may be reviewed further.

Early hip fracture surgery is safe for patients on direct oral anticoagulants

Objectives

To determine how preoperative direct oral anticoagulant (DOAC) use affects rates of blood transfusion, clinically important blood loss, and 30-day mortality in patients with hip fracture undergoing surgery within 48 hours of presentation to the emergency department.

Design

Retrospective cohort study.

Setting

Academic trauma center.

Patients

A total of 535 patients with hip fracture who underwent open cephalomedullary nail fixation or arthroplasty either taking a direct oral anticoagulant or no form of chemical anticoagulant/antiplatelet agent before presentation (control).

Main Outcome Measures

Demographics, time to surgery, type of surgery, blood transfusion requirement, clinically important blood loss, and 30-day mortality.

Results

Forty-one patients (7.7%) were taking DOACs. DOAC patients were older (81.7 vs. 77 years, P = 0.02) and had higher BMI (26.9 vs. 24.2 kg/m2, P = 0.01). Time from admission to surgery was similar between DOAC users (20.1 hours) and the control (18.7 hours, P > 0.4). There was no difference in receipt of blood transfusion (P = 0.4), major bleeding diagnosis (P = 0.2), acute blood loss anemia diagnosis (P = 0.5), and 30-day mortality (P = 1) between the DOAC and control group. This was true when stratifying by type of surgery as well.

Conclusions

Our results suggest that early surgery may be safe in patients with hip fracture taking DOACs despite theoretical risk of increased bleeding. Because early surgery has previously been associated with decreased morbidity and mortality, we suggest that hip fracture surgery should not be delayed because a patient is taking direct oral anticoagulants.

Level of Evidence

Prognostic Level III.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis

Background

In older adults, the recovery after hip fracture surgery is not always to be well expected due to high risks of adverse outcomes including perioperative complications and mortality. We aimed to evaluate the intertrochanteric fracture (IF) patients with diabetes mellitus (DM) and receiving surgical fixation with intramedullary nail on the perioperative complications, total hospital costs (THC), length of hospital stay (LOS), and mortality.

Methods

In this retrospective cohort study, among 487 consecutive intertrochanteric fracture patients with age over 65 years and treated surgically by using intramedullary nail between Jan. 2015 and Mar. 2020, 353 patients were included, including 81 with DM and 272 without DM. After using propensity-score matched (PSM) analysis, 80 patients remained in each group. The perioperative complications, 30-day, 90-day, 1-year, and 2-year survival rates, THC, and LOS were observed and compared between two groups. Overall survival was compared by Kaplan–Meier method.

Results

No significant between-group differences were found in 30-day, 90-day, 1-year, and 2-year mortality rates, THC, LOS, and other perioperative complications after PSM and McNemar’s tests (all p>0.05), except for neurological complications (p<0.004) and endocrine/metabolic complications (p<0.001). At a mean follow-up time of 36.2 months, there were no statistically significant differences between the groups based on the Kaplan–Meier survival curve (p=0.171, log-rank).

Conclusion

IF surgery patients with DM are more prone to suffer perioperative neurological and endocrine/metabolic complications and they should be managed individually while being aware of these risks henceforth. Further high evidence clinical trials are needed to expand in DM patients with IF.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Use of Intravenous Paracetamol Preoperatively Favors Lower Risk of Delirium and Functional Recovery in Elderly Patients with Hip Fracture: A Propensity Score-Matched Analysis

We aimed to investigate whether the use of intravenous paracetamol (IVP) preoperatively in intertrochanteric fracture (IF) patients aged 65 years or over receiving intramedullary fixation had significantly benefits on the pain score at discharge, delirium incidence, length of hospital stay (LOS), functional outcomes, and mortality. A retrospective analysis of all surgically treated patients presenting with IF was conducted at a single Level I trauma center in China between Jan. 2016 and Jan. 2020. The data concerning patients' demographics, injury-related data, surgery-related data, operation-related data, in-hospital data, and postoperative outcomes were extracted. To minimize potential confounding and selection bias, the propensity score matching (PSM) method was performed via the caliper matching method by using a 1 : 1 ratio. After PSM, McNemar's chi-square tests were used to examine the association of using IVP with outcome analyses. The Spearman correlations of IVP using, pain scores, and the factors which may influence them were also computed. After screening 2963 consecutive patients, 2166 were included finally, including 1576 in the non-IVP group and 590 in the IVP group. After PSM, 531 remained in each group. The pain scores at discharge were significantly between the two groups before and after matching (all p < 0.001). The differences of delirium rate and functional outcomes became significant after propensity score-based matching (p=0.001 and 0.033, respectively), although they were not significant before matching. No significant difference was observed in other operation-related data, LOS, and crude mortality rates at 30-day, 90-day, and 12-month before and after PSM. In conclusion, this study highlights the need for preoperative IVP use to optimize pain control, postoperative functional recovery, and minimize pain-related comorbidities such as delirium in elderly patients with hip fracture.

Relationship between predisposing and facilitating factors: Does it influence the risk of developing peri-operative pressure injuries?

