Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants

Early Hip Fracture Surgery in Patients Taking Direct Oral Anticoagulants Improves Outcome

Background/Objectives: The increasing numbers of already endemic hip fractures in the elderly taking anticoagulants is a growing concern for daily surgical practice. Ample evidence demonstrates decreased morbidity and mortality in the general population when surgery is performed at the earliest possibility. Direct anticoagulants are relatively new drugs that can cause increased perioperative bleeding. Current guidelines propose stopping the drug to allow for elimination before performing elective surgery. Optimal management in urgent hip surgery is presently based on expert opinion with arbitrary cut-offs. In this study, we investigated whether patients taking direct anticoagulants would benefit from early surgical treatment, regardless of the timing since last intake. Methods: A total of 340 patients were included in the analysis, of which 59 took direct anticoagulants. The primary outcomes were time to surgery, postoperative transfusion rate, postoperative hemoglobin decrease, length of postoperative in-hospital stay (LOPS), revision rate, and complication rate (medical and surgical). Results: Our findings showed that the anticoagulated group was fit for discharge earlier when operated on within 24 h (p = 0.0167). Postoperative transfusion and medical complication rate tended to be lower when the operation was performed earlier. Revision rate due to hematomas were higher in the direct anticoagulant group without a relationship to time to surgery. Simple linear regression could not determine a relationship between postoperative hemoglobin change and time to surgery. Conclusions: We suggest that directly anticoagulated patients needing hip fracture surgery must be considered for early surgery.

Dedicated anticoagulation management protocols in fragility femoral fracture care - a source of significant variance and limited effectiveness in improving time to surgery: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

INTRODUCTION

Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery.

METHODS

Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery.

RESULTS

Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219).

CONCLUSIONS

Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.

The impact of anticoagulant medications on fragility femur fracture care: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

INTRODUCTION

Due to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients.

METHODS

Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed.

RESULTS

Data on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83-10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48-0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88-1.22, p = 0.646 and 0.22 days, 95 %CI -0.45-0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03-1.57, p = 0.026).

CONCLUSIONS

Anticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes.

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 versus 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.

PATIENTS 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 versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/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 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Expedited surgery does not increase transfusion rates for patients with geriatric hip fracture taking factor Xa inhibitors

Objectives

Geriatric patients who sustain hip fractures and are taking factor Xa inhibitors (Xa-I) experience surgical delay. Our institution developed a pharmacokinetic protocol to formally guide and expedite surgical timing for these patients. The protocol is based on the patient's renal function and timing of last Xa-I dose. For patients with impaired renal function, longer wait times are recommended. The purpose of this study was to determine the effects of this protocol for patients with geriatric hip fracture taking Xa-I.

Design

Retrospective cohort study.

Setting

Level 1 trauma center.

Patients/Participants

A total of 164 patients aged 65 and older who were taking Xa-I before admission and underwent hip fracture surgery; 68 patients in the Standard group (2014-2018) and 96 patients in the Expedited group (2020-2022, after protocol implementation).

Intervention

Hip fracture surgery.

Main Outcome Measurements

Time to surgery (TTS), transfusion rate, blood loss, 90-day complication rates.

Results

The median TTS was significantly shorter in the Expedited group (28.6 hours, interquartile range 21.3 hours) than in the Standard group (44.8 hours, interquartile range 21.1 hours) (P < .001). There were no differences in overall transfusion rates. Multivariable regression analysis demonstrated that time to surgery was not predictive of transfusion rate in all patients (OR 1.00, 95% CI 0.99-1.02, P = .652). There were no differences in blood loss or rates of 90-day complications.

Conclusion

Geriatric patients with hip fractures and taking factor Xa inhibitors may warrant earlier surgery without an increased risk of transfusion or bleeding.

Level of Evidence

Therapeutic Level III.

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.