Operative delay for orthopedic patients on clopidogrel (plavix): a complete lack of consensus

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.

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.

Surgical Delay Is Not Warranted for Patients With Hip Fractures Receiving Non-Warfarin Anticoagulants

The purpose of this study was to evaluate whether patients with hip fractures receiving antiplatelet and direct oral anticoagulants treated within 48 hours of admission had worse surgical and clinical outcomes than those whose surgery was delayed more than 48 hours. Consecutive patients 55 years and older with an operatively treated hip fracture were analyzed. Patients receiving the following anticoagulants were included: antiplatelet drugs, factor Xa inhibitors, and direct thrombin inhibitors. Outcomes included surgical blood loss, procedure time, transfusion requirement, length of stay, complication rate, and need for intensive care unit or step-down unit level care. Patients who underwent surgery within 48 hours of presentation were compared with patients whose surgery was delayed more than 48 hours. Of 551 consecutive operative hip fracture patients, 78 (14.2%) were receiving the anticoagulant medications included in this study. Of these 78 patients, 58 had surgery within 48 hours and 20 had surgery after 48 hours. When comparing the early and delayed fixation cohorts, there was no difference in transfusion requirement, length of surgery, or blood loss. Type of anticoagulant made no difference in transfusion requirement, blood loss, or length of surgery. There was also no difference in the mean number of complications or in the need for intensive care unit or step-down unit level care. In this study, patients receiving antiplatelet therapy, factor Xa inhibitors, or direct thrombin inhibitors who underwent surgical fixation of their hip fracture within 48 hours of admission were at no higher risk for transfusion, increased surgical blood loss, longer operative time, or inpatient mortality. [Orthopedics. 2019; 42(3):e331-e335.].

Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention

BACKGROUND

The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown.

METHODS

We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation.

RESULTS

If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals.

CONCLUSION

Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.

Discontinuation of Plavix® (clopidogrel) for hip fracture surgery. A systematic review of the literature

The elderly population is increasing worldwide, associated with an increase in diseases related to aging, such as hip fractures. These patients are sometimes treated with clopidogrel. There are no arguments at present to clearly determine the risk/benefit ratio of early surgical management of traumatic hip fractures in patients treated with clopidogrel (perioperative blood loss, postoperative complications). The goal of this systematic review of the literature was to show that early surgical management (<48h) of patients treated with clopidogrel does not increase postoperative morbidity or mortality. Systematic review of the literature: level of evidence IV. A bibliographic search was performed in July 2015 in PubMed, Embase and Cochrane databases using the MeSh keywords "Clopidogrel or Plavix^®" AND "hip fracture". Two of the authors analyzed 48 articles based on the title and abstract. Twenty-one articles were selected and read completely with an analysis of the references. Nine articles were chosen. Early surgical management (<48h) of patients receiving clopidogrel did not increase mortality at 30days, 3months or 1 year (between 25 and 30% mortality at 1 year) and did not result in an increase in perioperative bleeding. The risk/benefit ratio of early surgical management of patients with hip fractures receiving clopidogrel is good; morbidity and mortality are not increased in these patients if surgery is performed immediately or less than 48h after admission.

LEVEL OF EVIDENCE

IV.

Decision making on timing of surgery for hip fracture patients on clopidogrel

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients. Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications. Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin.

