Anticoagulation therapy and hand surgery: Do we worry too much?

Twoon, Mark; Hallam, Marc-James

doi:10.4103/0970-0358.173144

Cited by 6 publications

(3 citation statements)

References 5 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…31 More recent studies have similarly concluded minimal impact of preoperative INR on complications following hand surgery, which is hypothesized to be due to the minimally invasive nature of the majority of hand procedures. [31][32][33] As such, preoperative INR should be more scrutinized prior to more invasive orthopaedic procedures, such as joint replacement and traumatic surgeries, compared to less invasive surgeries such as hand procedures.…”

Section: Discussionmentioning

confidence: 99%

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Wang¹,

Quan

Kapoor³

et al. 2022

Shoulder & Elbow

View full text Add to dashboard Cite

Background Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA. Methods Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups. Results Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0–1.25, >1.25–1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25–1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both). Discussion With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA. Level of Evidence III

show abstract

Section: Discussionmentioning

confidence: 99%

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Wang¹,

Quan

Kapoor³

et al. 2022

Shoulder & Elbow

View full text Add to dashboard Cite

show abstract

“…However, it is unclear where specific hand and wrist interventions fall along the spectrum in terms of bleeding risk 21,22 . Therefore, wide variability in daily practice continues to exist with regards to the management of antiplatelet and anticoagulant medication in patients undergoing hand or wrist surgery 23 .…”

Section: Jacobmentioning

confidence: 99%

Recommendations from the ICM-VTE: Hand & Wrist

2022

Journal of Bone and Joint Surgery

View full text Add to dashboard Cite

The ICM-VTE Hand & Wrist Delegates* Question: 1 -Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in hand surgery?Response/Recommendation: Surgeries involving general anesthesia for >90 minutes, surgeries requiring bedrest or limited ambulation postoperatively, and surgeries involving replantation or free vascularized tissue transfer should be considered major in Hand Surgery.Strength of Recommendation: Consensus.Delegates vote: Agree 90.48% Disagree 4.76% Abstain 4.76% (Strong Consensus)Rationale: Risk factors for venous thromboembolism (VTE) following hand surgery are poorly studied. This is partly due to the very low incidence of these adverse events, which was determined to be 0.0018% by Hastie et al., in a sample of 3,357 consecutive upper extremity surgeries 1 . As a result, it is extremely challenging to stratify procedures into high-or low-risk categories for VTE.Some studies of VTE risk following surgical procedures have included hand and wrist surgery in their samples. A study by Keller et al., of VTE following endoprosthesis surgeries included 183,420 upper extremity surgeries and reported a 0.4% incidence of VTE (2.69 times lower than that of lower extremity endoprosthesis surgery), but this study did not differentiate between hand, wrist, elbow, and shoulder procedures 2 . Similarly, studies investigating VTE prophylaxis following free tissue transfer have included upper extremity tissue transfers. Ricci et al., recommended subcutaneous heparin VTE prophylaxis following upper extremity free flaps, but based this recommendation on expert opinion given the lack of available evidence 3 . A National Surgical Quality Improvement Program (NSQIP) database study of VTE following plastic surgery analyzed 19,276 plastic surgery cases performed under general anesthesia and found a VTE incidence of 1.3% in cases lasting over 5 hours. In cases lasting less than 5 hours, VTE incidence was less than 0.36%. There were no hand surgical procedures that resulted in >2 VTE within this sample, although the total number of hand surgical cases that were complicated by VTE was not reported 4 . Consensus guidelines from the British Society for Surgery of the Hand (BSSH) cur-rently recommend mechanical VTE prophylaxis for cases under general anesthesia lasting >90 minutes and/or in patients with at least one VTE risk factor, and recommend the consideration of pharmacological prophylaxis in patients undergoing >90 minutes of general anesthesia with more than one risk factor, or prolonged immobility 5 .Given the lack of evidence differentiating high-and lowrisk hand surgeries, further study in this topic is needed, and current recommendations are based on a consensus of opinion among experts.

show abstract

“…As a result, wide variability exists in daily practice regarding their management. 5,6 Several studies have been published describing individual institutional experience with perioperative anticoagulant use in hand and wrist surgery.…”

mentioning

confidence: 99%

Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery

Gallant

Matzon

Beredjiklian

et al. 2023

J Am Acad Orthop Surg

View full text Add to dashboard Cite

There is wide variability in the management of patients on antithrombotic therapy requiring surgery of the hand and wrist. There are no specific guidelines regarding whether to temporarily cease or continue oral anticoagulants and antiplatelet agents. Discontinuation of these medications before surgery can lead to perioperative thromboembolic or ischemic events. On the other hand, continuation can lead to intraoperative or postoperative bleeding complications. This review discusses various anticoagulants and antiplatelet agents with special considerations for their management, analyzes the current literature, summarizes current recommendations, and provides direction for additional research.

show abstract

Anticoagulation therapy and hand surgery: Do we worry too much?

Cited by 6 publications

References 5 publications

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Recommendations from the ICM-VTE: Hand & Wrist

Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery

Contact Info

Product

Resources

About