Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review

Abstract

The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.

Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures

“…Currently there is strong evidence that acetylsalicylic acid does not increase the risk of bleeding during major surgery or regional anesthesia. On the other hand, clopidogrel should be stopped for 5 days before regional anesthesia such as spinal, epidural or peripheral nerve blocks [5,6]. Nonetheless, in our study, even patients on acetylsalicylic acid had a longer delay of surgery compared to controls.…”

“…We offer a local perspective from a single level 1 trauma center. Time to surgery, use of platelet aggregation inhibitors and anticoagulant medication and type of anesthesia have regional differences [1][2][3][4][5][6][7][8]. Madsen et al found that antithrombotic medication use in general increased 2.3 times from 19% to 43%, with the highest increase seen for anticoagulants.…”

“…It is considered a delayed emergency/major surgery with a high risk of bleeding. For anticoagulated patients, the delay is based on the type of blood-thinning medication used, current guidelines and product label information: acetylsalicylic acid-no delay; clopidogrel-5 days for neuraxial anesthesia, less for orthopedic surgery; acenocoumarin-INR < 1.5 for neuraxial anesthesia, higher values for orthopedic surgery yet no consensus regarding cut-off value; patients with an INR >3 should receive oral vitamin K; apixaban, rivaroxaban and dabigatran-2 to 5 days with more caution required for neuraxial anesthesia than for orthopedic surgery [1,5,6].…”

“…Patients on DOACs had similar perioperative hemoglobin change, transfusion rates and mortality compared to subjects without anticoagulants in both trochanteric -internal fixation and femoral neck -arthroplasty situations [19][20][21][22]. For DOACs surgery should therefore be reasonably delayed, until reversal agents become available [5,6].…”

“…The current recommendations aim to reverse the anticoagulant effect to more permissive cutoff values and thus avoid postponing surgery as much as possible [5][6][7][8].…”