Clinical implications of anticoagulant oral therapy in elderly patients with hip fracture.

Fabio Cosseddu; Edoardo Ipponi; Luigi Perna; Simone Paterni; Rodolfo Capanna; Lorenzo Andreani

doi:10.23750/abm.v93i3.12606

Clinical implications of anticoagulant oral therapy in elderly patients with hip fracture.

Authors

Fabio Cosseddu Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy https://orcid.org/0000-0003-3416-7071
Edoardo Ipponi Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
Luigi Perna Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
Simone Paterni Departement of Geriatrics, University of Pisa, Pisa, Italy
Rodolfo Capanna Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
Lorenzo Andreani Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy https://orcid.org/0000-0002-8268-6987

DOI: https://doi.org/10.23750/abm.v93i3.12606

Keywords:

Hip Fractures, Oral Anticoagulant, Warfarin, NOACs, Transfusions

Abstract

Background and aim:Proximal femur fractures (PFFs) are among the most common fractures, especially in the elderly population. A PFF often represents a life-changing event. Their dramatic effects are attributable not only to the massive hemorrhages caused by the fracture, but also to the high risk of dramatic complications. These risks are supposed to be even higher for patients under oral anticoagulant treatment. In this study we evaluated how oral anticoagulant therapy effected patient’s prognosis.

Methods:Ours was a case-control review of over-65 patients treated surgically for proximal femur fractures between 2013 and 2019. Cases were divided in 2 groups depending if they were (Group A) or were not (Group B) under oral anticoagulant therapy at the moment of hospitalization.

Results:200 cases were included in our study: 100 in Group A and 100 in Group B. Surgical delay was significantly higher for cases under oral anticoagulant treatment compared to the other cases. Group A cases were transfused with a significantly higher frequency and with more blood units compared to Group B (p=0.0300; p=0.013). Combined cardiological and vascular complications occurred in 21 cases (10.5%), being significantly more common in Group A (16) than Group B (5), as testified by a chi-square test (P=0.011).

Conclusions:Cases under oral anticoagulant therapy are frail patients with a higher risk to develop massive hemorrhages after an hip fracture. For this reason, it is mandatory to achieve an early stabilization of patient’s clinical conditions and then perform surgery as soon as possible.

References

Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma 2014; 28 (2): 63-9.

Marom O, Yaacobi E, Shitrit P, Brin Y, Cohen S, Segal D, Ohana N. Proximal Femoral Fractures in Geriatric Patients: Identifying the Major Risk Factors for Postoperative Infection in a Single-Center Study. Isr Med Assoc J. 2021 Aug;23(8):494-496.

Fischer H, Maleitzke T, Eder C, Ahmad S, Stöckle U, Braun KF. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res. 2021 Aug 4;26(1):86.

Max W, Sinnot P, Kao C, Sung HY, Rice DP. The burden of osteoporosis in California, 1998. Osteoporos Int 2002; 13 (6): 493-500

Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7(5):407–13.

Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P. Epidemiology of hip fractures. Z Gerontol Geriatr. 2019;52(1):10–6.

Dyer SM, Crotty M, Fairhall N, Magaziner J, Beaupre LA, Cameron ID, et al. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr. 2016;16(1):158.

Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl J Med. 2017;377(21):2053–62.

Eamer G, Taheri A, Chen S, Daviduck Q, Chambers T, Shi X, et al. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev. 2018;1(1):CD012485

Tarazona-Santabalbina FJ, Belenguer-Varea Á, Rovira E, Cuesta-Peredó D. Orthogeriatric care: improving patient outcomes. Clin Interv Aging. 2016;11:843–56.

Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep. 2018;8:13933.

Mears SC, Kates SL. A guide to improving the care of patients with fragility fractures, edition 2. Geriatr Orthop Surg Rehabil. 2015;6(2):58–120.

Fardellone P, Barnieh L, Quignot N, Gusto G, Kahangire DA, Worth G, O'Kelly J, Khachatryan A, Desamericq G. The clinical and economic burden after an osteoporosis fracture in France: a nationwide population-based study. Arch Osteoporos. 2021 Aug 26;16(1):124.

Wodchis WP, Or Z, Blankart CR, Atsma F, Janlov N, Bai YQ, Penneau A, Arvin M, Knight H, Riley K, Figueroa JF, Papanicolas I. An International Comparison of Long-Term Care Trajectories and Spending Following Hip Fracture. Health Serv Res. 2021 Aug 11.

Huang HK, Peng CC, Lin SM, Munir KM, Chang RH, Wu BB, Liu PP, Hsu JY, Loh CH, Tu YK. Fracture Risks in Patients Treated With Different Oral Anticoagulants: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2021 Apr 6;10(7):e019618.

Pareja Sierra T, Bartolomé Martín I, Rodríguez Solís J, Bárcena Goitiandia L, Torralba González de Suso M, Morales Sanz MD, Hornillos Calvo M. Predictive factors of hospital stay, mortality and functional recovery after surgery for hip fracture in elderly patients. Rev Esp Cir Ortop Traumatol. 2017 Nov-Dec;61(6):427-435.

Brunskill SJ, Millette SL, Shokoohi A, Pulford EC, Doree C, Murphy MF, Stanworth S. Red blood cell transfusion for people undergoing hip fracture surgery. Cochrane Database Syst Rev. 2015 Apr 21;(4):CD009699.

Schermann H, Gurel R, Gold A, Maman E, Dolkart O, Steinberg EL, Chechik O. Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications. Injury. 2019 Feb;50(2):398-402.

Gautier N, Pirson A, Lechat JP, Van Der Linden P. Impact of direct oral anticoagulant therapy on operative delay, blood loss, transfusion and postoperative morbidity mortality in hip fracture patient, an observational study. Thromb Res. 2020 Oct;194:165-167.