Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss

Factors contributing to perioperative blood transfusion during total hip arthroplasty in patients continuing preoperative aspirin treatment: a nomogram prediction model

BACKGROUND

Total hip arthroplasty (THA) is associated with considerable blood loss during the perioperative period, which commonly requires a blood transfusion, especially in patients who continue aspirin treatment preoperatively. Blood transfusion can significantly increase both the length of hospital stay and total treatment costs and is potentially associated with adverse reactions. However, a visual predictive model for assessing the risk of blood transfusion in THA patients is lacking. The aim of this study was to develop and validate a nomogram to predict the risk of blood transfusion during THA in patients who continue aspirin treatment preoperatively.

METHODS

From June 2016 to December 2022, 228 consecutive patients who continued preoperative aspirin treatment and underwent primary unilateral THA were enrolled in this retrospective study. Potential risk factors were screened using least absolute shrinkage and selection operator (LASSO) regression, and univariate and multifactorial logistic regressions were performed on the factors screened using LASSO regression to further control for confounding effects. Finally, a nomogram was constructed on the basis of the variables identified through multiple regression analysis. Internal validation was carried out using the Bootstrap method to assess the performance of the model using the C-index, area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA).

RESULTS

Among the 228 patients, 43 (18.9%) received a blood transfusion. Patients who received a blood transfusion had a longer hospital stay (p = 0.01). The independent risk factors for blood transfusion included the concomitant use of clopidogrel (OR = 4.415), preoperative hemoglobin level (OR = 0.062), total estimated blood loss volume (OR = 3.411), American Society of Anesthesiologists (ASA) class (OR = 1.274), and the use of tranexamic acid (OR = 0.348). The prediction model had a C-index of 0.862, an internally validated C-index of 0.833, and an AUC of 0.833, indicating excellent discriminatory power. The calibration curve showed a good calibration effect, and DCA indicated that the nomogram has strong clinical applicability.

CONCLUSIONS

Based on these five independent risk factors, our nomogram can accurately predict the risk of blood transfusion in THA patients who continue aspirin treatment preoperatively, thereby assisting surgeons in clinical decision-making.

Effectiveness of aspirin in preventing deep vein thrombosis following proximal femoral fracture surgery in Japan

Previous studies have shown that aspirin is effective as a prophylactic agent against venous thromboembolism (VTE) following proximal femoral fractures (PFF). In Japan, there is a lack of evidence regarding its efficacy and safety in this context. Consequently, aspirin is not covered by insurance for the prevention of venous thrombosis. This study aimed to investigate whether continued aspirin use in patients with PFF, who were already taking aspirin for cerebrovascular disease prevention before injury is effective as a prophylaxis for deep vein thrombosis (DVT). We retrospectively analyzed PFF patients (≥ 65 years) who underwent postoperative duplex ultrasonography from January 2010 to December 2023.The study compared patients taking aspirin alone (aspirin group) and those not taking antiplatelet agents or anticoagulants (control group), matched by propensity scores. We enrolled 1064 patients while 161 (15%) were in the aspirin group. After matching, 128 patients were analyzed. DVT incidence was not statistically significant between the aspirin (54) and control groups (60) (OR: 0.81; 95%CI: 0.49- 1.36; p = 0.44). Proximal DVT incidence was also similar (OR: 2; 95%CI: 0.50-7.00; p = 0.33). Additionally, since use of other postoperative antithrombotic prophylaxis (78%) is thought to have a significant impact on the incidence of DVT, a subgroup analysis was conducted to evaluate the effect of aspirin in patients who did not receive postoperative antithrombotic prophylaxis. Similarly, there was no statistically significant difference in either DVT (OR: 1.38; 95% CI: 0.55-3.42; p = 0.49) or proximal DVT (OR: 2.00; 95% CI: 0.37-10.92; p = 0.42). This study demonstrates that aspirin is not effective for preventing VTE in patients with PFF in Japan.

