Proximal femur fractures in patients taking anticoagulants

Abstract

Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs. Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed. Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios. Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days. Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended. There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting. Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

“…Published reviews and practical guidelines have indicated there is no consensus on an appropriate DOAC free period prior to acute hip fracture surgery [32][33][34]. The recommended time to surgery in guidelines has ranged from 12 h after the last dose to up to 4 days, depending on half-life of the DOAC and patient renal function [32][33][34][35].…”

“…Published reviews and practical guidelines have indicated there is no consensus on an appropriate DOAC free period prior to acute hip fracture surgery [32][33][34]. The recommended time to surgery in guidelines has ranged from 12 h after the last dose to up to 4 days, depending on half-life of the DOAC and patient renal function [32][33][34][35]. Most recommendations on time to surgery for patients pre-operatively taking DOACs have been made for patients undergoing elective surgery [32], and there has been limited examination of DOACs and time to surgery in the acute care setting, such as for hip fracture.…”

The Financial Burden of Delayed Hip Fracture Surgery: A Single-Center Experience

“…This can have a great impact on the timing of surgery, as reversal of the anticoagulation effect is often necessary for performing regional anesthesia, diminishing bleeding diathesis, and, in some cases, patient optimization as well [ 13 ]. Time to surgery is also influenced by other factors such as operating theater capacity, patient optimization, and day of admission.…”

“…Time to surgery is also influenced by other factors such as operating theater capacity, patient optimization, and day of admission. Even in countries like the UK, were the “Best Practice Tariff” (extra economic benefit per patient) is implemented, in 2017, 30% of patients were operated after 36 hours from presentation [ 13 , 14 ]. In our study, factors that influenced the cost of hip fracture treatment were LOS and the existence of major and minor complications.…”

“…Patients on anticoagulants experienced the most prominent delays, with a mean time to surgery of 6.06 days (95% CI: 5.35-6.76) and had also greater probability for complications. There is a lack of guidelines from the International Orthopaedic Association to guide surgeons regarding the management of patients under anticoagulation that present with hip fracture [ 13 ]. Orthopedic surgeons rely mostly on guidelines provided by other International Medical Bodies, such as the European Heart Rhythm Association and the European Society of Anaesthesiology, that have published guidelines regarding time from discontinuation of anticoagulant to surgery.…”