This study examined the relationship between the personal predisposing factors of patients and the severity of pressure injuries (PIs) developed during surgery. This retrospective cohort study collected 439 cases of peri-operative PIs. Using binary logistic regression to identify the variables associated with PI severity, the effects of interactions between associated variables were then tested. The results of this study revealed that among the personal predisposing factors, only higher patient age (P = .001) and higher body mass index (P < .001) posed a greater risk of stage 2 PIs or higher. Among the surgery-related facilitating factors, only patients who were placed in the prone position during surgery and patients who lost ≥1000 mL of blood during surgery were at greater risk of stage 2 PIs or higher, compared, respectively, to those placed in the supine position and those who lost ≤100 mL of blood. Furthermore, the amount of blood lost during surgery moderated the influence of age on PI severity. For elderly patients who are expected to lose a large blood volume during surgery or lose an immeasurable amount of blood due to the use of cardiopulmonary bypass, taking more precautionary measures to prevent PIs is recommended.

Risk Factors for Perioperative Hidden Blood Loss After Intertrochanteric Fracture Surgery in Chinese Patients: A Meta-Analysis

Study Design

A meta-analysis

Introduction

To perform a meta-analysis to explore the risk factors of perioperative hidden blood loss (HBL) in the treatment of intertrochanteric fracture for Chinese patients.

Significance

An extensive search of the literature was performed in the English databases of PubMed, Embase, and Cochrane Library and the Chinese databases of CNKI and WAN FANG (up to July 2021). We collected factors including demographic data and surgical factors. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

Finally, we collected 7 studies including 1377 patients in the final analysis. In our study, female patients (P <.00001), hypertension (P =.008), time from injury to operation (<2 days, P =.02), operation time (≥60 mins, P =.001), fracture type (A2.2 to A3.3, P <.00001), and without anticoagulation (P <.00001) were found to be associated with perioperative HBL in Chinese patients receiving the treatment of the intertrochanteric fracture. However, anesthesia, ASA classification, and body mass index were not associated with perioperative HBL.

Conclusions

In our study, female patients, hypertension, time from injury to operation (<2 days), operation time (≥60 mins), fracture type (A2.2 to A3.3), and without anticoagulation were related to increased risks of perioperative HBL in Chinese patients receiving the treatment for the intertrochanteric fracture. We hope this article can guide for surgeons to reduce perioperative HBL as far as possible in the treatment of intertrochanteric fracture.

The Impact of Preinjury Use of Antiplatelet Drugs on Outcomes of Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Objective

The study aimed to compare outcomes of traumatic brain injury (TBI) in patients on pre-injury antiplatelet drugs vs. those, not on any antiplatelet or anticoagulant drugs.

Methods

PubMed, Embase, and Google Scholar databases were searched up to 15th May 2021. All cohort studies comparing outcomes of TBI between antiplatelet users vs. non-users were included.

Results

Twenty studies were included. On comparison of data of 2,447 patients on pre-injury antiplatelet drugs with 4,814 controls, our analysis revealed no statistically significant difference in early mortality between the two groups (OR: 1.30 95% CI: 0.85, 1.98 I² = 80% p = 0.23). Meta-analysis of adjusted data also revealed no statistically significant difference in early mortality between antiplatelet users vs. controls (OR: 1.24 95% CI: 0.93, 1.65 I² = 41% p = 0.14). Results were similar for subgroup analysis of aspirin users and clopidogrel users. Data on functional outcomes was scarce and only descriptive analysis could be carried out. For the need for surgical intervention, pooled analysis did not demonstrate any statistically significant difference between the two groups (OR: 1.11 95% CI: 0.83, 1.48 I² = 55% p = 0.50). Length of hospital stay (LOS) was also not found to be significantly different between antiplatelet users vs. non-users (MD: −1.00 95% CI: −2.17, 0.17 I² = 97% p = 0.09).

Conclusion

Our results demonstrate that patients on pre-injury antiplatelet drugs do not have worse early mortality rates as compared to patients, not on any antiplatelet or anticoagulant drugs. The use of antiplatelets is not associated with an increased need for neurosurgical intervention and prolonged LOS.

Is proximal femoral nailing of unstable intertrochanteric fractures in the lateral decubitus position without a traction table as safe and effective as on a traction table?

OBJECTIVES

Using proximal femoral nailing (PFN) in the lateral decubitus (lateral) position may be an option when no traction table is available. We hypothesized that applying PFN would be effective and reliable in the lateral position without a traction table. To test our hypothesis, we compared the two techniques in a prospective, randomized controlled study.

PATIENTS AND METHODS

Eighty patients (> 60 years of age) with unstable intertrochanteric fractures were randomly operated on prospectively in the lateral position without a traction table (Group 1) or in the supine position with a traction table (Group 2) between April 2018 and April 2019. We compared the surgery preparation time, total anesthesia time, duration of surgery, fluoroscopy exposure time, and amount of bleeding between the two procedures. The type-apex distance (TAD), collodiaphyseal angle (CDA), reduction quality, and lag quadrant were measured radiologically. The Harris Hip Score (HHS) was also calculated.

RESULTS

The mean follow-up time was 18.5 (14-27) months in Group 1 and 19.9 (14-27) months in Group 2. The mean follow-up time, mean age, sex distribution, and fracture pattern were similar between the groups. The preparation time and total anesthesia time of Group 2 were longer than those of Group 1, and the fluoroscopy time of Group 2 was shorter than that of Group 1 (p < 0.05). No significant differences in surgical time, bleeding amount, TAD, CDA, target lag quadrant, reduction quality, or the HHS were observed between the two groups.

CONCLUSIONS

We concluded that PFN is a safe and effective alternative for the treatment of unstable intertrochanteric femoral fractures when a traction table is not available in the operating room.

