Should Recommended Laboratory-Test Cut-Offs Allowing Surgery Be Followed for Proximal Femoral Fractures in Patients on Direct Oral Anticoagulant Therapy?

BACKGROUND:  Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were vs. were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS: Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

MATERIALS AND METHODS: This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after vs. before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) vs. 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS: Mean blood loss was 287.1 mL in the Rec+ group and 411.7 mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8 g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION: Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48 h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE: IV; retrospective single-centre study.