## 1 Introduction  
Major orthopedic trauma in patients undergoing anticoagulant therapy represents an increasingly complex clinical challenge, particularly within an aging population characterized by polypharmacy and multiple comorbidities. The emergency management of patients with fractures or major orthopedic trauma presents a significant clinical challenge, particularly in elderly and frail individuals receiving anticoagulant therapy [1]. The concomitant use of anticoagulants and antiplatelet agents substantially elevates the risk of perioperative bleeding complications, especially in an urgent surgical setting where time constraints limit the opportunity for standard anticoagulation reversal protocols. The use of anticoagulants significantly increases the risk of perioperative hemorrhage, which is already elevated in this patient population [2]. In cardiac surgery, numerous studies have demonstrated the efficacy of removing anticoagulant drugs via extracorporeal circulation, leading to near-complete drug clearance within hours and reducing bleeding risk without significant adverse events. Recent clinical evidence highlights a significant incidence of major hemorrhagic events in this vulnerable cohort, necessitating the adoption of innovative, rapid-response strategies to improve perioperative safety and patient outcomes. In this context, extracorporeal hemoadsorption therapies such as CytoSorb(r) are emerging as promising adjuncts to traditional management approaches. As a result, the European Society of Anaesthesiology and Intensive Care (ESAIC) has included the CytoSorb(r) sorbent in its guidelines for the removal of ticagrelor and rivaroxaban during emergency cardiac procedures [3, 4, 5, 6].  
Recent studies suggest that purification techniques may have applications beyond cardiac surgery. [PERSON] et al. described a case involving a patient with acute kidney injury and bilateral hydroureteronephrosis [7]. This patient, who was anticoagulated with apixaban for atrial fibrillation, underwent hemofiltration with continuous renal replacement therapy (CRRT) and CytoSorb(r). This approach enabled the patient to receive surgical treatment that would have otherwise been postponed due to the risk of hemorrhage. Similarly, [PERSON] et al. reported a comparable case, further demonstrating the potential of this approach for enabling emergency surgical interventions [8].  
In trauma patients requiring urgent orthopedic surgery, the presence of direct oral anticoagulants (DOACs) and antiplatelet agents such as Ticagrelor represents a significant challenge. Among these agents, ticagrelor is particularly problematic due to its potent antiplatelet effect, high plasma protein binding, and the current lack of a specific reversal agent. Unlike dabigatran or factor Xa inhibitors, which can potentially be reversed with idarucizumab or andexanet alfa, no antidote is yet available for ticagrelor in clinical practice. Furthermore, platelet transfusion has limited efficacy in reversing its effect. In emergency settings where the time leading up to surgery is critical, and conventional reversal options are inadequate or unavailable, CytoSorb(r) hemoadsorption offers a promising alternative, with early data and case reports supporting its capacity to remove ticagrelor from circulation. This study aims to evaluate the potential clinical use of CytoSorb(r) to reduce bleeding risk and avoid surgical delay in trauma patients receiving Ticagrelor and/or Rivaroxaban. Our project aims to evaluate its efficacy and safety in orthopedic surgery for patients receiving ticagrelor and rivaroxaban. The primary objective is to assess the feasibility of reducing perioperative hemorrhagic complications and enabling more timely surgical interventions. The latest guidelines from the European Society of Regional Anaesthesia (ESRA) state that a washout period of 72 h is required for rivaroxaban, and five days is required for ticagrelor, before safely performing neuraxial anesthesia or deep nerve blocks [9, 10].