Full Reversal of Anticoagulants Before Cephalomedullary Fixation of Geriatric Hip Fractures May Not Be Necessary

Abstract

Objectives: To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures. Design: Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses. Setting: Two Level-1 trauma centers. Patients: One thousand four hundred forty-two geriatric (ages 60–105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither. Intervention: Cephalomedullary nail fixation. Main Outcome Measurements: Blood transfusion and calculated blood loss. Results: More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1–1.9] in contrast with 0.76 (95% CI, 0.5–1.2) for warfarin and 0.67 (95% CI, 0.3–1.4) for DOACs. Conclusions: Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.