gms | German Medical Science

Objectives: About one third of allpatients with hip fractures are taking an oral anticoagulation like acetylsalicylic acid, direct platelet aggregation inhibitors like Clopidogrel (APD), vitamin-K-antagonists like Warfarin (VKA) or direct oral anticoagulants like Rivaroxaban, Dabigatran and Apixaban (DOAC). Current German guidelines demand operative treatment within 24 hours despite anticoagulation. Our objective was to determine the effect of oral anticoagulation on patients with hip fractures receiving operative treatment within 24 hours after admission.

Methods: Only hip fracture patients treated within 24h after admission were included in the study. We included for the years 2015 to 2020 967 patients (mean age 83 +/- 7 years; 645 women and 322 men) treated either with arthroplasty or osteosynthesis in this retrospective study. Our study cohort consisted of 341 femoral neck fractures either treated with arthroplasty (n=221) or dynamic hip screw/femoral neck system (n=120) and 626 proximal femur fractures treated with a proximal femur nail. There were 298 patients taking APD, 146 taking DOAC and 54 taking VKA medication. All patients taking VKA received high dose Vitamin K or coagulation factors to normalize INR prior to surgery. Primary outcome measures were transfusion rate and pre- and postoperative hemoglobin (Hb) difference. Secondary outcome measures were mortality and incidence of postoperative hematoma that needed revision surgery.

Results and conclusion: Over 50% of the patients were taking anticoagulant drugs. There was no difference in time to surgery between the groups (none: 10 +/- 13 h; APD 13 +/- 10 h; DOAC 11 +/-7h; VKA 11 +/- 7 h; p>0.05). The preoperative Hb-level between the groups showed no significant difference. Overall, 243 patients needed blood transfusions (none: 20,7%; APD 25,6%; DOAC 39.7%; VKA 22,2%). Significantly more patients taking DOACs needed a transfusion compared to controls (p<0.05). Hb-difference was significantly lower for patients taking VKA (none: 2,8 +/- 2,4 g/dl; APD 2,9 +/- 2,0 g/dl; DOAC 2,7 +/- 1,8 g/dl; VKA 2,1 +/- 1,1 g/dl; p<0.05) . The rate of revision surgery for postoperative hematoma (n=34) showed no difference between the groups. Hospital mortality was 6,3% and did not differ between the groups. Average time to surgery was 7 hours longer in patients with a deadly course of disease(alive: 13 +/- 7 d vs dead 20 +/- 4 d; p=0,345) but this trend not reaching significance.

Early treatment of hip fractures within 24 hours is safe even for patients on anticoagulant medication. Over 25% of the patients needed blood transfusion so all patients should be preoperatively prepared for possible intraoperative transfusions.

Early treatment of hip fractures is safe even in patients with anticoagulant medication. About one quarter of the patients needed an intraoperative blood transfusion so all patients should be preoperatively prepared for a possible transfusion.