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Brameier DT, Tischler EH, Ottesen TD, McTague MF, Appleton PT, Harris MB, Weaver MJ, Suneja N. Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention. J Orthop Trauma 2024; 38:148-154. [PMID: 38385974 DOI: 10.1097/bot.0000000000002753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 02/23/2024]
Abstract
OBJECTIVES To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. METHODS DESIGN Retrospective cohort study. SETTING Three academic Level 1 trauma centers. PATIENT SELECTION CRITERIA Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. OUTCOME MEASURES AND COMPARISONS Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Devon T Brameier
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eric H Tischler
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Taylor D Ottesen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael F McTague
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Paul T Appleton
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Babagoli M, Ghaseminejad Raeini A, Sheykhvatan M, Baghdadi S, Shafiei SH. Influencing factors on morbidity and mortality in intertrochanteric fractures. Sci Rep 2023; 13:12090. [PMID: 37495718 PMCID: PMC10372085 DOI: 10.1038/s41598-023-38667-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023] Open
Abstract
We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.
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Affiliation(s)
- Mazyar Babagoli
- Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | | | - Mehrdad Sheykhvatan
- Orthopedic Surgery Research Center, Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroush Baghdadi
- Pediatric Orthopaedic Surgery Department, Montefiore Medical Center, New York, USA
| | - Seyyed Hossein Shafiei
- Orthopedic Surgery Research Center, Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
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The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario? Spine (Phila Pa 1976) 2020; 45:673-678. [PMID: 32358305 DOI: 10.1097/brs.0000000000003357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. SUMMARY OF BACKGROUND DATA While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. METHODS This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. RESULTS The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. CONCLUSION The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. LEVEL OF EVIDENCE 4.
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Yang Z, Ni J, Long Z, Kuang L, Gao Y, Tao S. Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis. J Orthop Surg Res 2020; 15:105. [PMID: 32164755 PMCID: PMC7068917 DOI: 10.1186/s13018-020-01624-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/04/2020] [Indexed: 12/28/2022] Open
Abstract
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 ScienceTM, 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.
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Affiliation(s)
- Zhanyu Yang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Jiangdong Ni
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China.
| | - Ze Long
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Letian Kuang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Yongquan Gao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Shibin Tao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
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The impact of antithrombotic therapy on surgical delay and 2-year mortality in older patients with hip fracture: a prospective observational study. Eur Geriatr Med 2020; 11:555-561. [PMID: 32297256 DOI: 10.1007/s41999-020-00293-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/18/2020] [Indexed: 02/07/2023]
Abstract
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.
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Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Azarfarin R, Noohi F, Kiavar M, Totonchi Z, Heidarpour A, Hendiani A, Koleini ZS, Rahimi S. Relationship between maximum clot firmness in ROTEM ® and postoperative bleeding after coronary artery bypass graft surgery in patients using clopidogrel. Ann Card Anaesth 2018; 21:175-180. [PMID: 29652280 PMCID: PMC5914219 DOI: 10.4103/aca.aca_139_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: The aim of the present study was to investigate the relationship between maximum clot firmness (MCF) in rotational thromboelastometry (ROTEM®) and postoperative bleeding in patients on clopidogrel after emergency coronary artery bypass graft surgery (CABG). Methods: This observational study recruited 60 patients posted for emergency CABG following unsuccessful primary percutaneous coronary intervention (PCI) while on 600 mg of clopidogrel. The study population was divided into 2 groups on the basis of their MCF in the extrinsically activated thromboelastometric (EXTEM) component of the (preoperative) ROTEM® test: patients with MCF <50 mm (n = 16) and those with MCF ≥50 mm (n = 44). Postoperative chest tube drainage amount, need for blood product transfusion, postoperative complications, and duration of mechanical ventilation after CABG were recorded. Results: No significant differences were observed between the two groups regarding duration of surgery, cardiopulmonary bypass, and aortic cross-clamp time. Chest tube drainage at 6, 12, and 24 h after Intensive Care Unit admission were significantly higher in the patients with MCF below 50 mm. The need for blood product transfusion was higher in the group with MCF <50 mm. In patients who experienced postoperative bleeding of 1000 mL or more, the ROTEM® parameters of INTEM (Intrinsically activated thromboelastomery) α and MCF, EXTEM α and MCF, and HEPTEM (INTEM assay performed in the presence of heparinase) MCF (but not FIBTEM (Thromboelastometric assay for the fibrin part of the clot) values) were significantly lower than those with postoperative bleeding <1000 mL (P ≤ 0.05). Conclusions: When platelet aggregometry is not available, the ROTEM® test could be useful for the prediction of increased risk bleeding after emergency CABG in patients who have received a loading dose of clopidogrel.
