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SOCIEDADE BRASILEIRA DE
ORTOPEDIA E TRAUMATOLOGIA
www.rbo.org.br

1 Review Article

2 Hand and wrist surgery without suspending

3 warfarin or oral antiplatelet – systematic review夽

4 Q1 Trajano Sardenberg ∗ , Francisco Simões Deienno, Raffaello de Freitas Miranda,

5 Denis Varanda, Andréa Christina Cortopassi, Paulo Roberto de Almeida Silvares
6 Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
7

8 a r t i c l e i n f o a b s t r a c t
9

10 Article history: To assess, through a systematic literature review, whether or not it is necessary to suspend
11 Received 10 May 2016 antithrombotic medications (warfarin, aspirin, and clopidogrel) to perform elective wrist
12 Accepted 19 May 2016 and hand surgeries. The search for articles was performed using a combination of keywords
13 Available online xxx in the databases available, without scientific design constraints, being selected series with
14 five or more surgeries; the selected articles were analyzed regarding serious (need for surgi-
15 Keywords: cal treatment) and mild complications (without surgery). Seven articles were retrieved and
16 Hand/surgery analyzed; 410 wrist and hand surgeries were performed in patients on warfarin or aspirin
17 Anticoagulants and clopidogrel, with three serious complications (0.7%) and 38 mild (9.2%); 2023 surgeries
18 Warfarin were performed in patients without use of antithrombotics, with zero serious and 18 (0.8%)
minor complications. Patients using warfarin or oral antiplatelet (aspirin, clopidogrel, and
aspirin associated with clopidogrel) need not suspend the medication to undergo wrist and
hand surgery.
© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora
Ltda. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Cirurgia da mão e do punho sem suspender varfarina ou antiplaquetários

orais – Revisão sistemática

r e s u m o
19

20 Palavras-chave: Avaliar, por meio de revisão sistemática da literatura, se há ou não necessidade de suspender
21 Mão/cirurgia medicamentos antitrombóticos (varfarina, AAS e clopidogrel) para a realização de proced-
22 Anticoagulantes imentos eletivos de cirurgia do punho e da mão. A busca de artigos foi feita por meio da
23 Varfarina combinação de palavras-chave nas bases de dados disponíveis, sem restrições de desenho
científico, sendo selecionadas séries com cinco ou mais cirurgias; os artigos selecionados
foram analisados em relação às complicações graves (necessidade de tratamento cirúrgico)

夽
Study conducted at Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil.
∗
Corresponding author.
E-mail: tsarden@fmb.unesp.br (T. Sardenberg).
http://dx.doi.org/10.1016/j.rboe.2017.07.001
2255-4971/© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001 RBOE 1128 1–6
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24 e leves (sem necessidade de tratamento cirúrgico). Sete artigos foram encontrados e anal-
25 isados; 410 cirurgias do punho e da mão foram feitas em pacientes em uso de varfarina ou
26 AAS e clopidogrel e observou três complicações graves (0,7%) e 38 leves (9,2%); 2.023 cirurgias
27 foram feitas em pacientes sem uso dos antitrombóticos, apresentaram zero complicações
28 graves e 18 leves (0,8%). Pacientes em uso de varfarina ou antiplaquetários orais (AAS, clo-
29 pidogrel e AAS associado a clopidogrel) não necessitam suspender a medicação para ser
30 submetidos a cirurgias do punho e da mão.
© 2016 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier
Editora Ltda. Este é um artigo Open Access sob uma licença CC BY-NC-ND (http://
31 creativecommons.org/licenses/by-nc-nd/4.0/).

