Aims. This meta-analysis and systematic review aimed to comprehensively investigate the effects of
Aims: The use of
It is now clear that vitamin K1 is part of a biochemical cycle that is essential for the conversion of specific bone peptides into a form that can bind calcium. We have used a recently described procedure for assaying vitamin K1 in plasma to test the involvement of this vitamin in fracture healing. Markedly depressed circulating levels were found in patients with fractures and the time taken for this level to return to normal appeared to be influenced by the severity of the fracture.
Introduction. There are no specific and clear guidelines regarding management of trauma patients who are on Warfarin. The objective of this study was to compare two methods of anticoagulation management in the pre-operative period for this group. Methods. This study was conducted in two phases. In the first half (October 2005 to April 2006) the trauma patients on Warfarin were managed by the traditional method. The second group of patients who were admitted during May to December 2006 was given a single stat dose of
Introduction. It is estimated 5% of patients over 65 years receive warfarin therapy. This paper aims to analyse whether a time delay to hip fracture fixation while waiting for the patients International Normalised Ratio (INR) to return to normal increases the mortality risk. Methods. A prospective database of 937 hip fractures was analysed. Patient demographics and time from admission to operation were recorded. The patients' INR on admission and during the preoperative period, the need for
Aims. Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. Methods. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or
Patients with hip fractures should have surgery within 36 hours of admission to hospital. This reduces mortality and is required for hospitals to receive the NHS Best Practice Tariff. Many patients with hip fractures take Warfarin and reversing the effect of this frequently delays surgery. We report the results of a case-control study. The primary outcome measure was the number of patients with an INR of 1.7 or less on the day following admission to hospital. This is considered an acceptable INR for hip fracture surgery in our department. In the control group the dose of
Background and Aims. Many orthopaedic patients admitted to hospital who require urgent surgery are also on Warfarin. Patients with an INR>2 have an increased risk of bleeding complications during surgery; however delay to surgery due to a high INR has both clinical and financial implications. This audit evaluates whether the appropriate management for correction of INR is employed as per local guidelines and, if not, whether this results in significant delay to operative treatment. Methods. A retrospective and prospective audit was performed analysing all Orthopaedic trauma admissions admitted to University Hospital Aintree in a 5 month period. Only those solely on warfarin, who were not acutely bleeding and required surgery in <24 hours were included. Results. A sample of 17 patients was obtained of which only 35.3% had correct INR reversal as per local guidelines. Errors that occurred included 81.1% not being given further
There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK). A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited. The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v.
Various studies have demonstrated that the necessity for reversal of Warfarin through the use of
Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a
Best Practice Tariff (BPT) recommends operation for hip fracture within 36 hours. Anticoagulation reversal often delays this. Audit of our service, to establish the impact on BPT of anticoagulation reversal, showed a loss of revenue and delays. Subsequently an ‘early trigger’ Intravenous
Newer irreversible oral anticoagulants such as rivaroxaban, a direct factor 10a inhibitor, are increasingly employed to prevent thromboembolic events in atrial fibrillation (AF) patients, and to manage venous thromboembolism (VTE). Unlike warfarin, these agents require no monitoring and involve infrequent dose adjustment. We report the case of a patient treated with rivaroxaban for AF. Patient presented with unprovoked sudden onset right shoulder pain which clinically resembled shoulder haemarthrosis. A single case was anonymised and retrospectively reviewed through examination of clinical and radiographic data. A 70 year old female with known AF presented to Accident and Emergency with sudden onset of right shoulder pain and limited movement, which developed over one hour. The pain was constant, localised to the shoulder and without trauma. Past medical history included severe aortic regurgitation and associated thoracic aortic aneurysm, heart