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Affiliation(s)
- Rasoul Azarfarin
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Fereidoon Noohi
- Cardiac Intervention Research Center, Rajaie Cardiovascular Medical And Research Center, University of Medical Sciences, Tehran, Iran
| | - Majid Kiavar
- Cardiac Intervention Research Center, Rajaie Cardiovascular Medical And Research Center, University of Medical Sciences, Tehran, Iran
| | - Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Avaz Heidarpour
- Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Amir Hendiani
- Faculty of Medicine, University of Medical Sciences, Tehran, Iran
| | | | - Saeid Rahimi
- Faculty of Medicine, University of Medical Sciences, Tehran, Iran
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Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review. Neurosurg Rev 2018; 41:1029-1036. [PMID: 29362950 DOI: 10.1007/s10143-018-0945-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.
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Yassa R, Khalfaoui MY, Hujazi I, Sevenoaks H, Dunkow P. Management of anticoagulation in hip fractures: A pragmatic approach. EFORT Open Rev 2017; 2:394-402. [PMID: 29071124 PMCID: PMC5644423 DOI: 10.1302/2058-5241.2.160083] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures. The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents. We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration. Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy. The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal. The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties. Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients.
Cite this article: EFORT Open Rev 2017;2:394–402. DOI: 10.1302/2058-5241.2.160083
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Affiliation(s)
| | | | | | | | - Paul Dunkow
- Blackpool Victoria Teaching Hospitals, Blackpool, UK
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Zhang J, Chen X, Wang J, Liu Z, Wang X, Ren J, Sun T. Poor prognosis after surgery for intertrochanteric fracture in elderly patients with clopidogrel treatment: A cohort study. Medicine (Baltimore) 2017; 96:e8169. [PMID: 28953670 PMCID: PMC5626313 DOI: 10.1097/md.0000000000008169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Choice of surgical approach in patients under clopidogrel treatment is controversial. Intertrochanteric fractures are common in the elderly, who also suffer from a number of comorbidities.The aim of this study is to assess the prognosis of elderly patients with clopidogrel treatment after surgery for intertrochanteric fracture.This was a cohort study of 238 elderly patients who underwent proximal femur intramedullary nailing for intertrochanteric fracture between January 2012 and December 2013 at the Geriatric Trauma Center of the Beijing Army General Hospital. The patients were divided into the clopidogrel (n = 32) and control (n = 206) groups according to their history of long-term clopidogrel treatment before surgery. Demographic and clinical characteristics, intraoperative parameters, postoperative complications, and 1-year survival were compared between the 2 groups.Preoperative American Society of Anesthesiologists (ASA) grade and the frequency of arterial stenting were different between the 2 groups (P = .002 and P < .001, respectively). The rate of intraoperative blood transfusion, ICU stay, and hospital stay were higher in the clopidogrel group compared with the control group (all P < .001). Postoperative complications were similar in the 2 groups. The 1-year mortality rate after surgery was significantly higher in the clopidogrel group compared with the control group (37.5% vs 20.3%, P = .030).Prognosis after surgery for intertrochanteric fracture was poorer in elderly patients with clopidogrel treatment; these patients had lower 1-year survival, more intraoperative blood transfusion, longer ICU stay, and longer hospital stay. ASA grade, arterial stenting, and anesthesia mode were prognostic factors.
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A retrospective comparison between delayed and early hip fracture surgery in patients taking clopidogrel: same total bleeding but different timing of blood transfusion. INTERNATIONAL ORTHOPAEDICS 2017; 41:1839-1844. [DOI: 10.1007/s00264-017-3571-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/30/2017] [Indexed: 01/27/2023]
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Discontinuation of Plavix ® (clopidogrel) for hip fracture surgery. A systematic review of the literature. Orthop Traumatol Surg Res 2016; 102:1097-1101. [PMID: 27863918 DOI: 10.1016/j.otsr.2016.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/06/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED 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.
