warfarin and Femoral-Neck-Fractures

Topics: Aged; Anticoagulants; Aspirin; Bandages; Coumarins; Dextrans; Exercise Therapy; Femoral Neck Fractures; Fibrinogen; Fractures, Bone; Hemorrhage; Hip Injuries; Humans; Iodine Isotopes; Physical Exertion; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Warfarin

The objective of this prospective audit was to compare two methods of anticoagulation reversal in the pre-operative period for hip fracture patients.. In the first part of the audit, our current practice was analysed. Data relating to the number of days from admission to surgery and the reasons for delay to surgery were collected. Also, data concerning common reasons for which the patients were started on warfarin and the time required for INR to drop to 1.5 or below were collected. In the second part of the audit, 45 patients with INR above 1.5 were given a single dose of vitamin K (1 mg i.v.) in addition to stopping warfarin.. The mean difference in the time for INR < 1.5 in the two groups was 2 days (52 h; P < 0.05). The mean difference in wait for surgery since admission between the two groups was 4 days (91 h; P < 0.05). There was no significant difference between the two groups as regards the average number of co-morbidities in the patient groups.. A single 1 mg intravenous dose of vitamin K significantly reduces the time for the reversal of INR and the pre-operative delay to surgery, in patients on long-term warfarin. We conclude that 1 mg of intravenous vitamin K on admission is a safe and effective treatment to avoid delay in the treatment in this group of patients.

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation; Female; Femoral Neck Fractures; Fracture Fixation; Humans; International Normalized Ratio; Male; Medical Audit; Practice Guidelines as Topic; Preoperative Care; Preoperative Period; Vitamin K; Warfarin

In a prospective controlled randomised trial, the prophylactic value of warfarin sodium (in doses aimed at maintaining a "Thrombotest" value of 10% and given from the day of admission until independent mobility had been achieved or for 3 mo, whichever was the sooner) was assessed in 160 elderly patients who had sustained a fracture of the femoral neck. Treatment significantly reduced the frequency of deep venous thrombosis (D.V.T.), whether indicated by the 125I-fibrinogen test during life or assessed by detailed post-mortem studies. Pulmonary embolism was eliminated in treated patients, but the difference in mortality between the treatment and control groups was not significant, indicating that causes of death other than pulmonary embolism are of major importance in these elderly patients. A case is made out for prophylactic anticoagulation on a selective basis.

Topics: Aged; Clinical Trials as Topic; Drug Evaluation; Female; Femoral Neck Fractures; Follow-Up Studies; Hemorrhage; Humans; Leg; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Aged; Female; Femoral Neck Fractures; Fractures, Bone; Hip; Humans; Male; Pulmonary Embolism; Thrombophlebitis; Warfarin

Syncope is a complicated clinical condition involving various diseases. Syncope due to myxoma-like right atrial thrombus is rarely seen in patient without structural heart disease.. A 61-year-old ambulant old male visited our emergency department for sudden syncope.. After the exclusion of neurological and coronary diseases, a right atrial block mass with a stalk connected to the atrial septum was accidentally found by echocardiography. Pulmonary embolism was subsequently revealed by computed tomographic pulmonary angiography. Atrial myxoma was initially suspected and surgical removal was conducted. Surprisingly, histological examination showed that the pedicled block mass was actually thrombus.. The myxoma-like right atrial thrombus and the emboli in the bilateral pulmonary trunks were resected. This patient received anticoagulant treatment with warfarin for 6 months additionally.. The patient was successfully discharged and being continually followed.. This patient had a past medical history of right femoral neck fracture, which might be responsible for the formation of the myxoma-like right atrial thrombus. We should always consider echocardiography examination in syncope patient at risk of thrombus formation.

Topics: Anticoagulants; Cardiac Surgical Procedures; Computed Tomography Angiography; Diagnosis, Differential; Echocardiography; Femoral Neck Fractures; Heart Atria; Heart Diseases; Humans; Incidental Findings; Male; Middle Aged; Myxoma; Pulmonary Artery; Pulmonary Embolism; Syncope; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Antithrombin III; Arthroplasty, Replacement, Hip; Diagnosis, Differential; Female; Femoral Neck Fractures; Heparin; Humans; Middle Aged; Popliteal Vein; Postoperative Complications; Protein C; Protein S; Thrombophilia; Treatment Outcome; Ultrasonography, Doppler, Duplex; Venous Thromboembolism; Warfarin

