Review Question - QID 220523

The patient presents with an intertrochanteric hip fracture with planned cephalomedullary nail fixation. Despite a recent dose of direct oral anticoagulant (DOAC) for atrial fibrillation, it is appropriate to proceed with surgery as scheduled without further intervention (Answer 4).

DOAC medications (e.g., apixaban, rivaroxaban, edoxaban) function to inhibit Factor Xa, a key enzyme involved in the direct and indirect coagulation cascade, which converts prothrombin to thrombin. DOAC medications are increasingly used over vitamin K antagonists (VKAs, such as warfarin) due to their ease of use and fixed dosing, which eliminates the need for regular laboratory monitoring. While formal guidelines have been published advocating for DOAC cessation >48 hours before elective surgery to reduce the risk of bleeding, their perioperative management in the trauma population is evolving. Expeditious surgery for hip fractures performed within 24-48 hours of injury is associated with decreased length of stay, reduced mortality risk, and fewer perioperative medical complications. These benefits have been shown to extend to patients taking DOAC medications, despite a modest but manageable increase in risk of intraoperative bleeding and postoperative hematoma reported in some studies. Therefore, early treatment of hip fractures within 48 hours is recommended, even in the setting of recent DOAC administration.

Brameier et al. performed a retrospective cohort study assessing patients 65 years of age and older on DOACs before hip fracture treatment. Patients with DOAC administration within 48 hours (n=71) and more than 48 hours (n=134) before surgical intervention were compared. The authors found that patients with delayed surgical management (>48 hours from last DOAC dose) were more likely to require transfusion (OR 2.39) and have a prolonged length of stay (7.6 days versus 5.9 days). Notably, there were no differences in blood loss, anemia, reoperations, readmissions, and mortality at 90 days and 1 year. Therefore, they concluded that providers should consider early intervention, even if a DOAC has been administered within 48 hours.

Moloney et al. analyzed 575 patients aged >60 years who underwent internal fixation for femur fractures and compared those who received a dose of enoxaparin on the day of surgery (n=164, 32%) with those who did not receive a dose. The authors found that transfusion rates, need for negative pressure wound therapy, and 30-day mortality rates did not differ between groups. They concluded that a prophylactic dose of enoxaparin delivered on the day of surgery does not have any adverse effects in terms of hemorrhage or wound drainage.

Leer-Salvesen et al. performed a study utilizing the Norwegian Hip Fracture Register, including 25,019 patients with femoral neck fractures treated with hemiarthroplasty. The authors compared patients who received a low molecular weight heparin (LMWH) agent preoperatively versus those who received LMWH thromboprophylaxis beginning postoperatively. Patients with LMWH initiated preoperatively were at lower risk for mortality and all-cause reoperation. There were no effects on intraoperative bleeding or hematoma formation. The authors concluded that preoperative administration of LMWH for hip fractures is beneficial for mortality and reoperation risk without any adverse bleeding effects.

Wang et al. completed a study assessing patients aged >65 years with femoral neck, intertrochanteric, and subtrochanteric hip fractures undergoing surgical intervention while on a DOAC. Patients undergoing surgery within 24 hours of admission experienced less preoperative blood loss and shorter length of stay. There were no differences in overall blood loss and transfusion rates between early (<24 hours) and delayed (24-72 hours) surgical groups. The authors concluded that early operative intervention appears safe in patients on Xa inhibitors.

Figures A and B are AP and lateral radiographs, respectively, demonstrating an intertrochanteric hip fracture.

Answer 1: Andexanet alfa (Andexxa) is indicated only in the setting of life-threatening or uncontrolled bleeding, and is not required for reversal before surgical management of hip fractures.
Answer 2: Fresh frozen plasma (FFP) should not be administered before surgery, as it does not effectively reverse the anticoagulant effect of apixaban.
Answer 3: Patients on DOACs undergoing early operative intervention for hip fractures experience less preoperative blood loss, along with no difference in overall blood loss or transfusion rates if surgery is performed within 24 hours of injury.
Answer 5: Prothrombin complex concentrate (PCC) should only be administered during hip fracture surgery if patients on DOACs are experiencing severe or life-threatening bleeding and rapid reversal is required.