[Treatment of proximal femur fractures in patients on direct oral anticoagulants (DOACs) : Review of perioperative management].

Abstract

Background: Proximal femur fractures are common injuries in older adults and, according to guidelines, require prompt surgical treatment. With the increasing use of direct oral anticoagulants (DOACs), uncertainties have arisen regarding the timing of surgery, the risk of bleeding, and perioperative management.

Research question: The aim is to evaluate the influence of DOACs on the timing of surgery, the risk of bleeding, and the safety of early surgical treatment for proximal femur fractures.

Materials and methods: Narrative review of the current literature, systematic reviews, meta-analyses, and current guideline recommendations (AWMF S3-LL).

Results: Patients on DOACs sometimes exhibit significantly prolonged time to surgery (TTS), often due to uncertainties in perioperative management. However, prolonged TTS is not consistently associated with increased mortality. The majority of studies show no significant difference in blood loss or transfusion requirements between DOAC-treated and nonanticoagulated patients when treated early. Calibrated laboratory methods are the gold standard, but are only available to a limited extent. Prothrombin complex concentrate (PPSB) and antidotes allow for reversal; however, the latter sometimes carry specific risks.

Conclusion: Based on current data, early surgery for proximal femur fractures can be performed despite DOAC use, particularly for minimally invasive procedures with a low risk of bleeding. Individual risk assessment, taking into account comorbidities, residual DOAC levels, and the type and extent of the procedure, remains crucial.