Patients sustaining a fractured neck of the femur are typically of advanced age with multiple comorbidities. As a consequence, the proportion of these patients receiving warfarin therapy is approximately 10%. There are currently few studies investigating outcomes in this subset of patients.. The purpose of this study was to assess the association between warfarin therapy and time to surgery, length of hospital stay, and survival in patients sustaining a fractured neck of the femur.. Data for 2036 patients admitted to our center between July 2009 and July 2014 with a fractured neck of the femur were extracted from the National Hip Fracture Database. Fifty-seven patients received no surgical treatment and were excluded from analysis. Multivariable ordinary least squares regression was performed to test the association between warfarin treatment on time to surgery and length of stay, and Cox proportional hazards to test followup survival. Variables included in the regression model were age, sex, American Society of Anesthesiologists (ASA) score, admission Abbreviated Mental Test Score (AMTS), fracture type, operation type, and premorbid Work Ability Index (WAI). One hundred fifty-two of 1979 surgically treated patients (8%) were receiving warfarin therapy at the time of admission.. After controlling for age, sex, ASA score, AMTS, fracture type, operation type, and WAI, we found that patients taking warfarin were less likely to go to surgery by 36 hours (odds ratio [OR], 0.20; 95% CI, 0.14-0.30), and less likely to go to surgery by 48 hours (OR, 0.17; 95% CI, 0.11-0.24). Patients taking warfarin had a longer length of stay (median, 15 days; interquartile range [IQR], 12-22 days) compared with patients not taking warfarin (median, 13 days; IQR, 9-20 days; p < 0.001). Survival analysis to June 2015 showed a higher mortality for patients taking warfarin (12-month survival, 66% vs 76%; hazard ratio, 1.57; 95% CI, 1.21-2.04; p < 0.001).. After controlling for multiple prognostic factors such as age, ASA score, AMTS, and WAI, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. This study highlights the need to view warfarin therapy as a 'red flag' in patients presenting with a fractured neck of the femur. Preoperatively, prompt warfarin reversal together with adequate investigation and optimization of the patient should ensure timely, safe surgery. Early involvement of the anesthesia team should ensure an appropriate level of postoperative care for these patients.. Level III, therapeutic study.

Topics: Aged; Aged, 80 and over; Anticoagulants; Female; Femoral Neck Fractures; Humans; Length of Stay; Male; Models, Theoretical; Retrospective Studies; Risk Factors; Survival Rate; Time Factors; Time-to-Treatment; Treatment Outcome; Warfarin

Insufficiency fractures are a common cause of morbidity among geriatric patients worldwide. Improved outcomes are known to result from decreased delay to definitive operative fixation and mobilization. Use of warfarin is an important potential cause of delay. The ideal mode of warfarin reversal is currently unknown. Prothrombin complex concentrates (PCCs) offer rapid correction with small infusion volume, both of which are important for elderly patients with multiple comorbidities. The authors present 2 cases of insufficiency fractures occurring in geriatric patients receiving warfarin therapy reversed with a 3-factor PCC. Both patients were independent, community ambulators without significant functional disability and returned to their prior level of functioning. There were no significant bleeding or venous thromboembolic complications. To the authors' knowledge, no previous reports have described the use of PCC in geriatric patients with fractures. Nonetheless, its potential is well documented in emergency and trauma surgery literature. The use of PCC could potentially allow surgeons and hospitals to avoid complications related to immobility and the associated costs of treatment, extended hospital stay, and readmission. The authors' limited experience suggests 3-factor PCC preparations may provide adequate correction to allow expeditious surgical treatment. [Orthopedics. 2017; 40(2):e367-e369.].

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Coagulation Factors; Femoral Neck Fractures; Fracture Fixation, Internal; Fractures, Stress; Humans; Male; Plasma; Postoperative Hemorrhage; Shoulder Fractures; Warfarin