Evaluation of Clopidogrel Safety in Geriatric Patients with Hip Fracture: A Retrospective Study

OBJECTIVE

To evaluate the risk of bleeding in elderly patients undergoing early hip fracture surgery with/without clopidogrel administration.

METHODS

This was a retrospective study, and patients over 65 years with fresh hip fracture were enrolled. For the patients taking clopidogrel, early surgical treatment was performed without 5-7 days waiting time. The patients were divided into groups according to their fracture type and the surgical method. Within each fracture/surgery group, the patients were further divided into subgroups according to whether they had clopidogrel administration. The patients' age, gender, American Society of Anesthesiologists (ASA) score, hemoglobin level at admission, and the time from admission to surgery were compared in the different groups. The bleeding outcomes, such as intraoperative blood loss and blood transfusion status, as well as secondary outcomes, such as operation duration and length of hospital stay, were also compared in these groups.

RESULTS

There were no statistically significant differences in patients' baseline characteristics and outcomes, including intraoperative blood loss, blood transfusion rate, operation duration and length of hospital stay, between the clopidogrel-administrated patients and the control patients. However, the percentage of patients taking general anesthesia was significantly higher in clopidogrel group than that in control group (P = 0.01). Similar intraoperative blood loss was found in the subgroups of hemi-hip replacement, internal fixation for intertrochanteric fracture of the femur (fracture type A1-2, short pin), and internal fixation of femoral neck fracture with cannulated nails. For the internal fixation of femoral neck fracture with cannulated nails, the blood loss is significantly less in both subgroups than that with other two surgical methods. Moreover, the total hip arthroplasty, with the highest bleeding risk among all the surgical methods involved, was rarely chosen to treat geriatric hip fracture in this study.

CONCLUSION

This study indicated that compared with patients without clopidogrel administration, elderly patients with hip fractures who receive clopidogrel as long-term anti-platelet therapy are relatively safe for surgery in less than 5-7 days after discontinuation of clopidogrel.

Management of proximal femur fractures in the elderly: current concepts and treatment options

As one of the leading causes of elderly patients’ hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients’ outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Safety of early surgery for geriatric hip fracture patients taking clopidogrel: a retrospective case-control study of 120 patients in China

Background:

Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal.

Methods:

Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student's t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables.

Results:

Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0–120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups.

Conclusions:

Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.

Worldwide research tendency and hotspots on hip fracture: a 20-year bibliometric analysis

We analyzed the overall knowledge structure, development trends, and research hotspots of 7684 publications related to hip fracture through the bibliometric method. Our results indicate this area has received more and more attention from researchers. Prevention of complications will be the focus of future studies.

INTRODUCTION

Hip fracture is an international public health problem, with high morbidity, mortality, and associated health care costs. Research on hip fracture has been developed rapidly in recent years, but no bibliometric studies have been performed. We aimed to identify the publication changes in scientific output relating to hip fracture over the past two decades.

METHODS

The scientific output relating to hip fracture from 2000 to 2019 was identified and selected from the Web of Science Core Collection. Excel 2019 was used to summarize the quantitative indicators including publication number, citations, H-index, journal's impact factors, and journal citation reports. VOS viewer and CiteSpace software tools were used for co-authorship, citation, co-citation, and co-occurrence analyses between countries, institutions, journals, authors, references, and keywords. Data were analyzed on November 13, 2020.

RESULTS

A total of 7684 publications were extracted. The USA was the leading contributor in this field with the largest publications (1876, 24.41%), the most citations (75,423 times), and the highest H-index (124). The number of publications in the Western European region is 1.82 times higher than that of North America region, and 3.59 times that of Eastern Asia region. The most productive institutions on hip fracture were University of Maryland (160). Injury (506) had the highest number of publications, while Osteoporosis International (20,483 times) was the most co-cited journal. Magaziner J and Parker MJ were the key researchers. The keywords were stratified into five clusters: cluster 1 ("operative approaches study"), cluster 2 ("rehabilitation study"), cluster 3 ("osteoporosis study"), cluster 4 ("outcomes and complications study"), and cluster 5 ("epidemiology study"). For hotspots, "tranexamic acid" showed a relatively latest average appearing years of 2017.52, followed by "30-day-mortality," "readmission," and "length of stay."

CONCLUSIONS

There will be an increasing number of publications on the hip fracture research based on the current global trends, and the USA stays ahead in this field. In terms of region, Western Europe had the greater impact than North America. It is recommended to pay attention to the promising hotspots, such as tranexamic acid, 30-day-mortality, readmission, and length of stay.

Intramedullary Fixation Does Not Cause a Large Amount of Hidden Blood Loss in Elderly Patients with Intertrochanteric Fractures

Purpose

Controversy remains around intramedullary fixation of intertrochanteric fractures in elderly patients when considering hidden blood loss (HBL). However, whether treating the fractures with intramedullary fixation causes a large amount of HBL is not known.

Patients and Methods

In this retrospective cohort study, 1,017 consecutive patients aged ≥65 years with acute intertrochanteric fractures were included and assigned to three groups (non-operative group, delayed surgery group, and acute surgery group) between July 2013 and January 2018. The data of patients’ demographics, injury-related data, operation-related data, comorbidities, perioperative hemoglobin values, transfusion data and serial of HBL calculated during hospitalization were collected and compared among three groups. All independent variables were further analyzed by multiple linear regression to evaluate the influential factors of HBL. A long-term follow-up was conducted and survival analysis was performed for all individuals.