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Soo CGKM, Della Torre PK, Yolland TJ, Shatwell MA. Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord 2016; 17:136. [PMID: 27005816 PMCID: PMC4804516 DOI: 10.1186/s12891-016-0988-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/16/2016] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Christopher G K M Soo
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia.
| | - Paul K Della Torre
- Orthopaedic surgery department, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW, 2139, Australia
| | - Tristan J Yolland
- Orthopaedic surgery department, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia
| | - Michael A Shatwell
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia
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Pean CA, Goch A, Christiano A, Konda S, Egol K. Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons. Geriatr Orthop Surg Rehabil 2015; 6:289-94. [PMID: 26623164 PMCID: PMC4647196 DOI: 10.1177/2151458515605156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Christian A Pean
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA ; Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Abraham Goch
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA ; Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Anthony Christiano
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA ; Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA ; Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth Egol
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA ; Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
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15
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Yoo HS, Cho YH, Byun YS, Kim MG. Is Taking an Antiplatelet Agent a Contraindication for Early Surgery in Displaced Femur Neck Fracture? Hip Pelvis 2015; 27:173-8. [PMID: 27536621 PMCID: PMC4972722 DOI: 10.5371/hp.2015.27.3.173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Hyun-Seung Yoo
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Young-Ho Cho
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Young-Soo Byun
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Min-Guek Kim
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
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16
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Does aspirin administration increase perioperative morbidity in patients with cardiac stents undergoing spinal surgery? Spine (Phila Pa 1976) 2015; 40:629-35. [PMID: 26030214 DOI: 10.1097/brs.0000000000000695] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To compare the perioperative morbidity of patients with cardiac stents after spine surgery who continue to take aspirin before and after the operation with a similar group of patients who preoperatively discontinued aspirin. SUMMARY OF BACKGROUND DATA The preoperative discontinuation of anticoagulant therapy has been the standard of care for orthopedic surgical procedures. However, recent literature has demonstrated significant cardiac risk associated with aspirin withdrawal in patients with cardiac stents. Although it has recently been demonstrated that performing orthopedic surgery while continuing low-dose aspirin therapy seems to be safe, studies focused on spinal surgery have not yet been performed. Because of the risk of intraspinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression, spinal surgeons have been reluctant to operate on patients taking aspirin. METHODS This institutional review board-approved study included 200 patients. Preoperative parameters and postoperative outcome measures were analyzed for 100 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy and 100 patients who continued to take daily aspirin through the perioperative period. The primary outcome measure was serious bleeding-related postoperative complications such as spinal epidural hematoma. The operative time, intraoperative estimated blood loss, hospital length of stay, transfusion of blood products, and 30-day hospital readmission rates were also recorded and compared. RESULTS The patients who continued taking aspirin in the perioperative period had a shorter hospital length of stay on average (4.1 ± 2.7 vs. 6.2 ± 5.8; P < 0.005), as well as a reduced operative time (210 ± 136 vs. 266 ± 143; P < 0.01), whereas there was no significant difference in the estimated blood loss (642 ± 905 vs. 697 ± 1187), the amount of blood products transfused, overall intra- and postoperative complication rate (8% vs. 11%), or 30-day hospital readmission rate (5% vs. 5%). No clinically significant spinal epidural hematomas were observed in either of the study groups. CONCLUSION The current study has observed no appreciable increase in bleeding-related complication rates in patients with cardiac stents undergoing spine surgery while continuing to take aspirin compared with patients who discontinued aspirin prior to surgery. Although very large studies will be needed to determine whether aspirin administration results in a small complication rate increase, the current study provides evidence that perioperative aspirin therapy is relatively safe in patients undergoing spinal surgery. LEVEL OF EVIDENCE 2.
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Stein MJ, Kang C, Ball V. Emergency department evaluation and treatment of acute hip and thigh pain. Emerg Med Clin North Am 2015; 33:327-43. [PMID: 25892725 DOI: 10.1016/j.emc.2014.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.
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Affiliation(s)
- Matthew Jamieson Stein
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA.
| | - Christopher Kang
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA
| | - Vincent Ball
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA.
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Doleman B, Moppett IK. Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression. Injury 2015; 46:954-62. [PMID: 25818054 DOI: 10.1016/j.injury.2015.03.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 12/29/2014] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- B Doleman
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - I K Moppett
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom.
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Ventura C, Trombetti S, Pioli G, Belotti LMB, De Palma R. Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients. Osteoporos Int 2014; 25:2591-7. [PMID: 25011985 DOI: 10.1007/s00198-014-2803-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/01/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect INTRODUCTION The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients. METHODS This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability. RESULTS From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 ± 12.3 days, and the overall percentage of patients operated within 2 days was 52.2%. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95% CI 0.582-6.539). CONCLUSIONS Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.
