The Hip Fracture Patient on Warfarin: Evaluating Blood Loss and Time to Surgery

Cohn, Matthew R.; Levack, Ashley E.; Trivedi, Nikunj N.; Villa, Jordan C.; Wellman, David S.; Lyden, John P.; Lorich, Dean G.; Lane, Joseph M.

doi:10.1097/bot.0000000000000857

Cited by 37 publications

(26 citation statements)

References 23 publications

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“…Studies investigating hip fracture treatment and the use of anticoagulants have so far reported conflicting results. While increased risk of complications was detected in one study [ 18 ], other studies discovered no such effect [ 19 , 20 ]. These diverse findings could be explained by different perioperative administration of anticoagulant drugs.…”

Section: Discussionmentioning

confidence: 99%

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

et al. 2020

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The aim of this study was to determine whether DOAC-users with a hip fracture have delayed surgery, longer length of hospital stay or altered risk of bleeding complications compared to non-users. Findings DOAC-users with a hip fracture did not have increased surgical delay, length of stay or risk of reported bleeding complications compared to patients without anticoagulation prior to surgery. Message Our study does not support delayed surgery for DOAC-users suffering a hip fracture.

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Section: Discussionmentioning

confidence: 99%

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

et al. 2020

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“…In 2006 Foss et al [ 6 ] found that the median calculated total peri-operative blood loss in patients that had undergone intramedullary nailing was increased compared to patients that were operated with arthroplasty due to a hip fracture (1.86 L versus 1.30 L, respectively). Similarly, in a recent study by Cohn et al in 2017 [ 28 ] they found significantly lower preoperative Hb in patients undergoing intra medullary nailing (extra-capsular fractures) and a greater blood loss in the warfarin group compared with a control group (1.22 L versus 1.19 L) but this was not statistically significant. In contrast we found no difference in the calculated blood-loss when comparing warfarin patients with the control patients.…”

Section: Discussionmentioning

confidence: 88%

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

Mattisson

Lapidus

Enocson

2018

BMC Musculoskelet Disord

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BackgroundHip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods.The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.MethodsA retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.ResultsThere were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).ConclusionWe found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

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“…Cohn et al in their study showed that 58.1% of the patients in warfarin underwent transfusion after surgery comparing to a 56.6% in the control group ( p = 0.86). Also, the blood loss was similar in the two groups ( p = 0.95) [33]. Even Lott et al in their study of 479 patients with PFF, in which 112 were in therapy with warfarin, did not notice statistical differences in the two groups in terms of blood loss ( p = 0.35) and post-operative transfusions ( p = 0.535) [34].…”

Section: Discussionmentioning

confidence: 99%

The impact of warfarin on operative delay and 1-year mortality in elderly patients with hip fracture: a retrospective observational study

et al. 2019

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Background Guidelines underline the importance of early surgery in elderly patients with proximal femoral fractures. However, most of these patients present a high number of comorbidities, some of which require the use of warfarin. Waiting for INR decrease is a cause of surgical delay, and this influences negatively their outcome. Methods We retrospectively reviewed all patients with proximal femoral fracture admitted to our unit from March 2013 to March 2017 to determine whether warfarin therapy is associated with reduction of survival, delay of surgery, and increased blood loss. From 1706 patient, a total of 1292 fulfilled the eligibility criteria and were included. Data regarding general information (type of fracture according to AO/OTA classification), pharmacological history regarding anticoagulant therapy pre-admission, surgery (type of surgery and time to surgery), clinical findings (blood loss), and date of exitus were collected. Results We identified 157 patients with warfarin, 442 with antiplatelet agents (aspirin, clopidogrel, ticlopidin), and 693 in the control group. We observed a significant difference in the warfarin group regarding an increased ASA score, Charlson Comorbidity Index, and blood loss. Patients taking warfarin experience delay to the theater significantly more than the other groups. Patients in warfarin therapy have a 42% higher risk of death within 1 year from their surgery. Patients who underwent surgery after 48 h have 1.5 times higher risk of mortality with respect to the patients who underwent surgery within 48 h. Conclusion Warfarin therapy at the time of proximal femoral fractures is associated with increased time to surgery, blood loss, and mortality.

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The Hip Fracture Patient on Warfarin: Evaluating Blood Loss and Time to Surgery

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

Cited by 37 publications

References 23 publications

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

The impact of warfarin on operative delay and 1-year mortality in elderly patients with hip fracture: a retrospective observational study

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