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Wohlrab J, Kegel T, Große R, Eichner A. Handlungsempfehlungen zur Risikominimierung beim Einsatz von Januskinase-Inhibitoren zur Therapie chronisch-entzündlicher Hauterkrankungen. J Dtsch Dermatol Ges 2023; 21:845-852. [PMID: 37574686 DOI: 10.1111/ddg.15136_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/25/2023] [Indexed: 08/15/2023]
Abstract
ZusammenfassungDer Ausschuss für Risikobewertung (PRAC) der Europäischen Arzneimittelagentur (EMA) hat gemäß Artikel 20 der Verordnung (EG) Nr. 726/2004 die Sicherheit für Januskinase‐Inhibitoren für die Behandlung von Entzündungserkrankungen neu bewertet und von den bisherigen Hinweisen in den jeweiligen Fachinformationen der betreffenden Präparate abweichende Sicherheitsangaben formuliert. Diese beziehen sich arzneistoff‐ und indikationsübergreifend auf die Beachtung eines möglicherweise erhöhten Risikos für venöse thromboembolische oder schwere kardiovaskuläre Ereignisse, eine erhöhte Infektionsrate sowie eine Erhöhung der Prävalenz von Hautkrebs. Deshalb wird empfohlen, bei Patienten mit unabhängigen Risikofaktoren (Alter ab 65 Jahre, Raucher oder ehemalige Raucher, Patientinnen mit oraler Kontrazeption beziehungsweise Hormonersatztherapie sowie anderen Risikofaktoren) Januskinase‐Inhibitoren nur dann therapeutisch einzusetzen, wenn es keine geeigneten Behandlungsalternativen gibt. Um im klinischen Alltag eine pragmatische und sorgfältige Erfassung von Risikopatienten zu ermöglichen, wurde interdisziplinär eine Checkliste erarbeitet, die aus der Perspektive des Dermatologen als Arbeitsmittel geeignet ist.
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Affiliation(s)
- Johannes Wohlrab
- Universitätsklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
- Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Thomas Kegel
- Universitätsklinik für Innere Medizin IV (Hämatologie und Onkologie), Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Regina Große
- Universitätsklinik für Gynäkologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Adina Eichner
- Universitätsklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
- Institut für angewandte Dermatopharmazie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
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Wohlrab J, Kegel T, Große R, Eichner A. Recommendations for risk minimization when using Janus kinase inhibitors for the treatment of chronic inflammatory skin diseases. J Dtsch Dermatol Ges 2023; 21:845-851. [PMID: 37345890 DOI: 10.1111/ddg.15136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/25/2023] [Indexed: 06/23/2023]
Abstract
In accordance with article 20 of Regulation (EC) No 726/2004, the Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) has re-evaluated the safety of Janus kinase inhibitors for the treatment of inflammatory diseases and formulated safety information deviating from the previous indications in the respective summary of product characteristics of the products concerned. These refer to the consideration of a possibly increased risk of venous thromboembolic or severe cardiovascular events, an increased infection rate and an increase in the prevalence of skin cancer across drugs and indications. Therefore, in patients with independent risk factors (age 65 years and older, smokers or former smokers, patients with oral contraception or hormone replacement therapy and other risk factors), it is recommended to use Janus kinase inhibitors therapeutically only if there are no suitable treatment alternatives. To facilitate a pragmatic and thorough detection of high-risk patients in everyday clinical practice, an interdisciplinary checklist was developed that is suitable as a working tool from the perspective of the dermatologist.
