Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Use of direct-acting anticoagulants (DOACs) delays surgery and is associated with increased mortality in hip fracture patients

PURPOSE

Treatment with direct-acting oral anticoagulants (DOACs) is increasing among hip-fracture patients, with accompanying safety concerns regarding spinal anesthesia (SA). The aim of this study was to investigate if DOAC use is associated with increased waiting time before surgery, increased mortality, or other adverse events.

METHODS

Registry data on surgically treated hip-fracture cases at a single hospital between 2015 and 2021 were analyzed. Multivariable regression analyses were performed with DOAC-status and choice of anesthesia as exposures, and waiting time, length of stay, transfusion, and mortality as outcomes.

RESULTS

2885 cases were included, 467 patients (16%) were using DOACs. DOAC users were older (86.3 vs. 82.2 years, p < 0.001), had a higher Charlson Comorbidity Index (2.1 vs. 1.5, p < 0.001) and had longer median time to surgery than non-DOAC cases (36 h vs 17 h, p < 0.001). General anesthesia (GA) was used in 19.3% of DOAC patients and in 3.0% of non-DOAC patients. DOAC-patients had an increased risk of one-month mortality (Adjusted Odds Ratio (AOR) 1.6 (1.1-2.3)) and one-year mortality (AOR 1.4 (1.1-1.8)). There were no differences in risk of blood transfusion. Patients on DOAC operated under GA had a lower risk of one-year mortality (AOR 0.5 (0.3-0.9)), but a similar one-month mortality to DOAC-patients operated under SA.

CONCLUSION

DOAC users had a longer waiting time to surgery, indicating postponement of surgery due to concerns of the safety of SA. The clinical practice should be changed to allow earlier surgery for DOAC patients.

Preoperative Drug Monitoring in Management of Patients with Hip Fracture on Treatment with Direct Oral Anticoagulants

Purpose

Aim of the present study was to evaluate whether monitoring direct oral anticoagulant (DOAC) levels may improve management of anticoagulated patients who need surgery for hip fracture.

Patients and Methods

A total of 147 out of 2231 (7.7%) patients with hip fracture admitted to a tertiary teaching hospital were on DOACs (group A), whereas 206 patients matched for age, sex, and type of fracture not on anticoagulant or P2Y12 platelet inhibitors were considered as control group (group B). Patients on DOACs were divided into two subgroups: A1 in which intervention was scheduled in relation to the last drug intake according to current guidelines, and A2 included patients in whom time of surgery (TTS) was defined according to DOAC levels. Neuraxial anesthesia was considered with DOAC levels <30 ng/mL, general anesthesia for levels in the range 30-50 ng/mL.

Results and conclusions

TTS was significantly lower in controls than in DOAC patients: surgery within 48 hours was performed in 80.6% of group B versus 51% in group A (p<0.0001). In A2, 41 patients underwent surgery within 48 hours (56%) in comparison to 32 A1 patients (45.1%; p=0.03). TTS and length of hospitalization were on average 1 day lower in patients with assay of DOAC levels. Finally, 35/39 (89%) patients with DOAC levels <50 ng/mL had surgery within 48 hours (26 under neuraxial anesthesia, without any neurological complication, and 13 in general anesthesia).

Conclusion

DOAC assay in patients with hip fracture may be useful for correct definition of time to surgery, particularly in patients who are candidates for neuraxial anesthesia. Two-thirds of patients with DOAC levels <50 ng/mL at 48 hours from last drug intake underwent uneventful neuraxial anesthesia, saving at least 24 hours in comparison to guidelines.

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.

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.

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.

Anticoagulation drug use and rehabilitation outcomes in post-acute hip fractured patients

PURPOSE

To assess the relationship between anticoagulant use and rehabilitation outcomes in post-acute hip fracture patients.

METHODS

A retrospective study (1/2017 to 5/2019) of 299 hip fractured patients.

OUTCOME MEASURES

Functional Independence Measure (FIM) and the motor FIM's effectiveness.

RESULTS

Patients treated with anticoagulation drugs exhibited a significant longer latency time from fracture to surgery (U = -4.37, p < 0.001) and from surgery to rehabilitation (U=-2.27, p = 0.023), and a significantly higher rate of cardiovascular diseases (χ2=0.15, p= 0.023) compared with untreated patients. No significant differences between the two patient groups were found regarding the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures.

CONCLUSIONS

Oral anticoagulants are not associated with rehabilitation outcomes of hip fracture patients.Implications rehabilitationAnticoagulation drug use is not associated with functional outcome of post-acute hip fracture patients.It is recommended to renew oral anticoagulants for patients on chronic treatment after surgery since no negative outcomes were found during rehabilitation under anticoagulant treatment and in light of the importance of these drugs in preventing thromboembolic complications.

Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures

BACKGROUND

Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures.

METHODS

This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS).

RESULTS

After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001).

CONCLUSIONS

Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.

Role of DOAC plasma concentration on perioperative blood loss and transfusion requirements in patients with hip fractures

BACKGROUND

There is an ever-increasing number of hip fracture (HF) patients on direct oral anticoagulants (DOAC). The impact of DOAC plasma level prior to HF surgery on perioperative blood loss and transfusion requirements has not been investigated so far.

MATERIALS AND METHODS

In this retrospective study of HF patients on DOACs admitted to the AUVA Trauma Center Salzburg between February 2015 and December 2021. DOAC plasma levels were analysed prior to surgery. Patients were categorized into four DOAC groups: Group A < 30 ng/mL, Group B 30-49 ng/mL, Group C 50-79 ng/mL, and Group D ≥ 80 ng/mL. Haemoglobin concentration was measured upon admission, prior to surgery, after ICU/IMC admission, and on day 1 and 2 post-surgery. Difference in the blood loss via drains, transfusion requirements and time to surgery were compared.

RESULTS

A total of 155 subjects fulfilled the predefined inclusion criteria. The median age of the predominantly female patients was 86 (80-90) years. Haemoglobin concentration in Group D was lower upon admissions but did not reach statistical significance. The decrease in haemoglobin concentration over the entire observation time was comparable between groups. Blood transfusion requirements were significantly higher in Group D compared to Group A and B (p = 0.0043). Time to surgery, intra- and postoperative blood loss via drains were not different among groups.

CONCLUSION

No strong association between the DOAC plasma levels and perioperative blood loss was detected. Higher transfusion rates in patients with DOAC levels ≥ 80 ng/mL were primarily related to lower admission haemoglobin levels. DOAC concentration measurement is feasible and expedites time to surgery.

Timing and safety of hip fracture surgery in patients on direct-acting oral anticoagulants

Background

Many geriatric patients presenting for emergency hip fracture surgery are on direct oral anticoagulants (DOACs) most of which are not easily reversible. A safe policy was required to reduce delays to surgery. Prior to institution of our hospital's protocol in January 2021, most of these patients had surgery after 48 h following the last dose of DOAC due to concerns about increased perioperative blood loss.

Methods

This was a prospective closed loop audit of the protocol-surgery within 24 h from last dose of DOAC (if creatinine clearance >50 ml/min) with administration of 1-g of tranexamic acid at anesthesia induction. 131 eligible patients (DOAC, n = 22; no anticoagulation, n = 109) between January-June 2021 who had emergency hip fracture surgery were identified. Primary outcome measures were peri-operative blood loss, transfusion requirements and policy compliance. Secondary outcome measures were 30-day mortality, thrombotic complications and wound bleeding.

Results

Compliance with surgical timing and tranexamic acid administration were 55% and 81% respectively after the second audit cycle. The mean estimated blood loss (EBL) in the DOAC group versus the non-anticoagulated control group was 500 ml and 330 ml respectively. The difference between these groups was statistically significant at an alpha level of 5% (P = 0.0115, 95% CI 38.48-299.16). The difference for intra-operative (RR 3.43; 95% CI 1.68-7.01) and post-operative blood transfusion (RR 2.10; 95% CI 1.23-3.58) for the 2 groups was also statistically significant. However, there was no case of massive blood transfusion in both groups. The DOAC group had a lower risk for 30-day mortality (RR 0.71; 95% CI 0.09-5.46). There was no major thrombotic complication in the DOAC group.

Conclusion

This audit has shown that this protocol is safe although clinicians should anticipate some degree of increased intra-operative blood loss. We will recommend continuation of this policy with sustained safety monitoring in order to reduce delays to surgery.

Proximal femur fractures in patients taking anti-coagulants: has anything changed?

With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy.

Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents.

Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.

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

OBJECTIVES

To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups.

DESIGN

Multicenter retrospective cohort.

SETTING

Three tertiary care, academic, Level I trauma centers.

PATIENTS

Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching.

MAIN OUTCOME MEASUREMENTS

The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality.

RESULTS

One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179).

CONCLUSIONS

This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized.

LEVEL OF EVIDENCE

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

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

Purpose

To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture.

Method

A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings.

Results

There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants.

Conclusions

The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01937-8.

