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Review
. 2022 May 22;5(3):e633.
doi: 10.1002/hsr2.633. eCollection 2022 May.

Perioperative intravenous iron to treat patients with fractured hip surgery: A systematic review and meta-analysis

Rhona C F Sinclair  1 , Miranda J A Bowman  2 , Iain K Moppett  3 , Michael A Gillies  4
Affiliations
Review

Perioperative intravenous iron to treat patients with fractured hip surgery: A systematic review and meta-analysis

Rhona C F Sinclair et al. Health Sci Rep. .

Abstract

Background: Treatment of preoperative anemia with intravenous iron is common within elective surgical care pathways. It is plausible that this treatment may improve care for people with hip fractures many of whom are anemic because of pre-existing conditions, fractures, and surgery.

Objective: To review the evidence for intravenous iron administration on outcomes after hip fracture.

Design: We followed a predefined protocol and conducted a systematic review and meta-analysis of the use of intravenous iron to treat anemia before and after emergency hip fracture surgery. The planned primary outcome was a difference in length of stay between those treated with intravenous iron and the control group. Other outcomes analyzed were 30-day mortality, requirement for blood transfusion, changes in quality of life, and hemoglobin concentration on discharge from the hospital.

Data sources: EMBASE, MEDLINE, The Cochrane Library (CENTRAL, DARE) databases, Clinicaltrials.gov, and ISRCTN trial registries. Date of final search March 2022.

Eligibility criteria: Adult patients undergoing urgent surgery for hip fracture. Studies considered patients who received intravenous iron and were compared with a control group.

Results: Four randomized controlled trials (RCT, 732 patients) and nine cohort studies (2986 patients) were included. The RCTs were at low risk of bias, and the nonrandomized studies were at moderate risk of bias. After metanalysis of the RCTs there was no significant difference in the primary outcome, length of hospital stay, between the control group and patients receiving intravenous iron (mean difference: -0.59, 95% confidence interval [CI]; -1.20 to 0.03; I 2 = 30%, p = 0.23). Intravenous iron was not associated with a difference in 30-day mortality (n = 732, OR: 1.14, 95% CI: 0.62-2.1; I 2 = 0%, p = 0.50), nor with the requirement for transfusion (n = 732, OR: 0.85, 95% CI: 0.63-1.14; I 2 = 0%, p < 0.01) in the analyzed RCTs. Functional outcomes and quality of life were variably reported in three studies.

Conclusion: The evidence on the use of intravenous iron in patients with hip fracture is low quality and shows no difference in length of acute hospital stay and transfusion requirements in this population. Improved large, multicentre, high-quality studies with patient-centered outcomes will be required to evaluate the clinical and cost-effectiveness of this treatment.

Keywords: anemia; hip fracture; intravenous iron.

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Conflict of interest statement

R. C. F. Sinclair has received an honorarium from Pharmacosmos UK. I. K. Moppett is Deputy Director of the Health Services Research Centre. I. K. Moppett is the colead of the Perioperative Specialist Interest Group of the Fragility Fracture Network and a member of the Quality Standards Group for NICE. I. K. Moppett has received research funding for studies into the perioperative management of hip fracture and his department has received consultancy funding from Astra Zeneca for work unrelated to hip fracture, blood transfusion, or intravenous iron. I. K. Moppett did not perform data extraction from the Moppett 2019 study. M. A. Gillies is a Chief Scientist's Office Scotland NHS Research Scheme Clinician. M. J. A. Bowman has no competing interests.

Figures

Figure 1
Figure 1
Preferred reporting items for systematic reviews and meta‐analyses flowchart of study selection.
Figure 2
Figure 2
Risk of bias for (A) randomized trials (Cochrane risk of bias tool) and (B) nonrandomized studies (Newcastle Ottawa Scale).
Figure 3
Figure 3
Sensitivity analysis for primary outcome, Length of Stay.
Figure 4
Figure 4
Forrest plot for secondary outcomes.
See this image and copyright information in PMC

References

    1. National Hip Fracture Database Report. 2019. https://www.nhfd.co.uk/files/2019ReportFiles/NHFD_2019_Annual_Report.pdf
    1. Brauer CA, Coca‐Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573‐1579. - PMC - PubMed
    1. Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010;113(2):482‐495. - PubMed
    1. Potter LJ, Doleman B, Moppett IK. A systematic review of pre‐operative anaemia and blood transfusion in patients with fractured hips. Anaesthesia. 2015;70(4):483‐500. - PubMed
    1. NICE. National Institute of Clinical Excellence Guideline [NG25] Blood Transfusion. www.nice.org.ukj2015

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