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Affiliation(s)
- Johannes Wohlrab
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute for Applied Dermatopharmaceutics, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thomas Kegel
- Department of Internal Medicine IV (Hematology and Oncology), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Regina Große
- Deparment of Gynecology, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Adina Eichner
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute for Applied Dermatopharmaceutics, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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Leverett GD, Marriott A. Intravenous tranexamic acid and thromboembolic events in hip fracture surgery: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2023; 109:103337. [PMID: 35643364 DOI: 10.1016/j.otsr.2022.103337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteoporotic hip fractures are a major health problem in developed countries. Surgical management is the mainstay of treatment for these injuries, and historically presents an increased risk of thromboembolism, blood loss and blood transfusion. Despite the demonstrated safety of tranexamic acid (TXA) in elective hip arthroplasty, there is uncertainty regarding the risk of thromboembolism with the administration of TXA during hip fracture surgery. This study aims to address the following questions regarding patients undergoing traumatic hip fracture surgery: 1. Does intravenous TXA increase the risk of thromboembolic events? 2. Does intravenous TXA reduce peri-operative blood loss? 3. Does intravenous TXA increase the risk of non-thromboembolic complications or post-operative mortality? METHODS A literature search of Ovid MEDLINE, Embase, PubMed, the Cochrane Register of Controlled Trials and CINAHL was conducted, assessing results from database inception until the 11th May, 2021. We included randomised controlled trials that investigated perioperative administration of intravenous TXA in patients undergoing hip fracture surgery, compared to a control cohort. We excluded articles published in a language other than English, evaluated elective hip arthroplasty, or did not report thromboembolic events. Included trials were analysed using RevMan v5.3. RESULTS Sixteen articles encompassing 1491 patients met inclusion criteria. The risk difference of thromboembolic events in the TXA group was 0.02 (95%C.I. -0.01-0.04; p=0.17). TXA reduced post-operative transfusion rates by 42% (range: 28-54%, p<0.0001). The mean haemoglobin was higher in the TXA group on post-operative day one (0.77g/dL, p<0.0001), day two (0.56g/dL, p<0.0001) and day three (0.42g/dL, p<0.0001). There was no statistically significant difference in non-thromboembolic complications or post-operative mortality across the two cohorts. DISCUSSION There is no conclusive evidence from the current published literature that peri-operative intravenous TXA administration increases the risk of thromboembolic events after hip fracture surgery. This meta-analysis reinforces that TXA is effective in reducing post-operative transfusions and haemoglobin decline after hip fracture surgery. This study found that TXA did not increase non-thromboembolic complications or post-operative mortality. Further large-scale studies evaluating thromboembolic complications as a primary outcome are required to definitively establish the safety of TXA in hip fracture surgery. LEVEL OF EVIDENCE I; meta-analysis of randomised controlled trials.
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Affiliation(s)
- Gregory D Leverett
- Department of Anaesthesia and Perioperative Medicine, Eastern Health, Victoria, Australia; Department of Medicine and Veterinary Science, University of Edinburgh, Edinburgh, Scotland.
| | - Andrew Marriott
- Department of Anaesthetics, Perioperative and Pain Medicine, Barwon Health, Victoria, Australia; Clinical Associate Professor, School of Medicine, IMPACT SRC, Deakin University, Victoria, Australia
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Tripathy SK, Varghese P, Kumarasamy AKN, Mishra NP, Neradi D, Jain M, Sarkar S, Sen RK. Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:33-43. [PMID: 36660490 PMCID: PMC9789237 DOI: 10.1007/s43465-022-00779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/09/2022] [Indexed: 11/28/2022]
Abstract
Purpose Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. Methods Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). Results There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). Conclusions Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. Level of evidence III.