Novel Anticoagulants and Hip Fractures in the Elderly

Introduction

Early surgery is recommended in hip fractures to reduce morbidity and mortality. Surgery is often delayed in patients on novel direct oral anticoagulants (DOACs). The purpose of our study was to investigate the impact of DOACs on patients with hip fractures.

Methods

A retrospective comparative analysis was performed. A total of 766 patients presented with neck of femur fractures in the study period. Patients under the age of 60, those managed conservatively and those on alternative anticoagulation (including warfarin, clopidogrel and aspirin) were excluded. Forty-seven (6.1%) patients were on DOACs, to which a group of 47 patients was matched for age, gender, fracture type and intervention to minimise confounding. Primary outcome data on time to surgery (TTS), pre-/postoperative haemoglobin, haemoglobin drop, length of stay (LOS) and 30-day mortality were collected, as well as secondary outcome data on blood transfusion and wound complications. The Charlson Comorbidity Index (CCI) was calculated for all patients.

Results

The mean Charlson Comorbidity Index was significantly increased in the DOAC group (p<0.0001). The mean time to surgery was 49.5 hours in the DOAC group versus 31.3 hours in the control group (p=0.0002). Haemoglobin drop for DOAC patients was 16.9 g/L and 15.9 g/L for control patients (p=0.6). Similarly, no significant increase in transfusion was required (p=0.74). Six DOAC patients and two control group patients died within 30 days of surgery (p=0.13). Wound complications were seen in five (10.6%) patients on DOAC and two (4.2%) patients in the control group (p=0.02).

Conclusion

The results demonstrate statistically significantly higher comorbidities, delay in surgery and higher wound complications in patients on DOAC but no significant difference in haemoglobin drop, blood transfusion and mortality.

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®

Background and Objectives: The increased use of direct oral anticoagulants (DOACs) results in an increased prevalence of DOAC treatment in hip fractures patients. However, the impact of DOAC treatment on perioperative management of hip fracture patients is limited. In this study, we describe the prevalence of DOAC treatment in a population of hip fracture patients and compare these patients with patients taking vitamin K antagonists (VKA) and patients not taking anticoagulants. Materials and Methods: This study is a retrospective analysis from the Registry for Geriatric Trauma (ATR-DGU). The data were collected prospectively from patients with proximal femur fractures treated between January 2016 and December 2018. Among other factors, anticoagulation was surveyed. The primary outcome parameter was time-to-surgery. Further parameters were: type of anesthesia, surgical complications, soft tissue complications, length of stay and mortality. Results: In total, 11% (n = 1595) of patients took DOACs at the time of fracture, whereas 9.2% (n = 1325) were on VKA therapy. During the study period, there was a shift from VKA to DOACs. The time-to-surgery of patients on DOACs and of patients on VKA was longer compared to patients who did not take any anticoagulation. No significant differences with regard to complications, type of anesthesia and mortality were found between patients on DOACs compared to VKA treatment. Conclusion: An increased time-to-surgery in patients taking DOACs and taking VKA compared to non-anticoagulated patients was found. This underlines the need for standardized multi-disciplinary orthopedic, hematologic and ortho-geriatric algorithms for the management of hip fracture patients under DOAC treatment. In addition, no significant differences regarding complications and mortality were found between DOAC and VKA users. This demonstrates that even in the absence of widely available antidotes, the safe management of geriatric patients under DOACs with proximal femur fractures is possible.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Management of ongoing direct anticoagulant treatment in patients with hip fracture

Aim of the present study was to investigate the effects of ongoing treatment with DOACs on time from trauma to surgery and on in-hospital clinical outcomes (blood losses, need for transfusion, mortality) in patients with hip fracture. Moreover we evaluated the adherence to current guidelines regarding the time from last drug intake and surgery. In this observational retrospective study clinical records of patients admitted for hip fracture from January 2016 to January 2019 were reviewed. 74 patients were in treatment with DOACs at hospital admission. Demographic data, comorbidities and functional status before trauma were retrieved. As control group we evaluated 206 patients not on anticoagulants matched for age, gender, type of fracture and ASA score. Time to surgery was significantly longer in patients treated with DOACs (3.6 + 2.7 vs. 2.15 ± 1.07 days, p < 0.0001) and treatment within 48 h was 47% vs. 80% in control group (p < 0.0001). The adherence to guidelines’ suggested time from last drug intake to surgery was 46%. Neither anticipation nor delay in surgery did result in increased mortality, length of stay or complication rates with the exception of larger perioperative blood loss (Hb levels < 8 g/dl) in DOACs patients (34% vs 9% p < 0.0001). Present results suggest that time to surgery is significantly longer in DOAC patients in comparison to controls and adherence to guidelines still limited.