Temporal trends in the use of antithrombotics at admission

Background and purpose - Currently, no clear evidence exists on the pattern of use of antithrombotics at admission in hip fracture patients and how this has changed over time. We investigated temporal trends in-and factors associated with-the use of antithrombotics in patients admitted with a fractured hip. Patients and methods - This was a population-based cohort study including all patients aged 18 years or above who were admitted with a hip fracture in Denmark from 1996 to 2012. The Danish national registries were used to collect information on medication use, vital status, and comorbidity. Results - From 1996 to 2012, the proportion of patients using antithrombotics in general increased by a factor of 2.3 from 19% to 43% (p < 0.001). More specifically, the use of anticoagulants increased by a factor of 6.8 and the use of antiplatelets increased by a factor of 2.1. When we adjusted for possible confounders, the use of antithrombotics still increased for every calendar year (relative risk (RR) = 1.03, CI: 1.03-1.04; p < 0.001). Age, sex, and Charlson comorbidity index were all associated with the use of antithrombotics (all p < 0.001). Interpretation - The proportion of hip fracture patients using antithrombotics at admission has increased substantially in Denmark over the last 2 decades. This highlights the need for evidence-based guidelines on how to handle patients using antithrombotics to ensure safe surgery and to avoid surgical delay.

Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis

Background

Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel.

Methods

All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I² statistic.

Results

A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures.

Conclusions

On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding.

Trial registration

This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0988-9) contains supplementary material, which is available to authorized users.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents

AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents.

METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared.

RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all).

CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons

OBJECTIVE

There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients.

METHODS

A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05.

RESULTS

Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution.

CONCLUSIONS

There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Is Taking an Antiplatelet Agent a Contraindication for Early Surgery in Displaced Femur Neck Fracture?

Purpose

The purpose of this study was to evaluate whether we have to stop the antiplatelet agents prior to hemiarthroplasty surgery in patients with displaced femur neck fractures to reduce postoperative complications.

Materials and Methods

We enrolled forty-three patients with displaced femur neck fractures who were treated by bipolar hemiarthroplasty and were taking antiplatelet agents. Group I included 21 patients who discontinued antiplatelet agents and had delayed operations at an average 5.7 days and group II included 22 patients who had had early operations within 24 hours without stopping the antiplatelet agents. We compared the pre- and postoperative levels of hemoglobin, the volume of postoperative transfusion requirement and complications. Student's t-test and chi-square test were used for statistical analysis.

Results

The average differences between preoperative and postoperative hemoglobin was 1.4±0.4 g/dL decrease in group I and 2.1±0.5 g/dL decrease in group II (P<0.001). Patients who received a blood transfusion were 11 in group I and 13 in group II (P=0.66). Total number of blood transfusion was 13 pints in group I and 18 pints in group II (P=0.23). Pneumonia occurred in one patient in each group. Four pressure sores and three diaper rashes were developed in group I. But there were no patients requiring massive transfusion, reoperation due to hematoma and infection in each group.

Conclusion

Although continuous taking of antiplatelet agents in displaced femur neck fracture is associated with an increased risk of postoperative bleeding, taking an antiplatelet agent itself is not a contraindication of early surgery.

Effects of anticoagulants on outcome of femoral neck fracture surgery

PURPOSE

To review records of 330 patients who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy.

METHODS

Medical records of 235 women and 95 men aged 48 to 103 years (mean, 81.6; standard deviation [SD], 13.1) who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy were reviewed. 30 patients were on warfarin, 105 on aspirin, 28 on clopidogrel, and 167 were controls. The latter 3 groups were combined as the non-warfarin group and compared with the warfarin group. Hospital mortality, time from admission to surgery, length of hospital stay, return to theatre, and postoperative complications (wound infection, deep vein thrombosis, and pulmonary embolism) were assessed.

RESULTS

The warfarin and control groups were significantly younger than the clopidogrel and aspirin groups (80.8 vs. 80.0 vs. 84.2 vs. 83.7 years, respectively, p<0.05). 81% of the patients underwent surgery within 48 hours of admission. The overall mean time from admission to surgery was 1.8 days; it was longer in the warfarin than the aspirin, clopidogrel, and control groups (3.3 vs. 1.8 vs. 1.6 vs. 1.6 days, respectively, p<0.001). The mean length of hospital stay was 17.5 (SD, 9.6; range, 3-54) days. The overall hospital mortality was 3.9%; it was 6.7% in the warfarin group, 3.8% in the aspirin group, 3.6% in the clopidogrel group, and 3.6% in the control group (p=0.80). Four patients returned to theatre for surgery: one in the warfarin group for washout of a haematoma, 2 in the aspirin group for repositioning of a mal-fixation and for debridement of wound infection, and one in the control group for debridement of wound infection. The warfarin group did not differ significantly from non-warfarin group in terms of postoperative complication rate (6.7% vs. 2.7%, p=0.228) and the rate of return to theatre (3.3% vs. 1%, p=0.318).