or blood platelet antagonists or warfarin or clopidogrel or 72

Introduction ticlopidine or aspirin or acetylsalicylic acid. The strategy was 73

adapted to search in MEDLINE (PubMed), Embase, Scopus, 74

32 The indication of continuous use of oral antithrombotic
LILACS, SciELO, and Cochrane Library (Reviews and Trials) 75
33 drugs for the treatment or prevention of cardiovascular and
databases. 76
34 cerebrovascular diseases has increased in recent decades.1,2
There was no period limitation for the study; the searches 77
35 Antithrombotic drugs are distributed in two groups: anticoag-
were carried out until December 2015. 78
36 ulants, warfarin being the most used, and antiplatelets, with
Articles that directly addressed the study topic, i.e., wrist 79
37 acetylsalicylic acid (ASA) and clopidogrel alone or in combina-
and hand surgery and the use or suspension of anticoagulants 80
38 tion, commonly used in the prevention of thrombotic diseases.
or antiplatelet agents, were selected through the analysis of 81
39 The adjustment of warfarin dosage to keep the patient in
their titles and, when necessary, abstracts retrieved through 82
40 an anticoagulated state, prevent thrombotic diseases, and
the search strategies in databases. 83
41 avoid causing serious bleeding is a complex treatment that
There were no restrictions regarding study design. How- 84
42 requires control through regular International Normalized
ever, only articles with sample size (patients or surgeries) 85
43 Ratio (INR) testing; warfarin suspension and reintroduction
equal to or greater than five patients operated on using war- 86
44 are even more difficult, and may lead to the development of
farin or antiplatelet drugs (ASA and clopidogrel) were selected. 87
45 new thrombotic events or hyperanticoagulation with bleeding
The bibliographic references of the selected articles were 88
46 risk. Suspension and reintroduction of oral antiplatelet agents
analyzed in search of other studies that may not have been 89
47 (ASA and clopidogrel) also present a high risk of thrombotic
previously retrieved. 90
48 diseases, as well as of thrombosis or bleeding.3–6
The articles were analyzed and the following charac- 91
49 Patients taking antithrombotic medications that require
teristics were recorded: sample size (number of surgeries 92
50 surgery put physicians in a dilemma: stopping antithrombotic
or patients); type of surgery; use of tourniquet; type of 93
51 medication to avoid excessive bleeding, but increasing the risk
antithrombotic medication (warfarin, antiplatelet associated 94
52 of thromboembolic disease, or maintaining the antithrom-
with warfarin, ASA, clopidogrel, or ASA associated with clo- 95
53 botic medication to prevent thromboembolism, but increasing
pidogrel); and number and severity of complications. 96
54 the risk of bleeding. Clinical experiences and meta-analysis
The complications assessed were those directly related to 97
55 studies indicate two groups of situations: surgeries and inva-
the effects of warfarin and antiplatelet agents (clopidogrel and 98
56 sive procedures with a low risk of bleeding (e.g., endoscopy,
ASA) on blood coagulation during surgery and up to two weeks 99
57 cataract surgery, arthrocentesis, and dermatological surger-
postoperatively: excessive bleeding and bruising. Complica- 100
58 ies) do not require discontinuation of antithrombotic therapy,
tions that were treated only with conservative methods were 101
59 and surgeries with increased risk of bleeding require the sus-
considered as mild; those that required reoperation were con- 102
60 pension of oral antithrombotic medication and, depending on
sidered as severe. 103
61 the risk of thrombosis, a transition period with heparin.4,7,8
62 The present study aimed to assess whether it is necessary to
63 suspend antithrombotic drugs (warfarin, aspirin, and clopid- Results
64 ogrel) for elective surgical procedures of the wrist and hand,
65 through a systematic review. A total of 387 articles were selected. After analyzing the 104

titles and abstracts and excluding duplicate studies, nine arti- 105

cles were selected. After reading their full texts, two were 106

Material and methods excluded, as the sample size was less than five surgeries or 107

patients. The analysis of the references of the nine articles 108

66 The search strategy for the databases used the terms did not retrieve any new papers. The final number of articles 109

67 hand surgery and anticoagulant or anticoagulants or indi- included for analysis was seven (Fig. 1). 110

