Preoperative characteristics identify patients with hip fractures at risk of transfusion

Development and validation of machine learning models to predict perioperative transfusion risk for hip fractures in the elderly

BACKGROUND

Patients with hip fractures frequently need to receive perioperative transfusions of concentrated red blood cells due to preoperative anemia or surgical blood loss. However, the use of perioperative blood products increases the risk of adverse events, and the shortage of blood products is prompting us to minimize blood transfusion. Our study aimed to construct a machine learning algorithm predictive model to identify patients at high risk for perioperative transfusion early in hospital admission and to manage their patient blood to reduce transfusion requirements.

METHODS

This study collected patients hospitalized for hip fractures at a university hospital from May 2016 to November 2022. All patients included in the analysis were randomly divided into a training set and validation set according to 70:30. Eight machine learning algorithms, CART, GBM, KNN, LR, NNet, RF, SVM, and XGBoost, were used to construct the prediction models. The models were evaluated for discrimination, calibration, and clinical utility, and the best prediction model was selected.

RESULTS

A total of 805 patients were included in the study, of whom 306 received transfusions during the perioperative period. We screened eight features used to construct the prediction model: age, fracture time, fracture type, hemoglobin, albumin, creatinine, calcium ion, and activated partial thromboplastin time. After evaluating and comparing the performance of each of the eight models, the model constructed by the XGBoost algorithm had the best performance, with MCC values of 0.828 and 0.939 in the training and validation sets, respectively. In addition, it had good calibration and clinical utility in both the training and validation sets.

CONCLUSION

The model constructed by the XGBoost algorithm has the best performance, using this model to identify patients at high risk for transfusion early in their admission and promptly incorporating them into a patient blood management plan can help reduce the risk of transfusion.

The correlates of post-surgical haematoma in older adults with proximal femoral fractures

BACKGROUND

Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients.

AIMS

This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients.

METHODS

Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma.

RESULTS

Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.

Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients

BACKGROUND

Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN.

METHODS

From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed.

RESULTS

Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05).

CONCLUSION

Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.

Factors affecting the need of postoperative blood transfusion in elderly patients with intertrochanteric hip fracture

INTRODUCTION

We investigated the risk factors that increased the frequency of blood transfusions in elderly patients with intertrochanteric hip fractures to determine blood transfusion risk before surgery and to take selective precautionary measures in the group at high risk for transfusion to ensure safe surgery.

MATERIALS AND METHODS

We retrospectively reviewed the electronic medical records of 203 patients who underwent surgical fixation of intertrochanteric hip fractures from January 2015 to December 2020. We hypothesized that patient sex, age, body mass index, preoperative hemoglobin, preoperative platelet count, glomerular filtration rate (GFR), preoperative albumin level, American Society of Anesthesiologist score, intraoperative blood loss, duration of surgery, method of anesthesia, and time from injury to surgery would affect the need for blood transfusion. Student's t-test, Chi-squared test, and the one-way analysis of variance test were used to determine whether differences between variables in the transfusion and non-transfusion groups were significant.

RESULTS

Unstable fractures (P = 0.002), general anesthesia (P = 0.028), lower preoperative hemoglobin levels (P < 0.001), and lower GFRs (P < 0.001) were identified as related to blood transfusions in univariate analysis. In multivariate logistic analysis, the need for allogeneic blood transfusion in unstable fractures was approximately 2.949 times higher than in stable fractures (P = 0.009). The risk in general anesthesia patients was about 2.953 times higher than in spinal anesthesia patients (P = 0.007). In addition, the need for allogeneic blood transfusion increased by about 1.293 times as preoperative hemoglobin levels decreased by 1 g/dL (P = 0.017) and increased by about 1.017 times as the GFR decreased by 1 mL/min/1.7m2 (P = 0.006).

CONCLUSION

Low preoperative hemoglobin levels, low GFRs, general anesthesia, and unstable fractures in elderly patients with intertrochanteric hip fractures increased the risk of blood transfusion.

