Assessing operative delay and complications in hip fracture patients on anticoagulants and antiplatelets

Abstract

Objectives: Hip fractures represent a prevalent geriatric cause of morbidity and mortality. The presence of multiple comorbidities requiring the use of an anticoagulant or antiplatelet medication adds complexity to management and influences outcomes. International guidelines suggest expedited surgery within 48 h; however, anticoagulant and antiplatelet medications commonly cause delays. Research exploring health outcomes in this group is unclear. Therefore, we aimed to determine the impact of anticoagulant and antiplatelet medications on operative delay and overall complications in hip fracture patients. Methods: A retrospective cohort study of hip fractures was performed at a tertiary hospital over a 3-year period from 1st January 2018 to 31st December 2020. Data collected included demographics, time to surgery, length of stay, postoperative blood transfusion, venous thromboembolism, acute coronary syndrome, stroke, infections in hospital and 120-day mortality. Patients were categorised based on the use of direct oral anticoagulants, warfarin and antiplatelet medications. Results: In total, 474 patients were included and 43.5% were on an anticoagulant or antiplatelet medication. Patients on these medications had more than twice the rate of operative delay (41.7% versus 17.2%, p < 0.001) with the greatest in the direct oral anticoagulant group (92.7% delay). After controlling for age and gender, this was still significant for direct oral anticoagulant ( p < 0.001) and antiplatelet group patients ( p = 0.02). These patients also had a 20% increased overall complication rate ( p < 0.001). On subgroup logistic regression, the increased complication rate was noted in the direct oral anticoagulant group ( p = 0.006) and the antiplatelet group ( p < 0.001) but not in the warfarin group ( p = 0.25). Time to surgery beyond 48 h was associated with a double increase in the odds of a postoperative complication ( p = 0.005). Conclusion: There is a significantly greater delay to surgery in hip fracture patients on anticoagulant or antiplatelet medications as well as a higher incidence of complications. Guidelines to expedite early safe surgery in this high-risk patient group are required.