Use of direct oral anticoagulants should not delay surgical intervention for patients with hip fractures

1. In geriatric patients with hip fractures on direct oral anticoagulants (DOACs), surgical treatment within 48 hours of their last preoperative DOAC dose had comparable complication rates and 1-year mortality compared with patients with surgery delayed past 48 hours.

2. Patients who underwent surgical management within 48 hours required fewer transfusions and had decreased length of stay, compared with those who underwent surgery beyond 48 hours. 

Evidence Rating Level: 2 (Good)

Geriatric hip fractures are associated with 1-year mortality rates as high as 33%. Surgical delays beyond 24 hours increase the 30-day mortality risk, while those more than 48 hours increase the 1-year mortality risk.  Rising use of DOACs complicates perioperative management due to consideration of bleeding risk, often leading to a required 48-hour discontinuation period before surgery. This retrospective cohort study used data from 3 level 1 trauma centers in the United States between 2010 and 2018, to investigate the relationship between the timing of the last DOAC dose before surgery (<48 vs. >48 hours) and postoperative complications and mortality rates. 205 patients (mean age [range], 81.9 [65-100] years; 65% female; mean Charlson Comorbidity Index [range], 6.4 [2-20]) were included in the study. 35% (71/205) of patients underwent surgery within 48 hours of their last preoperative DOAC dose. Patients with delayed surgery (>48 hours) experienced a mean time to surgery of 44.4 hours longer compared to those without delay. No significant differences were observed in total complications, readmission rates, 1-year mortality, estimated blood loss, or change in hemoglobin/hematocrit level, based on the timing of the last DOAC dose preoperatively. Notably, multivariate analysis controlling for age, CCI, DOAC prescribed, fracture type, sex, delayed surgery, and surgery type, demonstrated that patients delayed >48 hours from their last preoperative DOAC dose, were more likely to require a blood transfusion (OR 2.39, 95% CI, 1.05–5.44; P = 0.04). Compared with patients who waited more than 48 hours from their last preoperative DOAC dose, those who were treated within 48 hours had significantly shorter lengths of stay (5.9 vs. 7.6 days, P<0.005). Overall, this study found that geriatric patients with hip fractures who underwent surgery within 48 hours of their last preoperative DOAC dose had comparable mortality and complication rates, required fewer transfusions, and had decreased length of stay compared with patients delayed beyond 48 hours. These findings support early intervention for geriatric hip fractures rather than adherence to DOAC discontinuation guidelines. 

Click to read the study in the Journal of Orthopedic Trauma

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