failure, atrial fibrillation and hypertension. Observations were normal upon admission with no haemodynamic compromise or pyrexia. Examining the right shoulder demonstrated distension of shoulder joint capsule, tenderness and a reduced range of movement. Temperature and neurovascular status in the right arm were normal. Investigations upon admission included an INR of 1.2. An anteroposterior right shoulder radiograph showed no evidence of fracture. Patient was managed conservatively with simple oral analgesia. Importantly, rivaroxaban was withheld for 5 days and symptoms resolved. Warfarin therapy was subsequently commenced instead as treatment for AF. Patient was discharged one week later and seen in clinic two weeks post-discharge. A full recovery occurred and with a full range of movement in the right shoulder. In the UK, current National Institute for Health and Care Excellence (NICE) guidelines recommend the use of factor 10a inhibitors, for prevention of stroke in AF patients, and following elective total hip and knee replacement operations to prevent VTE. In turn, rivaroxaban is increasingly prescribed as first line therapy. Whereas warfarin has a documented association with haemarthrosis, there is no primary literature evaluating the incidence of factor 10a therapy associated haemarthrosis. In our case, the unprovoked shoulder haemarthrosis resolved following rivaroxaban cessation. In comparison with warfarin, rivaroxaban is irreversible. With warfarin and a high INR,
1. Six cases of quadriceps contracture in children are described. All were either premature or suffered severe illnesses soon after birth. 2. Some additional information is given about cases of the same condition previously published by other authors. 3. It is suggested that injections and infusions given to newborn babies are sometimes the cause of the condition. 4. Some of the therapeutic substances and measures which may be responsible are discussed. These include antibiotics,
Hip fractures are a common cause of morbidity and mortality in the elderly, with approximately 30,000 hip fractures a year in Canada. Many hip fracture patients are prone to heart failure and present anticoagulated with Warfarin for medical comorbidities including atrial fibrillation or previous thromboembolic disease. Reversal of warfarin anticoagulation to an INR < 1.5 preferred for surgery but this often contributes to a delay to hip fracture surgery, which increases patient pain, morbidity, mortality, and length of stay Octaplex is a small-volume prothrombin complex concentrate (PCC) that reverses Warfarin-related anticoagulation in 15–60 minutes. It has been shown to be safe and effective in the management of intracranial and gastrointestinal bleeding in warfarinised patients. It is recommended by Bone and Joint Canada as an option for urgent warfarin reversal in hip fracture patients. However, there has been no published literature on the use of Octaplex or other PCCs in orthopaedic patients. Our objective is to assess the effectiveness of Octaplex for rapid reversal of warfarin anticoagulation in hip fracture patients. A database review of all patients who received Octaplex was performed. Medical records of all hip fracture patients in Calgary who received Octaplex between December 2009 and February 2015 were reviewed. After application of inclusion and exclusion criteria, 33 patients were identified. A timeline of International Normalised Ratio (INR), Octaplex administration, and hip fracture surgery was recorded. Mortality and complications were assessed at 30 days. A single dose of Octaplex corrected the INR to < 1.5 in 29 cases (88%). Median time from administration of Octaplex to a measured INR < 1.5 was 1.1 hours. Median time from admission to hip fracture surgery was 22 hours. Mortality at 30 days was 15.2%, mostly from cardiac arrest. A further 12% of patients developed cardiac or thrombotic complications. Multiple medical comorbidities were common including coronary artery disease (55%), congestive heart failure (45%), and chronic pulmonary disease (39%). Patients who received both fresh frozen plasma (FFP) and Octaplex for warfarin reversal had much higher mortality than those who only received Octaplex (40% vs 4.3% mortality at 30 days), but also had more medical comorbidities. Octaplex is effective at rapidly reversing warfarin anticoagulation and reducing time to surgery, potentially reducing the morbidity and mortality of hip fractures. Administration of both Octaplex and FFP were associated with higher early mortality in this case series. Further research is required to assess the safety of Octaplex,
Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission.Aims
Methods
According to the 2004 ACCP guidelines on antithrombotic and thrombolytic therapy general extended prophylaxis with low molecular weight heparins,