Results

Our results showed that fixation by proximal femoral nail anti-rotation for intertrochanteric fracture has been estimated to contribute 11–34% of the increase of HBL during hospitalization and it does not increase the allogeneic transfusion rate. For HBL, male patients, unstable fracture, and blood transfusion may have strong influences. Surgical delay was associated with longer time from injury to hospital admission, higher ASA-grade, and comorbidities such as diabetes and coronary heart disease. Survival analysis revealed that mortality increased in patients with conservative treatment, where a rapid decline was found in the first year, especially in the 90 days after injury. A higher mortality rate was also obtained in patients with surgery delay than acute surgery patients.

Conclusion

In conclusion, HBL is the main component of total blood loss and it is more likely to result from the initial trauma rather than the surgery. Intertrochanteric fracture treated by intramedullary fixation does not cause a large amount of HBL.

Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss

PURPOSE

This study aimed to investigate the effects of aspirin on peri-operative hidden blood loss during hip fracture surgery by adjusting for possible factors affecting blood loss using a propensity score matching method.

METHODS

We retrospectively collected data from a cohort of isolated hip fracture patients (aged ≥ 65 years)who underwent surgery from January 2010 to December 2019. The study's primary outcome was blood loss from admission to the day after surgery in the aspirin and control groups. We estimated the hidden blood loss, calculated based on patient's blood volume, haemoglobin measurements, and blood transfusions. The secondary outcome focused on the requirement for blood transfusion. We adjusted for possible factors affecting blood loss using a propensity score matching method and statistically examined the effects of aspirin on hip fracture surgery.

RESULTS

We enrolled 806 patients of whom 271 (34%) were taking anticoagulant and antiplatelet drugs, while 114 (14%) were taking only aspirin (aspirin group). A total of 535 patients were not taking antiplatelets and anticoagulants (control group). In propensity score matching, 103 patients were matched. Aspirin was not associated with a significantly higher risk of hidden blood loss (aspirin group; median 598 mL [410-783 mL] vs control group; median 556 ml [321-741 mL], p = 0.14) and higher risk of blood transfusion requirement (aspirin group; 49 patients [48%] vs control group; 39 patients [38%], p = 0.21).

CONCLUSION

Aspirin did not affect peri-operative blood loss in hip fracture surgery. We concluded that patients taking aspirin can safely undergo hip fracture surgery without delay.

Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients?

INTRODUCTION

Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA.

MATERIALS AND METHODS

This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups.

RESULTS

Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups).

CONCLUSION

Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.

Proximal femur fractures in patients taking anticoagulants

Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs.

Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed.

Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios.

Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days.

Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended.

There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.

Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture

OBJECTIVE

To determine how timing of surgery affects transfusion, major complications, and mortality in patients who sustain a geriatric hip fracture while taking dual antiplatelet therapy (DAPT; typically aspirin and clopidogrel).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated Level 1 Trauma Center.

PATIENTS

Patients 65 years of age or older on DAPT with a geriatric hip fracture were investigated at a single institution between 2002 and 2017. Demographic and perioperative data were collected from patient records, institutional databases, and national hip fracture registry.

INTERVENTION

Fixation or arthroplasty.

MAIN OUTCOME MEASUREMENT

Transfusion, major complications, and 30-day mortality.

RESULTS

Of the 6724 patients sustaining a geriatric hip fracture, 122 patients were taking DAPT on admission. Timing of surgery did not influence transfused units (incidence rate ratio 1.00, 95% confidence interval: 0.87-1.15, P = 0.968) but did affect major complications (time modeled as quadratic term; odds ratios ranging from 0.20 to 7.91, ptime = 0.001, ptime*time<0.001) and 30-day mortality (odds ratio 1.32, 95% confidence interval: 1.03-1.68, P = 0.030).

CONCLUSION

Surgical delay does not change the need for transfusion of hip fracture patients on DAPT, but it is associated with increased probabilities of major complications and 30-day mortality.

LEVEL OF EVIDENCE

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

Should patients treated with oral anti-coagulants be operated on within 48 h of hip fracture?

To investigate if patients treated with oral anticoagulants (OAC) have delayed surgical intervention (more than 48 h) compared to patients without OAC therapy, and if there is an impact to surgery timing on hospitalization length and mortality. A retrospective cohort study of all patients aged over 65 registered with a new diagnosis of hip fracture who underwent surgery in one of the general hospitals run by Clalit, Israel between 01/01/2014 and 31/12/2017. Data was retrieved for patient demographics, OAC treatment, and Charlson comorbidity index. 5828 patients were operated for hip fractures, mean age was 82.8 years (65-108), 4013 (68.8%) were female. 415 were treated with direct oral anticoagulants (DOACs) (7.1%) and 311 with warfarin (5.3%) prior to their hospitalization. Patients taking OAC were less likely to be operated within 48 h from arrival to the hospital compared to patients not receiving OAC. The 30 day mortality was 4.2% among patients not receiving OAC, 6.0% among patients taking DOACs and 10.0% among patients receiving warfarin (p < 0.001). Adjusted odds ratio for mortality at 30 day among patients taking DOACs was similar to patients who didn't take OAC. (OR 1.0, CI 0.7, 1.6). The 30 day mortality rate of patients who were receiving OAC (either DOACs or warfarin) was not significantly different whether patients were operated within 48 h or not. Mortality rate was highest among patients taking warfarin. For patients who received DOACs, operation within 48 h wasn't associated with lower mortality rate. In these patients it seemed reasonable to adjust surgery time according to patients' characteristics and needs.

