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The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly

Abstract

Purpose

Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients’ ongoing anticoagulant treatments.

Methods

231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed.

Results

Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels.

Conclusion

This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.

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References

  1. Catania P, Passaretti D, Montemurro G, Ripanti S, Carbone S, Candela V, et al. Intramedullary nailing for pertrochanteric fractures of proximal femur: a consecutive series of 323 patients treated with two devices. J Orthop Surg Res. 2019;14(1):449.

    PubMed  PubMed Central  Article  Google Scholar 

  2. Bjorgul K, Reikeras O. Incidence of hip fracture in south eastern Norway: a study of 1,730 cervical and trochanteric fractures. Int Orthop. 2007;31:665–9.

    CAS  PubMed  Article  Google Scholar 

  3. Finsen V, Johnsen LG, Trano G, Hansen B, Sneve KS. Hip fracture incidence in central Norway: a follow-up study. Clin Orthop Relat Res. 2004;419:173–8.

    Article  Google Scholar 

  4. Ahn J, Bernstein J. Fractures in brief: intertrochanteric hip fractures. Clin Orthop Relat Res. 2010;468(5):1450–2.

    PubMed  PubMed Central  Article  Google Scholar 

  5. Johnston P, Wynn-Jones H, Chakravarty D, Boyle A, Parker MJ. Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture? J Orthop Trauma. 2006;20:675–9.

    CAS  PubMed  Article  Google Scholar 

  6. Uzer G, Elmadag NM, Yıldız F, Bilsel K, Erden T, Toprak H. Comparison of two types of proximal femoral hails in the treatment of intertrochanteric femur fractures. Ulus Travma Acil Cerrahi Derg. 2015;21:385–91.

    PubMed  Google Scholar 

  7. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am Vol. 2008;90(4):700–7.

    Article  Google Scholar 

  8. Dai CQ, Wang LH, Zhu YQ, Xu GH, Shan JB, Huang WC, et al. Risk factors of perioperative blood transfusion in elderly patients with femoral intertrochanteric fracture. Medicine (Baltimore). 2020;99(15):e19726.

    Article  Google Scholar 

  9. Loubignac F, Chabas JF. A newly designed locked intramedullary nail for trochanteric hip fractures fixation: results of the first 100 Trochanteric implantations. Orthopaed Traumatol Surg Res. 2009;95(2):139–44.

    CAS  Article  Google Scholar 

  10. Butt MS, Krikler SJ, Nafie S, Ali MS. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury. 1995;26(9):615–8.

    CAS  PubMed  Article  Google Scholar 

  11. Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC, et al. Perioperative blood transfusion and postoperative mortality. JAMA. 1998;279:199–205.

    CAS  PubMed  Article  Google Scholar 

  12. Lin PH, Chien JT, Hung JP, Hong CK, Tsai TY, Yang CC. Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study. BMC Musculoskelet Disord. 2020;21(1):244.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. Zhang K, Zhang S, Yang J, Dong W, Wang S, Cheng Y, et al. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric fractures: a meta-analysis. Med Sci Monit. 2014;20:1628–33.

    PubMed  PubMed Central  Article  Google Scholar 

  14. Yuan X, Yao Q, Ni J, Peng L, Yu D. Proximal femoral nail anti-rotation versus dynamic hip screw for intertrochanteric fracture in elders: a meta-analysis. Zhonghua Yi Xue Za Zhi. 2014;94(11):836–9.

    PubMed  Google Scholar 

  15. Lei J, Zhang B, Cong Y, Zhuang Y, Wei X, Fu Y, et al. Tranexamic acid reduces hidden blood loss in the treatment of intertrochanteric fractures with PFNA: a single-center randomized controlled trial. J Orthop Surg Res. 2017;12(1):124.

    PubMed  PubMed Central  Article  Google Scholar 

  16. Yu W, Zhang X, Wu R, Zhu X, Hu J, Xu Y, et al. The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high-risk patients: a retrospective comparative study with a minimum 3 years of follow-up. BMC Musculoskelet Disord. 2016;17(1):269.

    PubMed  PubMed Central  Article  Google Scholar 

  17. Liu Y, Sun Y, Fan L, Hao J. Perioperative factors associated with hidden blood loss in intertrochanteric fracture patients. Musculoskelet Surg. 2017;101(2):139–44.

    CAS  PubMed  Article  Google Scholar 

  18. Li B, Li J, Wang S, Liu L. Clinical analysis of peri-operative hidden blood loss of elderly patients with intertrochanteric fractures treated by unreamed proximal femoral nail anti-rotation. Sci Rep. 2018;8(1):3225.

    PubMed  PubMed Central  Article  Google Scholar 

  19. Zhou XD, Zhang Y, Jiang LF, Zhang JJ, Zhou D, Wu LD, et al. Efficacy and safety of tranexamic acid in intertrochanteric fractures: a single-blind randomized controlled trial. Orthop Surg. 2019;11(4):635–42.

