Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Journal of Orthopaedic Surgery and Research
Published in: Journal of Orthopaedic Surgery and Research 1/2020

01-12-2020 | Platelet Aggregation Inhibitor | Research article

Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis

Authors: Zhanyu Yang, Jiangdong Ni, Ze Long, Letian Kuang, Yongquan Gao, Shibin Tao

Published in: Journal of Orthopaedic Surgery and Research | Issue 1/2020

Login to get access

Abstract

Background

Hip fractures are common and account for a large proportion of orthopedic surgical admissions in elderly patients. However, determining the timing for surgery has been controversial for patients who develop hip fractures while on antiplatelet treatment.

Methods

Computerized databases for studies published from the inception date to January 2020, including the Cochrane Library, PubMed (Medline), EMBASE, Web of ScienceTM, ClinicalTrials, ClinicalKey, and Google Scholar, were searched using the keywords “Hip AND Fracture”, “Antiplatelet”, “Antithrombocyte”, “Platelet aggregation inhibitors”, “Aspirin”, “Plavix”, and “Clopidogrel”.

Results

In total, 2328 initial articles were identified. Twenty-four studies with 5423 participants were ultimately included in our analysis. Early surgery was associated with an increased transfusion rate in the antiplatelet group compared to the non-antiplatelet group (OR = 1.21; 95% CI, 1.01 to 1.44; p = 0.03). Early surgery for hip fracture patients on antiplatelet therapy was associated with a greater decrease in hemoglobin compared to delayed surgery (WMD = 0.75; 95% CI, 0.50 to 1.00; p < 0.001). However, early surgery appeared to decrease the length of hospitalization (WMD = − 6.05; 95% CI, − 7.06 to − 5.04; p < 0.001) and mortality (OR = 0.43; 95% CI, 0.23 to 0.79; p = 0.006).