Super elderly patients with intertrochanteric fractures do not predict worse outcomes and higher mortality than elderly patients: a propensity score matched analysis

We aimed to investigate whether super elderly patients aged over 90 years had significantly worse functional outcomes, perioperative complications, and survival rates. Among 3560 patients aged over 65 years presenting with intertrochanteric fractures and treated surgically between Jan 2014 and Jan 2019, 2242 patients were included, including 206 in super elderly group and 2036 in elderly group. After using propensity score matching to minimize the effects of possible confounding variables, 192 remained in each group. No significant difference was observed in functional outcomes, perioperative complications, or 30-day, 90-day, and 1-year mortality after propensity score matching and McNemar’s tests (p>0.05). After an average follow-up of 37 months, the Kaplan-Meier survival curve showed no significant difference between the two groups in terms of cumulative survival rate (p=0.081, log-rank). Our data demonstrated progressive increases in mortality and poor outcomes with increasing Elixhauser comorbidity scores, which represented the severity index of patients preoperatively. Our study also found that there were weak correlations between five characteristics and the patient age. These results all suggested that it is not the advanced age itself but other concomitant factors, that appear to be responsible for the adverse functional outcomes, perioperative complications, and mortality in super elderly patients.

Evaluation of the use of anti-platelet therapy throughout the peri-operative period in patients with femoral neck fracture surgery. A retrospective cohort study

INTRODUCTION

Fracture neck of femur (hip fracture) is a very common problem among old age group. Such elderly patients usually have some comorbidities for which they may use anti-platelet therapy (such as clopidogrel, aspirin, or others) for long duration (chronic use). These anti-platelet medications might make the blood thin and increase bleeding tendency. So, if these elderly people present with fracture neck of femur requiring surgical intervention, they might be at increased risk of bleeding and other complications if the use of these anti-platelet agents was continued throughout the peri-operative period.

OBJECTIVES

This current study aims to find out whether it is safe or not to continue the use of anti-platelet drugs during the peri-operative period in patients with hip fracture surgery. If it is safe and there are no complications, then there is no harm to continue the use of these drugs peri-operatively without any surgical delay. But if it is unsafe and there is increased risk of bleeding or blood transfusion or other complications, then such medications must be stopped peri-operatively. Thus, the medical practice and care will be improved to achieve patient safety.

METHODS

It was a retrospective study which reviewed files and notes of patients who had hip fracture surgery. These patients were divided into 2 groups. First group was on long-term anti-platelet treatment (APTG), and the use of these medicines continued during the peri-operative phase. The second group was not on anti-platelet treatment at all (NAPTG). Then, a comparison was done between both groups in terms of the following parameters during the peri-operative (pre- and post-operative) period: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively. So these measures are good parameters to assess bleeding tendency and bleeding risk. Data was collected, and statistical analysis was done using Pearson's chi-squared test and independent sample t test as appropriate.

RESULTS

325 participants were enrolled in the study. There were 163 patients in the APTG (Anti-Platelet Treatment Group) and 162 patients in the NAPTG (Non-Anti-Platelet Treatment Group). It has been found that there was no statistically significant difference between the APTG and NAPTG in terms of these peri-operative parameters: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively (P > 0.650).

CONCLUSION

It is safe to continue the use of anti-platelet therapy throughout the peri-operative phase in patients with hip fracture surgery. The continuation of such therapy is not associated with increased risk of bleeding or blood transfusion or other complications in patients who had surgical treatment for femoral neck fracture.

The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario?

STUDY DESIGN

Cohort.

OBJECTIVE

To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs.

SUMMARY OF BACKGROUND DATA

While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression.

METHODS

This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts.

RESULTS

The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups.

CONCLUSION

The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD.

LEVEL OF EVIDENCE

4.

Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study

Background

With an increase in the elderly population, the occurrence of hip fractures, femoral neck fractures, and intertrochanteric fractures (ITFs) is also increasing. It is important to establish effective perioperative methods that would help reduce the morbidity and mortality rates associated with ITFs. The purpose of this study was to determine the effects of ITFs according to the AO classification for perioperative hemoglobin drop.

Methods

Seventy-six patients with ITFs classified as AO 31-A1 or A2 and fixated with intramedullary nails participated in this retrospective cohort study. Medical records of these patients were retrospectively reviewed from September 2016 to August 2018. The perioperative hemoglobin drop was chosen as the main outcome measure and calculated as the difference between pre- and postoperative hemoglobin levels. Multivariate linear regression analysis was performed and included the following variables: AO classification (A1.1-A2.1 [stable] vs. A2.2-A2.3 [unstable]), time interval between injury and surgery, age, body mass index, and the use of anticoagulants.

Results

Among the 76 patients who met the inclusion criteria, a significantly higher hemoglobin drop was observed in the AO 31 A2.2-A2.3 (unstable) group than in the AO 31 A1.1-A2.1 (stable) group (p = 0.04). The multivariate analysis also showed a greater hemoglobin drop in the unstable group (p < 0.05).

Conclusions

Patients with unstable ITFs exhibited a greater hemoglobin drop and a hidden blood loss was suspected around the fracture site. We believe that this should be taken into consideration when presurgical blood transfusion is being planned for patients with unstable ITFs, to reduce associated postoperative complications, especially in patients with severe anemia or high risk of mortality.

