Abstract
The strategies of perioperative bridging anticoagulation in orthopedic surgical patients during oral anticoagulation (OAC) therapy with vitamin K antagonists (VKA) vary from center to center. The aim of this single-center study was to assess the risk of bleeding and thromboembolic events (TEs) in bridged patients on VKA who underwent orthopedic surgery due to trochanteric or hip fracture. The retrospective study included 64 patients (mean age: 80 years) who received VKA for at least 3 months prior to orthopedic procedure. All subjects were bridged with enoxaparin (40 mg once a day). The control group (n = 69) comprised of age-, sexand procedure-matched patients operated on for the same indications, but with neither a history of VKA therapy nor perioperative bridging anticoagulation. Severe postoperative bleeding occurred in 19 (29.7%) patients from the VKA group and in 13 (18.8%) controls (p = 0.16). Within the VKA group, intertrochanteric fractures (52.6%) and femoral neck fractures (47.4%) occurred more often in patients with bleeding than other lower extremity fractures (0%; p = 0.03). Severe adverse events (SAEs) were more common in the VKA group than in the controls (12.5% vs 1.5%; p = 0.01). Patients from the VKA group did not differ from the controls in the incidence of TEs (6.3% vs 8.9%; p = 0.31). No intrahospital mortality was documented. Prophylactic administration of enoxaparin is a common strategy of bridging anticoagulation in a hospital setting. This approach does not seem to be associated with an increase in thromboembolic risk nor higher risk of bleeding in orthopedic patients who received VKA preoperatively.
Highlights
A large proportion of older persons from many countries receive oral anticoagulation (OAC) with vitamin K antagonists (VKA); one example is the UK, where VKA are prescribed to approx. 1% of older patients.[1,2] Noticeably, such individuals are more prone to osteoporosis, an established risk factor for femoral neck fracture.Fixation of femoral neck and trochanteric fractures is a relatively common surgical procedure in older patients, associated with high comorbidity and mortality rates.[3,4,5] According to the literature, hip and trochanteric surgeries carry a 4% risk of perioperative mortality and a 3.2% risk of thromboembolism.[6]
Within the VKA group, intertrochanteric fractures (52.6%) and femoral neck fractures (47.4%) occurred more often in patients with bleeding than other lower extremity fractures (0%; p = 0.03)
This approach does not seem to be associated with an increase in thromboembolic risk nor higher risk of bleeding in orthopedic patients who received VKA preoperatively
Summary
Fixation of femoral neck and trochanteric fractures is a relatively common surgical procedure in older patients, associated with high comorbidity and mortality rates.[3,4,5] According to the literature, hip and trochanteric surgeries carry a 4% risk of perioperative mortality and a 3.2% risk of thromboembolism.[6] Despite the implementation of thromboprophylaxis, pulmonary embolism (PE) is still a common cause of perioperative mortality, accounting for approx. 0.7%, respectively.[9] A large proportion of patients being referred to an orthopedic treatment are at increased risk of venous thromboembolism (VTE), stroke or systemic embolism, due to the presence of atrial fibrillation (AF), mechanical heart valves or recurrent VTE; such individuals require long-term OAC therapy with VKA or new generation anticoagulants. The strategies of perioperative bridging anticoagulation in orthopedic surgical patients during oral anticoagulation (OAC) therapy with vitamin K antagonists (VKA) vary from center to center
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