Proximal Femoral Nail Antirotation After Antiplatelet Discontinuation in Elderly Intertrochanteric Fractures

Major hip-fracture guidelines generally favor surgery within 24-48 h of admission, but perioperative decision-making becomes more complex in older adults with recent antiplatelet exposure. Here, we describe a reproducible protocol for proximal femoral nail antirotation in elderly patients with intertrochanteric fractures after antiplatelet discontinuation. Rather than redefining guideline-based early fixation, this protocol provides a structured perioperative pathway in an antiplatelet-management context, with an earlier pathway defined as surgery performed within 5 days after the last antiplatelet dose when predefined clinical and laboratory criteria are met, and a delayed pathway used when further optimization is required. The protocol integrates preoperative triage, hemostatic evaluation, transfusion preparation, standardized operative steps, and postoperative thromboprophylaxis and antiplatelet resumption. Preoperative assessment includes fracture confirmation, medication history, comorbidity review, anesthesia evaluation, and coagulation-related laboratory testing. The pathway also specifies perioperative checkpoints intended to improve procedural consistency, including reduction quality, entry-point control, stepwise canal preparation, implant positioning, and postoperative surveillance for bleeding, thromboembolic events, and functional recovery. Representative results are provided to illustrate the range of perioperative outcomes observed during protocol implementation, including intraoperative blood loss, perioperative hemoglobin change, transfusion requirement, length of stay, and early postoperative complications. These representative findings are intended to illustrate protocol implementation and quality assurance rather than establish causal superiority between pathways.