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Affiliation(s)
- C Ventura
- Regional Agency for Health and Social Care of Emilia-Romagna , Viale A. Moro, 21, Bologna, 40127, Italy
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20
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Kasivisvanathan R, Abbassi-Ghadi N, Kumar S, Mackenzie H, Thompson K, James K, Mallett SV. Risk of bleeding and adverse outcomes predicted by thromboelastography platelet mapping in patients taking clopidogrel within 7 days of non-cardiac surgery. Br J Surg 2014; 101:1383-90. [PMID: 25088505 DOI: 10.1002/bjs.9592] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 02/05/2014] [Accepted: 05/19/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients often fail to stop clopidogrel appropriately before non-cardiac surgery. Thromboelastography platelet mapping (TEG-PM) can be used to measure the percentage adenosine 5'-diphosphate platelet receptor inhibition (ADP-PRI) by clopidogrel in these patients. METHODS This prospective case-control study investigated the risk of bleeding in patients who had taken clopidogrel within 7 days of scheduled operation. Patients underwent TEG-PM to stratify their bleeding risk. Low-risk (ADP-PRI below 30 per cent) and urgent priority high-risk (ADP-PRI 30 per cent or more) patients proceeded to surgery. The outcomes of these patients were compared with those of matched controls. Regression analysis, with bootstrapping validation, was used to identify independent risk factors for bleeding and an optimal cut-off value of ADP-PRI for cancellation of surgery. RESULTS From May 2008 to October 2013, 182 patients failed to discontinue clopidogrel. No correlation was observed between duration of clopidogrel omission and percentage ADP-PRI; 112 low-risk and 19 high-risk patients proceeded to surgery. High-risk patients had significantly greater intraoperative packed red blood cell (PRBC) transfusion in comparison with their matched controls, and a strong positive correlation between percentage ADP-PRI and units of intraoperative PRBCs transfused (r = 0·749, 95 per cent confidence interval (c.i.) 0·410 to 0·940; P < 0·001). Percentage ADP-PRI was the only independent risk factor for intraoperative PRBC transfusion (odds ratio 1·07, 95 per cent c.i. 1·02 to 1·13; P = 0·005). CONCLUSION An objective measure of platelet inhibition with TEG-PM, using an ADP-PRI cut-off of 34 per cent, can be used to prevent unnecessary cancellations, while minimizing patient risk.
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21
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Manaqibwala MI, Butler KA, Sagebien CA. Complications of hip fracture surgery on patients receiving clopidogrel therapy. Arch Orthop Trauma Surg 2014; 134:747-53. [PMID: 24682494 DOI: 10.1007/s00402-014-1981-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Moiz I Manaqibwala
- Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA,
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22
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Gleason LJ, Friedman SM. Preoperative management of anticoagulation and antiplatelet agents. Clin Geriatr Med 2014; 30:219-27. [PMID: 24721362 DOI: 10.1016/j.cger.2014.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article describes current literature and treatment plans for managing anticoagulation and antiplatelet agents in patients presenting with hip fractures. Indications for anticoagulation and antiplatelet agents are discussed, and management techniques for when patients present with hip fractures are reviewed.
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Affiliation(s)
- Lauren Jan Gleason
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, LMOB 1B, 110 Francis Street, Boston, MA 02215, USA.
| | - Susan M Friedman
- Department of Medicine, Highland Hospital, 1000 South Avenue, Box 58, Rochester, NY 14620, USA
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23
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Reguant F, Martínez E, Gil B, Prieto JC, del Milagro Jiménez L, Arnau A, Bosch J. [Hip fracture, antiplatelet drugs treatment and postoperative complications]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:504-510. [PMID: 23890876 DOI: 10.1016/j.redar.2013.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 05/30/2013] [Accepted: 06/06/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To assess the incidence of postoperative complications, blood transfusions and survival at one month, in the old patients operated for hip fracture undergoing chronic treatment with antiplatelet drugs. MATERIAL AND METHODS Two hundred twenty three patients operated for hip fracture were studied retrospectively, separated into 3 groups: patients who received acetylsalicylic acid (group I), patients who were given 100mg/day of acetylsalicylic acid or 300mg/day of triflusal (group II) and patients receiving>100mg/day of acetylsalicylic acid, or>300mg/day of triflusal or thienopyridines (group III). Surgery was delayed for 4 days in patients in group III. Demographic, biological, clinical and treatment characteristics, postoperative complications and survival at one month were recorded. RESULTS Patients in group III were older and sustain worse general health status. Patients with a higher transfusion requirement were those of group II (73.8%) (P=0.192), who also showed a higher percentage of anaemia on admission. Severe cardiovascular complications were experienced by 5.4% of group III patients, 4.8% of group II patients and 2.1% of group I patients. Patients from group III presented a significant amount of respiratory complications (P=0.007). CONCLUSIONS Our results suggest that delaying surgery for 4 days in patients treated with clopidogrel can be associated to an increase in postoperative respiratory complications and severe adverse cardiovascular events, without increasing the tranfusional index, hospital stay, mortality, and without complications related to neuraxial anaesthesia.