Effect and safety of topical application of tranexamic acid to reduce perioperative blood loss in elderly patients with intertrochanteric fracture undergoing PFNA

The specific method and dose of tranexamic acid (TXA) topically applied for intertrochanteric fractures have not been well established. The aim of this study is to investigate the efficacy and safety of TXA topically administered via our protocol for perioperative bleeding management in elderly patients with intertrochanteric fractures who underwent proximal femoral nail anti-rotation (PFNA).A retrospective comparative analysis was performed. The TXA group was composed of 82 patients with topical use of TXA, and the control group was composed of 82 patients without TXA use during the PFNA procedure. Intraoperative, total and hidden amounts of blood loss, drainage volumes, postoperative blood transfusion volumes and complications were compared between the 2 groups.The intraoperative, total and hidden amounts of blood loss and the drainage volumes were significantly lower in the TXA group than in the control group (P = .012, P < .01, P < .01, P = .014, respectively). The volume and rate of blood transfusion in the TXA group were significantly lower than those in the control group (P < .01). There were no significant differences in complications between the 2 groups (P > .05).Topical application of TXA offers an effective and safe option for reducing perioperative blood loss and transfusion in elderly patients with intertrochanteric fractures undergoing PFNA.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Blood transfusion rates and predictors following geriatric hip fracture surgery

BACKGROUND

Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

RESULTS

In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001).

CONCLUSIONS

Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

The Correlation Between Timing of Surgery and the Need for RBC Transfusions in the Geriatric Intertrochanteric Fracture Population

Objective:

To identify whether the timing of surgery affects red blood cell (RBC) transfusion requirements in the elderly with intertrochanteric fractures.

Methods:

We retrospectively studied all patients undergoing surgical fixation of their intertrochanteric fractures in our hospital between January 2009 and December 2018 and analyzed the relationship between the timing of surgery and RBC transfusion.

Results:

A total of 679 patients were included in this study. The need for RBC transfusion was lower in the patients who underwent surgery within 12 h after admission (timing of surgery <12 h, <12 h group) than those who underwent surgery over 12 h after admission (timing of surgery >12 h, >12 h group) (P = 0.046); lower in the the patients who underwent surgery within 24 h after admission (timing of surgery <24 h, <24 h group) than in those who underwent surgery over 24 h after admission (timing of surgery >24 h, >24 h group) (P = 0.008), and lower in the <24 h group compared to the patients who underwent surgery within 48 h after admission (timing of surgery <48 h, <48 h group) (P = 0.035). Moreover, the need for RBC transfusion was lower in the <24 h group (in the first 24 h from admission to surgery) than in the 24-48 h group (in the second 24 h from admission to surgery) (P = 0.016), and also lower in the <24 h group compared to the 48-72 h group (in the third 24 h from admission to surgery) (P = 0.047). However, there were no differences between the <12 h group and 12-24 h group, between the <12 h group and <24 h group, and between the 12-24 h group and <24 h group, respectively.

Conclusion:

Timing of surgery within 24 h contributes to the reduction of RBC transfusion in the elderly with intertrochanteric fractures.

Development of a Nomogram to Predict Postoperative Transfusion in the Elderly After Intramedullary Nail Fixation of Femoral Intertrochanteric Fractures

Purpose

The aim of our study was to explore the risk factors related to blood transfusion after intramedullary nail fixation of elderly femoral intertrochanteric fracture (FTF) and establish a nomogram prediction model.

Patients and Methods

We conducted a retrospective study including elderly FTF patients treated by intramedullary nail between January 2017 and December 2019. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were performed to determine risk factors for blood transfusion. A nomogram model was established to predict the risk of blood transfusion, and consistency coefficient (C-index) and correction curve were used to evaluate the prediction performance and consistency of the model.

Results

Of 148 patients, 119 were finally enrolled in the study and and 46 patients (38.7%) received a blood transfusion after the operation. Logistic regression analysis the female, lower preoperative Hb, ASA score >2, general anesthesia, and higher intraoperative blood loss were independently associated with the blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.910.

Conclusion

These risk factors are shown on the nomogram and verified. Through the assessment of the risk of blood transfusion and the intervention of modifiable risk factors, we may be able to reduce the blood transfusion rate to a certain extent, so as to further guarantee the safety of the elderly patients during the perioperative period.

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BACKGROUND

Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.

METHODS

This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.

RESULTS

There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.

CONCLUSIONS

Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.

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.

Development of a Nomogram for Predicting Blood Transfusion Risk After Hemiarthroplasty for Femoral Neck Fractures in Elderly Patients

Background

The aim of this study was to determine the risk factors and develop a nomogram for blood transfusions after hemiarthroplasty (HA) in patients with femoral neck fractures (FNFs).

Material/Methods

We performed a retrospective study including consecutive elderly FNF patients treated by HA between January 2015 and December 2017. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were conducted to determine risk factors for blood transfusion, and a nomogram model was constructed to predict the risk of blood transfusion. The predictive performance and consistency of the model were evaluated by the consistency coefficient (C-index) and the calibration curve, respectively.