To review records of 330 patients who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy.. Medical records of 235 women and 95 men aged 48 to 103 years (mean, 81.6; standard deviation [SD], 13.1) who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy were reviewed. 30 patients were on warfarin, 105 on aspirin, 28 on clopidogrel, and 167 were controls. The latter 3 groups were combined as the non-warfarin group and compared with the warfarin group. Hospital mortality, time from admission to surgery, length of hospital stay, return to theatre, and postoperative complications (wound infection, deep vein thrombosis, and pulmonary embolism) were assessed.. The warfarin and control groups were significantly younger than the clopidogrel and aspirin groups (80.8 vs. 80.0 vs. 84.2 vs. 83.7 years, respectively, p<0.05). 81% of the patients underwent surgery within 48 hours of admission. The overall mean time from admission to surgery was 1.8 days; it was longer in the warfarin than the aspirin, clopidogrel, and control groups (3.3 vs. 1.8 vs. 1.6 vs. 1.6 days, respectively, p<0.001). The mean length of hospital stay was 17.5 (SD, 9.6; range, 3-54) days. The overall hospital mortality was 3.9%; it was 6.7% in the warfarin group, 3.8% in the aspirin group, 3.6% in the clopidogrel group, and 3.6% in the control group (p=0.80). Four patients returned to theatre for surgery: one in the warfarin group for washout of a haematoma, 2 in the aspirin group for repositioning of a mal-fixation and for debridement of wound infection, and one in the control group for debridement of wound infection. The warfarin group did not differ significantly from non-warfarin group in terms of postoperative complication rate (6.7% vs. 2.7%, p=0.228) and the rate of return to theatre (3.3% vs. 1%, p=0.318).. It is safe to continue aspirin and clopidogrel prior to surgical treatment for femoral neck fracture. The risk of delaying surgery outweighs the peri-operative bleeding risk.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Clopidogrel; Female; Femoral Neck Fractures; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Ticlopidine; Warfarin

We describe a case of a patient on warfarin who developed an extensive haematoma after a hip hemiarthroplasty and was successfully treated with embolisation. This case highlights the importance of regular haematology input, careful consideration of a suitable surgical approach, close monitoring of postoperative wounds in patients on warfarin and the emerging role of embolisation.

Topics: Aged, 80 and over; Arthroplasty, Replacement, Hip; Buttocks; Embolization, Therapeutic; Female; Femoral Neck Fractures; Fracture Fixation, Internal; Hematoma; Hemiarthroplasty; Hip; Hip Fractures; Hip Joint; Hip Prosthesis; Humans; Iliac Artery; Postoperative Complications; Warfarin

Significant blood loss in neck-of-femur (NOF) fracture surgery contributes to the high morbidity and mortality. Since the introduction of the European Working Time Directive, trainee surgeons are more junior and inexperienced. We assessed NOF surgical blood loss in relation to the surgeon grade and experience. We assessed a prospective consecutive cohort of 105 acute NOF fracture patients treated surgically. Blood loss was calculated as the difference between the pre- and post-operative haemoglobin levels. Warfarin was reversed pre-operatively where necessary. There were 32 male and 73 female patients, with mean age 83.8 years (range 48-98). One patient died peri-operatively and was excluded. There were 49 intra-capsular fractures and 55 extra-capsular fractures, with no significant difference in group characteristics. Mean haemoglobin drop was 2.8 g/dL [intra-capsular fractures, 2.5 g/dL; extra-capsular fractures, 3.1 g/dL (p = 0.019)]. The difference in blood loss between different surgeon grades was not significant: consultants 2.4 g/dL (21 cases), senior staff grades 2.7 g/dL (17 cases), junior staff grades 3.1 g/dL (15 cases) and registrars 2.9 g/dL (50 cases). Whilst mean haemoglobin drop was least for consultants, the mean for trainees was only marginally higher than for experienced staff grade surgeons and lower than for their junior counterparts. Mean blood loss for patients taking anti-platelet agents was not significantly different (aspirin 2.7 g/dL, clopidogrel 3.7 g/dL, 4.4 g/dL for those taking both) compared to patients taking neither agent (2.8 g/dL). We conclude that surgeon grade does not significantly impact peri-operative haemoglobin drop, regardless of pre-operative morbidity. It is safe for trainees to operate, with adequate supervision where appropriate, on all NOF fracture patients without compromising blood loss.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Clinical Competence; Drug Substitution; Education, Medical, Continuing; Female; Femoral Neck Fractures; Fracture Fixation; Hemoglobins; Humans; Male; Middle Aged; Monitoring, Physiologic; Orthopedics; Outcome and Process Assessment, Health Care; Prospective Studies; United Kingdom; Warfarin

Aminoglycosides are useful antimicrobial agents for treating infective endocarditis; however, they occasionally cause troublesome side effects, such as nephrotoxicity and ototoxicity. We herein report a case of infective endocarditis caused by Enterococcus faecalis that was treated successfully with continuous infusion of ampicillin without adjunctive aminoglycosides. The serum ampicillin concentrations were higher than the minimal inhibitory concentration for the target strain. Although the use of ampicillin monotherapy is currently avoided because double β-lactam therapy is reportedly more effective, continuous penicillin administration remains an effective therapeutic choice for treating infective endocarditis.

