Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®
Abstract
:1. Introduction
2. Materials and Methods
2.1. Statistical Analysis
2.2. Ethics
3. Results
3.1. Baseline Characteristics
3.2. Anticoagulation at Admission
3.3. Influence of Anticoagulation on Type of Anesthesia Used, Surgical Complications, Length of Stay, Mortality and Time-to-Surgery
4. Discussion
Strengths and Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Veronese, N.; Maggi, S. Epidemiology and social costs of hip fracture. Injury 2018, 49, 1458–1460. [Google Scholar] [CrossRef] [PubMed]
- Papachristos, I.V.; Giannoudis, P.V. Proximal femur fractures in patients taking anticoagulants. EFORT Open Rev. 2020, 5, 699–706. [Google Scholar] [CrossRef] [PubMed]
- Schuetze, K.; Eickhoff, A.; Dehner, C.; Gebhard, F.; Richter, P.H. Impact of oral anticoagulation on proximal femur fractures treated within 24 h—A retrospective chart review. Injury 2019, 50, 2040–2044. [Google Scholar] [CrossRef] [PubMed]
- Lawrence, J.E.; Fountain, D.M.; Cundall-Curry, D.J.; Carrothers, A.D. Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture? Clin. Orthop. Relat. Res. 2017, 475, 273–279. [Google Scholar] [CrossRef] [Green Version]
- Moja, L.; Piatti, A.; Pecoraro, V.; Ricci, C.; Virgili, G.; Salanti, G.; Germagnoli, L.; Liberati, A.; Banfi, G. 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, e46175. [Google Scholar] [CrossRef] [Green Version]
- Ryan, D.J.; Yoshihara, H.; Yoneoka, D.; Egol, K.A.; Zuckerman, J.D. Delay in Hip Fracture Surgery: An Analysis of Patient-Specific and Hospital-Specific Risk Factors. J. Orthop. Trauma 2015, 29, 343–348. [Google Scholar] [CrossRef]
- Buecking, B.; Eschbach, D.; Bliemel, C.; Oberkircher, L.; Struewer, J.; Ruchholtz, S.; Sachs, U.J. Effectiveness of vitamin K in anticoagulation reversal for hip fracture surgery--a prospective observational study. Thromb. Res. 2014, 133, 42–47. [Google Scholar] [CrossRef]
- Maegele, M.; Grottke, O.; Schöchl, H.; Sakowitz, O.A.; Spannagl, M.; Koscielny, J. Direct Oral Anticoagulants in Emergency Trauma Admissions. Dtsch. Arztebl. Int. 2016, 113, 575–582. [Google Scholar] [CrossRef] [Green Version]
- Schermann, H.; Gurel, R.; Gold, A.; Maman, E.; Dolkart, O.; Steinberg, E.L.; Chechik, O. Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications. Injury 2019, 50, 398–402. [Google Scholar] [CrossRef]
- Hourston, G.J.; Barrett, M.P.; Khan, W.S.; Vindlacheruvu, M.; McDonnell, S.M. New drug, new problem: Do hip fracture patients taking NOACs experience delayed surgery, longer hospital stay, or poorer outcomes? Hip Int. 2020, 30, 799–804. [Google Scholar] [CrossRef] [Green Version]
- R Core Team. R: A Language and Environment for Statistical Computing; R Foundation for Statistical Computing: Vienna, Austria, 2021; Available online: https://www.R-project.org/ (accessed on 22 January 2022).
- Griffiths, R.; Alper, J.; Beckingsale, A.; Goldhill, D.; Heyburn, G.; Holloway, J.; Leaper, E.; Parker, M.; Ridgway, S.; White, S.; et al. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2012, 67, 85–98. [Google Scholar] [CrossRef] [PubMed]
- De Jong, L.A.; Koops, M.; Gout-Zwart, J.J.; Beinema, M.J.; Hemels, M.E.W.; Postma, M.J.; Brouwers, J.R.B.J. Trends in direct oral anticoagulant (DOAC) use: Health benefits and patient preference. Neth. J. Med. 2018, 76, 426–430. [Google Scholar] [PubMed]
- Leer-Salvesen, S.; Dybvik, E.; Ranhoff, A.H.; Husebø, B.L.; Dahl, O.E.; Engesæter, L.B.; Gjertsen, J.E. Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients? Eur. Geriatr. Med. 2020, 11, 563–569. [Google Scholar] [CrossRef] [PubMed]
- Tran, T.; Delluc, A.; de Wit, C.; Petrcich, W.; Le Gal, G.; Carrier, M. The impact of oral anticoagulation on time to surgery in patients hospitalized with hip fracture. Thromb. Res. 2015, 136, 962–965. [Google Scholar] [CrossRef]
- Ranhoff, A.H.; Martinsen, M.I.; Holvik, K.; Solheim, L.F. Use of warfarin is associated with delay in surgery for hip fracture in older patients. Hosp. Pract. 2011, 39, 37–40. [Google Scholar] [CrossRef]
- Frenkel Rutenberg, T.; Velkes, S.; Vitenberg, M.; Leader, A.; Halavy, Y.; Raanani, P.; Yassin, M.; Spectre, G. Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants. Thromb. Res. 2018, 166, 106–112. [Google Scholar] [CrossRef]
- Watson, H.G.; Baglin, T.; Laidlaw, S.L.; Makris, M.; Preston, F.E. A comparison of the efficacy and rate of response to oral and intravenous Vitamin K in reversal of over-anticoagulation with warfarin. Br. J. Haematol. 2001, 115, 145–149. [Google Scholar] [CrossRef]
