Proximal femur fractures in patients taking anti-coagulants: has anything changed?

Giannoudi, Marilena; Giannoudis, Peter V.

doi:10.1530/eor-22-0028

Cited by 6 publications

(14 citation statements)

References 65 publications

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“…The current literature does not support its use in VKA reversal for PFF surgery [ 2 ]. Ultimately, it is important that the benefit of reversal of VKA is balanced with the increased risk of thrombotic events [ 3 ]. Therefore, bridging with treatment-dose subcutaneous low-molecular-weight heparin (LMH) or intravenous unfractionated heparin should be considered in patients with mechanical heart valves and atrial fibrillation with recent history of stroke, deep vein thrombosis or pulmonary embolism [ 5 ].…”

Section: Resultsmentioning

confidence: 99%

“…Proximal femur fractures (PFF) are common injuries in elderly patients [ 1 ], [ 2 ], [ 3 ]. Higher average life expectancy and lifestyle changes in the elderly populations are predicted to lead to a continuous rise of PFF [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…Due to the high number of cardiovascular and cerebrovascular comorbidities in frail and elderly patients, many are under permanent anticoagulation. Studies suggest that up to 53.6 % of the patients are anticoagulated at the time of fracture [ 1 , 3 , 5 ]. In the past, the perioperative anticoagulation management in elderly patients with PFF was often approached with caution, as it was though that extended preoperative disruption was necessary to prevent complications like considerable bleeding, higher transfusion demand and the development of (post-operative) haematoma [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

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Anticoagulation management in elderly patients with proximal femur fractures – overview of current concepts

Youssef,

Dietrich,

Hättich

2023

Innovative Surgical Sciences

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Objectives Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial. Content This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF. Summary and Outlook Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Anticoagulation management in elderly patients with proximal femur fractures – overview of current concepts

Youssef,

Dietrich,

Hättich

2023

Innovative Surgical Sciences

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“…A idade mínima para inclusão nos estudos analisados foi de 60 anos, observadas nos estudos de Moreira e colaboradores (2021) e Finlayson e colaboradores (2019). A idade avançada pode estar relacionada não apenas ao aumento de fraturas, mas também ao aumento de comorbidades e medicamentos (Giannoudi & Giannoudis, 2022).…”

Section: Discussionunclassified

“…O envelhecimento é um processo biológico natural, no qual, mudanças anatômicas, fisiológicas e psicológicas são inerentes a este processo (Moreira et al, 2021;Yoon et al, 2013). Assim, esta população se torna mais propensa a doenças crônicas e acidentes, demandando de internações e intervenções cirúrgicas (Giannoudi & Giannoudis, 2022). Doenças senis, como a osteoporose, e limitações psicomotoras em idosos ocasiona o aumento do risco de fraturas e lesões por causas externas.…”

Section: Introductionunclassified

Óbitos por fratura do fêmur proximal: uma revisão sistemática

Medeiros¹,

Rossi²,

Kominski³

et al. 2022

RSD

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Introdução: As fraturas de fêmur proximal podem acontecer pessoas de todas as idades. Entretanto são mais comumente encontradas em pessoas com idade mais avançada, ainda mais frequentemente em mulheres acima de 60 anos. Essas fraturas podem ser consideradas emergências cirúrgicas, podendo ser agravadas com a presença de comorbidades. Os pacientes que apresentam esse tipo de fratura têm apresentado um índice de mortalidade aumentado, associado a condições gerais desse indivíduo como idade e fisiologia do paciente. Objetivo: Verificar as evidências científicas relacionadas a mortes causadas por fraturas do fêmur proximal na população em geral. Metodologia: Estudo descritivo, qualitativo, do tipo revisão bibliográfica sistemática. Para a pesquisa de artigos, foram utilizadas as plataformas de base de dados PubMed/Medline e Scielo e foram incluídos artigos publicados nos últimos dez anos (2012–2022). Foram utilizados os seguintes descritores: “fracture of the proximal femur”, “deaths” and “impacts”. Resultados e Conclusão: Foram encontrados um total de dez artigos indexados nas bases de dados Scielo®️, MedLine®️ e PubMed®️, no período de 2004 a 2021. Através dessa revisão sistemática foram correlacionados o tempo de internação, sexo dos pacientes, presenças de comorbidades. Essa análise apontou que uma maior exposição ao ambiente hospitalar, associada com as comorbidades podem realmente ser fatores que levem a um aumento da mortalidade nesses pacientes. Esses dados auxiliam na análise da expectativa quanto a mortalidade e morbidade ocasionada por essas fraturas.

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Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures

Fisher,

Salottolo,

Carrick

et al. 2024

Trauma Surg Acute Care Open

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ObjectiveThe perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures.MethodsThis retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative.ResultsThere were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28–4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14–1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43).ConclusionWomen taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury.Level of evidenceIV

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Proximal femur fractures in patients taking anti-coagulants: has anything changed?

Cited by 6 publications

References 65 publications

Anticoagulation management in elderly patients with proximal femur fractures – overview of current concepts

Anticoagulation management in elderly patients with proximal femur fractures – overview of current concepts

Óbitos por fratura do fêmur proximal: uma revisão sistemática

Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures

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