Topics: Aged; Aminoglycosides; Ampicillin; Anti-Bacterial Agents; Anticoagulants; Arthroplasty, Replacement, Hip; Atrial Fibrillation; Contraindications; Diagnosis, Differential; Endocarditis, Bacterial; Enterococcus faecalis; Femoral Neck Fractures; Gram-Positive Bacterial Infections; Humans; Infusions, Intravenous; Male; Microbial Sensitivity Tests; Mitral Valve; Postoperative Complications; Practice Guidelines as Topic; Pyelonephritis; Streptomycin; Warfarin

PURPOSE. To compare the effects of different warfarin reversal protocols on surgical delay and complication rate in hip fracture patients. METHODS. Records of 7 men and 17 women aged 68 to 93 (mean, 82) years who were on warfarin and underwent surgery for femoral neck fractures were reviewed. The time to surgery, complication rate, and mortality were recorded, as were the International Normalised Ratio (INR) on admission and the day of operation, as well as the dose, route, and time of administration of vitamin K for reversing the anticoagulation effect of warfarin. Patients were divided into 4 groups based on the warfarin reversal treatment. Group 1 (n=4) included patients who did not receive reversal treatment, as their admission INR was 1.5 or less. Group 2 (n=6) included patients who did not receive reversal treatment even though their INR was >1.6. Group 3 (n=5) included patients who received inappropriate reversal treatment (late or low-dose oral administration). Group 4 (n=9) included patients who received appropriate reversal treatment in terms of dose, route, and time of administration. RESULTS. Among the 4 groups, the mean INR was 2.2 (range, 1.3-4.6) on admission and 1.4 (range, 1.0-1.6) on the day of surgery. Group 1 was excluded from further analysis. Respectively in groups 2, 3, and 4, the mean times to surgery were 2.3, 2.6, and 1.2 days, and the complication rates were 67%, 20%, and 11%. CONCLUSION. Early administration of intravenous vitamin K for hip fracture patients on warfarin is recommended to ensure early operative management and avoid postoperative complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Clinical Protocols; Female; Femoral Neck Fractures; Hemorrhage; Humans; Male; Thromboembolism; Time Factors; Vitamin K; Warfarin

Topics: Anticoagulants; Emergencies; Femoral Neck Fractures; Humans; Injections, Intravenous; International Normalized Ratio; Preoperative Care; Time Factors; Vitamin K; Warfarin

Clopidogrel is an anti-platelet agent which causes an increase in bleeding time. An increasing number of patients presenting with an acute femoral neck fracture take clopidogrel in combination with other anti-platelet agents as regular prescription medication. Such patients may be at higher risk of increased peri-operative bleeding. No guidelines or recommendations currently exist regarding the routine discontinuation of clopidogrel in patients with fracture of the femoral neck awaiting surgery.. A telephone questionnaire was undertaken to examine the current practice amongst 110 orthopaedic departments in the UK regarding the discontinuation of clopidogrel prior to trauma surgery for femoral neck fractures. This was compared to the practice of discontinuing aspirin and warfarin in the same patient groups in these departments.. There appears to be significant variation in practice amongst orthopaedic departments with 43.6% having a policy of discontinuing clopidogrel. This compares to 37.3% of trusts having a policy of stopping aspirin and 97.3% stopping warfarin.. There is wide variation in practice regarding the discontinuation of clopidogrel preoperatively in patients due to undergo surgery for femoral neck fractures. These findings highlight the need to develop guidelines for the preoperative management of these patients.

Topics: Anticoagulants; Aspirin; Clinical Protocols; Clopidogrel; Contraindications; Femoral Neck Fractures; Health Care Surveys; Humans; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Preoperative Care; Professional Practice; Surgery Department, Hospital; Ticlopidine; United Kingdom; Warfarin

