Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis

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 Science TM , 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.

Development and validation of a nomogram to predict perioperative blood transfusion in patients undergoing total knee arthroplasty

“…In addition, the role of anti-inflammatory or antiplatelet drugs in blood management cannot be ignored. Recent meta-analyses showed that early hip fracture surgery was significantly related to a higher transfusion rate in patients with antiplatelet treatment than patients without antiplatelet treatment [27]. Therefore, antiplatelet drugs may play a role in influencing blood administration for TKA patients, and we will further study this potential mechanism in a later study.…”

Orthogeriatric Care: Reviewing Improvements in Outcomes

“…showed a small increase in bleeding, as evidence by transfusion rates (OR=1.21; 95%CI: 1.01 to 1.44; p < 0.05) and haemoglobin drop (WMD=0.75; 95%CI, 0.50 to 1 g/dL; p < 0.001) [130]. Patients treated with clopidogrel with a surgical delay of 5 days or more had more complications (pulmonary embolism, myocardial infarction, heart failure and pressure ulcers), than those that were treated in 24-72 h [130]. Although interruption of antiplatelet therapy in those at low risk for thrombotic complications may be considered, it seems safer to continue antiplatelet therapy in patients with a high thrombotic risk.…”

“…Current evidence from meta-analyses of observational studies including 245 patients treated with clopidogrel compared with 2400 controls indicates that it is unnecessary to delay surgery to restore platelet function when patients with hip fractures receive aspirin alone, clopidogrel alone or clopidogrel combined with aspirin. Furthermore, early surgery (≤48 h) significantly reduced mortality (OR=0.43; 95%CI: 0.23 to 0.79; p=0.006) and hospital stay (WMD = -6.05; 95%CI: -7.06 to -5.04; p < 0.001), which is important for patient recovery [130,131].…”

“…Neuroaxial anaesthesia has been proven to be safe in patients receiving aspirin treatment. Furthermore, of the aforementioned meta-analyses, 145 patients treated with clopidogrel were operated under spinal anaesthesia within 48-72 h following hip fracture, without any reported cases of clinical spinal hematoma [130,131]. To our knowledge, there are currently no published studies investigating prasugrel or ticagrelor regarding acute hip fracture surgery.…”

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

“…Since all available antiplatelet agents (i.e., aspirin, clopidogrel, ticagrelor and ticlopidine) act as irreversible inhibitors of platelet aggregation, the reversal of their effect mainly depends upon platelet half-life which varies between 7 and 10 days [62]. Many studies have shown that, even exposed to further potential blood loss, subjects taking antiplatelet agents do not experience more major bleeding events or mortality and do not require more blood transfusions [63][64][65][66]. Conversely, any delay with surgery is associated with poorer outcomes [64][65][66][67].…”