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Affiliation(s)
- F Reguant
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Barcelona, España.
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Al Khudairy A, Al-Hadeedi O, Sayana MK, Galvin R, Quinlan JF. Withholding clopidogrel for 3 to 6 versus 7 days or more before surgery in hip fracture patients. J Orthop Surg (Hong Kong) 2013; 21:146-50. [PMID: 24014772 DOI: 10.1177/230949901302100205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE. To compare morbidity and mortality after hip fracture surgery in patients withholding clopidogrel for 3 to 6 days versus ≥7 days or more. METHODS. Records of 16 men and 31 women aged 49 to 92 (mean, 80.2) years who underwent hip fracture surgery after withholding clopidogrel for 3 to 6 days (n=24) versus ≥7 days or more (n=23) were compared. The patients were taking clopidogrel owing to ischaemic heart disease (n=37), cerebrovascular disease (n=7), and intolerance to aspirin (n=3). Patient demographics, American Society of Anesthesiologists status, preoperative delay, length of hospital stay, perioperative haemoglobin reduction, receipt of blood and platelet transfusions, morbidity, and mortality were recorded. RESULTS. Respectively in the early-surgery and delayed-surgery groups, the mean surgical delay was 4.2 and 8.0 days, the mean length of hospital stay was 21.1 and 28.7 days, the mean peri-operative haemoglobin reduction was 1.5 and 1.1 g/dl, the mean units of blood transfusion per patient was 0.8 and 0.7. No severe intra-operative bleeding or wound haematoma was encountered in either group. Two patients in each group died within one month, and 2 more in the delayed-surgery group died within 3 months. The main cause of death was cardiovascular. CONCLUSION. Withholding clopidogrel for <7 days before surgery conferred no increased risk in hip fracture patients.
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Mas-Atance J, Marzo-Alonso C, Matute-Crespo M, Trujillano-Cabello JJ, Català-Tello N, de Miguel-Artal M, Forcada-Calvet P, Fernández-Martínez JJ. [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]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 57:240-53. [PMID: 23885649 DOI: 10.1016/j.recot.2011.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 12/30/2011] [Accepted: 12/30/2011] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- J Mas-Atance
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Arnau de Vilanova, Lleida, España.
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Mas-Atance J, Marzo-Alonso C, Matute-Crespo M, Trujillano-Cabello J, Català-Tello N, de Miguel-Artal M, Forcada-Calvet P, Fernández-Martínez J. 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. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013. [DOI: 10.1016/j.recote.2013.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Wordsworth DR, Halsey T, Griffiths R, Parker MJ. Clopidogrel has no effect on mortality from hip fracture. Injury 2013; 44:743-6. [PMID: 23290871 DOI: 10.1016/j.injury.2012.11.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 10/30/2012] [Accepted: 11/29/2012] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- D R Wordsworth
- Trauma and Orthopaedics, East of England Multi-Professional Deanery, Capital Park, Fulbourn, Cambridge, United Kingdom.
