Abstract
Introduction
The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases.
Materials and methods
The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event.
Results
Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3).
Conclusions
The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.
Similar content being viewed by others
Introduction
The incidence of cardiovascular diseases in patients undergoing orthopedic surgery is high due to a high prevalence of cardiovascular diseases in the population [1–5]. Bleeding and ischemic complications after orthopedic surgery are severe in patients with a history of cardiovascular disease; they often alter the result of surgery and may influence quality of life after surgery and prognosis [4, 6–10]. The question is whether the discontinuation of long-term anticoagulant therapy prior to skeletal or joint surgery is effective [1, 4, 7, 9–12]. Our prospective study investigated the issue of assessing risk factors of perioperative complications in patients with known cardiovascular disease undergoing neurosurgery, thoracic, abdominal, urological, and orthopedic surgical interventions; its results have already been published [13]. This study aims to compare the incidence of bleeding and ischemic complications after acute and elective orthopedic surgery in patients with known cardiovascular disease.
Materials and methods
This is a subanalysis of the Prague 14 study (registered on www.ClinicalTrials.gov under the identifier NCT01897220) which in total included 1,200 patients who were monitored from 2011 to 2013 and received neurosurgery, thoracic, abdominal, urological, or orthopedic surgery [13]. The inclusion criterion for this subanalysis was orthopedic or trauma surgery to the limbs, spine, or pelvis. All the patients had at least one of the following conditions: coronary artery disease, atrial fibrillation, valvular disease or prosthetic valve, prior stroke, deep vein thrombosis of a lower limb, or pulmonary embolism. Hypertension without the need for antiplatelet therapy was not an inclusion criterion for Prague 14.
Medical record data were monitored in terms of medical history (cardiovascular disease, risk factors, antithrombotic medication, and information about its discontinuation/continuation), surgical intervention and perioperative period (basic hematology and biochemistry tests, perioperative anticoagulant medication, length of operation, and perioperative complications), postoperative surgical site bleeding complications (intraoperative serious bleeding complicating the procedure or prolonging the procedure, postoperative serious bleeding requiring repeated transfusions or surgical revision), ischemic perioperative complications (myocardial infarction, new onset or recurrent heart failure, clinically manifest pulmonary embolism or deep venous thrombosis, acute stroke, and acute limb ischemia), and number of deaths.
Oracle database data were exported via a data mining program called Rapidminer, transferred to MS Excel file and then analyzed using the statistical software Stata. The limit for statistical significance was determined as p = 0.05. The demographic and basic data (age, gender, height, weight, surgical intervention, and medication) were evaluated via descriptive statistical methods. Analyses were conducted via logistic regression with and without adjusting for risk factors (gender, age, height, weight, chronic heart failure, hypertension, smoking, percutaneous coronary intervention, ASA score, warfarin vs discontinuation for 3 and more days prior to surgery, acute vs elective surgery, general vs regional anaesthesia, haemoglobin <100 g/l, thrombocytes >300.1012/l, thrombocytes <150.1012/l, and creatinine >100 mmol/l).
Results
The study cohort included 477 patients, 289 women (61 %), and 188 men (39 %). The overview of patients’ cardiovascular diagnoses is provided in Table 1. Two hundred seventy-two (57 %) patients underwent acute surgery, and 205 (43 %) had elective surgery. An overview of interventions that were performed in the study cohort is shown in Table 2. The patient age ranged between 33 and 99 years (acute: 34–89, elective: 33–99), and the average age was 79 years in acute and 71 years in elective surgery.
Perioperative bleeding were higher in elective surgery (range 10–7.500 ml, average 474 ml, median 400 ml, interquartile range 200–500 ml) compared with acute surgery (range 20–3.000 ml, average 270 ml, median 200 ml, interquartile range 150–300 ml). The overview of perioperative bleeding is shown in Table 3.