Results

Of 178 patients, 151 were finally enrolled in the study and 21 received blood transfusion. Binary logistic regression analysis showed the low preoperative hemoglobin (Hb), longer time to surgery, general anesthesia, longer surgery duration, and higher intraoperative blood loss (IBL) were risk factors for blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.940.

Conclusions

We found a correlation between blood transfusion requirement and low preoperative Hb, longer time to surgery, general anesthesia, longer surgery duration, and higher IBL, and we then developed a nomogram. Our nomogram model can be used to evaluate the transfusion risk for FNF patients after HA, and provides better guidance for clinicians to intervene perioperatively, so as to reduce the incidence of blood transfusion.

The association of mental health disease with perioperative outcomes following femoral neck fractures

INTRODUCTION

Mental illness in the United States is a growing problem, leading to significant implications for those effected as well as direct and indirect costs to the health care system. The association between psychiatric comorbidity and increased risk of perioperative adverse events has previously been described following elective orthopedic surgery, however, there is a paucity of literature evaluating the correlation between mental health disease and outcomes in patients in an orthopedic trauma setting.

METHODS

Utilizing data from the US National Hospital Discharge Survey, all patients undergoing surgery for femoral neck fracture were identified between the years 1990 and 2007. The association of depression, anxiety, dementia and schizophrenia on surgical outcomes were then analyzed using univariate regression analysis.

RESULTS

A cohort of 2,432,931 patients was identified. All psychiatric comorbidities were associated with a lower rate of routine discharge home following surgery (p < 0.001). Schizophrenia was associated with increased odds of any adverse event (p < 0.001), acute post-operative mechanical complications (p < 0.001) and increased length of stay (p < 0.001).

DISCUSSION

Patients undergoing surgery for femoral neck fracture with comorbid psychiatric illness are at increased risk for non-routine discharge. Schizophrenia is independently associated with an increased risk for post-operative complications. An awareness of these risks should optimize preoperative multidisciplinary patient care planning so as to maximize patient outcome and minimize resource utilization.

Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005-2016

BACKGROUND

Do prescription drugs with anti-inflammatory properties such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins increase the risk of postoperative bleeding measured with RBC transfusion in elderly hip fracture surgery patients?

STUDY DESIGN AND METHODS

Using the Danish Multidisciplinary Hip Fracture Database, 74,791 patients aged 65 years or older with surgery-treated hip fracture were identified during 2005-2016, and their use of NSAIDs, corticosteroids, and statins was ascertained. For each drug, patients were categorized as nonusers (no prescription ≤365 days prior to surgery), former users (one prescription 91-365 days), and current users (one prescription ≤90 days). Information on surgical treatment, transfusion, other medication and comorbidities were collected using Danish nationwide registries. A log-binomial model was used to estimate relative risks for RBC transfusion within 7 days of surgery and corresponding 95% confidence intervals. Adjustments were made for patient- and surgery-related factors.

RESULTS

Former and current users of NSAIDs, corticosteroids, and statins accounted for 22%, 10%, and 24%, respectively. Current users of NSAIDs had an increased adjusted relative risk of transfusion (1.07; confidence interval, 1.04-1.10) compared to nonusers. There was no association between current users of corticosteroids and statins and risk of transfusion.

CONCLUSION

NSAID use within 90 days of a hip fracture surgery was associated with an increased risk of RBC transfusion. Thus, current use of NSAIDs can be associated with an increased risk of postoperative bleeding, but we cannot rule out the influence of confounding.

An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule

Appropriate preoperative blood typing and cross-matching is an important quality improvement target to minimise costs and rationalise the use of blood bank resources. This can be facilitated using a maximum surgical blood ordering schedule (MSBOS) for specific operations. It is recommended that individual hospitals develop a site-specific MSBOS based on institutional data, but this is challenging in non-tertiary centres without electronic databases. Our aim was to audit our perioperative blood transfusions to develop a site-specific MSBOS. A retrospective audit of blood transfusions in surgical patients in our regional referral hospital was conducted using five years' coded administrative data. Procedures with higher transfusion rates warranting preoperative testing (type and screen with or without subsequent cross-matching) were identified. There were about 15,000 eligible surgical procedures performed in our institution over the audit period. The need for preoperative testing was identified for only a few procedures, namely laparotomy, bowel resection, major amputation, joint arthroplasty, hip/femur fracture and humerus surgery, and procedures for obstetric complications. We observed a reduction in transfusion rates over time for total joint arthroplasty. The use of coding data represents an efficient method by which centres without electronic anaesthesia information management systems can conduct large-scale audits to develop a site-specific MSBOS. This would represent a significant improvement for hospitals that currently base preoperative testing recommendations on expert opinion alone. As many procedures in regional centres have very low transfusion rates, hospitals with a similar case mix to ours could consider selectively auditing higher-risk operations where local data is most likely to alter testing recommendations.

