Effects of Anticoagulants on Outcome of Femoral Neck Fracture Surgery

Abstract

Purpose.

To review records of 330 patients who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy.

Methods.

Medical records of 235 women and 95 men aged 48 to 103 years (mean, 81.6; standard deviation [SD], 13.1) who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy were reviewed. 30 patients were on warfarin, 105 on aspirin, 28 on clopidogrel, and 167 were controls. The latter 3 groups were combined as the non-warfarin group and compared with the warfarin group. Hospital mortality, time from admission to surgery, length of hospital stay, return to theatre, and postoperative complications (wound infection, deep vein thrombosis, and pulmonary embolism) were assessed.

Results.

The warfarin and control groups were significantly younger than the clopidogrel and aspirin groups (80.8 vs. 80.0 vs. 84.2 vs. 83.7 years, respectively, p<0.05). 81% of the patients underwent surgery within 48 hours of admission. The overall mean time from admission to surgery was 1.8 days; it was longer in the warfarin than the aspirin, clopidogrel, and control groups (3.3 vs. 1.8 vs. 1.6 vs. 1.6 days, respectively, p<0.001). The mean length of hospital stay was 17.5 (SD, 9.6; range, 3–54) days. The overall hospital mortality was 3.9%; it was 6.7% in the warfarin group, 3.8% in the aspirin group, 3.6% in the clopidogrel group, and 3.6% in the control group (p=0.80). Four patients returned to theatre for surgery: one in the warfarin group for washout of a haematoma, 2 in the aspirin group for repositioning of a mal-fixation and for debridement of wound infection, and one in the control group for debridement of wound infection. The warfarin group did not differ significantly from non-warfarin group in terms of postoperative complication rate (6.7% vs. 2.7%, p=0.228) and the rate of return to theatre (3.3% vs. 1%, p=0.318).

Conclusion.

It is safe to continue aspirin and clopidogrel prior to surgical treatment for femoral neck fracture. The risk of delaying surgery outweighs the peri-operative bleeding risk.

Keywords

clopidogrel femoral neck fractures hospital mortality warfarin

References

Thakur

Czerwein

Butera

Palumbo

. Perioperative management of chronic anticoagulation in orthopaedic surgery. J Am Acad Orthop Surg 2010;18:729–38.

Robert-Ebadi

Le Gal

Righini

. Use of anticoagulants in elderly patients: Practical recommendations. Clin Interv Aging 2009;4:165–77.

Casaletto

Gatt

. Post-operative mortality related to waiting time for hip fracture surgery. Injury 2004;35:114–20.

Shiga

Wajima

Ohe

. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth 2008;55:146–54.

Beringer

Crawford

Brown

. Audit of surgical delay in relationship to outcome after proximal femoral fracture. Ulster Med J 1996;65:32–8.

Sexson

Lehner

. Factors affecting hip fracture mortality. J Orthop Trauma 1987;1:298–305.

Moran

Wenn

Sikand

Taylor

. Early mortality after hip fracture: Is delay before surgery important? J Bone Joint Surg Am 2005;87:483–9.

Inman

Michla

Partington

. Perioperative management of trauma patients admitted on clopidogrel (Plavix). A survey of orthopaedic departments across the United Kingdom. Injury 2007;38:625–30.

Hitos

Fletcher

. Venous thromboembolism and fractured neck of femur. Thromb Haemost 2005;94:991–6.

10.

Nwachuku

Jones

Clough

. Clopidogrel: Is a surgical delay necessary in fractured neck of femur? Ann R Coll Surg Engl 2011;93:310–3.

11.

Chechik

Thein

Fichman

Haim

Tov

Steinberg

. The effect of clopidogrel and aspirin on blood loss in hip fracture surgery. Injury 2011;42:1277–82.

12.

McDougall

Gray

Simpson

Whitehouse

Crawford

Donnelly

. Complications related to therapeutic anticoagulation in total hip arthroplasty. J Arthroplasty 2013;28:187–92.

13.

Simpson

Brew

Whitehouse

Crawford

Donnelly

. Complications of perioperative warfarin therapy in total knee arthroplasty. J Arthroplasty 2014;29:320–4.

14.

Palan

Odutola

White

. Is clopidogrel stopped prior to hip fracture surgery—A survey of current practice in the United Kingdom. Injury 2007;38:1279–85.

15.

Lavelle

EA Demers

Uhl

. Operative delay for orthopedic patients on clopidogrel (plavix): A complete lack of consensus. J Trauma 2008;64:996–1000.

16.

Sivakumar

McDermott

Bell

Pulle

Jayamaha

Ottley

. Dedicated hip fracture service: Implementing a novel model of care. ANZ J Surg 2013;83:559–63.

17.

Collyer

Reynolds

Truyens

Kilshaw

Corcoran

. Perioperative management of clopidogrel therapy: The effects on in-hospital cardiac morbidity in older patients with hip fractures. Br J Anaesth 2011;107:911–5.

18.

Maheshwari

Acharya

Monda

Pandey

. Factors influencing mortality in patients on antiplatelet agents presenting with proximal femoral fractures. J Orthop Surg (Hong Kong) 2011;19:314–6.

19.

Leonidou

Cam

Chambers

. Femoral neck fractures in patients on clopidogrel. The effect of delaying surgery and the introduction of the new SIGN guidelines. Surgeon 2011;9:318–21.

20.

British Orthopaedic Association Standards for Trauma (BOAST). Hip fracture in the older person. 2012.

21.

Sachs

Smith

Kuney

Paxton

. Does anticoagulation do more harm than good? A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty 2003;18:389–95.