Surgery within 24 hours of a hip fracture among patients taking direct oral anticoagulants may not be associated with a greater perioperative hemoglobin decrease compared with delayed surgery and could be linked to a shorter hospital stay, according to a multicenter retrospective cohort study.
In the study, investigators analyzed the outcomes of 875 patients aged 70 years or older with an isolated Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association 31A or 31B hip fracture who were taking direct oral anticoagulants (DOAC) at admission across five level 2 trauma centers in the Netherlands between 2018 and 2023.
The patients were stratified by time to surgery from emergency department presentation: fewer than 24 hours (early surgery; n = 504) vs 24 hours or more (delayed surgery; n = 371). The primary outcome was hemoglobin decrease, defined as the difference between preoperative hemoglobin measured at the emergency department and the lowest value within 24 hours postsurgery.
Secondary outcomes included hemoglobin decrease greater than 2 mmol/L, preoperative and postoperative blood transfusion, packed red blood cells administered, postoperative anemia, hospital stay, and in-hospital and 30-day mortality.
Multiple linear regression adjusted for age, sex, estimated glomerular filtration rate, preoperative hemoglobin, DOAC type, American Society of Anesthesiologists score, and surgical procedure. Missing data were addressed using multilevel multiple imputation by chained equations. The median hemoglobin decrease was 0.6 mmol/L in the early surgery cohort vs 0.9 mmol/L in the delayed surgery cohort, a median difference of 0.3 mmol/L. In adjusted analysis, early surgery was independently associated with a 0.25 mmol/L lower hemoglobin decrease compared with delayed surgery.
The investigators noted that no statistically significant differences were observed in hemoglobin decrease greater than 2 mmol/L (9% early vs 12% delayed), preoperative blood transfusion (3% vs 6%), postoperative blood transfusion (22% vs 18%), number of packed red blood cells administered, or postoperative anemia (27% vs 26%). In addition, in-hospital mortality was 1% in the early cohort vs 2% in the delayed cohort, and 30-day mortality was 3% vs 5%, with no statistically significant differences. Early surgery was associated with a shorter median hospital stay—6 vs 8 days in the delayed cohort, a 2-day difference—and a lower likelihood of discharge to a higher level of care.
Subgroup and regression analyses identified additional associations. Higher preoperative hemoglobin levels were associated with a greater hemoglobin decrease, particularly in female patients. Intramedullary nailing was associated with a greater hemoglobin decrease compared with hemiarthroplasty. Sensitivity analyses excluding patients undergoing surgery after more than 48 hours and stratifying by procedure and anesthesia type yielded results consistent with the primary analysis.
The investigators noted several limitations, including the retrospective design, absence of data on timing of last DOAC dose, lack of information on DOAC serum levels and adherence, and missing data for some variables. Additionally, the Health Intelligence Platform Santeon database lacked detailed data on comorbidities, fracture type, and functional status that may have influenced surgical timing as well as information on wound-related complications and reoperations.
“[S]urgery within 24 hours in patients with hip fracture on DOACs was not associated with a greater [hemoglobin] decrease, indicating the safety of early surgery,” concluded lead study author T. E. E. Schiepers, MD, of the Department of Trauma Surgery at St. Antonius Hospital as well as the Department of Geriatrics at the University Medical Center Utrecht at Utrecht University in the Netherlands, and colleagues.
Full disclosures can be found in the study.
Source: JBJS Open Access