CONCLUSION

It is safe to continue aspirin and clopidogrel prior to surgical treatment for femoral neck fracture. The risk of delaying surgery outweighs the peri-operative bleeding risk.

Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression

INTRODUCTION

Hip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes?

METHODS

A systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared.

RESULTS

For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58-1.38) or 30-day mortality (OR 1.10 95% CI: 0.48-2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00-1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference -7.09 days (95% CI: -10.14 to -4.04).

DISCUSSION

Early surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings.

Anti-platelet drugs in patients with femoral neck fractures undergoing cemented hip hemiarthroplasty surgery. A study of complications and mortality

OBJECTIVE

To assess complications and factors predicting one-year mortality in patients on antiplatelet agents presenting with femoral neck fractures undergoing hip hemiarthroplasty surgery.

MATERIAL AND METHODS

A review was made on 50 patients on preoperative antiplatelet agents and 83 patients without preoperative antiplatelet agents. Patients in both groups were treated with cemented hip hemiarthroplasty. A statistical comparison was performed using epidemiological data, comorbidities, mental state, complications and mortality. There was no lost to follow-up.

RESULTS

The one-year mortality was 20.3%. In patients without preoperative antiplatelet agents it was 14.4% and in patients with preoperative antiplatelet agents was 30%. Age, ASA grade, number of comorbidities and antiplatelet agent therapy were predictors of one-year mortality. The one-year mortality of patients on clopidogrel was 46.1%, versus 24.3% in patients on acetylsalicylic acid.

CONCLUSION

Patients with preoperative antiplatelet therapy were older and had greater number of comorbidities, ASA grade, delayed surgery, and a longer length of stay than patients without antiplatelet therapy. The one-year mortality was higher in patients with preoperative antiplatelet therapy.

Complications of hip fracture surgery on patients receiving clopidogrel therapy

INTRODUCTION

Clopidogrel (Plavix(®)) may influence patient safety during fracture surgery. Our study examines the incidence of complications for patients undergoing hemiarthroplasty on clopidogrel therapy.

MATERIALS AND METHODS

All patients, who underwent hemiarthroplasty between 2005 and 2011 were retrospectively reviewed. Patients were placed in two comparative groups based on the use of clopidogrel antiplatelet therapy. Records were reviewed for patient demographics, ASA score, pre and postoperative hemoglobin, time to surgery, length of stay, bleeding events, transfusions and complications. Comparative statistical analysis was performed using Fisher's exact test and Student's t test, using P < 0.05 to identify statistical significance.

RESULTS

A total of 203 charts were reviewed, of which 162 patients met inclusion/exclusion criteria. One hundred and twelve females and 50 males with mean age of 84 years were identified. The clopidogrel group consisted of 15 (9.3 %) patients and the nonclopidogrel group 147 (90.7 %). The clopidogrel group had more comorbidities resulting in a significantly higher ASA score (3.9 vs. 2.9), and lower preoperative hemoglobin (11.3 vs. 12.0). There was no significant difference identified in time to surgery, intraoperative blood loss, hemoglobin on days 1-3, or number of transfusions received between groups. Patients on clopidogrel were seen to have significantly longer hospital stays (10.6 vs. 7.4 days). However, a similar rate of wound and bleeding related complications (6.7 vs. 6.1 %) was seen.

CONCLUSIONS

The optimal treatment for hip fracture patients on antiplatelet therapy is unclear. However, in this study there appears to be no significant difference with regards to bleeding and bleeding related wound complications, suggesting it is safe to proceed with hemiarthroplasty for patients receiving clopidogrel.