Efficacy and Safety of Tranexamic Acid for Blood Salvage in Intertrochanteric Fracture Surgery: A Meta-Analysis

The use of tranexamic acid (TXA) for reducing blood loss in intertrochanteric fracture (IF) surgery remains controversial. We therefore performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of TXA in reducing transfusion requirements and blood loss for IF surgery. Databases, including PubMED, Cochrane, and Embase, were searched for RCTs that were published before February 2018 and that addressed the efficacy and safety of TXA in patients who underwent IF surgery. A total of 746 patients from 7 RCTs were subjected to meta-analysis. The results showed that TXA group had reduced surgical blood loss (weighted mean difference [WMD] = −37.24, 95% confidence interval [CI]: −48.70 to −25.77, P <.00001), reduced total blood loss (WMD = −199.08, 95% CI: −305.16 to −93.01, P = .0002), higher postoperative hemoglobin (WMD = 0.46, 95% CI: 0.12 to 0.79, P = .007), and hematocrit levels (WMD = 1.55, 95% CI: 0.64 to 2.47, P = .008) compared to control group, while no significant differences were found in transfusion rates (relative risk [RR] = 0.75, 95% CI: 0.50 to 1.11, P = .15), postoperative drainage (WMD = −38.82, 95% CI: −86.87 to 9.22, P = .11), and thromboembolic events (RR = 0.94, 95% CI: 0.41 to 2.19, P = .89). In patients undergoing IF surgery, the administration of TXA significantly reduced surgical blood loss and total blood loss, while it had no significant effect on transfusion rate, postoperative drainage, and the risk of thromboembolic events. Nevertheless, due to the variations in the included studies, additional RCTs are required to further validate these conclusions.

Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing

PURPOSE

The aim of our study was to determine predictive factors and requirement for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary device.

METHODS

Seventy-nine patients with extra capsular hip fractures treated with cephalo-medullary nailing were included in the study. Age, sex, ASA grade, timing of surgery, preoperative and postoperative haemoglobin, length of hospital stay, fracture type, number of units transfused and 30-day mortality were recorded.

RESULTS

The mean age was 82.3 years. Forty-seven patients underwent a short nail and 32 patients a long nail; 53.4% patients required blood transfusion postoperatively. Transfusion was required in 71.8% of the long nails (p < 0.05), 65.8% patients above the age of 80 (p < 0.05), 100% of the patients with hemoglobin below 90 g/L and 20 patients with a ASA grade of 3 (p < 0.05). 78.5% patients with A2 fracture and 75% of A3 fractures needed blood transfusion (p > 0.05). Length of hospital stay in non-transfusion group was 13 days and in transfusion group was 19 days (p < 0.05). 55.1% operated within 36 h and 47.6% operated after 36 h of admission needed transfusion (p > 0.05). Thirty-day mortality in patients needing blood transfusion was 5% and in non-transfusion group was 3.7% (p > 0.05).

CONCLUSION

Patient age, ASA grade, preoperative haemoglobin and length of nail are reliable predictors for perioperative blood transfusion in extra capsular hip fractures in elderly patients treated with cephalo-medullary nailing and reinforce a selective transfusion policy.

"Hidden" Preoperative Blood Loss With Extracapsular Versus Intracapsular Hip Fractures: What Is the Difference?

Purpose

Excessive blood loss with hip fracture management has been shown to result in increased rates of complications. Our goal is to compare blood loss and transfusion rates between patients with intracapsular and extracapsular (both intertrochanteric (IT) and subtrochanteric (ST)) hip fractures.

Methods

472 patients were evaluated over a five-year period. Those who presented to the hospital with a proximal femur fracture (femoral neck, IT or ST) were considered for the study. Exclusion criteria included polytrauma, gunshot injuries, periprosthetic fractures, and non-operative management. Primary endpoint was hemoglobin (Hgb) drop from admission to day of surgery (DOS); secondary endpoint was need for pre-op transfusion and discharge location.

