Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures

Dettoni, Federico; Castoldi, Filippo; Via, Alessio Giai; Parisi, Simona; Bonasia, Davide Edoardo; Rossi, Roberto

doi:10.1007/s00068-011-0073-x

Cited by 10 publications

(8 citation statements)

References 43 publications

(49 reference statements)

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“…The overall complication rate was 22.4% and was therefore compatible to complication rates described in previous studies [14,21]. The inhouse mortality rate was 4% but showed a significant increase for patients on anticoagulants (7.7%) consistent with other studies showing increased mortality for anticoagulants [22] Dettoni et al were able to determine two main factors for increased mortality and complications, namely warfarin and a delay in time to surgery in a large cohort of 875 hip fractures [23]. DOACS were evaluated as a risk for higher mortality and delay to surgery also by a large metaanalysis [24].…”

Section: Discussionsupporting

confidence: 84%

Do anticoagulants impact the “in-house mortality” after surgical treatment of proximal femoral fractures—a multivariate analysis

Fenwick

Pfann

Mayr

et al. 2022

International Orthopaedics (SICOT)

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Purpose The prevalence of proximal femur fractures is increasing with rising population age. Patients are presenting with more comorbidities. Anticoagulants create a challenge for the necessary early surgical procedure (osteosynthesis or arthroplasty). Our aim was to investigate the influence of anticoagulants on in-house mortality after surgical treatment of proximal femoral fractures. Methods A retrospective single-centre study was conducted including 1933 patients with an average age of 79.8 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. One treatment protocol was performed based on type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Results On average, patients with anticoagulants had a delay to surgery of 41.37 hours vs 22.1 hours for patients without (p < 0.000). Anticoagulants were associated with the occurrence of complications. The total complication rate was 22.4%. Patients with complications showed a prolonged time to surgery in comparison to those without (28.9 h vs 24.9 h; p < 0.00). In-house mortality rate was 4% and twice as high for patients on anticoagulants (7.7%; p < 0.00). Whilst there was no significant difference in the mortality rate between surgery within 24 and 48 hours (2.9% vs. 3.8%; p < 0.535), there was a significant increase in mortality of patients waiting more than 48 hours (9.8%; p < 0.001). Conclusions Pre-existing anticoagulant therapy in patients with proximal femur fractures is associated with a higher mortality rate, risk of complications and prolonged hospital stay. Further influential factors are age, gender, BMI and time to surgery.

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Section: Discussionsupporting

confidence: 84%

Do anticoagulants impact the “in-house mortality” after surgical treatment of proximal femoral fractures—a multivariate analysis

Fenwick

Pfann

Mayr

et al. 2022

International Orthopaedics (SICOT)

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“…Even in our study, warfarinised patients showed higher mortality compared to patients that do not assume any anticoagulant drugs or antiplatelet therapy. In an observational study by Dettoni et al published in 2011 including 875 patients with PFF, they noticed that warfarin therapy and delay in time to surgery were associated with a significantly higher risk for complications and mortality compared to all other patients [27]. Lawrence et al showed an association between warfarin therapy with prolonged time to surgery and an increased 1-year mortality rate in hip fracture patients and they suggested to consider warfarin therapy a “Red flag” in patients with PFF [28].…”

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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“…Lawrence et al in 2016 [ 18 ] showed an association between warfarin therapy with prolonged time to surgery (mean 46 h versus 24 h for the control group), and an increased 1-year mortality rate in hip fracture patients. In an observational study by Dettoni et al in 2011 [ 19 ] including 875 consecutive hip fracture patients they reported that the presence of two critical factors: warfarin therapy and a delay in time to surgery, was associated with a significantly higher risk for complications and mortality compared to all other patients. They concluded that the “discontinue drug and delay surgery” strategy is not suitable for hip fracture patients on warfarin therapy.…”

Section: Discussionmentioning

confidence: 99%

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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Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures

Abstract: The "discontinue drug, and delay surgery" strategy is not suitable for patients on anticoagulant (warfarin) therapy affected by a hip fracture.

Cited by 10 publications

References 43 publications

Do anticoagulants impact the “in-house mortality” after surgical treatment of proximal femoral fractures—a multivariate analysis

Do anticoagulants impact the “in-house mortality” after surgical treatment of proximal femoral fractures—a multivariate analysis

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

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

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