# Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures
## 4 Discussion
Due to the low number of patients receiving DOACs we decided to analyze them together as a group, even though there was a predominance of apixaban (69%). Several studies found both vitamin K antagonists and DOACs delayed emergency surgery [17; 18; 19; 20]. Patients on DOACs had similar perioperative hemoglobin change, transfusion rates and mortality compared to subjects without anticoagulants in both trochanter - internal fixation and femoral neck - arthroplasty situations [19; 20; 21; 22]. For DOACs surgery should therefore be reasonably delayed, until reversal agents become available [5; 6]. General and regional anesthesia are both suitable for hip fracture surgery [1; 3; 5; 6; 8]. A study by [PERSON] et al. found no difference in 30-day mortality. In-hospital mortality, acute respiratory failure, length of hospital stays, and readmissions were significantly reduced in the regional anesthesia group. On the other hand, pneumonia, heart failure, acute myocardial infarction, acute renal failure, cerebrovascular accident, postoperative delirium and deep vein thrombosis/pulmonary embolism were similar between the two techniques [3]. In our clinic, neuraxial anesthesia is the preferred technique and a previous survival analysis found similar survival to reports using general anesthesia [2]. This may be an important factor for the longer time to surgery in our patients on antithrombotic medication compared to what is generally reported in the literature [10; 11; 12; 13; 14; 15; 16; 17; 18; 19; 20; 21]. However, new evidence suggests mostly economic but no clinical benefit in hip fracture surgery under 24 h from hospital admission [7; 23]. The biggest limitation of our study is its retrospective nature with inborn confounders that cannot be controlled for. Other limitations are the lack of outcome measures and survival analysis. In addition, patients who received tranexamic acid to decrease bleeding were not accounted for. We did not take into consideration the INR, administration of vitamin K, platelet counts or the American Society of Anesthesiologists (ASA) physical status classification system. Within such a complex environment, hip fractures should be managed as a team, with careful consideration for perioperative support, surgical technique, choice of implant, rehabilitation and hospitalization costs [24; 25; 26]. Treatment of these fractures is considered major surgery and also a major risk factor for developing deep vein thrombosis/pulmonary embolism. As a consequence, these patients receive medical thromboprophylaxis. The current standard of care is a single dose of low molecular weight heparin for up to 30 days, even in patients without previous antithrombotic medication [1; 27]. For those already anticoagulated preoperatively, the same regimen should be reinstated as soon as possible after surgery [1; 5; 6; 27]. On the other hand, the perioperative management for platelet aggregation inhibitors and oral anticoagulants is not well standardized. There are several ways this can be achieved: stopping the medication, reducing dosage or bridging to a more controllable and shorter half-life low molecular weight heparin. Bridging to subcutaneous low molecular weight heparin twice a day is the most common strategy; however, the dosage is not standardized. For clopidogrel and warfarin there may even be a potential increased risk of cardiovascular events if stopped perioperatively [11; 28].