Results

304 patients were analyzed who sustained a proximal femur fracture. Median IC Hgb drop was 0.6g/dL; median EC Hgb drop was 1.1g/dL from admission to DOS (p = 0.0272). Rate of pre-operative transfusions was higher in EC (36/194 = 18.6%) than IC fractures (5/105 = 4.5%) (p = 0.0006), and overall transfusion rates remained higher throughout hospital stay (55.7% EC vs. 32.7% IC; p = 0.0001). Breakdown of bleeding rate and tranfusion rates between IT and ST fractures were not significant (p = 0.07; p = 0.4483). Extracapsular hip fractures were more likely to be discharged to a skilled nursing facility (SNF) (84.4% EC vs. 73.8% IC; p = 0.027).

Conclusion

Intracapsular hip fractures have significantly less pre-operative blood loss and fewer pre-operative transfusions than their extracapsular counterparts. These findings can be used to establish appropriate pre-operative resuscitative efforts, ensuring that hip fracture protocols account for the increased likelihood of blood loss in extracapsular fractures.

Assessing the impact of fracture pattern on transfusion requirements in hip fractures

PURPOSE

Hip fractures in the elderly represent a major source of morbidity and mortality, with allogeneic blood transfusions (ABTs) associated with increased mortality. This study assesses the ABT requirements between the most common patterns of hip fracture; intertrochanteric (IT) and intracapsular (IC). The impact of operation type on transfusion rates was also assessed.

METHODS

A retrospective study was performed for all patients entered on the national hip fracture database over 1 year in a teaching hospital. Records of 559 patients were reviewed and, following exclusion criteria, 474 were evaluated (198 IT, 276 IC). Baseline haematological parameters and ABTs were identified using hospital systems. Analysis was performed in SPSS, using independent samples t tests, one-way ANOVAs and Chi square tests.

RESULTS

Patient groups were matched on gender, anaesthetic type, American Society of Anesthesiologist (ASA) grade, cognitive score and coagulation parameters. A significantly greater proportion of IT patients required an ABT during admission (39.4 vs. 22.5 %, p < 0.001). For IT fractures a greater proportion of patients required an ABT when undergoing an intramedullary nail operation compared with those requiring a dynamic hip screw (67.4 vs. 32.0 %, p < 0.001). Similarly, for IC fractures transfusion rates in patients undergoing an internal fixation were significantly lower than those undergoing hemiarthroplasty or arthroplasty (9.4 vs. 26.4 vs. 20.8 %, p = 0.033).

CONCLUSION

Patients with IT hip fractures are significantly more likely to require an ABT than those with IC hip fractures. Patients undergoing an intramedullary nail for IT fractures have significantly higher transfusion rates than for other types of operation.

A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips

We systematically reviewed the observational associations of anaemia with outcomes and the effects of interventions to increase haemoglobin concentrations following hip fracture in older people. Anaemia on hospital admission was associated with increased mortality, relative risk 1.64 (95% CI 1.47-1.82), p < 0.0001. After adjustment for co-morbidities, the association of anaemia with increased mortality remained in four of eight observational studies. There was no association of postoperative transfusion with mortality after adjusting for covariates. Transfusion at 80 g.l(-1) vs 100 g.l(-1) increased acute myocardial infarction, relative risk 1.67 (95% CI 1.01-2.77), p = 0.05. Transfusion threshold was not associated with differences in other outcomes. There were insufficient high-quality studies to inform pre-operative blood transfusion or the use of peri-operative iron or erythropoietin. Studies for most interventions recruited too few participants to determine effects on infections, mortality or function.

Red blood cell transfusion for people undergoing hip fracture surgery

BACKGROUND

The incidence of hip fracture is increasing and it is more common with increasing age. Surgery is used for almost all hip fractures. Blood loss occurs as a consequence of both the fracture and the surgery and thus red blood cell transfusion is frequently used. However, red blood cell transfusion is not without risks. Therefore, it is important to identify the evidence for the effective and safe use of red blood cell transfusion in people with hip fracture.

OBJECTIVES

To assess the effects (benefits and harms) of red blood cell transfusion in people undergoing surgery for hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (31 October 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 10), MEDLINE (January 1946 to 20 November 2014), EMBASE (January 1974 to 20 November 2014), CINAHL (January 1982 to 20 November 2014), British Nursing Index Database (January 1992 to 20 November 2014), the Systematic Review Initiative's Transfusion Evidence Library, PubMed for e-publications, various other databases and ongoing trial registers.

SELECTION CRITERIA

Randomised controlled trials comparing red blood cell transfusion versus no transfusion or an alternative to transfusion, different transfusion protocols or different transfusion thresholds in people undergoing surgery for hip fracture.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed each study's risk of bias and extracted data using a study-specific form. We pooled data where there was homogeneity in the trial comparisons and the timing of outcome measurement. We used GRADE criteria to assess the quality (low, moderate or high) of the evidence for each outcome.