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Feely MA, Mabry TM, Lohse CM, Sems SA, Mauck KF. Safety of clopidogrel in hip fracture surgery. Mayo Clin Proc 2013; 88:149-56. [PMID: 23374618 PMCID: PMC3837691 DOI: 10.1016/j.mayocp.2012.11.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/12/2012] [Accepted: 11/13/2012] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Molly A Feely
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Abstract
OBJECTIVE Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants. DESIGN Study design is a retrospective cohort analysis using data extracted from hospital records and state death records. SETTING Regional medical center (level II trauma). METHODS Data for 1118 patients ≥60 years of age who had surgical treatment for a hip fracture between 2004 and 2008 were reviewed. Eighty-two patients undergoing late surgery (>3 days after admission) were excluded. Patients taking clopidogrel were compared against those not taking clopidogrel. In addition, patients taking clopidogrel only were compared against cohorts of patients taking both clopidogrel and aspirin, aspirin only, warfarin only, or no anticoagulant. RESULTS Seventy-four of 1036 patients (7%) were taking clopidogrel, although control groups included 253 patients on aspirin alone, 90 patients on warfarin, and 619 taking no anticoagulants. No significant differences were noted between patients taking clopidogrel and those not taking clopidogrel in estimated blood loss, transfusion requirement, final blood count, hematoma evacuation, hospital length of stay (LOS), or mortality while in hospital or at 1 year. A higher American Society of Anesthesiologists score was seen in the clopidogrel and warfarin groups (P = 0.05 each), increased LOS in the clopidogrel group (P = 0.05), and higher rate of deep vein thrombosis seen in those patients taking warfarin (P = 0.05). Clopidogrel only versus aspirin versus both aspirin and clopidogrel, versus no anticoagulant versus warfarin showed no significant differences in estimated blood loss, transfusion requirement, final blood count, bleeding or perioperative complications, or mortality. CONCLUSIONS Patients undergoing early hip fracture surgery who are taking clopidogrel, aspirin, or warfarin (with regulated international normalized ratio) are not at substantially increased risk for bleeding, bleeding complications, or mortality. Comorbidities and American Society of Anesthesiologists scores were significantly higher in the clopidogrel group, which may have resulted in the increased postoperative LOS in this group.
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Chechik O, Amar E, Khashan M, Kadar A, Rosenblatt Y, Maman E. In support of early surgery for hip fractures sustained by elderly patients taking clopidogrel: a retrospective study. Drugs Aging 2012; 29:63-8. [PMID: 22191724 DOI: 10.2165/11598490-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Ofir Chechik
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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The effect of the grade of surgeon on blood loss in fractured neck-of-femur surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:449-56. [DOI: 10.1007/s00590-012-1015-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 05/09/2012] [Indexed: 12/21/2022]
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Reguant F, Bosch J, Montesinos J, Arnau A, Ruiz C, Esquius P. [Prognostic factors for mortality in elderly patients with hip fracture]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:289-298. [PMID: 22579463 DOI: 10.1016/j.redar.2012.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 03/20/2012] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVE The objective of the study was to describe the population of patients undergoing surgery for hip fracture, to assess the incidence of mortality and identify associated prognostic factors, and to evaluate functionality at one year after surgery. PATIENTS AND METHODS A retrospective cohort study, with follow-up during the first year after hospital discharge, of patients over 64 years old undergoing surgery for non-traumatic hip fracture during 2008. Variables studied were sociodemographic parameters, clinical complications, functionality and mortality. RESULTS A total of 240 patients were included, with a mean age of 83.8 years (SD 7.3), of whom 75.8% were women, 51.7% were ASA III-IV and 28.3% had a Charlson index greater than 2. Surgical delay was greater than 48 h in 61.7% of patients, and the mean hospital stay was 19.6 days (SD 15.9). Over three-quarters (76.3%) of the patients had some postoperative complications, the most frequent being cardiovascular and the cognitive disorders. At one year from surgery, 38.4% were able to walk on their own. In hospital mortality was 7.9%, and was 16.7, 20.4 and 24.6% at 3, 6 and 12 months, respectively. Independent prognostic factors of mortality at one year after surgery were: age, ASA score, Charlson index and post-operative cardiovascular and renal complications. CONCLUSIONS Hip fracture is associated with a high post-operative morbidity and mortality rate with important limitations in gait and functional status at one year after surgery.
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Affiliation(s)
- F Reguant
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Barcelona, España; Unidad de Calidad, Innovación y Docencia, Universitat Internacional de Catalunya (UIC), Sant Cugat del Vallès, Barcelona, España
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Abstract
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.
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Affiliation(s)
- Mitchell J Steele
- Wollongong Hospital, 4 Mansion Pt Road, Grays Point, Sydney, NSW 2232, Australia.