Fractures of the Proximal Femur are a common and disabling injury requiring hospital admission and surgical treatment leading to approximately 86,000 inpatient episodes annually in the UK, with such patients occupying more than 20% of NHS orthopaedic beds. Based on current trends the number of hip fractures may rise to 120,000 per annum by 2015. As the age of the population increases, so does the prevalence of concomitant medical conditions. Atrial Fibrillation is rising in the general population. Recently, the benefit of treating these patients with warfarin to prevent stroke has been shown; as a consequence, the number of patients being treated with warfarin is on the increase. We have performed a retrospective study of all patients admitted to our unit with Fractures of the neck of the femur between 2001 and 2006, from the Accident and Emergency department with a primary diagnosis of Proximal Femoral Fracture (1987 patients). 138 patients were on long term warfarin at the time of their admission (6.9% of admissions). 90.4% were being warfarinised for AF, 7.6% for DVT and the rest for other indications. Of these Patients only 12 (8.7%) received active reversal to their warfarin. (All received
Major orthopaedic surgeries such as total hip and total knee replacements are considered a major risk factor for venous thromboembolism (VTE). Without prophylaxis, DVT occurs in 10–40% of general surgical or medical patients and 40–60% of patients following major orthopaedic surgery. There has, however, been a perception that VTE is less common in Asia than in Western countries. New evidence has emerged recently that contradicts this perception. Results from multinational epidemiological studies (SMART, AIDA, ENDORSE) clearly showed that the rate of venographic and symptomatic thrombosis after major joint replacement in Asian patients is similar to that previously reported in patients in Western countries. However, thromboprophylaxis is not routinely used in Asia, even in situations considered high risk in Western countries. The ENDORSE study reported that less than 20% of at-risk surgical patients in Asia received prophylaxis compared with over 80% in Western countries. This leaves the majority of patients at risk of developing VTE and VTE-related conditions, which continues after hospital discharge. Current guidelines recommend the use of thromboprophylaxis for at least 10 days and up to 35 days in patients undergoing total joint replacement. Available anticoagulants are effective at preventing VTE but are associated with various limitations, such as parenteral administration as in the case of UFH and LMWH. A narrow therapeutic window, unpredictable pharmacology, frequent coagulation monitoring and dose-adjustment as in the case of
Aim: Evaluate the incidence of complications related to timing (time between admission ad operation) and oral antiplatelet/anticoagulant therapy in patients treated for a hip fracture. Materials and Methods: We prospectively evaluated 5 groups of 30 patients each, selected out of 875 consecutive patients admitted at the First Aid Unit of our Hospital with a proximal femoral fracture: group A – patients on Warfarin therapy, treated more than 5 days after admission (in order to allow the wash-out of Warfarin, as advised by many Anaesthesiologist Associations); B – patients treated more than 5 days after admission, not on Warfarin therapy; C – patients treated less than 48 hours after admission, not on Warfarin therapy; D – patients on Aspirin/NSAIDS therapy, treated more than 5 days after admission; E – patients on Ticlopidine/Clopidogrel therapy, treated more than 5 days after admission. The groups were comparable regarding age, gender, pre-trauma walking ability, mental state, fracture type and treatment. Blood loss, number of RBC transfusions, complications during hospitalization and up to 6 months after discharge, duration of hospitalization, degree of functional recovery and 2 years mortality were recorded. Statistical analysis included Kruskall-Wallis, U-Mann-Whitney and Logistic Regression Tests (SPSS 13.0 software). Results: Group A showed higher preoperative blood loss (p=0.002), and longer hospitalization (p<
0.001), compared to all other groups. Groups D and E showed no higher complication and mortality rate in comparison to group B and C, while group A showed higher complication and mortality rate. Standing alone, timing and Warfarin appear not to be significant risk factors, while taken together they represent a high risk factor for complications ad mortality (p=0.009). Conclusion: Patients on Warfarin therapy, affected by hip fracture, are at high risk of complications and mortality, if the recommendation of postponing treatment until drug wash-out is accepted. Reversal of anticoagulation using