Conclusion

It is unnecessary to delay surgery to restore platelet function when patients with hip fractures receive antiplatelet therapy. Furthermore, early surgery can significantly reduce mortality and hospital stay, which is conducive to patient recovery. Future randomized trials should determine whether the results are sustained over time.
Appendix
Available only for authorised users
Literature
1.
Morris AH, Zuckerman JD. National consensus conference on improving the continuum of care for patients with hip fracture. J Bone Joint Surg Am. 2002;84-a(4):670–4.
2.
Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2(3):141–9.CrossRefPubMed
3.
Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the Scottish hip fracture audit. J Bone Joint Surg Br. 2008;90(10):1357–63.CrossRefPubMed
4.
Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Epidemiology and outcome after hip fracture in the under 65s-evidence from the Scottish hip fracture audit. Injury. 2008;39(10):1175–81.CrossRefPubMed
5.
Baggish AL, Sabatine MS. Clopidogrel use in coronary artery disease. Expert Rev Cardiovasc Ther. 2006;4(1):7–15.CrossRefPubMed
6.
Pickard AS, Becker RC, Schumock GT, Frye CB. Clopidogrel-associated bleeding and related complications in patients undergoing coronary artery bypass grafting. Pharmacotherapy. 2008;28(3):376–92.CrossRefPubMed
7.
Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003;28(3):172–97.PubMed
8.
Lavelle WF, Demers Lavelle EA, Uhl R. Operative delay for orthopedic patients on clopidogrel (plavix): a complete lack of consensus. J Trauma. 2008;64(4):996–1000.CrossRefPubMed
9.
Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.CrossRefPubMedPubMedCentral
10.
Manning BJ, O'Brien N, Aravindan S, Cahill RA, McGreal G, Redmond HP. The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures. Injury-Int J Care Injured. 2004;35(2):121–4.CrossRef
11.
Harty JA, McKenna P, Moloney D, D’Souza L, Masterson E. Anti-platelet agents and surgical delay in elderly patients with hip fractures. J Orthop Surg (Hong Kong). 2007;15(3):270–2.CrossRef
12.
Dettoni F, Castoldi F, Giai Via A, Parisi S, Bonasia DE, Rossi R. Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures. Eur J Trauma Emerg Surg. 2011;37(5):511–8.CrossRefPubMed
13.
Leonidou A, Cam NB, Chambers IR. Femoral neck fractures in patients on clopidogrel. The effect of delaying surgery and the introduction of the new SIGN guidelines. Surgeon-J Royal Colleges Surgeons Edinburgh Ireland. 2011;9(6):318–21.CrossRef
14.
15.
Lee A, Larson R, Morrison D, Chiang W. Drescher F. Aspirin versus anticoagulation for the prevention of venous thromboembolism in orthopedic patients after lower extremity reconstructive surgery - a systematic review. Chest. 2012;142(4). https://​doi.​org/​10.​1378/​chest.​1374115.
16.
Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579–85.CrossRefPubMed
17.
Kulachote N, Sa-Ngasoongsong P, Sirisreetreerux N, et al. The impacts of early hip surgery in high-risk elderly taking antithrombotic agents and afflicted with intertrochanteric fracture. J Med Assoc Thailand. 2015;98(9, Suppl. 8):S76–81.
18.
Akaoka Y, Yamazaki H, Kodaira H, Kato H. Risk factors for the effect of anticoagulant and antiplatelet agents on perioperative blood loss following proximal femoral fractures. Medicine. 2016;95(27):e4120.
19.
Purushothaman B, Webb M, Weusten A, Bonczek S, Ramaskandhan J, Nanu A. Decision making on timing of surgery for hip fracture patients on clopidogrel. Ann R Coll Surg England. 2016;98(2):91–5.CrossRef
20.
Hwang J-Y, Oh S, Kim C-S, Chang J-E, Min S-W. Perioperative complications following preoperative cessation of antithrombotic agents for total knee arthroplasty: a retrospective study. Medicine. 2016;95(48):e5487.
21.
Zhang JZ, Gao J, Han L, et al. Safety of early minimally invasive surgical treatment of elderly patients with hip fractures without ceasing anti-platelet drugs. Academic J Second Military Med University. 2017;38(4):447–51.
22.
Lott A, Haglin J, Belayneh R, Konda SR, Leucht P, Egol KA. Does use of oral anticoagulants at the time of admission affect outcomes following hip fracture. Geriatr Orthop Surg Rehabil. 2018;9:2151459318764151.PubMedPubMedCentral
23.