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Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Paulson Varghese
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | | | - Narayan Prasad Mishra
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Deepak Neradi
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Soumya Sarkar
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, India
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Does tranexamic acid reliably reduce blood loss in proximal femur fracture surgery? Eur J Trauma Emerg Surg 2023; 49:209-216. [PMID: 35852549 PMCID: PMC9925497 DOI: 10.1007/s00068-022-02042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The aim of our study was to investigate the use of tranexamic acid in patients with proximal femoral fractures and compare the total blood loss, transfusion rates, complications, and the application method. METHODS A retrospective single center cohort study (level I trauma center) with 1479 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 was performed. 1 g of tranexamic acid was applied (systemic, topic or combined application). Patient data, surgical procedure, complications, and mortality were assessed. Hemoglobin levels, blood loss and transfusion rates for patients with and without tranexamic acid and the application methods were compared. RESULTS 667 femoral neck fractures, 701 pertrochanteric and 109 subtrochanteric fractures were included. Mean age was 80.8 years. 274 patients received tranexamic acid. At admission average hemoglobin was 12.2 g/l. Hemoglobin drop postoperatively was less after tranexamic acid (9.72 vs. 9.35 g/dl). Transfusion rates were lowered significantly by 17.1% after tranexamic acid. Blood loss was reduced for all patients after tranexamic acid independent of fracture morphology. The combination of 1 g i.v. and 1 g topical-applied tranexamic acid seems to be more effective. Complication rates did not differ. CONCLUSION Tranexamic acid is effective in reducing blood loss and transfusion rates, without increasing the risk of thromboembolic events after proximal femoral fractures. For open reduction and nailing and arthroplasty in fracture setting combined topical and single i.v. application seems most effective and closed reduction with nailing can be treated by single dose i.v. application of 1 g tranexamic acid.
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Kim CH, Hwang J, Lee SJ, Yoon PW, Yoon KS. The effect of tranexamic acid in open reduction and internal fixation of pelvic and acetabular fracture: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29574. [PMID: 35866801 PMCID: PMC9302337 DOI: 10.1097/md.0000000000029574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture. METHODS MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications. RESULTS We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%). CONCLUSIONS Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jaeho Hwang
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Soong Joon Lee
- Department of Orthopedic Surgery, Seoul National University Boramae Hospital, Seoul, Republic of Korea
- *Correspondence: Soong Joon Lee, Department of Orthopedic Surgery, Seoul National University Boramae Hospital, 39, Boramae-Gil, Dongjak-gu, Seoul, South Korea (e-mail: )
| | - Pil Whan Yoon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kang Sup Yoon
- Department of Orthopedic Surgery, Seoul National University Boramae Hospital, Seoul, Republic of Korea
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Jiganti M, Pipitone O, Than J, Stanley R, Passanise A, Krumrey J. A Single Dose Versus Two Doses of Tranexamic Acid for Extracapsular Hip Fractures. Cureus 2022; 14:e21239. [PMID: 35174034 PMCID: PMC8841038 DOI: 10.7759/cureus.21239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/05/2022] Open
Abstract
Objective In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. Methods This retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler’s formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. Results Patient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m2 vs. 24 kg/m2, p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). Conclusion In the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.
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Moran J, Kahan JB, Morris J, Joo PY, O’Connor MI. Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery. Geriatr Orthop Surg Rehabil 2022; 13:21514593221124414. [PMID: 36081840 PMCID: PMC9445454 DOI: 10.1177/21514593221124414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction The timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients. Methods All patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients. Results A total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001). Conclusions Patients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.
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Affiliation(s)
- Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Jensa Morris
- Center for Musculoskeletal Care and Yale New Haven Health, Yale School of Medicine, New Haven, CT, USA
- Hospitalist Service, Yale New Haven Hospital, New Haven, CT, USA
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Mary I. O’Connor
- Department of Orthopaedic Surgery, Vori Health, San Francisco Bay Area, CA, USA
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10
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Expanded use of tranexamic acid is safe and decreases transfusion rates in patients with geriatric hip fractures. OTA Int 2021; 4:e147. [PMID: 34765898 PMCID: PMC8575430 DOI: 10.1097/oi9.0000000000000147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 07/19/2021] [Indexed: 12/01/2022]
Abstract