68 rect thrombin inhibitors or platelet aggregation inhibitors or The study by Smith and Hooper9 was classified as a 111

69 blood platelet antiaggregants or platelet antiaggregants or retrospective cohort. All surgeries were performed with the 112

70 blood platelet aggregation inhibitors or platelet inhibitors or use of a tourniquet. The sample (surgeries) included: 1370 113

71 antiplatelet agents or antiplatelet drugs or platelet antagonists surgeries without antithrombotic medication (843 for carpal 114

Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001 RBOE 1128 1–6
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Medline (Via PubMed) 78 articles

Embase (excluding PubMed) 143 articles

Scopus 147 articles

Lilacs 0 articles

Scielo 0 articles

Cochrane library (Reviews) 2 articles

Cochrane library (Clinical Trials) 17 articles

Total number of articles – 3 87

Selection after exclusion of duplicate articles and after

reading of titles and abstracts – 9 articles

Selection after reading the complete articles and application of the inclusion
criteria (number of surgery or patients ≥ 5) – 7 articles

Fig. 1 – Studies retrieved on hand and wrist surgery in patients using antithrombotic drugs (warfarin, aspirin, and
clopidogrel).

115 tunnel syndrome [CTS] and 527 for Dupuytren contracture); the use of a tourniquet. The sample (surgeries) consisted 139

116 22 in use of warfarin in patients with INR < 3 (nine for CTS and of 57 patients using warfarin (INR between 1.4 and 3.2), 40 140

117 13 for Dupuytren contracture); and one in use of clopidogrel using clopidogrel, and 24 using clopidogrel and ASA. The 141

118 (Dupuytren contracture). The patient in use of clopidogrel surgeries performed were: 59 for CTS, 12 for Dupuytren 142

119 who underwent surgery for Dupuytren contracture presented contracture, five for trigger finger, and 45 other surgeries. 143

120 excessive bleeding treated conservatively, thus characterized Six patients (five using clopidogrel and one using clopido- 144

121 as a mild complication. All other patients operated on (1370 grel and ASA) presented excessive bleeding conservatively 145

122 without antithrombotic medication and 22 with warfarin) did treated, thus characterizing a mild complication; one patient 146

123 not present excessive bleeding or bruising complications. on clopidogrel with a diagnosis of Vaughan-Jackson syndrome, 147

124 Wallace et al.10 conducted a non-controlled clinical retro- who underwent resection of the distal ulna, tenosynovec- 148

125 spective series. All surgeries were performed with the use of tomy, and tendon transfer, presented a hematoma that 149

126 a tourniquet. The sample (surgeries) included: 55 patients in required surgical treatment, thus characterizing a severe 150

127 use of warfarin (INR between 1.3 and 2.9; 17 for CTS, 12 for complication. 151

128 Dupuytren contracture, five for trigger finger, and 21 other Boogaarts et al.13 conducted a retrospective cohort study. 152

129 surgeries). Two patients (one operated for CTS and one who Patients were operated on without tourniquet, with local 153

130 underwent a trapeziectomy) developed hematoma, which was anesthesia using epinephrine. All patients underwent surgery 154

131 conservatively treated, thus indicating a mild complication. for CTS; 423 did not use antithrombotic medication, 25 155

132 Jivan et al.11 conducted a retrospective case-control study. had their antiplatelet medication suspended, and six were 156

133 The patients were operated with the use of a tourniquet. All operated on while using antiplatelet medication; of the 31 157

134 patients underwent surgery for CTS, 48 without the use of patients on antiplatelet medication (25 suspended and six 158

135 antithrombotic medication and 48 using ASA. No bleeding or non-suspended), 30 were on ASA and one was using clopid- 159

136 bruising complications were observed in both groups. ogrel. Therefore, only six patients using ASA or clopidogrel 160

137 Edmunds and Avakian12 conducted a non-controlled, were operated. No bleeding or bruising complications were 161

138 prospective clinical series. The patients were operated with observed in any operated patients. 162

Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001 RBOE 1128 1–6
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163 Bogunovic et al.5 conducted a prospective cohort study.