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Nandi S, Aghazadeh M, Talmo C, Robbins C, Bono J. Perioperative clopidogrel and postoperative events after hip and knee arthroplasties. Clin Orthop Relat Res 2012; 470:1436-41. [PMID: 22402810 PMCID: PMC3314755 DOI: 10.1007/s11999-012-2306-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 02/23/2012] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Sumon Nandi
- Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120 USA
| | - Mehran Aghazadeh
- Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120 USA
| | - Carl Talmo
- Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120 USA
| | - Claire Robbins
- Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120 USA
| | - James Bono
- Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120 USA
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Abstract
INTRODUCTION Antiplatelet agents such as aspirin and clopidogrel are increasingly encountered in clinical practice. Otorhinolaryngological surgeons are involved in the peri-operative decision of whether to continue treatment and risk haemorrhage or to discontinue treatment and risk thrombosis. METHODS Literature relating to the risk of spontaneous or operative haemorrhage was reviewed. The morbidity and mortality associated with cessation of agents was evaluated. Published guidelines were also evaluated. A protocol for the management of antiplatelet agents in the peri-operative period, with particular reference to ENT operations, is presented. CONCLUSION SIGNIFICANT morbidity and mortality is associated with the premature cessation of antiplatelet agents. Data from cardiac surgery suggest that operative blood loss only marginally increases in patients on aspirin and clopidogrel. However, the management of antiplatelet agents in the peri-operative period should be made after multidisciplinary consultation.
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Leonidou A, Cam NB, Chambers IR. Femoral neck fractures in patients on Clopidogrel. The effect of delaying surgery and the introduction of the new SIGN guidelines. Surgeon 2011; 9:318-21. [DOI: 10.1016/j.surge.2010.11.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 10/11/2010] [Accepted: 11/25/2010] [Indexed: 10/18/2022]
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Haidar R, Taher AT. How long should we delay hip fracture surgery for elderly patients on clopidogrel? Injury 2011; 42:1509-10. [PMID: 20637460 DOI: 10.1016/j.injury.2010.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 06/21/2010] [Indexed: 02/02/2023]
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Chechik O, Thein R, Fichman G, Haim A, Tov TB, Steinberg EL. The effect of clopidogrel and aspirin on blood loss in hip fracture surgery. Injury 2011; 42:1277-82. [PMID: 21329923 DOI: 10.1016/j.injury.2011.01.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/29/2010] [Accepted: 01/13/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality. PATIENTS AND METHODS Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets). RESULTS The mean perioperative blood loss was 899±496 ml for patients not on clopidogrel, 1091±654 ml for patients on clopidogrel (p=0.005) and 1312±686 ml for those on combined clopidogrel and aspirin (p=0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p=0.0012) and prolonged surgical time (p=0.0002). There were no cases of mortality in the early postoperative period. CONCLUSIONS Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.
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Affiliation(s)
- Ofir Chechik
- Department of Orthopedics B, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Christy JM, Stawicki SP, Jarvis AM, Evans DC, Gerlach AT, Lindsey DE, Rhoades P, Whitmill ML, Steinberg SM, Phieffer LS, Cook CH. The impact of antiplatelet therapy on pelvic fracture outcomes. J Emerg Trauma Shock 2011; 4:64-9. [PMID: 21633571 PMCID: PMC3097583 DOI: 10.4103/0974-2700.76841] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 09/10/2010] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan M Christy
- Department of Orthopaedics, Division of Critical Care, Trauma and Burn, The Ohio State University Medical Center, Columbus, OH, USA
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Marsland D, Colvin PL, Mears SC, Kates SL. How to optimize patients for geriatric fracture surgery. Osteoporos Int 2010; 21:S535-46. [PMID: 21057993 DOI: 10.1007/s00198-010-1418-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/14/2010] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- D Marsland
- Department of Orthopaedic Surgery, Johns Hopkins University/Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Platelet Aggregation Inhibitors, Platelet Function Testing, and Blood Loss in Hip Fracture Surgery. ACTA ACUST UNITED AC 2010; 69:1217-20; discussion 1221. [PMID: 21068622 DOI: 10.1097/ta.0b013e3181f4ab6a] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE To assess the effects of Plavix on patients requiring nonelective orthopaedic surgery. DESIGN Retrospective cohort study. SETTING University-affiliated teaching institutions. PATIENTS AND PARTICIPANTS The orthopaedic trauma registry was used to retrospectively identify all patients taking clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ) who required nonelective orthopaedic surgery from 2004 to 2008. Twenty-nine patients were identified on Plavix (PG) and 32 matched patients in the control group not taking Plavix (NPG). The Plavix group was separated into those with a surgical delay less than 5 days of the last dose (PG < 5) (n = 28) and a delay greater than 5 days (PG > 5) (n = 1). A randomized age- and injury-matched control group not on Plavix was separated with surgical delay less than 5 days (NPG < 5) (n = 29) and delay greater than 5 days (NPG > 5) (n = 3). INTERVENTION A retrospective review was performed comparing pre- and postoperative hemoglobin, blood transfusion requirements, surgical delay, 30-day mortality, and postoperative complications. MAIN OUTCOME MEASUREMENTS Statistical analyses were performed using the Student t test and chi square test to identify differences between the groups. RESULTS : The mean preoperative hemoglobin of the PG and the NPG was 11.2 g/dL and 12.3 g/dL (P = 0.03). Transfusion rates were similar with 18 of 28 in the PG compared with 13 of 29 in the NPG (P = 0.22). The mean surgical delay between the PG and NPG was 1.88 and 1.68 days (P = 0.64). Overall complications between the PG and NPG was nine of 28 and nine of 29 (P = 0.92). In both groups, two patients had postoperative wound drainage, which resolved without intervention. One patient in each group required revision surgery for nonunion. The 30-day mortality in the Plavix group was zero of 28 (0%) compared with one of 29 (3%) in the control group (cardiac arrest) (P = 0.32). CONCLUSIONS In this study, there were no serious complications or increased transfusion requirements in the Plavix group. Avoiding surgical delay for patients on Plavix requiring nonelective orthopaedic surgery appears to be safe. The goal should be early operative intervention to decrease the morbidity and mortality of surgical delay. This is especially true for patients with hip fractures, which was the most common nonelective orthopaedic surgery required of patients on Plavix in this study.
