This review of 304 carpal tunnel release procedures examines the necessity of stopping antithrombotic medications prior to carpal tunnel release surgery

Chu, Michael W.

Cook, Julia A.

Evans, Tyler A.

Lucich, Elizabeth A.

Sasor, Sarah E.

Tholpady, Sunil S.

Wooden, William A.

IUPUIScholarWorks

Assessing the Necessity of Stopping Antithrombotic Agents Before Wide-Awake Hand Surgery

JAMA Surg. 2018 Mar; 153(3): 284–285.Published online 2017 Nov 29.doi: 10.1001/jamasurg.2017.3927: 10.1001/jamasurg.2017.3927PMCID: PMC5885929PMID: 29188281Assessing the Necessity of Stopping Antithrombotic Agents BeforeWide-Awake Hand SurgerySarah E. Sasor, MD, Tyler A. Evans, MD, Julia A. Cook, MD, Elizabeth A. Lucich, MD, William A. Wooden,MD, Sunil S. Tholpady, MD, PhD,  and Michael W. Chu, MDDivision of Plastic Surgery, Department of Surgery, Indiana University, IndianapolisRichard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IndianaCorresponding author.Article InformationCorresponding Author: Michael W. Chu, MD, Division of Plastic Surgery, Department of Surgery, IndianaUniversity, 545 Barnhill Dr, #232, Indianapolis, IN 46202 (dr.michael.chu@gmail.com).Accepted for Publication: July 2, 2017.Published Online: November 29, 2017. doi:10.1001/jamasurg.2017.3927Author Contributions: Drs Sasor and Chu had full access to all of the data in the study and take responsibility forthe integrity and accuracy of the data analysis.Study concept and design: Sasor, Evans, Wooden, Tholpady, Chu.Acquisition, analysis, or interpretation of data: Sasor, Cook, Lucich, Tholpady.Drafting of the manuscript: Sasor, Evans, Wooden, Tholpady.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Sasor, Cook, Tholpady.Administrative, technical, or material support: Lucich, Wooden, Chu.Study supervision: Sasor, Wooden, Chu.Conflict of Interest Disclosures: None reported.Meeting Presentation: This paper was presented at the Annual Meeting of the Association of VA Surgeons, May 9,2017, Houston, Texas.Received 2017 May 17; Accepted 2017 Jul 2.Copyright 2017 American Medical Association. All Rights Reserved.This review of 304 carpal tunnel release procedures examines the necessity of stopping antithromboticmedications prior to carpal tunnel release surgery.Many patients requiring carpal tunnel release (CTR) surgery are taking long-term antithrombotic (AT)1 1 1 11,2 1,2 1,212Assessing the Necessity of Stopping Antithrombotic Agents Before Wid... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885929/?report=printable1 of 4 6/4/2019, 2:57 PMagents for various medical conditions. This presents a challenge for hand surgeons, who must weigh therisk of bleeding if AT therapy is continued against the risk of thrombosis if AT therapy is temporarilystopped. Previous studies have shown that it is safe to continue AT therapy in patients undergoingdermatologic, cataract, and dental surgery; however, to our knowledge, there is no consensus on themanagement of oral AT agents in elective hand surgery. The goal of this study is to evaluate the safety ofcontinuing AT use in the perioperative period in wide-awake CTR using an open surgical technique.MethodsThe researchers undertook a retrospective review of wide-awake CTR procedures performed at a singleinstitution from February 2013 to April 2016. The study was granted exempt status by the institutionalreview board of Indiana University; study design obviated the need for consent procedures. All cases useda standard, open surgical approach (using a longitudinal palmar incision) and an anesthetic of lidocaine, 1%, with 1:100 000 epinephrine. The researchers classified all patients into 1 of 2 groups: patients taking oralAT agents at the time of surgery, and patients who were naive to AT agents. Patients in whom AT therapyhad been used but discontinued preoperatively were excluded. Demographics, comorbidities, tobacco use,electromyography findings, tourniquet use, operative time, estimated blood loss (EBL), complications, andoutcomes were recorded. Statistical analysis was performed using the t test and Fisher exact test in SPSS(SPSS Inc).ResultsDuring the study period, 304 CTR procedures were performed on 246 patients (for 58 patients, bilateralprocedures were required). Most patients were male (88.5%), and the mean age at surgery was 59.9 years(range, 25.3 years to 91.2 years). Ninety-nine patients (32.6%) were taking prescribed AT agents at the timeof surgery. Six patients (4 taking warfarin and 2 taking dual antiplatelet therapy) had had AT medicationtemporarily stopped in preparation for surgery and were therefore excluded from the study. The remaining93 patients continued their normal AT regimen through surgery. There were 69 patients taking aspirin, 7taking warfarin, 9 taking clopidogrel, 1 taking dabigatran, 3 taking warfarin plus aspirin, and 4 taking dualantiplatelet therapy. Patients treated with AT agents were older than the control group (mean, 66.1 years vs56.9 years; P < .001). They were also more likely to be male (96.8% vs 84.4%; P = .002), diabetic (55.9%vs 22.9%; P < .001), and nonsmokers (82.8% vs 71.7%; P = .04). Average preoperative median nerve motorlatencies at the