The Impact of Surgical Timing on Outcomes Following Hip Fracture Surgery in Patients Receiving Direct Oral...

Hip fractures are among the most common fragility injuries in older adults. With an ageing population and increasing use of direct oral anticoagulants (DOACs), the number of anticoagulated hip fracture patients continues to rise. However, the optimal timing of surgery in this population remains controversial. A systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed, Embase, and the Cochrane Library (January 2010-January 2026) identified six eligible cohort studies, comprising one prospective and five retrospective studies, comparing early (<24 hours) versus delayed (24-48 hours) hip fracture surgery in patients receiving DOAC therapy. Primary outcomes measured perioperative bleeding, assessed by change in haemoglobin concentration and postoperative transfusion requirements. Secondary outcomes included length of hospital stay, postoperative complications, 30- and 90-day all-cause mortality, and operative time. Meta-analysis of six studies demonstrated no significant difference in postoperative transfusion requirements between early and delayed surgery (odds ratio (OR) 1.18, 95% confidence interval (CI) 0.91-1.52; I² = 12%). Meta-analysis of four studies demonstrated a small but statistically significant reduction in perioperative haemoglobin drop in patients undergoing delayed surgery (mean difference (MD) 0.29 g/dL, 95% CI 0.01-0.58; I² = 12%). Early surgery was associated with a significantly shorter hospital length of stay (MD -1.27 days, 95% CI -2.39 to -0.15; I² = 34%) and a lower risk of postoperative complications (OR 0.49, 95% CI 0.31-0.78; I² = 13%). No significant difference in 30- and 90-day mortality was observed between groups (OR 1.03, 95% CI 0.47-2.27; I² = 0%). Early hip fracture surgery in DOAC-treated patients was not associated with increased postoperative transfusion requirements or mortality compared with delayed surgery. Although delayed surgery was associated with a statistically significant reduction in perioperative haemoglobin decline, the magnitude of this difference is unlikely to be clinically significant. Early surgery was associated with fewer postoperative complications and a shorter hospital length of stay, supporting expedited operative management in appropriately selected patients receiving DOAC therapy.