MAIN RESULTS

We included six trials (2722 participants): all compared two thresholds for red blood cell transfusion: a 'liberal' strategy to maintain a haemoglobin concentration of usually 10 g/dL versus a more 'restrictive' strategy based on symptoms of anaemia or a lower haemoglobin concentration, usually 8 g/dL. The exact nature of the transfusion interventions, types of surgery and participants varied between trials. The mean age of participants ranged from 81 to 87 years and approximately 24% of participants were men. The largest trial enrolled 2016 participants, over 60% of whom had a history of cardiovascular disease. The percentage of participants receiving a red blood cell transfusion ranged from 74% to 100% in the liberal transfusion threshold group and from 11% to 45% in the restrictive transfusion threshold group. There were no results available for the smallest trial (18 participants). All studies were at some risk of bias, in particular performance bias relating to the absence of blinding of personnel. We judged the evidence for all outcomes, except myocardial infarction, was low quality reflecting risk of bias primarily from imbalances in protocol violations in the largest trial and imprecision, often because of insufficient events. Thus, further research is likely to have an important impact on these results.There was no evidence of a difference between a liberal versus restricted threshold transfusion in mortality, at 30 days post hip fracture surgery (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.67 to 1.26; five trials; 2683 participants; low quality evidence) or at 60 days post surgery (RR 1.08, 95% CI 0.80 to 1.44; three trials; 2283 participants; low quality evidence). Assuming an illustrative baseline risk of 50 deaths per 1000 participants in the restricted threshold group at 30 days, these data equate to four fewer (95% CI 17 fewer to 14 more) deaths per 1000 in the liberal threshold group at 30 days.There was no evidence of a difference between a liberal versus restricted threshold transfusion in functional recovery at 60 days, assessed in terms of the inability to walk 10 feet (3 m) without human assistance (RR 1.00, 95% CI 0.87 to 1.15; two trials; 2083 participants; low quality evidence).There was low quality evidence of no difference between the transfusion thresholds in postoperative morbidity for the following complications: thromboembolism (RR 1.15 favouring a restrictive threshold, 95% CI 0.56 to 2.37; four trials; 2416 participants), stroke (RR 2.40 favouring a restrictive threshold, 95% CI 0.85 to 6.79; four trials; 2416 participants), wound infection (RR 1.61 favouring a restrictive threshold, 95% CI 0.77 to 3.35; three trials; 2332 participants), respiratory infection (pneumonia) (RR 1.35 favouring a restrictive threshold, 95% CI 0.95 to 1.92; four trials; 2416 participants) and new diagnosis of congestive heart failure (RR 0.77 favouring a liberal threshold, 95% CI 0.48 to 1.23; three trials; 2332 participants). There was very low quality evidence of a lower risk of myocardial infarction in the liberal compared with the restrictive transfusion threshold group (RR 0.59, 95% CI 0.36 to 0.96; three trials; 2217 participants). Assuming an illustrative baseline risk of myocardial infarction of 24 per 1000 participants in the restricted threshold group, this result was compatible with between one and 15 fewer myocardial infarctions in the liberal threshold group.

AUTHORS' CONCLUSIONS

We found low quality evidence of no difference in mortality, functional recovery or postoperative morbidity between 'liberal' versus 'restrictive' thresholds for red blood cell transfusion in people undergoing surgery for hip fracture. Although further research may change the estimates of effect, the currently available evidence does not support the use of liberal red blood cell transfusion thresholds based on a 10 g/dL haemoglobin trigger in preference to more restrictive transfusion thresholds based on lower haemoglobin levels or symptoms of anaemia in these people. Future research needs to address the effectiveness of red blood cell transfusions at different time points in the surgical pathway, whether pre-operative, peri-operative or postoperative. In particular, such research would need to consider people who are symptomatic or haemodynamically unstable who were excluded from most of these trials.

Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood?

BACKGROUND

Hip fractures are common injuries that result in blood loss and frequently require the transfusion of blood products. We sought to identify risk factors leading to increased blood transfusion in patients presenting with hip fractures, especially those factors that are modifiable.

METHODS

We retrospectively reviewed the cases of all patients who had fixation of their hip fractures between October 2005 and February 2010. The need for transfusion was correlated with potential risk factors, including age, sex, preoperative hemoglobin, fracture type, fixation method and more.

