Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

Leif Mattisson, Lasse J Lapidus, Anders Enocson, Leif Mattisson, Lasse J Lapidus, Anders Enocson

Abstract

Background: Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.

Methods: A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.

Results: There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).

Conclusion: We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Keywords: Anticoagulation treatment; Hip fracture; Intramedullary nailing; Surgical treatment; Warfarin.

Conflict of interest statement

Ethics approval and consent to participate

The study was performed according to the Helsinki declaration and approved by the Regional Ethical Review Board in Stockholm, Sweden (Ref.nr. 2015/165–31/4) at 25 February 2015, and a completion of the ethics application (Ref.nr. 2017/1860–32) at 11 October 2017. (email: epn.se/stockholm) Informed consent was waived because of the retrospective design of this study that did not involve any additional risk for patients.

Consent to publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Anticoagulation’s therapy in atrial fibrillation – National Swedish guidelines.
    1. The new guidelines from European Society of Cardiology (ESC) 2016. [Internet].
    1. Anticoagulation’s therapy in atrial fibrillation – treatment recommendation: Information from the Swedish Medical Products Agency, 2017;28(1):12–31. [Internet].
    1. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609–1616. doi: 10.1503/cmaj.092220.
    1. Desai SJ, Wood KS, Marsh J, Bryant D, Abdo H, Lawendy A-R, et al. Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood? Can J Surg. 2014;57(5):342–348. doi: 10.1503/cjs.030413.
    1. Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. Bone Joint Surg Br. 2006;88(8):1053–1059. doi: 10.1302/0301-620X.88B8.17534.
    1. Ashouri F, Al-Jundi W, Patel A, Mangwani J. Management of Warfarin Anticoagulation in patients with fractured neck of femur. ISRN Hematology. 2011;2011:294628. doi: 10.5402/2011/294628.
    1. White RH, McKittrick T, Hutchinson R, Twitchell J. Temporary discontinuation of warfarin therapy: changes in the international normalized ratio. Ann Intern Med. 1995;122(1):40–42. doi: 10.7326/0003-4819-122-1-199501010-00006.
    1. Charalambous CP, Yarwood S, Paschalides C, Siddique I, Hirst P, Paul A. Factors delaying surgical treatment of hip fractures in elderly patients. Ann R Coll Surg Engl. 2003;85(2):117–119. doi: 10.1308/003588403321219911.
    1. Tharmarajah P, Pusey J, Keeling D, Willett K. Efficacy of warfarin reversal in orthopedic trauma surgery patients. J Orthop Trauma. 2007;21(1):26–30. doi: 10.1097/BOT.0b013e31802c4f3c.
    1. Purmonen T, Törmälehto S, Säävuori N, Kokki H. Budget impact analysis of warfarin reversal therapies among hip fracture patients in Finland. Drugs in R&D. 2015;15(1):155–162. doi: 10.1007/s40268-015-0088-6.
    1. Gao F-Q, Li Z-J, Zhang K, Sun W, Zhang H. Four methods for calculating blood-loss after Total knee arthroplasty. Chin Med J. 2015;128(21):2856–2860. doi: 10.4103/0366-6999.168041.
    1. Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013;44(6):726–729. doi: 10.1016/j.injury.2012.08.025.
    1. Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012;7(10):e46175. doi: 10.1371/journal.pone.0046175.
    1. Aqil A, Hossain F, Sheikh H, Aderinto J, Whitwell G, Kapoor H. Achieving hip fracture surgery within 36 hours: an investigation of risk factors to surgical delay and recommendations for practice. J Orthop Traumatol. 2016;17(3):207–213. doi: 10.1007/s10195-015-0387-2.
    1. Colais P, Di Martino M, Fusco D, Perucci CA, Davoli M. The effect of early surgery after hip fracture on 1-year mortality. BMC Geriatr. 2015;15:141. doi: 10.1186/s12877-015-0140-y.
    1. Carretta E, Bochicchio V, Rucci P, Fabbri G, Laus M, Fantini MP. Hip fracture: effectiveness of early surgery to prevent 30-day mortality. Int Orthop. 2011;35(3):419–424. doi: 10.1007/s00264-010-1004-x.
    1. Lawrence JE, Fountain DM, Cundall-Curry DJ, Carrothers AD. Do patients taking warfarin experience delays to theatre, longer hospital stay, and poorer survival after hip fracture? Clin Orthop Relat Res. 2017;475(1):273–279. doi: 10.1007/s11999-016-5056-0.
    1. Dettoni F, Castoldi F, Giai Via A, Parisi S, Bonasia DE, Rossi R. Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures. European J Trauma and Emerg Surg : Official Publicof the European Trauma Soc. 2011;37(5):511–518. doi: 10.1007/s00068-011-0073-x.
    1. Bhatia M, Talawadekar G, Parihar S, Smith A. An audit of the role of vitamin K in the reversal of international normalised ratio (INR) in patients undergoing surgery for hip fracture. Ann R Coll Surg Engl. 2010;92(6):473–476. doi: 10.1308/003588410X12664192075774.
    1. Moores TS, Beaven A, Cattell AE, Baker C, Roberts PJ. Preoperative warfarin reversal for early hip fracture surgery. J Orthop Surg (Hong Kong) 2015;23(1):33–36. doi: 10.1177/230949901502300108.
    1. Asad EP, Nicole MA, Brian LE. Prothrombin complex concentrate for critical bleeding. Ann Pharmacother. 2011;45(7–8):990–999.
    1. Palareti G. A guide to oral anticoagulant therapy. Italian Fed of Anticoagulation Clin Haemost. 1998;28(Suppl 1):1–46.
    1. Kumar D, Mbako AN, Riddick A, Patil S, Williams P. On admission haemoglobin in patients with hip fracture. Injury. 2011;42(2):167–170. doi: 10.1016/j.injury.2010.07.239.
    1. Smith GH, Tsang J, Molyneux SG, White TO The hidden blood loss after hip fracture. Injury. 2011;42(2):133–135. doi: 10.1016/j.injury.2010.02.015.
    1. Kadar A, Chechik O, Steinberg E, Reider E, Sternheim A. Predicting the need for blood transfusion in patients with hip fractures. Int Orthop. 2013;37(4):693–700. doi: 10.1007/s00264-013-1795-7.
    1. Swain DG, Nightingale PG, Patel JV. Blood transfusion requirements in femoral neck fracture. Injury. 2000;31(1):7–10. doi: 10.1016/S0020-1383(99)00191-6.
    1. Cohn MR, Levack AE, Trivedi NN, Villa JC, Wellman DS, Lyden JP, Lorich DG, Lane JM. The hip fracture patient on warfarin: evaluating blood loss and time to surgery. J Orthop Trauma. 2017;31(8):407–413. doi: 10.1097/BOT.0000000000000857.
    1. Fazal MA, Bagley C, Garg P. Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing. Chin J Traumatol. 2018;21(1):16–19. doi: 10.1016/j.cjtee.2017.09.002.
    1. Boone C, Carlberg KN, Koueiter DM. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2) J Orthop Trauma. 2014;28:e96–e100. doi: 10.1097/BOT.0b013e3182a7131c.

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