- Ahmed, I.; Khan, M.A.; Nayak, V.; Mohsen, A. An evidence-based warfarin management protocol reduces surgical delay in hip fracture patients. J. Orthop. Traumatol. 2014, 15, 21–27. [Google Scholar] [CrossRef] [Green Version]
- Mullins, B.; Akehurst, H.; Slattery, D.; Chesser, T. Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre. BMJ Open 2018, 8, e020625. [Google Scholar] [CrossRef] [Green Version]
- Cordero, J.; Maldonado, A.; Iborra, S. Surgical delay as a risk factor for wound infection after a hip fracture. Injury 2016, 47 (Suppl. S3), S56–S60. [Google Scholar] [CrossRef]
- Liu, X.; Dong, Z.; Li, J.; Feng, Y.; Cao, G.; Song, X.; Yang, J. Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: A retrospective multicenter study. J. Orthop. Surg. Res. 2019, 14, 382. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Patient Characteristics | n = 15,099 Patients |
---|---|
Age (n = 14,882 patients) | 85 years (80–89 years) * |
Gender (n = 15,047) | |
female | 71.9% (n = 10,811) |
ASA-Score (n = 14,898) | |
1 | 1.4% (n = 209) |
2 | 21.6% (n = 3216) |
3 | 68.8% (n = 10,249) |
4 | 8.1% (n = 1210) |
5 | 0.1% (n = 14) |
Anticoagulation on admission (n = 14,469) | |
No Anticoagulation | 46.4% (n = 6720) |
Vitamin K antagonist | 9.2% (n = 1325) |
Acetylsalicylic acid | 30.7% (n = 4448) |
Other thrombocyte aggregation inhibitors | 4.0% (n = 583) |
Direct thrombin inhibitor (Dabigatran) | 1.6% (n = 234) |
Direct Factor Xa inhibitor (Rivaroxaban, Apixaban, Edoxaban) | 9.4% (n = 1361) |
Heparin | 1.4% (n = 206) |
Other | 0.9% (n = 131) |
Type of fracture (n = 15,099) | |
Femoral neck fracture | n = 6908 |
Pertrochanteric fracture | n = 7537 |
Subtrochanteric fracture | n = 654 |
Time-to-surgery (Median/IQR) (n = 14,949) | 17.6 h (7.1 h–25.8 h) |
<12 h | 36.4% (n = 5447) |
12–24 h | 34.7% (n = 5192) |
24–36 h | 12.6% (n = 1883) |
36–48 h | 7.8% (n = 1160) |
>48 h | 8.5% (n = 1267) |
Anaesthesia (n = 14,891) | |
General anesthesia | n = 13,770 |
Spinal anaesthesia | n = 1121 |
Surgical revisions (during index stay) | n = 15,080 |
Yes | n = 434 |
Reposition (after luxation) | n = 28 |
soft tissue intervention | n = 184 |
Removal of implant or osteosyntesis | n = 40 |
Revision of osteosynthesis | n = 62 |
Conversion to hemiarthroplasty | n = 25 |
Conversion to total hip arthroplasty | n = 30 |
Girdlestone | n = 5 |
Periosteosynthetic/Periprothetic fracture | n = 20 |
Others | n = 141 |
Mortality | |
During initial stay (n = 14,944) | 5.4% (n = 804) |
Length of stay (Median/IQR) (n = 13,830) (survivors) | 15.1 days (10.1–22.0 days) |
Anesthesia % (n = x) | Surgical Complication % (n = x) | Soft Tissue Complications % (n = x) | Length of Stay Days Median (IQR) | Mortality | ||
---|---|---|---|---|---|---|
General Anesthesia | Spinal Anaesthesia | |||||
No therapeutic Anticoagulation | 91.5% (n = 10.306) | 8.5% (n = 953) | 2.7% (n = 304) | 1.1% (n = 125) | 15.1 d (10.0–21.1 d) | 4.6% (n = 523) |
Vitamin K antagonist | 96.6% (n = 1255) | 3.4% (n = 44) | 4.2% (n = 55) | 1.8% (n = 24) | 17.1 d (12.1–24.0) | 6.5% (n = 86) |
DOAC | 96.6% (n = 1497) | 3.4% (n = 53) | 3.3% (n = 52) | 1.7% (n = 27) | 17.0 (11.1–23.0) | 8% (n = 125) |
Significance VKA vs. DOAC | p = 1 ** | p = 1 ** | p = 0.951 ** | p ≤ 0001 * | p = 0.158 ** |
Time-to-Surgery | Surgical Complications | |
---|---|---|
HR (95%-CI) | OR (95%-CI) | |
Vitamin K antagonist * | 0.63 (0.60–0.67) | 1.52 (1.12–2.03) |
DOAC * | 0.61 (0.58–0.64) | 1.23 (0.90–1.65) |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Aigner, R.; Buecking, B.; Hack, J.; Schwenzfeur, R.; Eschbach, D.; Einheuser, J.; Schoeneberg, C.; Pass, B.; Ruchholtz, S.; Knauf, T.; et al. Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®. Medicina 2022, 58, 379. https://doi.org/10.3390/medicina58030379
Aigner R, Buecking B, Hack J, Schwenzfeur R, Eschbach D, Einheuser J, Schoeneberg C, Pass B, Ruchholtz S, Knauf T, et al. Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®. Medicina. 2022; 58(3):379. https://doi.org/10.3390/medicina58030379
Chicago/Turabian StyleAigner, Rene, Benjamin Buecking, Juliana Hack, Ruth Schwenzfeur, Daphne Eschbach, Jakob Einheuser, Carsten Schoeneberg, Bastian Pass, Steffen Ruchholtz, Tom Knauf, and et al. 2022. "Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®" Medicina 58, no. 3: 379. https://doi.org/10.3390/medicina58030379