Hoerlyck C, Ong T, Gregersen M, et al. Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis. Arch Orthop Trauma Surg. 2019;140(2):171–6.CrossRefPubMedPubMedCentral
24.
Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.CrossRefPubMed
25.
Al Khudairy A, Al-Hadeedi O, Sayana MK, Galvin R, Quinlan JF. Withholding clopidogrel for 3 to 6 versus 7 days or more before surgery in hip fracture patients. J Orthop Surg. 2013;21(2):146–50.CrossRef
26.
Chechik O, Amar E, Khashan M, Kadar A, Rosenblatt Y, Maman E. In support of early surgery for hip fractures sustained by elderly patients taking clopidogrel: a retrospective study. Drugs Aging. 2012;29(1):63–8.CrossRefPubMed
27.
Cox G, Talbot C, Topp K, Templeton P. Clopidogrel and proximal femoral fractures: does timing of surgery affect blood loss and length of admission? A preliminary study prior to multicenter trial. Eur J Trauma Emerg Surg. 2009;35(3):291–5.CrossRefPubMed
28.
Johansen A, White J, Turk A. Clopidogrel therapy-implications for hip fracture surgery. Injury-Int J Care Injured. 2008;39(10):1188–90.CrossRef
29.
Pailleret C, Ait Hamou Z, Rosencher N, et al. A retrospective comparison between delayed and early hip fracture surgery in patients taking clopidogrel: same total bleeding but different timing of blood transfusion. Int Orthop. 2017;41(9):1839–44.CrossRefPubMed
30.
Sa-Ngasoongsong P, Kulachote N, Sirisreetreerux N, et al. Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents. World J Orthop. 2015;6(11):970–6.CrossRefPubMedPubMedCentral
31.
Yoo HS, Cho YH, Byun YS, Kim MG. Is taking an antiplatelet agent a contraindication for early surgery in displaced femur neck fracture? Hip Pelvis. 2015;27(3):173–8.CrossRefPubMedPubMedCentral
32.
Sim W, Gonski PN. The management of patients with hip fractures who are taking clopidogrel. Australas J Ageing. 2009;28(4):194–7.CrossRefPubMed
33.
Zehir S, Zehir R, Sarak T. Early surgery is feasible in patients with hip fractures who are on clopidogrel therapy. Acta Orthop Traumatol Turc. 2015;49(3):249–54.PubMed
34.
Anekstein Y, Tamir E, Halperin N, Mirovsky Y. Aspirin therapy and bleeding during proximal femoral fracture surgery. Clin Orthop Relat Res. 2004;418:205–8.CrossRef
35.
Chechik O, Thein R, Fichman G, Haim A, Tov TB, Steinberg EL. The effect of clopidogrel and aspirin on blood loss in hip fracture surgery. Injury. 2011;42(11):1277–82.CrossRefPubMed
36.
Collinge CA, Kelly KC, Little B, Weaver T, Schuster RD. The effects of clopidogrel (Plavix) and other oral anticoagulants on early hip fracture surgery. J Orthop Trauma. 2012;26(10):568–73.CrossRefPubMed
37.
Feely MA, Mabry TM, Lohse CM, Sems SA, Mauck KF. Safety of clopidogrel in hip fracture surgery. Mayo Clin Proc. 2013;88(2):149–56.CrossRefPubMed
38.
Ghanem ES, Richard RD, Wingert NCH, Gotoff JR, Graham JH, Bowen TR. Preoperative use of clopidogrel does not affect outcomes for femoral neck fractures treated with hemiarthroplasty. J Arthroplasty. 2017;32(7):2171–5.CrossRefPubMed
39.
Ginsel BL, Taher A, Whitehouse SL, Bell JJ, Pulle CR, Crawford RW. Effects of anticoagulants on outcome of femoral neck fracture surgery. J Orthop Surg. 2015;23(1):29–32.CrossRef
40.
Kennedy MT, Roche S, Fleming SM, Lenehan B, Curtin W. The association between aspirin and blood loss in hip fracture patients. Acta Orthop Belg. 2006;72(1):29–33.PubMed
41.
Kragh AM, Walden M, Apelqvist A, Wagner P, Atroshi I. Bleeding and first-year mortality following hip fracture surgery and preoperative use of low-dose acetylsalicylic acid: an observational cohort study. BMC Musculoskelet Disord. 2011;12:254.CrossRefPubMedPubMedCentral
42.
Thaler HW, Frisee F, Korninger C. Platelet aggregation inhibitors, platelet function testing, and blood loss in hip fracture surgery. J Trauma. 2010;69(5):1217–20.CrossRefPubMed
43.
Clareus A, Fredriksson I, Wallen H, Gordon M, Stark A, Skoldenberg O. Variability of platelet aggregation in patients with clopidogrel treatment and hip fracture: a retrospective case-control study on 112 patients. World J Orthop. 2015;6(5):439–45.CrossRefPubMedPubMedCentral
44.
Hossain FS, Rambani R, Ribee H, Koch L. Is discontinuation of clopidogrel necessary for intracapsular hip fracture surgery? Analysis of 102 hemiarthroplasties. J Orthop Traumatol. 2013;14(3):171–7.CrossRefPubMedPubMedCentral
45.
