Early surgical care of the anticoagulated hip fracture patient within 24 hours

Carlos Pankratz; Raffael Cintean; Matti Hofmann; Dominik Boitin; Christoph Dehner; Florian Gebhard; Konrad Schuetze

doi:10.1016/j.injury.2024.111924

Early surgical care of the anticoagulated hip fracture patient within 24 hours

Injury. 2024 Sep 28;55(12):111924. doi: 10.1016/j.injury.2024.111924. Online ahead of print.

Authors

Carlos Pankratz¹, Raffael Cintean², Matti Hofmann², Dominik Boitin², Christoph Dehner², Florian Gebhard², Konrad Schuetze³

Affiliations

¹ Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Electronic address: Carlos.pankratz@uniklinik-ulm.de.
² Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
³ Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Electronic address: Konrad.schuetze@uniklinik-ulm.de.

PMID: 39395386
DOI: 10.1016/j.injury.2024.111924

Abstract

Introduction: Hip fractures are still associated with high morbidity and mortality. Despite international guidelines advocating for urgent surgical treatment, delays often occur, particularly for patients on long-term antithrombotic therapy. We hypothesised that urgent surgical care for the anticoagulated hip fracture patient is not associated with severe bleeding complications.

Material and methods: For the period from 2015 to 2021, we retrospectively reviewed clinical records of 1142 patients with proximal femur fractures treated within 24 h of admission to our trauma centre (mean age 80.4 ± 12.4 years; 761 females, 381 males). The cohort comprised 409 femoral neck and 733 trochanteric fractures, managed with either arthroplasty (n = 297), hip-preserving techniques (n = 147), or intramedullary nailing (n = 698). Of these, 583 patients (51.1 %) were on long-term antithrombotic therapy. The primary endpoints included transfusion rate and the difference in haemoglobin (Hb) levels from pre- to postoperative. Secondary endpoints were in-patient mortality and occurrence of postoperative haematomas requiring surgical revision. A regression analysis was performed.

Results: The mean time to surgery was 10.3 h, with delays observed in patients on direct oral anticoagulants (DOACs). Overall, 25.9 % (n = 296) of the patients required blood transfusions. The transfusion rate was dependent on duration of the surgery, preoperative Hb level, and anticoagulation with DOACs. Similarly, the Hb difference was found to be dependent on the duration of surgery, preoperative Hb level, and anticoagulation with DOACs. In-patient mortality was 5.3 % (n = 60). Regression analysis indicated that mortality was dependent on a high ASA classification of 4 and the time to surgery, but not on the type of antithrombotic therapy. 3.1 % of the patients needed surgical revision due to postoperative haematoma with prolonged duration of surgery and antithrombotic therapy (PAI [OR = 3.7, 95 % CI: 1.1-12.7], DOACs [OR = 3.4, 95 % CI: 1.3-8.8], and VKA [OR = 5.5, 95 % CI: 1.8-17.1], p < 0.05) as independent risk factors.

Conclusion: As postoperative haematoma and the need for transfusion are manageable situations, we conclude that immediate surgical treatment of hip fracture patients on long-term antithrombotic therapy within 24 h is feasible and patients may benefit.

Keywords: Anticoagulation; Antithrombotic therapy; Early surgical care; Geriatric outcome; Geriatric trauma; Hip fracture; Pertrochanteric fracture.