Direct oral anticoagulants (DOACs) increase time to operating room without increasing postoperative hematologic complications in patients with fragility fractures of the proximal femur

Abstract

Introduction

Fragility fractures of the proximal femur are common injuries with significant morbidity and mortality. The use of direct oral anticoagulant (DOAC) medications is increasing among the elderly and is associated with perioperative bleeding-related complications. The primary aim of this study was to examine how DOAC use affects surgical timing and postoperative hematologic complications in patients treated operatively for fragility fractures of the proximal femur. The effect of an institutional tranexamic acid (TXA) protocol implemented during the study period was investigated as a secondary aim.

Materials and methods

This was a retrospective analysis performed at a Level I trauma center. Between March 1, 2018 and April 1, 2022, 746 patients age 50 years and older who underwent surgical treatment for a fragility fracture of the femoral neck, intertrochanteric, or subtrochanteric region of the proximal femur (AO/OTA 31A, 31B, 32) and who were either on no chemical anticoagulation, warfarin, or a DOAC at the time of injury were included. The primary outcomes were time to operating room (TTOR), postoperative transfusion, 30-day venous thromboembolism (VTE), and 30-day hospital readmission. Multivariable logistic regression modeling was used to analyze the effect of anticoagulant, TXA use, and TTOR on these outcomes.

Results

TTOR was increased for patients on warfarin (38.3 ± 26.1 h) or a DOAC (46.4 ± 23.4 h) compared to patients not on anticoagulation (28.0 ± 19.0 h) (p < 0.001). There was no significant difference in transfusion rates among patients not on anticoagulants (31.8 %), warfarin (43.4 %), or a DOAC (29.6 %). Multivariable regression showed a decrease in transfusion rate (OR 0.35, 95 % CI 0.23–0.53) and 30-day readmission (OR 0.31, 95 % CI 0.15–0.61) for intravenous (IV) TXA.

Conclusions

DOAC use was associated with an increase in TTOR without increased rates of transfusion, VTE, or hospital readmission in patients with fragility fractures of the proximal femur. Intravenous TXA was associated with reduced postoperative transfusion and 30-day readmission.