Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial

Rafael Anaya,Angela Merchán-Galvis,Patricia Guilabert,Mireia Rodriguez,Angélica Millan,Victoria Moral,José María Gil,Maria Jose Martinez-Zapata,Francesca Reguant,Jordi Llorca,Percy-Efrain Pantoja,Ana Ruiz

doi:10.3390/jcm10225371

Abstract

Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Highlights

In industrialised countries, most proximal femur fractures occur in elderly patients, accounting for approximately 42–50% of all fractures [1]
* ITT, intention to treat, all randomised patients were analysed; PP, per protocol, only randomised patients who underwent surgery were analysed. The results of this randomised clinical trial (RCT) point to platelet function monitoring as an effective strategy to reduce the admission-to-surgery interval when neuraxial anaesthesia is used for elderly patients on chronic antiplatelet treatment admitted with femur fractures
The early surgery strategy compared to delayed surgery reduced the admission-to-surgery interval by 2 days, without increasing perioperative adverse events (AEs) and complications, and reduced hospital stays by 3 days

Summary

Introduction

Most proximal femur fractures occur in elderly patients, accounting for approximately 42–50% of all fractures [1]. Associated comorbidities and chronic treatments increase the complexity of perioperative management of elderly patients It is not uncommon for hip fracture patients to be receiving chronic antiplatelet treatment, which lengthens hospital stay. I.e., within less than 48 h, has been reported to decrease morbidity and mortality, hospital stay, and perioperative complications associated with femur fractures [8,9]. Even patients on antiplatelet treatment seem to experience reduced mortality and hospital stay from early surgery under general anaesthesia [10,11,12]. Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy

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