Most orthopaedic surgery is elective, with the goal of improving quality of life. Patients who are considering elective procedures must weigh the potential benefits and the potential risks, which can include serious medical complications and death. One of our jobs as orthopaedic surgeons is to define and minimize those risks, in collaboration with our medical colleagues.
A patient considering orthopaedic surgery who is taking an antiplatelet medication faces two types of risk. First is the risk of a thrombotic event if the patient stops taking the medication. Second is the risk of bleeding complications during or after surgery, if the patient continues the medication. As orthopaedic surgeons, we must help the patient understand these risks and do what we can to help minimize them.
Two useful articles on this issue are “Take an Aspirin and I’ll (Safely) Put You On-Call to the OR in the Morning,” by Robert A. Peterfreund, MD, PhD, and “The Management of Antiplatelet Therapy in Patients with Coronary Stents Undergoing Noncardiac Surgery” by T.H. Chen and Robina Matyal, MD. Links to both can be found in the online version of this article.
Patients take medications that inhibit platelet function as prophylaxis against thrombotic vascular events. Patients who take antiplatelet medications and their orthopaedic surgeons need to consider and carefully balance the medical risks of discontinuing these medications with the surgical risks (hematoma, blood loss, infection, and nerve or spinal cord compression) associated with continuing them during surgery.
Because we, as orthopaedic surgeons, cannot be expected to keep up with developments in medicine and cardiology any more than cardiologists and primary care physicians can be expected to know everything about our specialty, the decision to stop an anticoagulant should be made jointly with the doctors who are most familiar with the patient’s medical history. In this age of cell phones and electronic communication, such coordination is easier than ever.
Patients with coronary artery disease, peripheral vascular disease, or a prior stroke take aspirin to limit the risk of new events. Patients with diabetes mellitus, congestive heart failure, renal insufficiency, and other conditions that place them at high risk for vascular disease also take prophylactic aspirin.
Aspirin is associated with a slight increase in blood loss, but does not increase bleeding complications or mortality in noncardiac surgery. Because the risk of thrombotic events after acute aspirin withdrawal is felt to outweigh the risk of bleeding complications with surgery, with few exceptions (procedures within the central nervous system, middle ear, posterior eye, and possibly prostate surgery), aspirin is not stopped for surgery or spinal/epidural anesthesia.
Coronary balloon angioplasty was associated with a high rate of reocclusion. The placement of stents to hold the dilated artery open helped, but was associated with hyperplasia of the intima and reocclusion. Stents that elute drugs that inhibit intimal hyperplasia also inhibit intimal coverage of the stent, which can itself act as a nidus for thrombus.
For these reasons, patients with non–drug-eluting coronary artery stents only need to be on dual antiplatelet therapy for 3 months, but patients with drug-eluting stents should remain on aspirin and clo-pidogrel for at least 1 year. Patients with any form of stent should stay on aspirin for life. Stent thrombosis is associated with acute myocardial infarction and sudden cardiac death. Premature discontinuation of antiplatelet therapy is the strongest predictor of late stent thrombosis, and evidence exists showing that the risk of thrombosis increases during the perioperative period.
It is often recommended that elective surgery should be delayed for at least 1 year after insertion of a drug-eluting stent. However, based on the evidence, some small elective surgeries such as carpal tunnel release can be done safely without stopping antiplatelet therapy.
For nonelective surgery, the risks of bleeding must be weighed against the risks of acute thrombosis in deciding whether or not to stop antiplatelet therapy. Patients who are difficult to cross match or who refuse blood transfusions may elect to take the risks of stopping antiplatelet therapy. Ongoing bleeding in patients on antiplatelet therapy is treated with platelet transfusions.
David C. Ring, MD, PhD, and Gregory H. Sirounian, MD, are members of the AAOS Patient Safety Committee.
Disclosure information: Dr. Ring—Biomet, Wright Medical Technology, Inc., Illuminos, Journal of Hand Surgery–American, Journal of Orthopaedic Trauma, American Shoulder and Elbow Surgeons, American Society for Surgery of the Hand. Dr. Sirounian—no information available.
- Patients taking antiplatelet medication who are considering elective orthopaedic surgery must weigh the risks of continuing or stopping their medication prior to surgery.
- Orthopaedic surgeons must work with the patient’s other doctors to help define and minimize the risks and with the patient to ensure informed consent.
- Aspirin treatment does not have to stop for surgery and patients with drug-eluting stents on clopidogrel or similar medications should try to delay surgery for at least 1 year or when their doctor believes they can safely discontinue the medication.
- Peterfreund RA: Take an aspirin and I’ll (safely) put you on-call to the OR in the morning. APSF Newsletter Spring-Summer 2012:14–15. http://www.apsf.org/newsletters/html/2012/spring/07_aspirin.htm
- Chen TH, Matyal R: The management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth 2010;Dec;14(4):256–73. Epub 2010 Nov 7. Review. PubMed PMID: 21059610.
- Edmunds I, Avakian Z: Hand surgery on anticoagulated patients: A prospective study of 121 operations. Hand Surg 2010;15(2):109-13. PubMed PMID: 20672399.