Manaqibwala MI, Butler KA, Sagebien CA. Complications of hip fracture surgery on patients receiving clopidogrel therapy. Arch Orthop Trauma Surg. 2014;134(6):747–53.CrossRefPubMed
46.
Nydick JA, Farrell ED, Marcantonio AJ, Hume EL, Marburger R, Ostrum RF. The use of clopidogrel (Plavix) in patients undergoing nonelective orthopaedic surgery. J Orthop Trauma. 2010;24(6):383–6.CrossRefPubMed
47.
Wallace HC, Probe RA, Chaput CD, Patel KV. Operative treatment of hip fractures in patients on clopidogrel: a case-control study. Iowa Orthop J. 2012;32:95–9.PubMedPubMedCentral
48.
Wordsworth DR, Halsey T, Griffiths R, Parker MJ. Clopidogrel has no effect on mortality from hip fracture. Injury. 2013;44(6):743–6.CrossRefPubMed
49.
Eriksson BI, Bauer KA, Lassen MR, Turpie AG. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med. 2001;345(18):1298–304.CrossRefPubMed
50.
51.
Maheshwari R, Acharya M, Monda M, Pandey R. Factors influencing mortality in patients on antiplatelet agents presenting with proximal femoral fractures. J Orthop Surg (Hong Kong). 2011;19(3):314–6.CrossRef
52.
Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int. 2004;15(11):897–902.CrossRefPubMed
53.
White SM, Griffiths R. Projected incidence of proximal femoral fracture in England: a report from the NHS Hip Fracture Anaesthesia Network (HIPFAN). Injury. 2011;42(11):1230–3.CrossRefPubMed
54.
Palan J, Odutola A, White SP. Is clopidogrel stopped prior to hip fracture surgery--a survey of current practice in the United Kingdom. Injury. 2007;38(11):1279–85.CrossRefPubMed
55.
Soo CG, Della Torre PK, Yolland TJ, Shatwell MA. Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord. 2016;17:136.CrossRefPubMedPubMedCentral
56.
Doleman B, Moppett IK. Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression. Injury. 2015;46(6):954–62.CrossRefPubMed
57.
Herman CR, Buth KJ, Kent BA, Hirsch GM. Clopidogrel increases blood transfusion and hemorrhagic complications in patients undergoing cardiac surgery. Ann Thorac Surg. 2010;89(2):397–402.CrossRefPubMed
58.
Purkayastha S, Athanasiou T, Malinovski V, et al. Does clopidogrel affect outcome after coronary artery bypass grafting? A meta-analysis. Heart. 2006;92(4):531–2.CrossRefPubMedPubMedCentral
59.
Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922–7.CrossRefPubMed
60.
Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55(3):146–54.CrossRefPubMed
61.
Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87(8):1123–6.CrossRefPubMed
62.
63.
Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436–42.CrossRefPubMed
64.
Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. Cmaj. 2010;182(15):1609–16.CrossRefPubMedPubMedCentral
65.
Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692–7.CrossRefPubMed
66.
67.
Melton LJ 3rd. Hip fractures: a worldwide problem today and tomorrow. Bone. 1993;14(Suppl 1):S1–8.CrossRefPubMed
68.
Sambu N, Warner T, Curzen N. Clopidogrel withdrawal: is there a “rebound” phenomenon? Thromb Haemost. 2011;105(2):211–20.CrossRefPubMed
Metadata
Title
Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis
Authors
Zhanyu Yang
Jiangdong Ni
Ze Long
Letian Kuang
Yongquan Gao
Shibin Tao
Publication date
01-12-2020
Publisher
BioMed Central
Published in
Journal of Orthopaedic Surgery and Research / Issue 1/2020
Electronic ISSN: 1749-799X
DOI
https://doi.org/10.1186/s13018-020-01624-7

Other articles of this Issue 1/2020

Journal of Orthopaedic Surgery and Research 1/2020 Go to the issue

Research article

Wrist movements induce torque and lever force in the scaphoid: an ex vivo study

Research article

Arthroscopic fixation of humeral greater tuberosity fracture using a W-shaped suture

Research article

Creation of a planned or central-clefted puncture combined with a second puncture during vertebroplasty to treat osteoporotic vertebral compression fractures with large clefts

Research article

Hemostatic effect of tourniquet combined with tranexamic acid in total knee arthroplasty: a network meta-analysis

Research article

Effect of lesser trochanter posteromedial wall defect on the stability of femoral intertrochanteric fracture using 3D simulation

Research article

Influence of marital status on overall survival in adult patients with chordoma: a SEER-based study