Elderly patients with hip fracture frequently receive antiplatelet therapy due to their multiple comorbidities, including cardiovascular disease [4]. The current study demonstrated that the continuation of antiplatelet medication during the perioperative period in these patients result in similar outcomes after CMN for proximal femoral fractures as in patients who were not on antiplatelet therapy. There were no significant differences between the two groups with respect to perioperative results, postoperative medical and surgical complications, readmission, and in-hospital and 1-year mortality. Only total transfusion volume and ICU admission showed a significant increase in elderly patients on continuous perioperative antiplatelet therapy. However, the lengths of ICU and hospital stay after the admission showed no significant differences between the two groups. We believe that the higher rate of ICU admission is related to comorbidities in patients of the study group on continuous perioperative antiplatelet medication, which make them on that medication and require close monitoring postoperatively compared to the control group not on antiplatelet medication.
The incidence of hip fractures have increased as the population has aged [12]. Due to the high incidence of cardiovascular or cerebrovascular comorbidities in geriatric population, many patients have received long-term antiplatelet treatment [3]. Aspirin ingestion was found to increase perioperative blood transfusion requirements in hip fracture surgery [13]. Grujic and Martin [14] showed that clopidogrel treatment was associated with a 37-fold risk for reoperation after general, orthopaedic, vascular or cardiothoracic surgery, and that the effect was reduced but still present in patients in whom treatment was stopped for 7 days prior to surgery. Furthermore, the platelet aggregation is fully reactivated 10 days after withdrawing from antiplatelet therapy [5]. However, withdrawal of antiplatelet agents in patients with hip fracture prior to operation may induce a rebound effect and potentially lead to thromboembolic events in patients with atherosclerosis [5, 7]. Discontinuation of clopidogrel and delay in surgical intervention for hip fractures are also linked to high rates of DVT and PE [15]. Furthermore, delaying surgical intervention for proximal femoral fractures has been reported to increase perioperative complications and mortality [9]. Therefore, surgeons may find it difficult to make decisions about the timing of surgery and whether antiplatelet medication should be continued or discontinued in individual elderly patients. Moreover, there is a lack of uniformed consensus among surgeons regarding these issues.
At our institution, elderly patients with hip fracture underwent surgical management as soon as they were medically optimized according to the same protocol for patients who are not on antiplatelet therapy, with the rationale to reduce perioperative complications and mortality associated with surgical delay. However, the surgeon must prudently consider the risks and benefits of this policy in each patient. For elderly patients with proximal femoral fracture treated with CMN according to this policy, we conducted the present study to compare patients on continuous antiplatelet therapy and those who were not on antiplatelets, and to evaluate the effect of continuing antiplatelet therapy during the perioperative period on outcomes after the surgery.
Chechik et al. [16] in their matched cohort study reported that patients receiving antiplatelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and thrombo-embolic or postoperative bleeding events. However, their study involved patients aged > 40 years including elderly patients, and comprised patients with all intracapsular and extracapsular hip fractures individually treated with three procedures based on the fracture pattern; proximal femoral nailing, dynamic hip screw plating, and hemiarthroplasty. We believe that their study design with the selection of patient age group and fracture pattern makes their conclusion less representative. The results between elderly patients with comorbidities and relatively healthy young patients may vary and several fracture types and procedures may cause bias to the results. Collinge et al. [17] reported that 74 patients taking clopidogrel who underwent early hip fracture surgery were not at a substantially higher risk for bleeding and bleeding complications, and did not have a higher mortality rate, than 619 patients not on clopidogrel. However, clopidogrel medication was stopped at the time of admission in most of the patients and restarted the therapy after surgery. Furthermore, the results might have been affected by the fact that they did not report the type of anesthesia. Doleman and Moppett [18] reported in a meta-analysis that early hip fracture surgery appears safe with similar mortality rates between patients on clopidogrel and those not on clopidogrel, although there may be a small increase in the rate of blood transfusion. Although our findings agree with their study, there is no consistent guideline across studies thus far on whether to discontinue antiplatelet drugs at admission and restart postoperatively, or continue antiplatelets perioperatively in elderly patients with hip fracture. In addition, most of these studies enrolled relatively young patients and the elderly, as well as patients treated with various surgical procedures according to the fracture type. Meanwhile, our study was aimed solely at elderly patients (≥ 70 years) treated only with minimally invasive method of CMN for extracapsular proximal femoral fractures for the two groups matched for age, gender, ASA grade, the time to operation, anesthesia type, and operation time. Under these conditions, the current study demonstrated that early surgery with continuing perioperative antiplatelet medication is safe and has no negative effect on surgical outcomes if more attention is paid to perioperative transfusion and ICU care for these patients. We believe that this design of the current study strengthens our results when compared with previous studies.
Zhang et al. [19] reported that continuation of preoperative clopidogrel for patients undergoing intramedullary nailing for an intertrochanteric fracture resulted in higher chances of intraoperative transfusion, increased ICU admission and total duration of hospitalization, and a lower one-year survival rate, leading to poor prognosis. Our results were consistent with those of Zhang et al. in terms of total transfusion volume and ICU admission rates. However, in our study, there were no significant differences in the lengths of ICU and hospital stay, the occurrence of postoperative complications, and in-hospital and 1-year mortality rates between the two groups. This difference could be due to the inclusion of patients on other antiplatelet drugs such as aspirin, which are less potent than clopidogrel. However, our study was aimed at patients older than those enrolled in the study by Zhang et al. with better matching of two groups. Subsequently, similar results were observed between these two groups treated with CMN according to the same protocol.
Our study is limited by its retrospective design and relatively small sample size. We did, however, identify consecutive elderly patients over 70 years of age undergoing only CMN according to the same protocol from admission to discharge regardless of antiplatelet medication prior to admission, and formed two well-matched groups. Second, as this study was aimed at geriatric hip fracture patients on only antiplatelet agents, additional research should be conducted using other anticoagulants that have a different mechanism of action from antiplatelets.
Nevertheless, our study has its strengths as it enrolled consecutive hip fracture patients over 70 years of age, undergoing only one procedure (CMN) using the same implant, managed according to the same protocol by one experienced surgeon in a single center. Therefore, the potential for bias due to variations in several diagnoses and procedures performed is expected to be minimal, and our results would have allowed us to draw significant conclusions. Second, both groups in our study were well matched with respect to gender, age, ASA grade, time to operation after admission, BMI, preoperative Hb and Hct levels, anesthesia, and operation time. The mean age was over 80 years with high prevalence of ASA score 3 in both groups. Third, the scope of this study included addressing issues related specifically to the continuation of antiplatelet drugs and early surgery regardless of antiplatelet medication in elderly patients. Finally, this study compared perioperative outcomes including estimated blood loss and transfusion, postoperative complications, and readmission and mortality rates between the two matched groups.
The results of this study contribute to the body of evidence that hip fracture surgery can be performed in elderly patients without interruption of ongoing antiplatelet therapy prior to admission as safely and promptly as in patients not receiving antiplatelet therapy. In the future, well-controlled prospective studies or large multicenter comparative studies involving a large number of patients are recommended to corroborate the results of this study.
