Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

Abstract

Background: Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.

Methods: A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.

Results: There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).

Conclusion: We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Keywords: Anticoagulation treatment; Hip fracture; Intramedullary nailing; Surgical treatment; Warfarin.