RESULTS

A total of 835 patients had fixation of their hip fractures during the study period; 631 met the inclusion criteria and 249 of them (39.5%) were transfused. We found an association between need for blood transfusion and female sex (p = 0.018), lower preoperative hemoglobin (p < 0.001), fracture type (p < 0.001) and fixation method (p < 0.001). Compared with femoral neck fractures, there was a 2.37 times greater risk of blood transfusion in patients with intertrochanteric fractures (p < 0.001) and a 4.03 times greater risk in those with subtrochanteric fractures (p < 0.001). Dynamic hip screw (DHS) fixation decreased the risk of transfusion by about half compared with intramedullary nail or hemiarthroplasty. We found no association with age, delay to operation (p = 0.17) or duration of surgery (p = 0.30).

CONCLUSION

The only modifiable risk factor identified was fixation method. When considering blood transfusion requirements in isolation, we suggest a potential benefit in using a DHS for intertrochanteric and femoral neck fractures amenable to DHS fixation.

Management of hip fractures in the elderly

The purpose of this clinical practice guideline is to help improve treatment and management of hip fractures in the elderly based on current best evidence. The guideline contains twenty-five recommendations, including both diagnosis and treatment. Of those recommendations, strong evidence supports regional analgesia to improve preoperative pain control, similar outcomes for general or spinal anesthesia, arthroplasty for patients with unstable (displaced) femoral neck fractures, the use of a cephalomedullary device for the treatment of patients with subtrochanteric or reverse obliquity fractures, a blood transfusion threshold of no higher than 8 g/dL in asymptomatic postoperative patients, intensive physical therapy postdischarge, use of an interdisciplinary care program in patients with mild to moderate dementia, and multimodal pain management after hip fracture surgery. In addition to the recommendations, the work group highlighted the need for better research in the treatment of hip fractures.

Preoperative factors associated with red blood cell transfusion in hip fracture patients

INTRODUCTION

Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients.

METHOD

The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database.

RESULTS

Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion.

CONCLUSION

Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.

Predicting the need for blood transfusion in patients with hip fractures

PURPOSE

The need for perioperative blood management measures aimed at improving patient outcomes and reducing allogenic blood transfusion (ABT) is increasingly recognised. Our study aim is to create an algorithm to predict and manage the need for blood transfusion in patients with hip fractures.

METHODS

We retrospectively assessed 1,484 patients with hip fractures and analysed the probability of receiving an ABT within 72 hours of admission. Univariate, multiple logistic regression analysis and a probability algorithm for predicting the need for blood transfusion on the basis of independent multivariate predictors were used.

RESULTS

Significant predictors for ABT were: older age; lower haemoglobin on admission; female gender; type of surgical implant (cephalomedullary nail and dynamic hip screw more than hemiarthroplasty); and a shorter wait time from admission to surgery. A regression model algorithm correctly predicted the need for an ABT in 73 % of the cases.

CONCLUSION

An algorithm and a simple clinical tool were devised to predict and manage the need for a blood transfusion within 72 hours of admission in patients with hip fractures.

Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature

Reasons for variation in transfusion practice in orthopedic surgery are not well understood. This systematic review identified and appraised the quality of the literature in this area to assess the impact of factors associated with the use of allogeneic red blood cell (RBC) transfusion in orthopedic procedures. MEDLINE and EMBASE databases were searched for relevant English language publications. Articles containing a range of MeSH and text terms regarding "blood transfusion," "predictors," and "multiple logistic regression" were retrieved. Articles that focused on patients undergoing orthopedic procedures and that met prespecified inclusion criteria were appraised in terms of potential bias and the appropriateness of statistical approach. A total of 3641 citations were retrieved, and 29 met the inclusion criteria for the review. Articles reported on a range of orthopedic procedures including total hip arthroplasty; total knee arthroplasty, total shoulder arthroplasty, and spinal surgery. Most studies were conducted in the United States (n = 12) or Canada (n = 5). Study quality was moderate; 50% or more of the quality criteria were assessed in 15 articles. Particular areas of concern were the lack of prospective studies, lack of clarity in defining the time interval between risk factor assessment and transfusion outcome, and lack of model validation. A narrative synthesis found that 2 factors consistently influenced the use of RBC transfusion-decreased hemoglobin (n = 25) and increased patient age (n = 18). Increased surgical complexity (n = 12), low body weight (n = 9), presence of additional comorbidities (n = 9), and female sex (n = 7) were also important factors. The general quality of the studies in the field is weak. However, low hemoglobin and increasing age were consistently identified as independent risk factors for RBC transfusion in orthopedic practice. Additional or alternative analytical approaches are required to obtain a more comprehensive, holistic understanding of the decision to transfuse RBCs to patients undergoing orthopedic surgery.