[Randomised comparative study of early versus delayed surgery in hip-fracture patients on concomitant treatment with antiplatelet drugs. Determination of platelet aggregation, perioperative bleeding and a review of annual mortality]

OBJECTIVE

A review of the perioperative management of patients with hip fractures and concomitant therapy with antiplatelet agents, and to analyse the differences in mortality and perioperative bleeding in early surgery (<48 h) versus delayed surgery (>5 days). Platelet aggregation was measured on admission and immediately before surgery in all patients included in the study

PATIENTS AND METHODS

A total of 175 patients over 65 years old, with low energy hip fracture were randomised into 3 groups: Patients on antiplatelet therapy undergoing early surgery, patients on antiplatelet therapy undergoing delayed surgery, and patients not on antiplatelet therapy undergoing early surgery. The same clinical and laboratory data were collected prospectively up to 12 months for all the patients. The platelet aggregation was determined by a semi-quantitative computerised system based on impedance aggregometry in whole blood.

RESULTS

Bleeding, transfusion requirements and analytical results showed no significant differences between groups. More than half (59.8%) of the patients not taking antiplatelet therapy had normal platelet aggregation on admission, while 13.5% of those taking antiplatelet agents did not. Multivariate analysis showed increased mortality at 12 months for the variables, low Barthel index before hip fracture (OR: 0.9-0.9) and number of transfusions (OR: 1.1-1.5). The average lenth of stay was 4.1 days greater in the delayed surgery group.

CONCLUSION

Early surgery for patients receiving antiplatelet therapy has similar clinical outcomes to the delayed, but improves hospital efficiency by reducing the average length of stay. The antiplatelet drug reported by the patient showed low concordance with the determination of the platelet aggregation.

Clopidogrel has no effect on mortality from hip fracture

Over 76,000 patients in the UK sustain a proximal femoral fracture. Clopidogrel is currently the world's second best selling drug. There has been much recent controversy surrounding the optimal time for surgical intervention in this medically challenging group of patients. This consecutive series of 1225 patients from our unit over six years included thirty patients concurrently taking clopidogrel whilst sustaining a hip fracture. Our study demonstrated no significant difference in ASA grade, intra-operative blood loss or subsequent transfusion, post-operative wound complication, or mortality to one year in those taking clopidogrel. The authors therefore advocate timely surgical intervention as rapidly as circumstances allow.

Safety of clopidogrel in hip fracture surgery

OBJECTIVE

To compare postoperative outcomes of hip fracture surgery in patients who were and were not taking clopidogrel at the time of surgery.

PATIENTS AND METHODS

Using the Rochester Epidemiology Project database, we performed a population-based, retrospective cohort study comparing patients who were and were not taking clopidogrel at the time of hip fracture surgery between January 1, 1996, and June 30, 2010. Primary outcomes were perioperative bleeding and mortality. Secondary outcomes were perioperative thrombotic events.

RESULTS

During the study period, 40 residents of Olmsted County, Minnesota (median age, 83 years), who were taking clopidogrel underwent hip fracture repair. These 40 patients were matched 2:1 with 80 control patients (median age, 84 years). The groups were similar in age, sex, American Society of Anesthesiologists score, type of surgical procedure, and use of deep venous thrombosis prophylaxis. The mean time from admission to surgery was less than 36 hours for each cohort. Perioperative bleeding complications and mortality were not significantly different between patients who were and were not taking clopidogrel at the time of hip fracture surgery. Combined bleeding outcome criteria was met in 48% of the clopidogrel cohort and 45% of the control cohort (relative risk, 1.06; 95% CI, 0.70-1.58; P=.80). One-year mortality was 28% in the clopidogrel cohort and 29% in the control cohort (hazard ratio, 1.33; 95% CI, 0.84-2.12; P=.23).

CONCLUSION

Although the small sample size precludes making a definitive conclusion, we found no evidence that prompt surgical treatment of hip fracture in patients taking clopidogrel compromises perioperative outcomes.