Objectives: To determine the effect of a standardized tranexamic acid (TXA) protocol on red blood cell transfusions and adverse events in fragility hip fracture patients. Design: Retrospective cohort study. Setting: Academic Tertiary Care Center. Patients/Participants: Series of 209 patients with fragility hip fractures treated operatively from April 1, 2019 to September 30, 2019. Intervention: Eligible patients received 4 intravenous doses of TXA. Some patients missed doses and only received between 1 and 3 doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture > 48 hours prior to presentation. Main Outcome Measures: Red blood cell transfusion; major adverse vascular events; minor drug related adverse events. Results: Patients who received all 4 doses of TXA (n = 70) had a significantly lower transfusion rate compared to those who did not receive any TXA (7.1% vs 28.1%, P = .003). There were no significant differences in the number of major or minor adverse events between the 2 groups. Conclusions: The use of a standardized TXA protocol of 4 doses significantly decreases transfusion rates in eligible patients undergoing operative intervention for fragility hip fracture without an increase in major or minor adverse events. These findings are even more pronounced in patients with decreased preoperative hemoglobin. Level of Evidence: Prognostic Level III
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11
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The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries. J Am Acad Orthop Surg 2021; 29:e576-e583. [PMID: 33788803 DOI: 10.5435/jaaos-d-20-00750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/08/2021] [Indexed: 02/01/2023] Open
Abstract
Tranexamic acid (TXA) use has expanded across many surgical specialties. It has been shown to reduce blood loss, decrease transfusion rates, and, in some cases, improve mortality. Within orthopaedic surgery, its popularity has primarily grown within arthroplasty and spinal surgery. It has only recently gained traction within the field of orthopaedic trauma and fracture care. At this time, most literature focuses on hip fracture and pelvic trauma surgery. For hip fractures, the results are encouraging and generally support the claim that TXA may lower overall blood loss and decrease transfusions. Conversely, less support exists for TXA use in fractures of the acetabulum or pelvic ring. Based on the current fracture-related studies, TXA does not seem to carry an increased risk of thromboembolism or other complications. In addition, few studies have been noted discussing the route of administration, timing, or dosage. This article reviews the most current literature regarding TXA use in fracture care and expands on the need for further research to evaluate the role of TXA in orthopaedic trauma populations who carry a high risk for transfusion.
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Tarazona-Santabalbina FJ, Ojeda-Thies C, Figueroa Rodríguez J, Cassinello-Ogea C, Caeiro JR. Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3049. [PMID: 33809573 PMCID: PMC7999190 DOI: 10.3390/ijerph18063049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.
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Affiliation(s)
- Francisco José Tarazona-Santabalbina
- Department of Geriatric Medicine, Hospital Universitario de la Ribera, Alzira, 46600 Valencia, Spain
- CIBERFES, Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable, Instituto Carlos III, 28029 Madrid, Spain
| | - Cristina Ojeda-Thies
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Jesús Figueroa Rodríguez
- Department of Physical Medicine and Rehabilitation, Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | | | - José Ramón Caeiro
- Department of Orthopaedics and Traumatology, Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
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13
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Cuff DJ, Simon P, Gorman RA. Randomized prospective evaluation of the use of tranexamic acid and effects on blood loss for proximal humeral fracture surgery. J Shoulder Elbow Surg 2020; 29:1627-1632. [PMID: 32713466 DOI: 10.1016/j.jse.2020.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce blood loss in orthopedic surgery. It has been shown to decrease blood loss in upper- and lower-extremity arthroplasty, as well as lower-extremity fracture surgery. The use of TXA for proximal humeral fracture surgery has yet to be evaluated. The purpose of this study was to examine the effects of TXA on blood loss in patients undergoing open reduction-internal fixation (ORIF) or arthroplasty for the treatment of proximal humeral fractures. MATERIALS AND METHODS A total of 101 patients were randomized to receive either a single preoperative dose of intravenous TXA (53 patients) or a control dose of saline solution (48 patients) at the time of proximal humeral fracture surgery. On the basis of patient age and fracture pattern, ORIF was performed in 57 patients (30 TXA and 27 control patients) and reverse shoulder arthroplasty (RSA) was performed in the other 44 patients (23 TXA and 21 control patients). Intraoperative blood loss plus 24-hour drain output was used to calculate total blood loss for each procedure. The preoperative-to-postoperative change in hemoglobin level was also evaluated for each patient. Further stratification of blood loss and change in hemoglobin level based on procedure (ORIF or RSA) was performed as well. RESULTS Compared with the control group, the TXA group had less average intraoperative blood loss (178 mL vs. 129 mL, P < .0001), less postoperative drain output (103 mL vs. 62 mL, P < .0001), and less total blood loss (280 mL vs. 188 mL, P < .0001). Compared with the control group, the TXA group had a smaller average preoperative-to-postoperative change in hemoglobin level (-2.6 g/dL vs. -1.5 g/dL, P < .0001). Further stratification based on procedure showed that among patients undergoing ORIF and patients undergoing RSA, those receiving TXA had less average total blood loss and a smaller decrease in hemoglobin level than the control group. No identifiable intraoperative or postoperative complications associated with the use of TXA occurred in any patient. CONCLUSION TXA was effective in reducing total blood loss and led to a smaller preoperative-to-postoperative decrease in hemoglobin level compared with control in patients undergoing surgery for proximal humeral fractures. This effect was consistent in patients treated with either ORIF or arthroplasty as the surgical procedure. TXA can be used to decrease blood loss in the surgical treatment of proximal humeral fractures.