Risk factors of perioperative blood transfusion in elderly patients with femoral intertrochanteric fracture

This study aimed to discuss the risk factors of perioperative blood transfusion after the application of proximal femoral nail antirotation (PFNA) in the treatment of elderly patients with femoral intertrochanteric fracture (FIF). Moreover, this study also aimed to analyze the causes of perioperative blood transfusion and provide guidance for clinical treatment.Records of elderly patients with FIF who were treated with PFNA in our hospital from September 2014 to May 2017 were reviewed. They were divided into transfused and nontransfused groups. The Student t test, Chi-squared test, and Fisher exact test were used in univariate analysis of 11 variables. Multivariate logistic regression analysis was performed to analyze the possible risk factors associated with postoperative blood transfusion after the application of PFNA in elderly patients with FIF. Correlations were sought using the Spearman rank correlation analysis.The univariate analysis showed that age, sex, type of fracture, admission hemoglobin (Hb), admission albumin, and intraoperative blood loss were significantly associated with perioperative blood transfusion (P = .000, .019, .000, .000, .000, and .007, respectively). The multivariate logistic regression analysis demonstrated that age (P = .019, odds ratio [OR] = 1.062), type of fracture (P = .001, OR = 4.486), and admission Hb (P = .000, OR = 0.883) were independent risk factors of postoperative blood transfusion. We found a significant positive correlation between perioperative blood transfusion and age (r = 0.264, P = .000) and type of fracture (r = 0.409, P = .000), but a negative correlation between perioperative blood transfusion and admission Hb (r = -0.641, P = .000).The main factors affecting perioperative blood transfusion are age, fracture type, and admission Hb. These results indicate that, in high-risk patients who are older in age, more unstable fractures, and lower admission Hb, monitoring Hb concentrations during the perioperative period is important to correct severe anemia in a timely manner and avoid exacerbating existing underlying diseases and inducing severe complications.

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.

Impact of Antiplatelet Therapies on Patients Outcome in Osteosynthetic Surgery of Proximal Femoral Fractures

BACKGROUND

Proximal femoral fractures should be treated in a timely manner. Affected patients often require antiplatelet therapy (APT) due to cardiovascular diseases. Guidelines recommend 5-7 days APT interruption for elective surgery. Early osteosynthetic surgery of proximal femoral fractures despite of APT should be considered.

AIM OF THE STUDY

To evaluate whether early osteosynthetic surgery despite of APT is associated with increased blood loss, complications and mortality.

METHODS

Data of patients with proximal femoral fractures, who were treated by osteosynthesis at the Department of Trauma Surgery at the Medical University of Vienna were collected retrospectively. Study groups were formed by time to surgery and APT interruption. The primary endpoint of the study was the perioperative blood loss. Secondary endpoints were complications, 30-day and 1-year mortality, time to surgery, and the total length of hospital stay.

RESULTS

The osteosynthetic treatment of proximal femoral fractures despite of APT resulted in a shorter time to surgery (13.8 vs. 66.0 h; p < 0.01). In patients on APT, the TBL (total perioperative blood loss) was higher without need for revision or an increase in the need for packed red blood cells if surgery was performed within 24 h after admission. APT had no significant influence on mortality. Patients who underwent surgery within 24 h after admission had a lower mortality. The complication rate was higher in patients who underwent surgery later than 24 h after admission.

CONCLUSIONS

Surgery within 24 h after admission, regardless of APT, resulted in a shorter hospitalization length and was associated with less common complications and a lower mortality.

Hidden blood loss after hip hemiarthroplasty using the superPATH approach: A retrospective study

OBJECTIVE

The purpose of this study was to compare perioperative hidden blood loss after hip hemiarthroplasty via the SuperPATH approach and the conventional posterior approach (the Moore approach).

PATIENTS AND METHODS

From January 2015 to January 2017, 130 patients (80.7 ± 6.0 years) with displaced femoral neck fracture (Garden type III or IV) undergoing hip hemiarthroplasty were included in this study. As a non-randomisation study, Fifty-two patients (SuperPATH group) were operated using the SuperPATH approach, and 78 patients (Moore group) were operated with the conventional posterior approach (Moore approach). The demographic and relevant clinical information of the patients were collected. According to the combination formulas of Nadler, Gross and Sehat, the hidden blood loss (HBL) of each patient was calculated. Student's t-test for independent samples was used to compare the normally distributed variables and the Mann-Whitney U test was used to compare variables not following a normal distribution.

RESULTS

The visible blood loss (VBL) in the SuperPATH group was 123.7 ± 47.5 ml, the hidden blood loss (HBL) was 1084.1 ± 816.8 ml and the HBL% was 82.7 ± 16.5%. In the Moore group, the VBL was 303.6 ± 139.6 ml, the HBL was 700.2 ± 563.8 ml and the HBL% was 61.5 ± 23.8%. The patients in the SuperPATH group had more HBL and HBL% (P < 0.05). However, no significant difference was observed of total blood loss (TBL) between the two groups (P = 0.125).

CONCLUSIONS

HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of TBL. Compared with the conventional approach, the SuperPATH approach had a greater amount of HBL. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety.

The influence of pre-operative antiplatelet and anticoagulant agents on the outcomes in elderly patients undergoing early surgery for hip fracture

BACKGROUND

Early surgery improves the prognosis of elderly patients with hip fractures. However, many patients take antiplatelet and anticoagulant therapies for comorbidities. This study compared perioperative outcomes and 1-year mortality rates with early surgery in elderly patients with hip fractures taking or not taking these agents preoperatively.

