Safety of Early Surgery for Geriatric Hip Fracture Patients Taking Clopidogrel: A Retrospective Case-Control Study of 120 Patients in China
Geriatric hip fractures represent a significant health challenge globally due to their high incidence and associated morbidity and mortality rates. With aging populations, the incidence of hip fractures is expected to rise, with projections estimating approximately 6.26 million hip fractures annually by 2050. Early surgical intervention is widely recommended in various guidelines to improve outcomes for these patients. However, a considerable proportion of geriatric hip fracture patients are on oral antiplatelet or anticoagulant medications, such as clopidogrel, due to comorbidities like cardiovascular and cerebrovascular diseases. The use of clopidogrel poses a dilemma for surgeons, as it inhibits platelet activation and aggregation, potentially increasing the risk of perioperative bleeding. Traditional practice in China has been to delay surgery for at least 5 to 7 days after discontinuing clopidogrel to mitigate this risk. However, delayed surgery is associated with increased complications and mortality in elderly patients. This study aimed to investigate the safety of early surgery within 5 days of clopidogrel withdrawal for geriatric hip fracture patients in China.
The study was conducted as a single-site, retrospective, paralleled comparison study at Beijing Jishuitan Hospital, a leading orthopedic hospital in China. The study population included elderly patients (≥65 years) with acute hip fractures who were hospitalized between November 2016 and April 2018. Patients were included if they had an X-ray-confirmed hip fracture and underwent operative treatment. Exclusion criteria included pathological fractures due to tumors, periprosthetic fractures, multiple injuries, coagulopathy, thrombocytopenia, bleeding disorders, use of antiplatelet or anticoagulant drugs other than clopidogrel, and chronic conditions such as peptic ulcers, liver disease, or end-stage renal disease.
The study compared two groups: the clopidogrel group, consisting of 60 patients who were taking clopidogrel before injury and discontinued it less than 5 days before surgery, and the control group, consisting of 60 patients who were not taking any antiplatelet or anticoagulant drugs. The control group was matched 1:1 with the clopidogrel group based on sex, fracture type, operative procedure, and time from injury to operation (±10 hours). The primary outcome of the study was perioperative blood loss, while secondary outcomes included transfusion requirements, complications, and mortality rates.
Baseline characteristics of the two groups were comparable. The median age was 80.0 years in the clopidogrel group and 81.0 years in the control group. Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the percentage of patients undergoing general anesthesia were similar between the groups. The clopidogrel group had a significantly higher prevalence of coronary heart disease (61.7% vs. 18.3%) and cerebrovascular disease (45.0% vs. 15.0%) compared to the control group. The median time from injury to operation was 68.5 hours in the clopidogrel group and 68.0 hours in the control group, with 88.3% of patients in the clopidogrel group undergoing surgery within 48 hours of admission.
Perioperative blood loss was estimated using a formula that accounted for hemoglobin (HB) levels at various time points, total blood volume (TBV), and the amount of transfused blood. The median estimated perioperative blood loss was 745 mL in the clopidogrel group and 772 mL in the control group, with no significant difference between the groups (P = 0.866). Intra-operative transfusion rates were higher in the clopidogrel group (36.7% vs. 20.0%; P 0.050). Subgroup analysis of different surgical procedures showed comparable transfusion rates between the two groups. Only one patient in the clopidogrel group received a platelet transfusion due to significant intra-operative blood loss.
The study also compared perioperative complications and mortality rates between the two groups. There were no significant differences in the incidence of perioperative complications, including cerebral infarction, acute coronary syndrome, deep vein thrombosis (DVT), chest infection, urinary tract infection, decubitus ulcers, or acute upper gastrointestinal hemorrhage. The rates of intensive care unit (ICU) admission, in-hospital mortality, and 30-day mortality were also comparable between the groups. One-year mortality data were available for 98 patients (50 in the clopidogrel group and 48 in the control group). Six patients in each group died within the first year after surgery, with causes of death including lung infection, heart failure, acute cardiac arrest, and tumors.
The findings of this study suggest that early surgery within 5 days of clopidogrel withdrawal is safe for geriatric hip fracture patients with low thrombotic risk. The study found no significant increase in perioperative blood loss, transfusion requirements, complications, or mortality rates compared to patients not taking antiplatelet drugs. The higher intra-operative transfusion rate in the clopidogrel group may reflect surgeons’ concerns about potential bleeding risks, but this did not translate into a higher overall transfusion rate or worse outcomes.
The study’s results are consistent with previous research indicating that early surgery does not significantly increase perioperative bleeding or transfusion requirements for hip fracture patients taking clopidogrel. The high prevalence of clopidogrel resistance, estimated at 30% to 50% in some studies, may partially explain why early surgery did not result in increased blood loss. Additionally, the use of a multidisciplinary orthogeriatric co-management model in this study likely contributed to optimized perioperative care and outcomes.
In conclusion, this study provides evidence supporting the safety of early surgery within 5 days of clopidogrel withdrawal for geriatric hip fracture patients in China. The findings suggest that delaying surgery to allow for a longer clopidogrel withdrawal period may not be necessary for patients with low thrombotic risk. Early surgical intervention can help reduce the complications and mortality associated with delayed surgery in this vulnerable population. Future research should focus on prospective, multi-center studies with larger sample sizes to further validate these findings and explore the safety of surgery within 48 hours or without withholding clopidogrel.
doi.org/10.1097/CM9.0000000000001668
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