PHASE 1: INITIAL TRIAGE & SURGICAL TIMING

PATIENT WITH PRIOR STROKE NEEDING ORTHOPEDIC SURGERY(Assessment of Surgical Urgency)

WHAT IS THE SURGICAL INDICATION?

HIP FRACTURE (Urgent/Emergent).*Goal: Operate within 24–48 hours to reduce mortality.

ELECTIVE ARTHROPLASTY (THA/TKA).*Goal: Balance functional improvement against stroke recurrence risk.

Hemorrhagic Stroke <4 Weeks Ago→ HIGH MORTALITY RISK (~75%).Consider non-operative management or delay ≥4 weeks.

Ischemic Stroke (Any timing) OR Hemorrhagic &gt;4 Weeks→ PROCEED TOWARD SURGERY WITHIN 48 HOURS.

<3 Months → DELAY SURGERY.(8-fold increased risk of recurrent stroke. Re-evaluate later).

≥3 Months (Ideal: 3–6 Months) → OPTIMAL WINDOW.Risk plateaus. Proceed to optimization.

PHASE 2: PRE-OPERATIVE OPTIMIZATION & ANESTHESIA

PRE-OP HEMOSTATIC EVALUATION(Assess Baseline Antithrombotic Therapy)

EMERGENCY SETTING: Warfarin → RAPID REVERSAL REQUIRED.Administer Vitamin K + PCC. → PROCEED TO OR.

MANAGE CHRONIC MEDICATION (Scheduled Cessation)

Warfarin → Stop 5 days pre-op. NO BRIDGING (unless mechanical heart valve or stroke <3mo).

DOACs → Stop 48 hours pre-op (longer if significant renal impairment for Dabigatran). NO BRIDGING.

Aspirin (Secondary Prevention) → CONTINUE PERIOPERATIVELY (Bleeding risk outweighs stroke rebound risk).

INTRAOPERATIVE MANAGEMENT*Anesthesia: Neuraxial preferred (if clearance allows). Blood Conservation: TXA generally safe.

PHASE 3: POST-OPERATIVE MANAGEMENT & DISCHARGE

POST-OP VTE PROPHYLAXIS STRATEGY*Context: Stroke patients are 'High Risk'. Virchow's triad active in paretic limb.

Immediate Post-Op (0–24 hrs)→ Mechanical prophylaxis only (SCDs). Avoid full-dose anticoagulation.

Once Hemostasis Secured (24–48+ hrs)→ Initiate Pharmacologic Prophylaxis.

PREFERRED: POTENT AGENT(*LMWH (Enoxaparin) OR DOAC (Rivaroxaban/Apixaban)). Watch for emerging Factor XIa inhibitors.

LONG-TERM SURVEILLANCE*High vigilance for VTE. Low threshold for ultrasound in swollen paretic limb. Resume long-term stroke prevention anticoagulation when surgically safe.

EMERGENCY CESSATION

ortho