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Sim W, Gonski PN. The management of patients with hip fractures who are taking Clopidogrel. Australas J Ageing 2010; 28:194-7. [PMID: 19951341 DOI: 10.1111/j.1741-6612.2009.00377.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Welkee Sim
- Sutherland Hospital, Kingsway, Caringbah, New South Wales, Australia
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Mak JCS, Cameron ID, March LM. Evidence‐based guidelines for the management of hip fractures in older persons: an update. Med J Aust 2010; 192:37-41. [DOI: 10.5694/j.1326-5377.2010.tb03400.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 09/17/2009] [Indexed: 01/06/2023]
Affiliation(s)
- Jenson C S Mak
- Sacred Heart Rehabilitation Service, St Vincent's Hospital, Sydney, NSW
- Department of Geriatric Medicine, Gosford Hospital, Gosford, NSW
- Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW
| | - Ian D Cameron
- Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW
| | - Lyn M March
- Institute of Bone and Joint Research, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW
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Abstract
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.
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Affiliation(s)
- Dejan Grujic
- From the Huntington Memorial Hospital, Pasadena, California
| | - David Martin
- From the Huntington Memorial Hospital, Pasadena, California
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Vidal EIO, Moreira-Filho DC, Coeli CM, Camargo KR, Fukushima FB, Blais R. Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality? Osteoporos Int 2009; 20:723-9. [PMID: 18839050 DOI: 10.1007/s00198-008-0757-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 08/18/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED This study aims to analyze whether the interval from hospital admission to surgery may be used as a surrogate of the actual gap from fracture to surgery when investigating in-hospital hip fracture mortality. After analyzing 3,754 hip fracture admissions, we concluded that those intervals might be used interchangeably without misinterpretation bias. INTRODUCTION The debate regarding the influence of time to surgery in hip fracture (HF) mortality is one of the most controversial issues in the HF medical literature. Most previous investigations actually analyzed the time from hospital admission to surgery as a surrogate of the less easily available gap from fracture to surgery. Notwithstanding, the assumption of equivalency between those intervals remains untested. METHODS We analyzed 3,754 hospital admissions of elderly patients due to HF in Quebec, Canada. We compared the performance as predictors of in-hospital mortality of the delay from admission to surgery and the actual gap from fracture to surgery using univariate and multiple logistic regression analysis. RESULTS The mean times from fracture to surgery and from admission to surgery were 1.84 and 1.02 days (P < 0.001), respectively. On univariate logistic regression, both times were slightly significant as mortality predictors, yielding similar odds ratios of 1.08 (P < 0.001) for time from fracture to surgery and 1.11 (P < 0.001) for time from admission to surgery. After accounting for other covariates, neither times remained significant mortality predictors. CONCLUSION The gap from admission to surgery may be used as a surrogate of the actual delay from fracture to surgery when studying in-hospital HF mortality.
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Affiliation(s)
- E I O Vidal
- Social and Preventive Medicine Department, State University of Campinas, Campinas, SP, Brazil.
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Purushothaman B. Anti-platelet agents and surgical delay in elderly patients with hip fractures. J Orthop Surg (Hong Kong) 2008; 16:130; author reply 130. [PMID: 18453679 DOI: 10.1177/230949900801600132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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