To assess if pneumatic compression in conjunction with chemoprophylaxis is an effective way to reduce the incidence of deep vein thrombosis in orthopedic trauma patients sustaining fragility hip fractures.. Two hundred patients admitted to the authors' institution between May 1998 and June 2002 for fractures of the hip were prospectively studied. All patients were treated operatively and received the VenaFlow calf compression device on both lower extremities immediately following surgery. Chemical prophylaxis of either aspirin (n = 67) or warfarin (n = 133) was administered in addition to mechanical compression. A noninvasive serial color flow duplex scan was performed 1 to 11 days postoperatively (mean 4.5 days) to determine the presence or absence of deep vein thrombosis. All patients were followed clinically 3 months postoperatively for a clinical evaluation of symptomatic deep vein thrombosis or pulmonary embolism.. Overall, the incidence of deep vein thrombosis was 3.5% (7 of 200) and included only 1 proximal thrombosis (1 out of 200, or 0.5%) and no pulmonary embolism. Five of the 7 patients positive for deep vein thrombosis were in the mechanical compression and warfarin prophylaxis group and 2 were in the aspirin arm of the study. For patients with deep vein thrombosis, the average number of risk factors was 3.71, whereas patients without clots averaged 1.75 clinical risk factors (P < or = 0.05). Three patients in the warfarin group developed bleeding complications (1 with a gastrointestinal bleed and 2 with minor bleeding not at the operative site). No evidence of a symptomatic deep vein thrombosis or pulmonary embolism was reported within a 3-month period following hospitalization.. Our findings suggest mechanical compression with the VenaFlow calf compression device in conjunction with chemoprophylaxis is an effective means of reducing thromboembolic disease in this high-risk population.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Female; Femoral Neck Fractures; Heparin; Hip Fractures; Humans; Male; Prospective Studies; Pulmonary Embolism; Risk Factors; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Warfarin

Warfarin anti-coagulation can cause significant delay in acute surgical admissions. We reviewed fracture neck of femur patients operated over a period of 4 years in our unit. There was an average delay to surgery of 4.36 days in patients on warfarin as against an average delay of 1.78 days in patients not on warfarin (p < 0.001). The review was followed up with a questionnaire-based survey of consultant haematologists, and a general agreement towards a protocol-based use of vitamin K(1) was noted. The reasons for limited use of vitamin K(1) include the lack of studies and guidelines specifically addressing the pre-operative emergency admissions. We highlight a practical problem shared across different specialities and identify the areas for future studies.

Topics: Aged; Aged, 80 and over; Anticoagulants; Emergencies; Epidemiologic Methods; Female; Femoral Neck Fractures; Humans; Male; Middle Aged; Preoperative Care; Time Factors; United Kingdom; Vitamin K 1; Warfarin

A survey was conducted of the attitudes and practices of New Zealand orthopaedic surgeons on the use of pharmacological thromboprophylaxis (PT) for patients undergoing major hip or knee surgery. A questionnaire was sent to all 106 consultant surgeons known to perform hip or knee surgery and a response rate of 89% was obtained. The results suggested that while almost all surgeons used PT at some time, only about one-third of elective surgery patients and just a few per cent of patients with neck of femur fracture (NOFF) receive PT. For about three-quarters of surgeons, heparin (usually low molecular weight) was the most frequently used PT. About half of the surgeons began prophylaxis pre-operatively and about half stopped it when the patients were mobile postoperatively. Previous venous thromboembolism was felt by almost all surgeons to be a very important indication for PT; gross obesity, prolonged pre-operative immobility and active malignancy were thought to be very important factors by approximately one-half of the surgeons. The presence of a major bleeding diathesis or active peptic ulcer was cited as a contraindication to PT by more than two-thirds of all surgeons. Fear of bleeding complications and the rarity of thromboembolic complications were cited as reasons for limited use of PT by about one-third of surgeons. The results suggest that most surgeons usually rely on non-pharmacological methods of thromboprophylaxis, particularly for NOFF patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Arthroplasty; Aspirin; Femoral Neck Fractures; Heparin; Heparin, Low-Molecular-Weight; Hip Joint; Humans; Knee Joint; New Zealand; Orthopedics; Premedication; Surveys and Questionnaires; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Arthroplasty; Aspirin; Dextrans; Femoral Neck Fractures; Heparin; Hip Joint; Humans; Postoperative Complications; Pulmonary Embolism; Warfarin

Topics: Aged; Dextrans; Female; Femoral Neck Fractures; Gastrointestinal Hemorrhage; Humans; Male; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Administration, Oral; Aged; Dextrans; Female; Femoral Neck Fractures; Follow-Up Studies; Humans; Male; Middle Aged; Phlebography; Postoperative Care; Postoperative Complications; Premedication; Thromboembolism; Time Factors; Warfarin

Topics: Anticoagulants; Drug Therapy; Femoral Fractures; Femoral Neck Fractures; Fracture Fixation; Fractures, Bone; Humans; Immobilization; Pelvic Bones; Preventive Medicine; Thromboembolism; Warfarin