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Affiliation(s)
- Derek J Cuff
- Suncoast Orthopaedic Surgery and Sports Medicine, Venice, FL, USA.
| | - Peter Simon
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA; Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - R Allen Gorman
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA
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14
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de Groot R, Nijmeijer WS, Folbert EC, Vollenbroek-Hutten MMR, Hegeman JH. 'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary? Arch Osteoporos 2020; 15:19. [PMID: 32088776 DOI: 10.1007/s11657-020-0698-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/07/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group. PURPOSE In previous literature, elderly with a hip fracture are frequently defined as ≥ 70 years. However, given the ageing population and the rapidly increasing number of 'nonagenarians' (aged ≥ 90 years), the question rises whether this definition is still actual. The aim of this study is to determine whether nonagenarians show differences compared to patients aged 70-79 years and patients aged 80-89 years in terms of patient characteristics, complications and mortality rate. METHODS From April 2008 until December 2016, hip fracture patients aged ≥ 70 years treated according to our orthogeriatric treatment model were included. Patients were divided into three different groups based on age at admission: 70-79 years, 80-89 years and ≥ 90 years. Patient characteristics, risk of early mortality, complications and outcomes were analysed. Risk factors for 30-day mortality in nonagenarians were determined. RESULTS A total of 1587 patients were included: 465 patients aged 70-80 years, 867 patients aged 80-90 years and 255 patients aged ≥ 90 years. Nonagenarians were more often female and had a lower haemoglobin level at admission. Prefracture, they were more often living in a nursing home, were more dependent in activities of daily living and mobility and had a higher risk of early mortality calculated with the Almelo Hip Fracture Score (AHFS). Post-operative, nonagenarians suffer significantly more often from delirium and anaemia. The 30-day mortality and 1-year mortality were significantly higher. Differences increased gradually with age. CONCLUSION Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.
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Affiliation(s)
- R de Groot
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - W S Nijmeijer
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands.
- Telemedicine Group, Biomedical Signals and Systems, Faculty of Electrical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.
| | - E C Folbert
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - M M R Vollenbroek-Hutten
- Telemedicine Group, Biomedical Signals and Systems, Faculty of Electrical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
- ZGT Academy, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - J H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
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15
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Houston BL, Uminski K, Mutter T, Rimmer E, Houston DS, Menard CE, Garland A, Ariano R, Tinmouth A, Abou-Setta AM, Rabbani R, Neilson C, Rochwerg B, Turgeon AF, Falk J, Breau RH, Fergusson DA, Zarychanski R. Efficacy and Safety of Tranexamic Acid in Major Non-Cardiac Surgeries at High Risk for Transfusion: A Systematic Review and Meta-Analysis. Transfus Med Rev 2020; 34:51-62. [DOI: 10.1016/j.tmrv.2019.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/06/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022]
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16
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Krebs NM, VanWagner MJ, Marchewka T, Faraj U, Vitale CR. Tranexamic Acid in the Treatment of Hip Fractures: A Clinical Review. Spartan Med Res J 2019; 3:7026. [PMID: 33655149 PMCID: PMC7746023 DOI: 10.51894/001c.7026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although regularly used as a method to reduce blood loss in elective orthopedic procedures (e.g., total hip and knee arthroplasty), there currently is little evidence concerning the optimal dosage, timing and route for the use of tranexamic acid to reduce postoperative blood loss in hip fracture repair. SUMMARY OF THE EVIDENCE The current literature suggests that tranexamic acid may be used to reduce postoperative blood loss in addition to reducing the risk of requiring blood transfusions following the surgical repair of hip fractures. Furthermore, it may have the potential to improve patient outcomes and decrease the overall costs of caring for this patient population. CONCLUSIONS Further studies are needed to truly gauge the effect of tranexamic acid on long-term patient outcomes and hospital costs.