Discussion
164 The patients were operated with the use of a tourniquet.
165 The sample (surgeries) included 107 patients who did not use
The analysis of the results of the seven selected studies 223
166 antithrombotic medication (39 for CTS, 23 for trigger finger,
addressed hand and wrist surgeries in patients using war- 224
167 and 45 for other surgeries) and 107 operated on while using
farin or oral antiplatelet agents (ASA and clopidogrel) indicates 225
168 antiplatelet medication (48 for CTS, 21 for trigger finger and
that the frequency of severe complications, defined as bleed- 226
169 38 for other surgeries). Among the patients using antiplatelet
ing or bruising requiring surgical treatment, was extremely 227
170 agents, 76 used ASA, five used clopidogrel, and 11 used clo-
low – three in 410 (0.7%). The three serious complications 228
171 pidogrel and ASA. No serious complications were observed
occurred in patients undergoing complex surgical wrist pro- 229
172 in patients who did not use antiplatelet medication. One of
cedures (wrist arthrodesis associated with tenosynovectomy; 230
173 the patients using antiplatelet medication presented severe
resection of the distal ulna associated with tenosynovectomy 231
174 bleeding requiring reoperation (the patient had rheumatoid
and tendon transfer; and first-row carpectomy); one patient 232
175 arthritis and was using a high dose of ASA, and underwent
used high-dose ASA, one used clopidogrel, and one used 233
176 arthrodesis of the wrist and tenosynovectomy). The rates
warfarin.5,6,12 Bogunovic et al.5 emphasize the similarity of the 234
177 of conservatively treated bruisings (which did not require
situation of patients using antiplatelet agents, in which seri- 235
178 surgery and were characterized as mild complications) were
ous complications were observed in those with rheumatoid 236
179 14% for patients who did not use medication and 17% in
arthritis undergoing bone procedures. In the 184 surgeries per- 237
180 those who used antiplatelet agents; this difference was not
formed on patients using warfarin, one serious complication 238
181 statistically significant. No infection or dehiscence of sur-
was observed.6 239
182 gical wound was observed in the group of patients using
Mild complications, defined as bleeding or bruising that 240
183 antiplatelet agents. The ecchymosis size, digital sensitivity,
did not require surgical treatment, occurred in 35 out of 241
184 and Quick-Dash presented statistically similar results in oper-
410 surgeries (8.5%). The prospective studies by Bogunovic 242
185 ated patients using antiplatelet agents vs. those who were
et al.5,6 including a control group (patients who did not use 243
186 not.
antiplatelet agents or warfarin) presented the largest amount 244
187 Bogunovic et al.6 conducted another prospective cohort
of mild complications, but the authors adopted a broad def- 245
188 study on this issue, this time addressing warfarin. The sample
inition of the term hematoma (“any bulging with palpable 246
189 included 50 surgeries in patients using warfarin alone (32) or
fluid collection, regardless of size”) Edmunds and Avakian12 247
190 associated with ASA (18; 27 for CTS, two for trigger finger, five
reported six minor complications in patients using clopido- 248
191 for mass or synovial cysts resection, four for tendon surgeries,
grel and ASA, subjectively defined as “excessive intraoperative 249
192 and 12 for bone surgeries) and 50 surgeries in patients who did
bleeding.” Stone et al.14 analyzed the results of over 10,000 250
193 not use antithrombotic medication (21 for CTS, eight for trigger