METHODS

Among 418 patients undergoing surgery for hip fractures at our institution from 2014 to 2016, 266 patients over 65 years who had surgery within 48 hours of admission were enrolled. We excluded patients with high-energy injuries, multiple or pathological fractures, and patients undergoing osteosynthesis for femoral neck fractures. The study population was divided into those who underwent hemiarthroplasty for neck fractures and those who underwent osteosynthesis for trochanteric fractures. We also divided the population into patients receiving chronic anticoagulation therapy (medicated group: 19 hemiarthroplasty, 70 osteosynthesis) and patients not receiving anticoagulation therapy (non-medicated group: 47 hemiarthroplasty, 130 osteosynthesis). Comorbidities, intraoperative blood loss, estimated blood loss from admission to the first and seventh day after surgery, transfusions, length of stay, complications, and 1-year mortality rates were evaluated.

RESULTS

Diabetes mellitus and cerebrovascular disorders were significantly more common in the medicated group for both surgery types. In the osteosynthesis group, estimated blood loss on the first day was 710 ml in the medicated group and 572 ml in the non-medicated group (P = 0.015). In the hemiarthroplasty group, corresponding values were 668 and 480 ml, respectively (P = 0.016). Estimated blood loss on the seventh day, complications, length of stay and 1-year mortality rate were not increased significantly.

CONCLUSIONS

The medicated group had an increase in estimated blood loss on the first day. However, there was no significant increase in transfusions, complications and 1-year mortality rates. Early surgery for elderly patients with hip fractures is recommended, even for those taking antiplatelet and anticoagulant agents.

The Safety of Continuing Antiplatelet Medication Among Elderly Patients Undergoing Urgent Hip Fracture Surgery

Elderly patients with hip fractures who are receiving antiplatelet therapy are commonly encountered in clinical practice. This study sought to elucidate the safety of urgent hip surgery without termination of antiplatelet medication among patients taking a combination of aspirin and dipyridamole, aspirin alone, or dipyridamole alone. This retrospective cohort study included 176 patients 55 years or older who had uncomplicated hip fractures and underwent surgery within 48 hours after admission. On the basis of the preoperative medication regimen, the patients were divided into the following 4 groups: those receiving aspirin and dipyridamole combined (n=29); those receiving aspirin alone (n=63); those receiving dipyridamole alone (n=28); and those not receiving antiplatelet medication (n=56). Main outcomes, including total blood loss, transfusion rate, and 1-year mortality, were analyzed. There was no significant difference in total blood loss, transfusion rate, or 1-year mortality among the 4 groups. The group receiving aspirin and dipyridamole combined preoperatively had increased intraoperative blood loss (mean, 309.14±189.15 mL) compared with the group not receiving antiplatelet medication (mean, 214.64±119.21 mL; P=.005). There was no significant difference in the hazard ratio (P>.05) for 1-year mortality among the 4 groups after adjusting for confounding covariates, including age, sex, Charlson Comorbidity Index, and duration of hospital stay. Patients receiving antiplatelet medication, including aspirin, dipyridamole, or both, who have uncomplicated hip fractures may undergo urgent surgery without a significant difference in total blood loss, transfusion rate, or 1-year mortality compared with patients not receiving anti-platelet medication. [Orthopedics. 2019; 42(5):268-274.].

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures

BACKGROUND

The aim of this study was to determine the amount of blood loss and the rate of blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed.

METHODS

The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed.

RESULTS

Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate.

CONCLUSION

Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

Perioperative antiplatelet in elderly patients aged over 70 years treated with proximal femur fracture: continue or discontinue?

Background

Antiplatelet medication has been frequently performed in elderly patients with hip fracture, because of comorbidities. This observational cohort study was to evaluate the effect of continuous perioperative antiplatelet medication on the outcomes after cephalomedullary nailing (CMN) in elderly patients with a proximal femur fracture.

Methods

One hundred and sixty-two consecutive patients aged ≥70 years undergoing CMN for proximal femur fracture between January 2015 and January 2017 were recruited. Of the 162 patients, 47 (study group) taking antiplatelets preoperatively due to comorbidities were compared with 107 (control group) who were not on antiplatelets. 8 patients taking anticoagulant medication were excluded. Postoperative hemoglobin (Hb) and hematocrit (Hct) levels, transfusion amount and estimated blood loss (EBL), occurrence of venous thromboembolism (VTE) and delirium, intensive care unit (ICU) admission, complications, length of hospital stay, readmission, and in-hospital and 1-year mortalities were measured and compared between the two groups.

Results

A higher number of patients in the study group had concomitant cardiovascular (p = 0.006) and endocrinologic (p = 0.004) diseases, received perioperative transfusion (p = 0.003), and were admitted to ICU postoperatively (p = 0.014). However, there were no significant differences in postoperative Hb and Hct levels, EBL, length of hospital stay, and the incidences of VTE and delirium between the two groups. In addition, in-hospital and 1-year mortalities as well as postoperative complications showed no significant differences between both groups.

Conclusions

CMN can be performed without delay in elderly patients with proximal femoral fracture receiving antiplatelet therapy prior to admission without discontinuing antiplatelets, and is as safe as in patients who are not on antiplatelet medication. However, more caution is required with respect to transfusions and ICU care after surgery in these patients.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2504-5) contains supplementary material, which is available to authorized users.

Comparison of plate and intramedullary nail fixation of extra-articular tibial fractures: A retrospective study exploring hidden blood loss

PURPOSE

To explore the hidden blood loss (HBL) in treatment of extra-articular tibial fractures with plate and intramedullary nail fixation.

