Preoperative direct oral anticoagulants treatment and all-cause mortality in elderly patients with hip fracture: A retrospective cohort study

Impact of oral anticoagulation on inhospital mortality of patients with hip fracture - Analysis of nationwide hospitalization data

OBJECTIVES

Oral anticoagulation (OAC) may have an impact on mortality in cases hospitalized for hip fracture (HF). We studied nationwide time trends of OAC prescriptions and compared time trends of inhospital mortality of HF cases with and without OAC in Germany DESIGN: Retrospective cohort study SETTING: Nationwide German hospitalization, Diagnosis-Related Groups Statistic PATIENTS/PARTICIPANTS: All hospital admissions for HF 60 years and older in the years 2006 through 2020.

INTERVENTION

Additional diagnosis with a personal history of long-term use of anticoagulants (ICD code Z92.1).

MAIN OUTCOME MEASUREMENTS

Inhospital mortality RESULTS: Cases hospitalized for HF 60 years and older increased by 29.5%. In 2006, 5.6% had a documented history of long-term use of OACs. This proportion rose to 20.1% in 2020. Age-standardized hospitalization mortality in HF cases without long-term use of OACs in males decreased steadily from 8.6% (95% confidence intervals 8.2 - 8.9) in 2006 to 6.6% (6.3 - 6.9) in 2020 and in females from 5.2% (5.0 - 5.3) to 3.9% (3.7 - 4.0). Mortality of HF cases with long-term use of OACs remained unchanged: males 7.0% (5.7 - 8.2) in 2006 and 7.3% (6.7 - 7.8) in 2020, females 4.8% (4.1 - 5.4) and 5.0% (4.7 - 5.3).

CONCLUSION

Inhospital mortality of HF cases with and without long-term OAC show different trends. In HF cases without OAC, mortality decreased from 2006 to 2020. In cases with OAC such a decrease could not be observed.

Risk factors for prolonged preoperative waiting time of intertrochanteric fracture patients undergoing operative treatment

Purpose

Intertrochanteric fracture is a common fracture in older adults. We observed the case characteristics of intertrochanteric fracture and analyzed the risk factors for prolonged preoperative waiting time based on patient data from a 6 year period. Investigate the post-admission treatment of intertrochanteric fracture.

Methods

We retrospectively reviewed the medical records from July 2015 to July 2021 of patients hospitalized for intertrochanteric fracture who had undergone internal fixation surgery in the orthopedic ward of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine. Data regarding gender, age, AO/OTA classification, preoperative waiting time, preoperative medical comorbidities, and complicated deep venous thrombosis (DVT) of lower limbs were collected. Statistical tests were used to evaluate the factors influencing preoperative preparation time and DVT.

Results

A total of 1812 cases were retrospectively analyzed, 1258 patients (69.43%) had three or more medical comorbidities. The average preoperative waiting time was 5.09 ± 3.27 days. Advanced age, more preoperative medical comorbidities and DVT led to longer preoperative waiting times, and preoperative medical comorbidities were an independent risk factor. Patients with advanced age and preoperative medical comorbidities were more likely to have DVT.

Conclusion

Age and preoperative medical comorbidities are risk factors for DVT and prolonged preoperative preparation time in intertrochanteric fracture patients. Preoperative medical comorbidities are an independent risk factors affecting the preoperative waiting time, and a combination of multiple comorbidities almost predicts the delay of the operation time.

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

Purpose

To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture.

Method

A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings.

Results

There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants.

Conclusions

The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01937-8.

Therapeutic management of traumatic tension hematoma with potential skin necrosis: a retrospective review of 180 patients

INTRODUCTION

Tension hematoma is a frequent traumatic condition in elderly population under anticoagulation treatments. However, scarce literature exists focused in the management of this condition. In this article, a retrospective study of patients that suffered from traumatic tension hematomas treated at a plastic surgery department is reported. The objective was to evaluate the approach that provided better clinical outcomes, and the establishment of an evidence-based protocol.

METHODS

This retrospective study comprised 180 patients suffering from tension hematomas. Patients were divided in four groups: the first and second groups included patients that underwent debridement and coverage in one stage and two stages, respectively. The third group included patients that required debridement without skin grafting, and the fourth group, patients with hematomas that only necessitated drainage. Demographic variables, comorbidities, timing and complication rates of each technique were evaluated.

RESULTS

Length of hospital stay, medical complication and mortality rates were significantly higher in patients who underwent debridement and coverage surgeries in two separate procedures (p < 0.05). Patients with small-sized hematomas (avg 0.63% of total body surface) required only debridement. Patients that only required hematoma drainage, were treated during the first 24 h after injury (p < 0.03).

CONCLUSIONS

Treatment of tension hematomas through early drainage should be performed as soon as possible from the time of injury. An evidence-based protocol should be established in every emergency department to improve patient clinical outcomes. When debridement and coverage surgery are required, they should be performed in one stage, to reduce length of hospital stay and the incidence of medical complications.

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.