Dual antiplatelet therapy with aspirin and clopidogrel: what is the risk in noncardiac surgery? A narrative review

Clopidogrel is one of the most commonly prescribed medications and is currently recommended along with aspirin as treatment to be used for 1 year in all patients without contraindications following an acute coronary syndrome. Patients who are committed to clopidogrel therapy due to recent coronary artery stent implantation may require noncardiac surgery during this recommended period of dual antiplatelet therapy (DAPT). Due to differing rates of endothelialization, patients who undergo bare-metal stent implantation generally require ≥ 1 month of uninterrupted DAPT, and those who undergo drug-eluting stent implantation require ≥ 12 months. Many surgeons ask their patients to stop taking clopidogrel in advance of their procedure to decrease perioperative bleeding. This practice is based largely on anecdotal experience and extrapolated from limited data in cardiac surgery. Premature cessation of aspirin and/or clopidogrel following coronary artery stenting, however, has been associated with acute stent thrombosis, myocardial infarction, and death. We searched PubMed for English language articles published from 1960 to 2012, using the keywords aspirin, clopidogrel, surgery, general, vascular, genitourinary, thoracic, orthopedic, ophthalmologic, dermatologic, endoscopy, colonoscopy, cardiac device implantation, pacemaker, defibrillator, bronchoscopy, bridging, bleeding complications, and transfusion, including various combinations. s were reviewed to confirm relevance, and then the full articles were extracted. References from extracted articles were also reviewed for relevant articles. Literature regarding perioperative clopidogrel continuation is predominantly composed of small, nonrandomized data, but suggests that most noncardiac surgeries or procedures can be performed safely while patients are taking clopidogrel. In this article, we review the current best evidence on the risk for bleeding with clopidogrel therapy in noncardiac surgery, summarize recent guidelines on appropriate duration of DAPT, and make recommendations on the management of perioperative DAPT.

In support of early surgery for hip fractures sustained by elderly patients taking clopidogrel: a retrospective study

BACKGROUND

Early surgical treatment is indicated to reduce mortality and morbidity associated with immobilization due to hip fracture. The judiciousness of postponing surgery to allow withdrawal of clopidogrel and return of normal platelet function (5-10 days) in elderly patients being chronically treated with this antiplatelet medication is a matter of ongoing controversy.

OBJECTIVE

The purpose of this study was to compare the morbidity and mortality rates in elderly patients receiving long-term treatment with clopidogrel who were operated on with or without delay (due to withdrawal of clopidogrel) following a hip fracture.

METHODS

We compared relevant demographic and medical/surgical parameters in patients receiving long-term treatment with clopidogrel who sustained a hip fracture and underwent either early (n = 30, mean ± SD age 81.6 ± 8.7 years, 17 males [57%]) or delayed (n = 30, mean ± SD age 83.3 ± 7.1 years, 13 males [43%]) surgical intervention between May 2007 and February 2010.

RESULTS

Both groups were similar with regard to sex, age, co-morbidities and fracture type. The mortality rate was similar in both groups. Patients in the delayed treatment group had more complications associated with prolonged immobilization (pulmonary embolism, pulmonary oedema, decubitus ulcer). Time from admission to surgery and hospitalization stay were significantly longer in the delayed treatment group than in the early treatment group (mean ± SD 7 days and 12 hours ± 2 days and 17 hours compared with 1 day and 16 hours ± 1 day [p < 0.0001] and 17 days and 17 hours ± 7 days and 5 hours versus 11 days and 2 hours ± 4 days and 19 hours [p = 0.0002], respectively).

CONCLUSIONS

Early surgical intervention for hip fracture in patients receiving long-term treatment with clopidogrel appears to be safe in terms of bleeding complications. It has the potential to enable earlier mobilization and shorter hospitalization and may reduce mortality and complications associated with immobilization.

Clopidogrel dilemma for orthopaedic surgeons

BACKGROUND

Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates.

METHOD

This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis.

