Poor prognosis after surgery for intertrochanteric fracture in elderly patients with clopidogrel treatment: A cohort study

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.

Mid-Term Follow-Up Results After Hemiarthroplasty Using Long Femoral Stem Prosthesis (Peerless-160) for Intertrochanteric Fractures in Octogenarians

Purpose

To analyze the clinical effect and imaging data of cementless bipolar hemiarthroplasty employing a long femoral stem (peerless-160) and 2 reconstructed femoral titanium wires to repair intertrochanteric fractures among the octogenarians.

Methods

Between June 2014 and August 2016, 58 octogenarians with femoral intertrochanteric fractures underwent the long femoral stem (peerless-160) cementless bipolar hemiarthroplasty by the same surgeon. We assessed clinical and radiological outcomes such as operative time, bleeding volume, blood transfusion volume, length of hospital stay, full weight-bearing walking time, walking ability calculated by Koval classification and Harris Hip Score (HHS), including fracture healing and greater trochanter fragments subsidence.

Result

The surgery was successfully performed in all patients. The average operation time was 72.8 ± 13.2 min, the average blood loss during surgery was 225.0 ± 91.4 mL, 200 mL of blood was transfused, the mean duration of hospitalization was 11.9 ± 4.0 days, the mean time of full weight bearing was 12.5 ± 3.8 days. Patients were followed up for 24-68 months, averagely 49.4 ± 10.3 months. During follow-up, 4 (6.9%) patients died, and 1 (1.7%) was completely lost to ask about the recent situation. The average Harris Hip Score at the last follow-up was 87.8 ± 6.1, most of the patients recovered walking ability, under radiological examination, the prosthesis showed no signs of loosening. All trochanteric fractures gradually healed, the clinical and radiographic signs of healing occurred at average of 4.0 ± 1.1 months postoperatively.

Conclusion

For osteoporotic unstable intertrochanteric fractures in octogenarians, this study confirmed that the Cementless Bipolar Hemiarthroplasty Using a Long Femoral stem (peerless-160) with double cross binding technique is a satisfactory and safe choice for the octogenarians.

Is Timing to Surgery an Independent Risk Factor for Complications Following Operative Treatment of Periprosthetic Lower Extremity Fractures?

OBJECTIVE

To identify whether timing to surgery was related to major 30-day morbidity and mortality rates in periprosthetic hip and knee fractures [OTA/AO 3 (IV.3, V.3), OTA/AO 4 (V4)].

DESIGN

Retrospective database review.

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS

Patients in the NSQIP database with periprosthetic hip or knee fractures between 2007 and 2015.

INTERVENTION

Surgical management of periprosthetic hip and knee fractures including revision or open reduction internal fixation.

MAIN OUTCOME MEASUREMENTS

Major 30-day morbidity and mortality after operative treatment of periprosthetic hip or knee fractures.

RESULTS

A total of 1265 patients, mean age 72, including 883 periprosthetic hip and 382 periprosthetic fractures about the knee were reviewed. Delay in surgery greater than 72 hours is a risk factor for increased 30-day morbidity in periprosthetic hip and knee fractures [relative risk = 2.90 (95% confidence interval: 1.74-4.71); P-value ≤ 0.001] and risk factor for increased 30-day mortality [relative risk = 8.98 (95% confidence interval: 2.14-37.74); P-value = 0.003].

CONCLUSIONS

Using NSQIP database to analyze periprosthetic hip and knee fractures, delay to surgery is an independent risk factor for increased 30-day major morbidity and mortality when controlling for patient functional status and comorbidities. Although patient optimization and surgical planning are paramount, minimizing extended delays to surgery is a potentially modifiable risk factor in the geriatric periprosthetic lower extremity fracture patient.

LEVEL OF EVIDENCE

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

The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly

PURPOSE

Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients' ongoing anticoagulant treatments.

METHODS

231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed.

RESULTS

Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels.

CONCLUSION

This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.

Surgical Selection of Unstable Intertrochanteric Fractures: PFNA Combined with or without Cerclage Cable