patients undergoing major arterial surgery in use of clopid- 251
194 finger, three tendon surgeries, three for de Quervain tenosyn-
ogrel alone or in combination with ASA, and did not find 252
195 ovitis, one wrist arthroscopy, three soft tissue surgeries, and 11
evidence of excessive intraoperative bleeding. 253
196 bone surgeries). The mean INR in patients using warfarin was
The four studies reporting surgery in patients using 254
197 2.3. All surgeries were made with the use of a tourniquet and
warfarin6,9,10,12 adopted INR equal to or less than three as a 255
198 local anesthetic was injected without epinephrine at the sur-
parameter to perform the surgery without suspending anti- 256
199 gical site. No serious complications were observed in patients
coagulant; apparently, the selection of the INR value was 257
200 who did not use antithrombotic medication. In patients using
determined subjectively. The four studies showed an INR 258
201 warfarin, one serious complication requiring a new surgical
variation from 1.3 to 3.2. Wallace et al.10 reported two mild 259
202 intervention was observed (patient submitted to carpectomy
complications, and the INR ranged from 1.3 to 2.9. The study 260
203 of the first row who developed hematoma and compression
by Bogunovi et al.6 presented a case with serious complication 261
204 of the median nerve four days after surgery). Regarding mild
in which the INR was 2.1 preoperatively and 5.4 on the fourth 262
205 complications that did not require hospitalization or reope-
day after the operation, when the complication was detected. 263
206 ration, patients using warfarin had a higher incidence of
Although the INR parameter of less than or equal to 3 or 3.5 is 264
207 bruisings only at two weeks postoperatively, which paired with
subjective, the observed results suggest that this limit is safe. 265
208 the group that did not use antithrombotic medication at four
The seven studies analyzed had low levels of evidence, as 266
209 weeks. There were no relevant clinical differences between the
only three were prospective studies presenting better detail- 267
210 groups regarding pain, edema, and upper limb dysfunction.
ing and care in design and execution; these studies reported 268
211 Tables 1 and 2 present summaries of the results from the
more cases of mild and severe complications, probably due to 269
212 seven articles included.
the fact that the definitions of the complications were more 270
213 The indication for the use of warfarin and antiplatelet
precise.5,6,12 271
214 agents in the seven studies analyzed were atrial fibrillation,
The risks of thrombotic diseases with the suspension of 272
215 cardiomyopathy, mitral valve prosthesis, coarctation of the
warfarin or antiplatelet agents depend on multiple factors, 273
216 aorta, venous thromboembolism, valvular prosthesis, atrio-
starting immediately after the suspension, and can last for 274
217 ventricular communication, primary prevention of coronary
months. Drug reintroduction is difficult and undergoes risks. 275
218 disease, secondary prevention of coronary disease, com-
Bell et al.,15 in a study conducted in Canada on the use of med- 276
219 bined secondary prevention of coronary and cerebrovascular
ications after surgery, concluded that patients with long-term 277
220 diseases, pulmonary thrombosis, deep venous thrombosis,
use of warfarin have the potential risk of unintentional dis- 278
221 thrombotic disorders, cardiovascular disease, peripheral vas-
continuation of medications after elective surgery. Therefore, 279
222 cular disease, and neurovascular disease.

Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001 RBOE 1128 1–6
 RBOE 1128 1–6
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001
Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic

Table 1 – Characteristics and summary of results of the seven articles.

Authors Type of study Tourniquet use AT Number of surgeries Mild complications Severe complications

With AT Without AT With AT Without AT With AT Without AT Totalcomplications

Smit and Cohort study Yes Warfarin 23 (22 with 1.370 1 (Bleed- Zero Zero Zero 1 (4.3%) (With AT)
Hooper9 (retrospec- (INR ≤ 3) and warfarin and ing/clopidogrel)
(2004) tive) clopidogrel 1 with
clopidogrel)
Wallace Non- Yes Warfarin (INR 55 Does not 2 (hematoma) Does not Zero Zero 2 (3.6%) (With AT)
et al.10 (2004) controlled 1.3–2.9) refer refer

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(retrospec-

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tive)
Jivan et al.11 Case-control Yes ASA 48 48 Zero Zero Zero Zero Zero (with and
(2008) studies (ret- without AT)
rospective)
Edmunds and Non- Yes Warfarin (INR 121 (57 Does not 6 (bleeding; 5 Does not 1 (hematoma/ Zero 7 (5.8%) (With AT)
Avakian12 controlled 1.4–3.2) warfarin, 40 refer clopidogrel refer clopidogrel)
(2010) clinical series clopidogrel with and 1 with
(prospective) and clopidogrel, ASA + clopidogrel)
ASA + clopidogrel and 24 with
clopido-
grel + ASA)
Boogaarts Cohort study No (local ASA 6 448 Zero Zero Zero Zero Zero (with and
et al.13 (2010) (retrospec- anesthesia without AT)
tive) with
epinephrine)
Bogunovic Cohort study Yes clopidogrel, 107 107 15 13 1 (bleed- Zero 16 (15%) with AT
et al.5 (2013) (prospective) ASA, and (hematoma) (hematoma) ing/high dose 13 (12.1%)
ASA + clopidogrel of ASA) without AT
Bogunovic Cohort study Yes Warfarin 50 (32 50 14 5 (hematoma) 1 Zero 15 (30%) with AT
et al.6 (2015) (prospective) (mean INR warfarin and (hematoma) (hematoma + 5 (10%) without
2.3); 18 war- 18 with war- median nerve AT
farin + ASA farin + ASA) compression)
Total 410 2023 38 (9.2%) 18 (0.8%) 3 (0.7%) Zero 41 (10%) with AT
18 (0.8%) without
AT

AT, antithrombotic.
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Table 2 – Summary and aggregation of the results of the Acknowledgments

seven articles.
Surgeries using warfarin, warfarin + ASA, or antiplatelet agents To the librarian Enilze de Souza Nogueira Volpato for the help 312
(AAS; clopidogrel; AAS + clopidogrel): 410 on the articles search and references citation. 313
Mild complications: 38 (9.2%)
314
Severe complications: three (0.7%)
references
Surgeries using warfarin: 184
315
Mild complications: 16 (8.6%)
Severe complications: one (0.5%)
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282 The ideal study, which was not retrieved in the literature, surgery. J Hand Surg. 2013;38(6):1063–70. 331
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285 of these drugs suspended. 7. Jaffer AK, Brotman DJ, Chukwumerije N. When patients on 335
286 The limitations of the present study, due in part to the warfarin need surgery. Cleve Clin J Med. 2003;70(11):973–84. 336

287 methodological restrictions of the articles selected, hinder 8. Jamula E, Anderson J, Douketis JD. Safety of continuing 337

288 more emphatic conclusions regarding the need to suspend warfarin therapy during cataract surgery: a systematic review 338

289 antithrombotic drugs for wrist and hand surgeries. However, and meta-analysis. Thromb Res. 2009;124(3):292–9. 339
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292 tubular bones, can be performed without suspending warfarin unnecessary for hand surgery. J Hand Surg Br. 343
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294 studies suggest the following practices in the surgical man- 11. Jivan S, Southern S, Majumber S. Re: the effects of aspirin in 345

295 agement of patients taking antithrombotic drugs: in order patients undergoing carpal tunnel decompression. J Hand 346

296 not to discontinue warfarin, patients should have INR less Surg Eur. 2008;33(6):813–4. 347
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298 antiplatelet agents (ASA and clopidogrel) may present greater 2010;15(2):109–13. 350
299 intraoperative bleeding and require greater hemostasis care. 13. Boogaarts HD, Verbeek AL, Bartels RH. Surgery for carpal 351
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302 essary to elucidate this theme. Moreover, the introduction of 14. Stone DH, Goodney PP, Shanzer A, Nolan BW, Adans JE, Powell 354
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Conflicts of interest

311 The authors declare no conflicts of interest.

Please cite this article in press as: Sardenberg T, et al. Hand and wrist surgery without suspending warfarin or oral antiplatelet – systematic
review. Rev Bras Ortop. 2017. http://dx.doi.org/10.1016/j.rboe.2017.07.001 RBOE 1128 1–6