wrist did not differ significantly between the AT user and non-AT user groups (6.9milliseconds vs 6.7 milliseconds; P = .44), nor did the rate of intraoperative tourniquet use (32% vs 56% forAT user and nonuser groups, respectively; P = .22).Estimated blood loss was higher in the no-tourniquet group for both AT users (4.33 mL vs 3.22 mL; P = .02) and non-AT users (4.21 mL vs 3.13 mL; P = .006). Mean operating time was shorter in the no-tourniquet group for both those treated with AT agents (20.1 minutes vs 25.7 minutes; P = .001) and thosenot treated with AT agents (22.40 minutes vs 24.52 minutes; P = .13). There was no statistical difference inEBL (3.94 mL vs 3.89 mL; P = .87) or operative time (22.0 minutes vs 23.0 minutes; P = .38) in AT andnon-AT patient groups overall.Rates of postoperative complications were similar between the AT group and the non-AT group (5.4% vs4.9%; P > .99). No hematomas or neurological complications were reported, and no patients requiredreoperation during the study period. Overall, 91.8% of patients reported improvement of symptomspostoperatively, with a mean follow-up time of 3.3 months (Table).DiscussionOral AT agents are commonly prescribed for patients with atrial fibrillation, mechanical heart valves,Assessing the Necessity of Stopping Antithrombotic Agents Before Wid... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885929/?report=printable2 of 4 6/4/2019, 2:57 PMvascular disease, or previous thromboembolism. Interruption of these agents may increase morbidity riskand often necessitates multiple preoperative office visits, which are inconvenient for patients and result inan increased burden on the health care system. Despite this, temporary cessation of AT medications in theperioperative period remains common practice in elective hand surgery. There are few reports on the effectsof AT on elective hand surgery, and to our knowledge, this study is the first to provide evidence that ATmedications may be safely continued in wide-awake CTR with or without a tourniquet. Complications werefew, and there were no major differences in outcomes between groups.References1. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematicreview. Arch Intern Med. 2003;163(8):901-908. [PubMed: 12719198]2. Edmunds I, Avakian Z. Hand surgery on anticoagulated patients: a prospective study of 121 operations.Hand Surg. 2010;15(2):109-113. [PubMed: 20672399]3. Lindsley RC. Perioperative management of systemic oral anticoagulants in patients having outpatienthand surgery. J Hand Surg Am. 2008;33(7):1205-1207. [PubMed: 18762121]4. Smit A, Hooper G. Elective hand surgery in patients taking warfarin. J Hand Surg Br.2004;29(3):206-207. [PubMed: 15142687]5. Wallace DL, Latimer MD, Belcher HJ. Stopping warfarin therapy is unnecessary for hand surgery. JHand Surg Br. 2004;29(3):203-205. [PubMed: 15142686]6. Armstrong MJ, Gronseth G, Anderson DC, et al. Summary of evidence-based guideline: periproceduralmanagement of antithrombotic medications in patients with ischemic cerebrovascular disease: report of theGuideline Development Subcommittee of the American Academy of Neurology. Neurology.2013;80(22):2065-2069. [PMCID: PMC3716407] [PubMed: 23713086]Figures and TablesAssessing the Necessity of Stopping Antithrombotic Agents Before Wid... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885929/?report=printable3 of 4 6/4/2019, 2:57 PMTable:Demographics, Procedural Data, and Postoperative OutcomesDemographics and Procedural Data AT(n = 93)No AT(n = 205)P ValueMale, No. (%) 90 (96.8) 173 (84.4) .002Mean age at surgery, y 66.2 56.9 <.001Tobacco use at time of surgery, No. (%) 16 (17.2) 58 (28.3) .04Diabetes, No. (%) 52 (55.9) 47 (22.9) <.001Median nerve motor latency at wrist, ms 6.9 6.7 .44Tourniquet use during surgery, No. (%) 32 (34.4) 56 (27.3) .22OutcomesEstimated blood loss, mL 3.9 3.9 .87Operative time, min 22.0 23.0 .38Complications, No. (%)Overall 5 (5.4) 10 (4.9) >.99Infection 4 (4.3) 5 (2.4) .47Postoperative antibiotics 4 (4.3) 4 (2.0) .26Intravenous antibiotics 0 (0) 1 (0.5) >.99Admission 0 (0) 1 (0.5) >.99Wound dehiscence 1 (1.1) 3 (1.5) >.99Delayed wound healing 1 (1.1) 1 (0.5) .53Hematoma 0 (0) 0 (0) >.99Other 0 (0) 1 (0.5) >.99Postoperative outcomesLost to follow-up, No. (%) 16 (17.2) 32 (15.6) >.99Improvement of symptoms, No. (%) 75 (90.4) 159 (93.0) .47Mean follow-up, mo 3.4 3.3Symptoms improved 3.4 3.4No improvement in symptoms 2.6 2.2Open in a separate windowAbbreviation: AT, antithrombotic agents.Assessing the Necessity of Stopping Antithrombotic Agents Before Wid... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885929/?report=printable4 of 4 6/4/2019, 2:57 PM

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Sarah E. Sasor

Tyler A. Evans

Julia A. Cook

Elizabeth A. Lucich

William A. Wooden

Sunil S. Tholpady

Michael W. Chu

Crossref

JAMA Surgery

https://scholarworks.iupui.edu/bitstream/1805/19531/1/Assessing%20the%20Necessity%20of%20Stopping%20Antithrombotic%20Agents%20Before%20Wide-Awake%20Hand%20Surgery.pdf

Assessing the Necessity of Stopping Antithrombotic Agents Before Wide-Awake Hand Surgery

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