Timing of Surgery for Hip Fracture in Patients on Direct Oral Anti-coagulants: A Population-Based Cohort Study

Background In patients with hip fracture on direct oral anti-coagulants (DOACs), timely surgery is important in optimising outcomes but the safety of early surgery is unclear. This study aims to evaluate the timing of surgery on peri- and post-operative outcomes in patients with hip fracture on DOAC therapy. Methods Single-centre, retrospective, population-based cohort study of patients on DOAC therapy compared to standard care with low-molecular-weight heparin (LMWH) undergoing surgery for hip fracture. Data obtained: patient demographics, fracture classification, American Society of Anaesthesiologists (ASA) classification, time to surgery, procedure performed, type of DOAC, timing of last DOAC dose, use of reversal agents or pro-coagulants and length of stay. Outcomes assessed: pre- and post-operative haemoglobin levels, incidence of blood transfusion, major haemorrhage, venous thromboembolism (VTE) and death within 30 days of surgery. Results A total of 755 patients were included. Compared to standard treatment, DOAC use was associated with a similar change in pre- and post-operative haemoglobin levels ( P = .90), risk of blood transfusion (RR: 1.04, 95% CI: .70–1.54, P = .84), haemorrhage (RR: 1.51, 95% CI: .53-4.28, P = .44), VTE (RR: .92, 95% CI: .12–7.20, P = .94) and mortality (RR: 1.85, 95% CI: .89–3.84, P = .10), all of which were independent of the timing of surgery. Conclusion This study builds on growing evidence that surgery for hip fracture in patients on DOAC therapy is not associated with an excessive risk of haemorrhage, irrespective of the timing of surgery. Timely surgical fixation of the hip fracture in this population is indicated in the absence of other risk factors for haemorrhage.