Post-operative complications associated with the pre-operative use of Aspirin in patients undergoing surgery for hip or femoral fracture: a meta-analysis

BACKGROUND

The number of patients with hip and femoral fractures is increasing and is expected to further increase in upcoming years due to the ageing population and the life expectancy of the general population. In this analysis, we aimed to systematically assess the post-operative complications associated with the pre-operative use of Aspirin in patients undergoing surgery for hip or femoral fracture.

METHODS

Common online databases: Google Scholar, Web of Science, MEDLINE, Cochrane database, EMBASE ( www.sciencedirect.com ), and http://www.

CLINICALTRIALS

gov were searched for English-based studies which reported post-operative outcomes in patients with versus without the use of Aspirin prior to surgery for hip or femoral fracture. The endpoints of this analysis included cerebro-vascular attack, acute coronary syndrome/cardiovascular complications, hematoma, deep venous thrombosis, pulmonary embolism, patients requiring blood transfusion, bleeding events, and in-hospital mortality. RevMan software 5.4 was the statistical software used for this meta-analysis. Risk ratio (RR) with 95% confidence intervals (CI) was used to represent the post-analytical result.

RESULTS

A total number of 2823 participants were included in this analysis whereby 821 were assigned to Aspirin prior to surgery. Results of this analysis showed that post-operatively the risk of cerebrovascular attack (RR: 1.62, 95% CI 0.29-9.20; P = 0.58), cardiovascular complication (RR: 1.86, 95% CI 0.62-5.52; P = 0.27), pulmonary embolism (RR: 2.45, 95% CI 0.77-7.77; P = 0.13), bleeding events (RR: 1.24, 95% CI 0.39-3.96; P = 0.71), and in-hospital mortality (RR: 0.95, 95% CI 0.47-1.91; P = 0.89) were not significantly higher in those patients who were and who were not taking Aspirin pre-operatively. The risk of deep venous thrombosis (RR: 1.82, 95% CI 0.23-14.60; P = 0.57), hematoma formation (RR: 1.57, 95% CI 0.11-21.49; P = 0.74) and patients requiring blood transfusion post-operatively (RR: 1.22, 95% CI 0.99-1.52; P = 0.07) were not significantly different in patients who were on Aspirin and those who were not on Aspirin pre-operatively.

CONCLUSION

The post-operative complications associated with the pre-operative use of Aspirin in patients undergoing surgery for hip or femoral fracture were apparently not significantly different when compared to patients who were not on Aspirin. Therefore, Aspirin should not be considered an absolute contraindication in patients undergoing surgery for hip or femoral fracture. Hence, an early or emergency surgery for hip or femoral neck fracture in patients on Aspirin therapy should apparently not pose any problem. Further larger trials should be able to confirm this hypothesis.

The management of anticoagulated fragility femoral fracture patients

Approximately 20% of patients sustaining a fragility femur fracture use an anticoagulant, and over 30% use an antiplatelet medication, both of which can result in surgical delay. Previously confined to fractures of the proximal femur, performance assessment, outcome and surgical delay is now assessed for all fractures of the femur in older patients, including those involving implants. This narrative review draws together all literature pertaining to anticoagulation and antiplatelet management in older patients with a fracture of the femur to address 5 key points: prevalence of anticoagulant and antiplatelet use; analysis of management protocols; collation of national guidelines; comparison of perioperative management; timing of surgery and perioperative outcomes.Our review found that the prevalence of fragility femur fracture patients taking anticoagulant and antiplatelet medication ranges from 20-40% and 25-35% respectively. More anticoagulated patients are taking direct oral anticoagulants compared to vitamin k antagonists with growing implications for variation in practice and delays to surgery.Several national guidelines exist although these are characterised by marked variation, there is little standardisation, and none are generalised across all fragility femur fractures.Expedited surgery within 36 hours of admission in patients taking an anticoagulant or antiplatelet medication is safe and has been demonstrated in fractures of the proximal femur across many small number studies although no such evidence exists in non-proximal femur fractures despite this population sharing similar characteristics. There is a need for all fractures of the femur in older people to be considered when researching and assessing performance in this population to prevent needless variation and delay.

Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin.

METHODS

A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents.

RESULTS

Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators.

CONCLUSIONS

Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.

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

Objective

The 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.

Methods

This 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 χ2 tests, 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.

Results

There 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).

Conclusion

Women 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 evidence

IV.

A retrospective cohort study of the effect of intravenous tranexamic acid infusion on geriatric hip fractures patients undergoing proximal femoral nail antirotation

Background: Tranexamic acid (TXA) has been used in the management of bleeding. We are conducting a retrospective cohort study to analyse the effect of intravenous TXA infusion on the surgical outcomes of geriatric hip fracture cases which undergoes proximal femoral nail antirotation.  Methods: In this study, 364 patients who had undergone proximal femoral nail antirotation between January 2018 and December 2019 in United Christian Hospital have been recruited. Two-hundred thirteen patients were recruited in controlled group and 151 patients were recruited in TXA group. One gram of TXA acid was injected intravenously on induction of anaesthesia and before surgical incision. Outcomes including length of stay, operation time, intraoperative blood loss, haemoglobin and haematocrit drop and post-operative blood transfusion have been measured. Results: There was a reduction in operative time, intraoperative blood loss, post-operative haemoglobin and haematocrit drop and post-operative blood transfusion in TXA group, with a reduction in the intraoperative blood loss (Controlled group: 97.8 ±  67.7 ml, TXA group: 76.0 ± 71.4, Difference −22.3%, p-value: 0.0036) and post-operative haematocrit drop (Controlled group: 0.04 ± 0.03, TXA group: 0.03 ± 0.03, Difference −25%, p-value: 0.05) being statistically significant. The length of stay is not statistically significant between the two groups. TXA is an antifibrinolytic agent which acts by binding to plasminogen which inhibits plasma formation. It has a potential reduction in blood loss in major operations.  Conclusion: Intravenous TXA infusion helps to reduce blood loss in a patient undergoing proximal femoral nail antirotation. It is safe to use in the geriatric group of patients. We would recommend the usage of TXA infusion to improve the surgical outcome.

Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study

Background

To investigate whether hypocalcemia influenced total blood loss and transfusion rate in elderly patients with hip fracture.

Methods

From our hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium level was corrected for albumin concentration, and hypocalcaemia was defined as corrected calcium < 2.11 mmol/L. Hemoglobin and hematocrit were obtained on admission day and postoperative day, and blood transfusions were collected. According to the combination formulas of Nadler and Gross, the total blood loss of each patient was calculated. Risk factors were further analyzed by multivariate linear regression.

Results

A total of 583 consecutive elderly hip fracture patients were finally included (mean age 79.32 ± 8.18 years, 68.61% female). On admission, the mean serum corrected calcium level was 2.17 ± 0.14 mmol/L, and the prevalence of hypocalcemia was 33.11% (95% CI: 29.42–37.02). When comparing patients with normal calcium, hypocalcemia patients exhibited a higher blood transfusion rate (7.69% vs 16.06%, P < 0.05), and significantly larger total blood loss (607.86 ± 497.07 ml vs 719.18 ± 569.98 ml, P < 0.05). Multivariate linear regression analysis showed that male, anemia on admission, time from injury to hospital, intertrochanteric fracture, blood transfusion and hypocalcemia were independently associated with increased total blood loss (P < 0.05).

Conclusion

Hypocalcemia is common in elderly patients with hip fracture, and significantly associated with more total blood loss and blood transfusion. The other risk factors for increased total blood loss are male, anemia on admission, time from injury to hospital, intertrochanteric fracture, and blood transfusion.

Level of evidence

Level III, retrospective study.