Early versus delayed surgery for hip fragility fractures in patients treated with direct oral anticoagulants

Abstract

Background: Delaying surgical treatment for hip fragility fractures increases mortality, but early intervention in patients treated with direct oral anticoagulant (DOAC) may increase the risk of perioperative blood loss due to residual drug activity. This study aimed to evaluate the effect of the timing of hip fragility fractures surgeries in patients treated with DOAC.

Methods: We retrospectively reviewed all records of DOAC-treated patients who underwent surgery for hip fragility fractures between 2011 and 2019. They were divided into three groups according to time to surgery since admission to the emergency room (ER), ≤ 24, 24-48, and ≥ 48 h. Blood loss, peri and postoperative complications, readmissions, and short- and long-term mortality were compared between groups.

Results: Of the 171 suitable patients (59 males and 112 females), 32 (18.7%) were in the ≤ 24 h group, 93 (54.4%) in the 24-48 h group, and 46 (26.9%) in the ≥ 48 h group. Timing of surgery did not affect blood loss, as indicated by changes in pre- and postoperative hemoglobin levels (p = 0.089) and proportion of perioperatively administered packed cells (p = 0.949). There was a trend towards increased 30-day mortality in the ≥ 48 h group compared to the 24-48 h and ≤ 24 h groups (13.0, 4.3 and 3.1%, respectively. p = 0.099), and a trend towards increased 90 day mortality (6.5, 3.2, and 0%, respectively. p = 0.298).

Conclusions: Early surgery did not increase perioperative blood loss. Delayed surgery ≥ 48 h of patients receiving DOAC who underwent surgery for hip fragility fractures showed a trend towards increased 30 day and 90 day mortality.

Keywords: Direct oral anticoagulants; Fragility fracture; Hip fracture; Perioperative complications; Postoperative blood loss.