RESULTS

Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism.

CONCLUSIONS

The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.

Perioperative clopidogrel and postoperative events after hip and knee arthroplasties

BACKGROUND

Hip and knee arthroplasties are widely performed and vascular disease among patients having these procedures is common. Clopidogrel is a platelet inhibitor that decreases the likelihood of thrombosis. It may cause intraoperative and postoperative bleeding, but its discontinuation increases the risk of vascular events. There is currently no consensus regarding the best perioperative clopidogrel regimen that balances these concerns.

QUESTIONS/PURPOSES

We determined (1) the relationship between time of perioperative clopidogrel administration and postoperative bleeding-related events after hip and knee arthroplasties and (2) patient characteristics or surgical factors that may predict these events.

METHODS

We retrospectively queried our inpatient pharmacy database for patients who received clopidogrel from 2007 to 2009 and identified 116 patients who underwent hip or knee arthroplasty. We recorded the time of perioperative clopidogrel administration, bleeding-related postoperative events, patient characteristics, and surgical factors.

RESULTS

Patients who withheld clopidogrel 5 or more days before hip or knee arthroplasty had lower rates of reoperation for infection and antibiotics prescribed for the surgical wound. Postoperative events did not vary with timing of clopidogrel resumption after surgery. Advanced age, an American Society of Anesthesiologists (ASA) score of 4, and revision surgery predicted increased readmission, reoperation for hematoma or infection, antibiotic use, and death.

CONCLUSIONS

Holding clopidogrel for at least 5 days before hip or knee arthroplasty may lower the rate of bleeding-related events. We found no increase in events when patients resumed clopidogrel immediately after surgery. Advanced age, ASA score of 4, and revision surgery may be risk factors for bleeding-related events.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clopidogrel: is a surgical delay necessary in fractured neck of femur?

INTRODUCTION

This paper assesses the outcomes of patients after surgery for a proximal femur fracture while on clopidogrel. It describes a single-centre retrospective observational study over a two-year period.

PATIENTS AND METHODS

A total of 31 surgical patients were included in this study. Of these, 28 were on clopidogrel and 3 on dipyridamole. Patients were split into subgroups based on when surgery took place and the type of hip fracture. The 'early surgery' (<48 hours from admission to theatre) group contained 16 patients (51.6%) and the 'late surgery' (>48 hours) group composed 15 patients (48.4%). Type of surgery performed and pre-and postoperative haemoglobin (Hb) levels were recorded. Furthermore, the number of units of blood transfused per patient as well as complications before and after surgery were noted.

RESULTS

A significantly larger mean hb drop occurred in the early surgery group (3.2g/dl) compared with the late surgery group (2.3g/dl) (p=0.027). The mean length of inpatient stay was 21 days in the early and 23 days in the late group (p=0.456). A significantly larger hb mean drop occurred in patients with extracapsular hip fractures (3.4g/dl; n=16) compared with patients with intracapsular fractures (2.3g/dl; n=15) (p=0.020). The extracapsular patients had longer stays in hospital: 24.5 days versus 19.8 days in the intracapsular group (p=0.521). There was no statistical difference in the 30-day mortality between the early surgery (3/16 deaths) and late surgery (2/15 deaths) groups (p=0.481).

CONCLUSIONS

Patients with extracapsular fractures, treated with early surgery, appear to be most at risk of complications after surgery.

Clopidogrel: is a surgical delay necessary in fractured neck of femur?

INTRODUCTION

This paper assesses the outcomes of patients after surgery for a proximal femur fracture while on clopidogrel. It describes a single-centre retrospective observational study over a two-year period.

PATIENTS AND METHODS

A total of 31 surgical patients were included in this study. Of these, 28 were on clopidogrel and 3 on dipyridamole. Patients were split into subgroups based on when surgery took place and the type of hip fracture. The 'early surgery' (<48 hours from admission to theatre) group contained 16 patients (51.6%) and the 'late surgery' (>48 hours) group composed 15 patients (48.4%). Type of surgery performed and pre-and postoperative haemoglobin (Hb) levels were recorded. Furthermore, the number of units of blood transfused per patient as well as complications before and after surgery were noted.