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Affiliation(s)
- Nathan M Krebs
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Michael J VanWagner
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Tiffany Marchewka
- Michigan State University College of Osteopathic Medicine Medical Student
| | - Usama Faraj
- Michigan State University College of Osteopathic Medicine Medical Student
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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18
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Nijmeijer WS, Folbert EC, Vermeer M, Vollenbroek-Hutten MMR, Hegeman JH. The consistency of care for older patients with a hip fracture: are the results of the integrated orthogeriatric treatment model of the Centre of Geriatric Traumatology consistent 10 years after implementation? Arch Osteoporos 2018; 13:131. [PMID: 30456430 DOI: 10.1007/s11657-018-0550-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 11/13/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED In the past 10 years after implementation, the orthogeriatric treatment model led in general to consistent outcomes for 1555 older adults in terms of most of the complications and mortality. Surgery was more often delayed to 24-48 h after arrival at the hospital, while the length of hospital stay shortened. INTRODUCTION Since 1 April 2008, patients aged ≥ 70 years presenting themselves with a hip fracture at Ziekenhuisgroep Twente (ZGT) have been treated according to the orthogeriatric treatment model. The aim of this study was to investigate if outcomes of the orthogeriatric treatment model are consistent over the first 10 years after implementation. METHODS Between 1 April 2008 and 31 December 2016, patients aged ≥ 70 years who were surgically treated at ZGT for a hip fracture were included and divided into three periods equally distributed in time. Patient characteristics, in-hospital logistics, complications, and mortality data were compared between the three periods. RESULTS A total of 1555 patients were included. There was a shift in the surgical treatment for the fractured neck of femur from dynamic hip screw/cannulated screws to hemiarthroplasty (p < 0.001). Surgery within 24 h after arrival to the hospital decreased (p < 0.001), while surgery within 48 h stayed the same (p = 0.085). Length of hospital stay significantly decreased over time (p < 0.001). Complication rates were consistent except for the number of postoperative anemia, delirium, and urinary tract infections. Mortality rates did not change over the years. CONCLUSIONS The orthogeriatric treatment model leads in general to consistent outcomes concerning mortality and most of the complications, except for postoperative anemia, delirium, and urinary tract infections. Inconsistent complication rates were influenced by altered diagnosis and treatment protocols. Length of hospital stay reduced, while time to surgery was more often delayed to 24-48 h. Monitoring clinical outcomes of the orthogeriatric treatment model over time is recommended in order to optimize and maintain the quality of care for this frail patient population.
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Affiliation(s)
- W S Nijmeijer
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands. .,Telemedicine Group, Biomedical Signals and Systems, Faculty of Electrical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.
| | - E C Folbert
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - M Vermeer
- ZGT Academy, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - M M R Vollenbroek-Hutten
- Telemedicine Group, Biomedical Signals and Systems, Faculty of Electrical Engineering, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.,ZGT Academy, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - J H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
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Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures. J Orthop Trauma 2018; 32:565-572. [PMID: 30339646 DOI: 10.1097/bot.0000000000001286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures. METHODS A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis. RESULTS Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV-). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV- cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge. CONCLUSIONS In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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