    PubMed  PubMed Central  Article  Google Scholar 

  20. Tengberg PT, Foss NB, Palm H, Kallemose T, Troelsen A. Tranexamic acid reduces blood loss in patients with extracapsular fractures of the hip: results of a randomised controlled trial. Bone Joint J. 2016;98:747–53.

    PubMed  Article  Google Scholar 

  21. Hou G, Zhou F, Tian Y, Ji H, Zhang Z, Guo Y, Lv Y. Predicting the need for blood transfusions in elderly patients with pertrochanteric femoral fractures. Injury. 2014;45(12):1932–7.

    PubMed  Article  Google Scholar 

  22. Lawrence VA, Silverstein JH, Cornell JE, Pederson T, Noveck H, Carson JL. Higher Hb level is associated with better early functional recovery after hip fracture repair. Transfusion. 2003;43(12):1717–22.

    PubMed  Article  Google Scholar 

  23. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, et al. Anti-fibrinolytic use for minimizing perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2011;3:CD001886.

    Google Scholar 

  24. Schuetze K, Eickhoff A, Dehner C, Gebhard F, Richter PH. Impact of oral anticoagulation on proximal femur fractures treated within 24 h—a retrospective chart review. Injury. 2019;50(11):2040–4.

    CAS  PubMed  Article  Google Scholar 

  25. Thakur NA, Czerwein JK, Butera JN, Palumbo MA. Perioperative management of chronic anticoagulation in orthopaedic surgery. Am Acad Ortho Surg. 2010;18:729–38.

    Article  Google Scholar 

  26. 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.

    PubMed  Article  Google Scholar 

  27. Zhang J, Chen X, Wang J, Liu Z, Wang X, Ren J, et al. Poor prognosis after surgery for intertrochanteric fracture in elderly patients with clopidogrel treatment: a cohort study. Medicine (Baltimore). 2017;96(39):e8169.

    Article  Google Scholar 

  28. Gross JB. Estimating allowable blood loss corrected for dilution. J Am Soc Anesthesiol. 1983;58(3):277–80.

    CAS  Article  Google Scholar 

  29. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962;51(2):224–32.

    PubMed  Google Scholar 

  30. Kumar CN, Srivastava MPK. Screw versus helical proximal femoral nail in the treatment of unstable trochanteric fractures in the elderly. J Clin Orthop Trauma. 2019;10(4):779–84.

    PubMed  Article  Google Scholar 

  31. Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br. 2006;88(8):1053–9.

    CAS  PubMed  Article  Google Scholar 

  32. Yu XW, Ai ZS, Gao YS, Zhang CQ. Blood loss closely correlates with body mass index in total hip arthroplasty performed through direct lateral approach. Saudi Med J. 2013;34(7):709–13.

    PubMed  Google Scholar 

  33. Walsh ME, Ferris H, Coughlan T, Hurson C, Ahern E, Sorensen J, et al. Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database. Osteoporos Int. 2020;30:1.

    Google Scholar 

  34. Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. 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(10):e46175.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  35. Díaz VJ, Cañizares AC, Martín IA, Peinado MA, Doussoux PC. Predictive variables of open reduction in intertrochanteric fracture nailing: a report of 210 cases. Injury. 2016;47(Suppl 3):S51–5.

    PubMed  Article  Google Scholar 

  36. Mattesi L, Noailles T, Rosencher N, Rouvillain JL. Discontinuation of Plavix®(clopidogrel) for hip fracture surgery. A systematic review of the literature. Orthop Traumatol Surg Res. 2016;102(8):1097–101.

    CAS  PubMed  Article  Google Scholar 

  37. Taranu R, Redclift C, Williams P, Diament M, Tate A, Maddox J, et al. Use of anticoagulants remains a significant threat to timely hip fracture surgery. Geriatr Orthop Surg Rehabil. 2018;22(9):2151459318764150.

    Google Scholar 

  38. Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, et al. Aspirin in patients undergoing non-cardiac surgery. N Engl J Med. 2014;370(16):1494–503.

    CAS  PubMed  Article  Google Scholar 

  39. 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.

    CAS  PubMed  Article  Google Scholar 

  40. Goodnough LT, Shander A, Brecher ME. Transfusion medicine: looking to the future. Lancet. 2003;361(9352):161–9.

    PubMed  Article  Google Scholar 

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No funding sources were utilized to conduct and complete this study.

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Correspondence to Ömer Erşen.

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Tüzün, H.Y., Bilekli, A.B. & Erşen, Ö. The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly. Eur J Trauma Emerg Surg 48, 1879–1884 (2022). https://doi.org/10.1007/s00068-021-01670-8

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  • DOI: https://doi.org/10.1007/s00068-021-01670-8

Keywords

  • Elderly
  • Intertrochanteric fractures
  • Blood loss
  • Perioperative blood transfusion