On admission haemoglobin in patients with hip fracture

Several authors have identified on admission haemoglobin level as the most useful predictor of transfusion risk in patients with a hip fracture. A low postoperative haemoglobin unexplained by perioperative blood loss is not uncommon in these patients. The drop in haemoglobin after re-hydration prior to surgery should depend not only on the degree of dehydration but also on the amount of blood lost in the fracture.We could find no study in the English literature estimating the magnitude of this fall in haemoglobin after re-hydration prior to surgery.We conducted a prospective study to estimate the magnitude of fall in haemoglobin after rehydration prior to surgery by repeating the full blood count after at least 12 h of preoperative fluid resuscitation in 127 patients with hip fracture (75 consecutive at one centre and 52 consecutive at another).The average preoperative drop in haemoglobin was 2.23 gram/decilitre (g/dL) (p-value = 0.00) in subtrochanteric fractures, 1.1 g/dL (p-value = 0.001) in intertrochanteric fractures and 0.7 g/dL (p-value = 0.02) in intracapsular fractures. Fifteen patients with a haemoglobin level >9 g/dL on admission were found to have a haemoglobin level <9 g/dL on repeat test and were prevented from going to theatre without arrangements for perioperative transfusion during this study. Their predicted average postoperative haemoglobin without perioperative blood transfusion was calculated to be 6.5 g/dL.The on admission haemoglobin level was found to be falsely reassuring and could lead to a very low postoperative haemoglobin level. This could prove to be dangerous for many patients especially if remains undetected for several hours. We recommend that all patients with subtrochanteric fractures,and all patients with intertrochanteric or intracapsular fractures with a haemoglobin of less than 12 g/dL on admission have a repeat haemoglobin level performed prior to their surgery.

The hidden blood loss after hip fracture

INTRODUCTION

Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death. We speculate that a significant proportion of the blood loss related to hip fractures has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury.

METHODS

In a retrospective study all patients with both a diagnosis of hip fracture and an operative delay of >48 h were assessed. The information collected included: fracture classification, serial haemoglobins and patient co-morbidities. The exclusion criteria included a pre-injury diagnosis of anaemia, anti-coagulation and gastrointestinal bleeds.

RESULTS

Between 2007/2008 sixty-eight intracapsular and fifty extracapsular hip fracture patients had serial haemoglobins and operative delays of >48 h (mean 75 h, range 48-270 h). The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (+/-SEM 2.2) and 108.5 g/L (+/-SEM 2.2) respectively. This difference was statistically significant (Student's t-test p<0.05). The mean haemoglobin drop in the extracapsular and intracapsular fracture groups was 20.2 g/L (range 0-49 g/L) and 14.9 g/L (range 0-59 g/L) respectively.

CONCLUSIONS

Hip fracture patients have a large drop in haemoglobin that is associated with the initial trauma rather than the operation. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients even when the initial haemoglobin is apparently normal.

Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures

BACKGROUND

Patients undergoing surgical procedures are usually asked to discontinue any anticoagulant/antiplatelet therapy and delay surgery for at least 5 days to reduce the risk of major bleeding and spinal hematoma.

AIM

The purpose of this study was to determine if this strategy is suitable for patients on anticoagulant/antiplatelet therapy affected by a hip fracture, evaluating the effect of anticoagulant/antiplatelet therapy and surgical timing on mortality and complication rates for patients affected by a hip fracture.

PATIENTS AND METHODS

We performed an observational study on patients referring to our hospital for a hip fracture. We evaluated patients on warfarin, ticlopidine, and aspirin therapy matched to patients not on anticoagulant or antiplatelet therapy, out of 875 consecutive patients treated for a hip fracture in a 5-year period. Blood loss, blood transfusions, length of hospitalization, walking ability, complications, and mortality at 1 year of follow-up were recorded. Kruskal-Wallis, Mann-Whitney U, and logistic regression statistical tests were performed.

RESULTS

Patients on warfarin therapy operated more than 5 days after admission showed significantly higher complication and mortality rates compared to all other patients. Two critical factors were identified: warfarin therapy and excessive time to surgery; these factors are not significant if taken alone, while they become a high-risk factor if taken together.

CONCLUSION

The "discontinue drug, and delay surgery" strategy is not suitable for patients on anticoagulant (warfarin) therapy affected by a hip fracture.