A significant number of senior citizens take direct oral anticoagulant (DOAC) medications for prophylaxis against strokes, myocardial infarctions, other forms of thromboembolic disease, and numerous other conditions potentially caused by blood clots traveling through their vascular systems. When such individuals sustain hip fractures, surgical repair is often delayed for a time interval sufficient to allow anticoagulant effects to diminish. But is such postponement necessary?

At the AAOS 2024 Annual Meeting in San Francisco, Devon Brameier, MBBS, orthopaedic surgery resident in the Harvard Combined Orthopaedic Residency Program, and her colleagues attempted to answer this question by reviewing data collected regarding preoperative anticoagulant use in patients scheduled to undergo hip fracture surgery at three hospitals affiliated with Harvard University. AAOS Now Editorial Board member Stuart A. Green, MD, FAAOS, sat down with Dr. Brameier to discuss the findings.

Dr. Green: What motivated you to do this study?
Dr. Brameier: In the literature, there wasn’t a clear conclusion what to do with [patients taking anticoagulants prior to hip fracture surgery]. We didn’t know what the impact of those medications was or how we should be approaching these patients. And so, we wanted to address that.

How did you go about gathering your data?
We did this as a retrospective cohort study. We have a tool called the Research Patient Data Registry at our hospitals to identify patients who had hip fractures and had been prescribed DOACs over a 9-year period.

Did you stratify by type of anticoagulant?
The numbers weren’t high enough to specifically look at those.

What were some of your data and conclusions?
We ended up having 205 patients who were on DOACs prior to surgery and were seen and treated for hip fractures. Of that, two-thirds of our patients were waiting more than 48 hours from their last dose before they were treated surgically for their hip fracture.

We then looked at the outcomes—whether being treated early or delayed, based on their DOAC, impacted their outcomes. We saw that there were no differences in mortality or complication rates or readmission rates. Interestingly enough, those patients who were treated early [after admission to the hospital] had a lower rate of needing a transfusion and had a significantly shorter length of stay.

Well, that surprises me. From a surgeon’s perspective, you don’t want your patient to be anticoagulated while you’re operating on them.
What we actually see is those patients are already actively bleeding from their fracture site. And if we’re leaving them while they’re still anticoagulated for 48 hours, they’re actually going to be bleeding more from that fracture. Whereas, if we treat them early, within 48 hours [of admission], we’re stabilizing that fracture and actually reducing their main source of bleeding.

Do you anticoagulate after surgery?
We do. One thing that we’re interested in looking at again is what kind of anesthetic was used for these patients, because DOACs are a contraindication for spinal anesthetic and would be a reason why you would want to delay surgery and let them wean off.

What is your clinical recommendation based on these findings?
I would say that we need to really consider whether or not we should be delaying these patients.

Recommendations of waiting for 48 hours were based on elective patients, and our fracture patients are not the same, so we should really be thinking critically. We should be at least considering operating early.

Stuart A. Green, MD, FAAOS, is cofounder and past president of the Limb Lengthening and Reconstruction Society, past president of the Association of Bone and Joint Surgeons, and an attending surgeon at the Tibor Rubin Long Beach VA Medical Center. He is the son, first cousin, and father of AAOS Fellows. Dr. Green is a member of the AAOS Now Editorial Board.