Complications developed in 55 (11.6 %) patients, bleeding in 32 (6.9 %) patients, ischemia in 19 (4.0 %), and both in 4 (0.8 %) patients (who underwent acute surgery). Bleeding complications occurred in 14 (5.1 %) patients having acute surgery and in 22 (10.7 %) patients operated on electively. Ischemic complications developed in 22 (8.1 %) patients having acute surgery and in one (0.1 %) who was operated on electively. A detailed overview of complications is shown in Table 4.
After the comparison of all complications between the acute surgery patients and elective patients, we found no statistical difference (p = 0.842, OR 1.06), even when adjusted for proven risk factors (age, general anaesthesia, and use of warfarin) the difference did not change (p = 0.350, OR 0.76). Nonetheless, the statistical differences were apparent when comparing the individual complications. The incidence of bleeding complications was significantly higher after elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, use of warfarin) the difference was even more distinct (p = 0.015, OR 2.44). On the other hand, the incidence of ischemic complications was significantly higher after acute surgery (p = 0.005, OR 18.0), and when adjusted (age) the difference remained significant, despite the considerable decline in the odds ratio (p = 0.044, OR 8.3).
Discussion
The issue of postoperative complications in patients with cardiovascular disease has been viewed from many aspects. One of them is the incidence of bleeding and ischemic complications in regard to perioperative anticoagulant prophylaxis, or conversely, the discontinuation of long-term anti-aggregation therapy prior to orthopedic surgeries [7, 10–12, 14]. Our study aimed to assess the risk of complications in relation to either acute or planned orthopedic surgery.
We think that the significantly higher incidence of bleeding complications in elective interventions is affected by the extent of the procedure, which was larger in the planned surgery than in the acute. Table 2 shows that 87 (81 %) out of 108 total hip arthroplasty (THA) cases were elective (including all 15 hip revisions), within total knee arthroplasty (TKA) cases, 63 (100 %) were elective surgeries, and 12 (55 %) out of 22 thoracolumbar spine surgeries were also elective—all these elective surgeries were associated with bigger perioperative bleeding (Table 3). On the contrary, acute surgery usually involved minor blood loss; 151 (69 %) of 219 acute surgeries to lower limbs were either minimally invasive (ORIF PFN/DHS, ORIF UTN) or procedures in anatomical regions with minimal blood loss (fixation of patellar fractures, evacuation of hematoma, ORIF of ankle fractures, and Achilles tendon suture).
We believe that the higher incidence of ischemic complications after acute surgery could be caused by the worse general health status of older patients and the condition of their arteries. However, the statistical significance remained even after age adjustment, which was the main risk factor. Therefore, we suspect that the higher number of ischemic complications in acute surgery patients could relate to the fact that 183 (67 %) of 272 acute surgeries were performed on the pelvis, hip joint, and femur, the regions most at risk of deep vein thrombosis, including all of the potential consequences to a patient [1, 4, 6, 15]. Only 89 (43 %) of the 205 elective operations involved these body areas.
Acute surgeries were conducted due to trauma, which presented a stressful situation to a patient, including potentially higher risk of ischemic complications. A trauma can contribute to the onset of hemodynamic instability, which may be considered another risk factor for ischemic complications in acute surgery patients. A great contribution of presented analysis is the fact that ischemic complications may be prevented with adequate preoperative preparation [16].
Conclusion
The study showed significantly higher incidence of bleeding complications after elective orthopedic surgery when compared with acute procedures. On the other hand, the incidence of ischemic complications in acute surgery patients was significantly higher when compared with elective surgical interventions. When analyzing elective and acute orthopedic surgeries, the spectra of procedures and involved body regions were strikingly different. Based on the study findings, we may propose focusing on the prevention of bleeding complications in elective orthopedic surgery, but concentrating on prevention of ischemic complications in acute surgery. The continuation of long-term antiplatelet therapy could also be part of the prevention in patients indicated for acute orthopedic surgery. However, such an essential recommendation should be validated by a prospective study primarily focused on perioperative continuation of long-term antiplatelet therapy in acute orthopedic surgery.
