Higher coagulation activity in hip fracture patients: A case‐control study using rotational thromboelastometry

Abstract

Introduction Trauma‐induced coagulopathy has been extensively investigated in the multitrauma setting, but only sparsely following moderate orthopedic trauma. The purpose of this study was to evaluate changes in the hemostatic profile of patients with hip fractures, using rotational thromboelastometry (ROTEM). Methods 198 patients with hip fractures who underwent surgery were included in the study. A matched group of 52 healthy individuals was also enrolled. Demographics, conventional laboratory assays, and ROTEM parameters were recorded and compared between patients and healthy adults. The preoperative and postoperative ROTEM values of fractured patients were also compared. Results The conventional coagulation assays were similar for the 2 groups. However, several ROTEM parameters including EXTEM MCF (P < .001), EXTEM alpha angle (P < .001), INTEM MCF (P < .001), INTEM A10 (P < .001), and INTEM alpha angle (P < .001) significantly differed between the 2 groups indicating a higher coagulation potential following hip fractures. Also, fractured patients had significantly lower INTEM and EXTEM CT values (P = .008 and P = .012, respectively) and significantly lower INTEM and EXTEM CFT values (P < .001). Adjusted analysis for confounders further confirmed the direct relationship between hip fracture and higher coagulation activity. Last, INTEM CT and CFT significantly decreased (P = .008 and P < .001, respectively), while INTEM MCF, A10, and alpha angle significantly increased (P < .001) postoperatively, indicating that surgery further increases the coagulation potential. Conclusion A higher coagulation activity following hip fractures and surgical treatment can be detected by ROTEM shortly after the injury, even when this is undetectable by conventional coagulation assays.

The Procoagulant Effect of COVID-19 on the Thrombotic Risk of Patients with Hip Fractures Due to Enhanced Clot Strength and Fibrinolysis Shutdown

“…Increased clot strength resulting in a hypercoagulable state has been also demonstrated in patients with hip fractures [ 14 ]. The combining effect of COVID-19 associated coagulopathy and hip fracture coagulopathy on clot firmness may be one of the major causes for increased thromboembolic incidence in this population [ 8 , 30 , 31 ]. Although CFT was shortened in our COVID-19 patients with hip fractures, indicating an accelerated clot formation dynamic due to COVID-19, CT was similar between COVID-19 and non-COVID-19 patients.…”

“…To compare the hemostatic profile of patients with COVID-19 and hip fractures with the coagulopathy associated with each of these two conditions separately, we used two previously recruited groups of patients [ 8 , 11 ]. Specifically, 198 previously recruited non-COVID-19 patients with hip fractures represented the first comparison group showing the hemostatic profile associated with hip fractures without COVID-19 [ 8 ], while 21 previously recruited patients with mild COVID-19 (i.e., without need for admission to the intensive care unit due to COVID-19 related respiratory distress, similar severity to our newly enrolled patients) and without fractures represented the second comparison group showing the hemostatic profile of mild COVID-19 [ 11 ]. Patients in both these groups were on thromboprophylaxis with low molecular weight heparin (LMWH).…”

“…Although with the advent of modern thromboprophylaxis the incidence of venous thromboembolism after hip fractures has been substantially decreased, the rate is still relatively high [ 6 ]. Several causes contribute to the thrombotic risk of hip fractures including endothelial damage and immobilization, while enhanced thrombin generation due to trauma-induced coagulopathy has also been hypothesized [ 7 , 8 ]. Numerous studies have also shown that COVID-19 results in a prothrombotic state with devastating clinical implications due to arterial and venous thromboembolic events [ 9 , 10 , 11 , 12 ].…”

“…Viscoelastic methods such as rotational thromboelastometry (ROTEM) provide a detailed insight into clot dynamics. Due to their advantageous properties, these methods have the potential to detect the level of hypercoagulability associated with increased thromboembolic risk [ 8 ]. Broad evidence exists regarding the use of viscoelastic methods to predict thromboembolic rates [ 13 , 14 ].…”

The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study

“…Second viscoelastic tests provide a dynamic analysis from the clot formation to the clot lysis whereas conventional tests evaluate only the initial steps of the coagulation mechanism until thrombin generation. Therefore, a ROTEM analysis could be used to monitor changes in blood coagulability such as hypofibrinolysis in those patients who receive TXA [21]. Several different ROTEM tests have been developed, focusing on different components of coagulation.…”