RESULTS

A significantly larger mean hb drop occurred in the early surgery group (3.2g/dl) compared with the late surgery group (2.3g/dl) (p=0.027). The mean length of inpatient stay was 21 days in the early and 23 days in the late group (p=0.456). A significantly larger hb mean drop occurred in patients with extracapsular hip fractures (3.4g/dl; n=16) compared with patients with intracapsular fractures (2.3g/dl; n=15) (p=0.020). The extracapsular patients had longer stays in hospital: 24.5 days versus 19.8 days in the intracapsular group (p=0.521). There was no statistical difference in the 30-day mortality between the early surgery (3/16 deaths) and late surgery (2/15 deaths) groups (p=0.481).

CONCLUSIONS

Patients with extracapsular fractures, treated with early surgery, appear to be most at risk of complications after surgery.

The impact of antiplatelet therapy on pelvic fracture outcomes

INTRODUCTION

Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx.

METHODS

Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)-a combination of Young-Burgess (pelvic ring), Letournel-Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed.

RESULTS

A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04).

CONCLUSIONS

Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.

How to optimize patients for geriatric fracture surgery

Low-energy fragility fractures account for >80% of fractures in elderly patients, and with aging populations, geriatric fracture surgery makes up a substantial proportion of the orthopedic workload. Elderly patients have markedly less physiologic reserve than do younger patients, and comorbidity is common. Even with optimal care, the risk of mortality and morbidity remains high. Multidisciplinary care, including early orthogeriatric input, is recommended to anticipate and treat complications. This article explores modern treatment strategies for this challenging group of patients and provides guidance for systematically preparing and optimizing elderly patients before surgery, based on best available current evidence and recommendations by relevant health organizations.

The management of patients with hip fractures who are taking Clopidogrel

AIM

To assess the outcomes of patients with acute proximal hip fractures who were taking Clopidogrel.

METHOD

A retrospective study of 135 patients with proximal hip fractures. Demographic data and clinical outcomes were collected via review of hospital medical records.

RESULTS

21 patients taking Clopidogrel on admission were compared with 114 patients not on Clopidogrel. The groups were similar in their baseline characteristics. Postoperative haemoglobin and wound haematoma, hospital length of stay and death rate were similar in both groups even when the patients on Clopidogrel were operated on within 2 days of fracture. Days to surgery were longer in the Clopidogrel group than the control group (3.5 vs 0.9).

CONCLUSIONS

This study demonstrated that patients on Clopidogrel do not have a worse outcome than those who were not taking the medication. We feel that it is safe to perform surgery as soon as possible.

Perioperative Clopidogrel is Seven Days Enough?

Despite the prevalence of surgical candidates on clopidogrel, no definitive guidelines exist for stopping the drug preoperatively. A 7 day off-clopidogrel period is commonly considered safe with regards to bleeding complications. We sought to put the 7-day window to the test with regards to major bleeding events requiring either blood transfusions or return trips to the operating room. We collected data for patients taking clopidogrel in the perioperative period between 2005 and 2007 (n = 170). This data was then compared with the data of all of the patients undergoing surgery at our institution for the same time period (n = 34,480). Patients taking clopidogrel experienced a significantly higher rate of return trips to the operating room (6.5%) compared with nonclopidogrel patients (0.015%). Interestingly, we found no significant difference between those stopping clopidogrel more than 7 days preoperatively and those that did not (5% and 7.5%, respectively). There did not seem to be a significant difference in blood transfusion rates between the two clopidogrel groups. Patients on perioperative clopidogrel require reoperations for bleeding at a significantly higher rate compared with patients not taking clopidogrel. Discontinuing clopidogrel 7 days before surgery is not enough to negate this difference and these patients still experience a drastically higher rate of reoperations for bleeding.