Due to the instability of unstable intertrochanteric fractures, the selection of a suitable internal fixation has always been a challenge for orthopedic surgeons. This study is aimed at comparing the clinical efficacy of PFNA combined with cerclage cable and without cerclage cable and finally recommend a stable internal fixation method to provide the basis for clinical therapy. From January 2014 to January 2018, we retrospectively analyzed all cases of unstable intertrochanteric fractures who received treatment in the Orthopedics Department of our hospital and finally screened 120 cases, 51 of whom were treated with cerclage cable, 69 without cerclage cable. The follow-up period was one year. HHS, BI, and RUSH scores were given within the specified time. We divided the patients into the PFNA+cable (PFNA combined with cerclage cable) group and the PFNA group. The time of fracture healing and weight-bearing in the PFNA+cable group was shorter than that in the PFNA group. With regard to HHS, BI, and RUSH, the PFNA+cable group was higher than the PFNA group at 1 month, 3 months, 6 months, and 12 months after operation. For HHS rating, the PFNA+cable group has a higher excellent rate than the PFNA group, which was 96.1% and 84.1%, respectively. All the results mentioned above were statistically significant. Compared with the group without cerclage cable, the application of cerclage cable can reduce the incidence of complications. From the comparison between the two groups, it can be seen that the surgical method of PFNA combined with cerclage cable can not only help to improve the stability of fracture reduction, shorten the time of fracture healing and postoperative weight-bearing, and significantly improve patients' self-care ability but also reduce the incidence of postoperative complications. Therefore, we think PFNA combined with cerclage cable is a good choice.

[Locking plate fixation of distal periprosthetic femoral fractures : Clinical outcome and mortality]

Hintergrund

Die Versorgung distaler periprothetischer Femurfrakturen (PFF) stellt aufgrund des geriatrischen Patientenkollektivs eine große interdisziplinäre Herausforderung dar und erfolgt (abhängig vom Frakturtyp) häufig mittels winkelstabiler Plattenosteosynthese (WPO), wobei bisher nur wenige Daten zum klinischen Outcome existieren. Ziel der Untersuchung ist die Identifikation von Risikofaktoren für ein schlechtes Outcome und erhöhte Mortalität.

Methoden

In dieser retrospektiven Studie wurden 36 Fälle mit distaler PFF untersucht. Eingeschlossen wurden nur Versorgungen mit WPO. Neben relevanten Vorerkrankungen (ASA-Score, Charlson Index), der Frakturmorphologie und relevante Komplikationen, wurden u.a. die 1- und 3-Jahres-Mortalität, sowie das klinische Outcome mit Hilfe des Lysholm-Scores erfasst.

Ergebnisse

Die 1- und 3- Jahres Mortalität betrug 9% bzw. 26%, wobei dies ausschließlich ASA 3 und 4 Patienten betraf. Der Lysholm Score zeigte eine hohe Variabilität (65 ± 27 Punkte) mit höheren Werten in der ASA 1-2 Subgruppe (82 vs. 63 Punkte) aber unabhängig vom Frakturtyp. Als Risikofaktoren für die 3-Jahres Mortalität konnten der präoperative ASA-Score, der Charlson Komorbiditätsindex und das Patientenalter identifiziert werden.

Diskussion

Die dargestellte Fallserie weist eine hohe absolute Mortalitätsrate auf, auch wenn diese im Vergleich zu bisher publizierten Daten, etwas geringer war. Die Rate an Sekundärdislokationen, fehlender Frakturheilung oder Folgeoperationen war ebenfalls gering. Die WPO erscheint daher als geeignete Versorgung für Frakturen mit stabiler Prothese. Jedoch besteht eine hohe Variabilität im klinischen Outcome unabhängig vom Frakturtyp, sowie signifikant erhöhte Mortalitätsraten bei vorerkrankten Patienten.

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

The impact of antithrombotic therapy on surgical delay and 2-year mortality in older patients with hip fracture: a prospective observational study

PURPOSE

To analyze the associations of oral anticoagulant and antiplatelet treatments in older patients requiring surgical treatment for hip fracture with mortality, length of stay, waiting time to surgery and postsurgical immediate complications.

METHODS

A prospective observational study, including surgically treated hip fracture patients aged 65 years and older. We analyzed admission status variables, and time to surgery, length of stay and immediate surgical and medical complications. We recorded a 2-year survival follow-up.

RESULTS

Of the 237 patients studied, 32.5% received antiplatelet treatment and 17.7% received oral anticoagulant treatment. The overall 2-year mortality was 29.1%. The 2-year mortality rate reached the 33.8% for antiplatelet-treated patients (n.s.) and 45.2% for oral anticoagulated patients (p = 0.011). The length of stay increased significantly associated with the oral anticoagulant or high-dose antiplatelet treatment (p < 0.001). The same happened for the time to surgery (p < 0.001), but no delay was observed for patients with low-dose antiplatelet treatment. Oral anticoagulated and antiplatelet-treated patients had a higher Charlson comorbidity index (p = 0.004, p = 0.019) and ASA score (p = 0.006, p = 0.011). Those treatments were also associated with a higher rate of some immediate postsurgical medical complications. We found a relationship between low hemoglobin at admission and high-dose antiplatelet treatment (p = 0.044).

CONCLUSIONS

Hip fracture patients following previous oral anticoagulant treatment have a higher 2-year mortality rate. The oral anticoagulant or high-dose antiplatelet treatments are significantly associated with an increase in the length of stay, related to time to surgery, but we could not demonstrate an effect on early mortality.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

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.