METHODS

We conducted a retrospective study including 209 consecutive patients treated by plate (Group LCP) or intramedullary nail fixation (Group IMN) for extra-articular tibial fractures between January 2015 to December 2017. Demographics, intraoperative data, perioperative laboratory values, transfusion rate, and early complications were collected and analyzed.

RESULTS

Of 209 patients, 96 patients fixed with IMN and 113 fixed with LCP. The average HBL was 272.71 ± 57.88 ml in Group LCP and 507.66 ± 109.81 ml in Group IMN, and there was statistical difference in the HBL between two groups (p < 0.001). The Hb and Hct loss, surgical duration, and postoperative number of anemic patients in Group IMN were significantly higher than in Group LCP (p < 0.001), and IMN fixation has a significantly higher rate of transfusion (p = 0.027), whereas patients in group IMN has significantly less VBL (p < 0.001), shorter postoperative hospital stay (p < 0.001), and less superficial infection (p = 0.014).

CONCLUSIONS

There was a significant amount of hidden blood loss after reamed intramedullary nail fixation for extra-articular tibial fractures, which was much higher than expected. In view of the morbidity of acute anaemia and transfusion, we suggest that for patients who suffer from extra-articular tibial fractures with multiple injuries, or those with low haemoglobin preoperatively, plates might be more suitable than nail fixation.

Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications

INTRODUCTION

Direct oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral.

MATERIALS AND METHODS

This is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients.

RESULTS

Patients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015).

CONCLUSIONS

DOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

Hidden blood loss and its risk factors after hip hemiarthroplasty for displaced femoral neck fractures: a cross-sectional study

Purpose

Several authors have reported the degree of total blood loss (TBL) following hemiarthroplasty for displaced femoral neck fracture; however, the research specifically investigating on hidden blood loss (HBL) after hip hemiarthroplasty is still lacking. The purpose of this study is to evaluate the HBL in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures and to analyze its risk factors.

Patients and methods

From January 2015 to December 2016, 212 patients (57 males and 155 females) with displaced femoral neck fracture undergoing hip hemiarthroplasty were included in this study. The demographic and relevant clinical information of the patients were collected. According to the Gross’s formula, each patient’s height, weight, and preoperative and postoperative hematocrit were recorded and used for calculating the total perioperative blood loss and HBL. Risk factors were further analyzed by multivariate linear regression.

Results

The HBL was 525±217 mL, with 61.0%±13.6% in the total perioperative blood loss (859±289 mL), and the perioperative hemoglobin (Hb) loss was 23.8±7.4 g/L. Multivariate linear regression analysis revealed that HBL was positively associated with higher American Society of Anesthesiologists (ASA) classification (regression coefficient=62.169, 95% CI=15.616–108.722; P=0.009), perioperative gastrointestinal bleeding/ulcer (regression coefficient=155.589, 95% CI=38.095–273.083; P=0.010), and transfusion (regression coefficient=192.118, 95% CI=135.578–248.659; P<0.001). Compared with females, males had a risk of increased HBL (regression coefficient=87.414, 95% CI=28.547–146.280; P=0.004), and general anesthesia had an increased HBL compared with spinal anesthesia (regression coefficient=68.920, 95% CI=11.707–126.134; P=0.018).

Conclusion

HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures in the perioperative period, because it is a significant portion of TBL. Female patients, patients with higher ASA classification and perioperative gastrointestinal bleeding/ulcer, patients who were administered general anesthesia, or patients who underwent transfusion had a greater amount of HBL after hip hemiarthroplasty was performed. Having a correct understanding of HBL may help surgeons improve clinical assessment capabilities and ensure patients’ safety.

Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review

The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.

Perioperative Platelet Inhibition in Elective Inguinal Hernia Surgery—Increased Rate of Postoperative Bleeding and Hematomas?

In patients on oral antiplatelet therapy secondary to critical vascular diseases, the risk of interrupting antiplatelet therapy has to be weighed against the risk of postoperative hematoma or bleeding when surgery is planned. The goal of this study was to determine the risk of postoperative hematoma and postoperative bleeding in elective inguinal hernia surgery during continuous platelet inhibition. Patients receiving either elective total extraperitoneal hernioplasty or Lichtenstein repair for inguinal hernia were included. Patients with mere suture repair, emergency hernia repair, combination of different simultaneous operations, and patients under therapeutic anticoagulation with heparin were excluded. Postoperative bleeding/hematoma was determined by physical examination and graded according to the Clavien-Dindo classification. Between January 2006 and December 2013, 561 patients with elective surgical repair of an inguinal hernia were included. A total of 29 patients were under continuous perioperative platelet inhibition (PI) with either aspirin or clopidogrel in addition to perioperative antithrombotic prophylaxis with subcutaneous dalteparin injections (PI group). A total of 532 patients received perioperative antithrombotic prophylaxis only (control group). The number of patients under antiplatelet therapy increased from 1.3% (Jan. 2006–Dec. 2009) to 10.0% (Jan. 2010–Dec. 2013; P &lt; 0.0001). Postoperative hematoma/bleeding occurred in 5 PI patients (17.2%) versus 38 control patients (7.1%, P = 0.062). Rate of postoperative bleeding or hematoma is not higher under mono antiplatelet therapy for elective inguinal hernia repair. Since the majority of hematomas can be treated conservatively, it seems unnecessary to stop mono platelet inhibition perioperatively.

Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review

The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

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