References
Decker RC, Foley JR, Moore TJ (2010) Perioperative management of the patient with cardiac disease. J Am Acad Orthop Surg 18(5):267–277
Kadono Z, Yasunaga H, Horiguchi H, Hashimoto H, Matsuda S, Tanaka S, Nakamura K (2010) Statistics for orthopedic surgery 2006–2007: data from the Japanese Diagnosis Procedure Combination database. J Orthop Science 15(2):162–170
Neuhaus V, Bot AG, Swellengrebel CH, Jain NB, Warner JJ, Ring DC (2014) Treatment choise affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus. J Shoulder Elbow Surg 23(6):800–806
Lee HL, Chiu KY, Yiu KH, Ng FY, Yan CH, Chan PK (2013) Perioperative antithrombotic management in joint replacement surgeries. Hong Kong Med J 19(6):531–538
Sanders RD, Bottle A, Jameson SS, Mozid A, Aylin P, Edger L, Ma DQ, Reed MR, Walters M, Lees KR, Maze M (2012) Independent preoperative predictors of outcomes in orthopedic and vascular surgery the influence of time interval between an acute coronary syndrome or stroke and the operation. Ann Surg 255(5):901–907
Bushnell BD, Horton JK, McDonald MF, Robertson PG (2008) Perioperative medical comorbidities in the orthopaedic patient. J Am Acad Orthop Surg 16(4):216–227
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R (2012) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl S):E326S–E350S
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen, Colwell CW, Ray JG (2004) Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126(3 Suppl S):338S–400S
Oberweis BS, Nukala S, Rosenberg A, Guo Y, Stuchin S, Radford MJ, Berger JS (2013) Thrombotic and bleeding complications after orthopedic surgery. Am Hearth J 165(3):427–433
Vetter TR, Boudreaux AM, Papapietro SE, Smith PW, Taylor BB, Porterfield JR Jr (2012) The perioperative management of patients with coronary artery stents: surveying the clinical stakeholders and arriving at a consensus regarding optimal care. Am J Surg 204(4):453–461
Biondi-Zoccai G, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, Testa L, Sheiban I, Sangiorgi G (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease. Eur Heart J 27(22):2667–2674
Korte W, Cattaneo M, Chassot PG, Eichonger S, von Heymann C, Hofmann N, Rickli H, Spannagl M, Ziegler B, Verheugt F, Huber K (2011) Peri-operative management of antiplatelet therapy in patients with coronary artery disease. Thromb Haemost 105(5):743–749
Widimsky P, Motovska Z, Havluj L, Ondrakova M, Bartoska R, Bittner L, Dusek L, Dzupa V, Knot J, Krbec M, Mencl L, Pachl J, Grill R, Haninec P, Waldauf P, Gurlich R (2014) Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The Prague-14 registry. Neth Heart J 22(9):372–379
Chrastina J, Hrabovsky D, Zvarova M, Riha I, Novak Z (2014) The effect of anticoagulation and anti-agregation treatment on the extent, development ant prognosis of acute craniocerebral injury. Acta Chir Orthop Traumatol Cech 81(1):77–84 (in Czech)
Cluett J, Caplan J, Yu W (2008) Preoperative cardiac evaluation of patients with acute hip fracture. Am J Orthop 37(1):32–36
Motovska Z (2011) Management of antiplatelet therapy in patients at risk for coronary stent thrombosis undergoing non-cardiac surgery. Drugs 71(14):1797–1806
Acknowledgments
The study was supported by a research grant of the Czech Ministry of Health IGA No. NT 11506-6/2010. The authors thank to Olga Dzupova for the help with manuscript correction.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None declared by any of the authors.
Rights and permissions
About this article
Cite this article
Džupa, V., Waldauf, P., Moťovská, Z. et al. Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease. Arch Orthop Trauma Surg 136, 907–911 (2016). https://doi.org/10.1007/s00402-016-2468-y
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-016-2468-y