Emergency hand surgery without interruption of antithrombotic therapy: postoperative bleeding risk

The perioperative management of antithrombotic therapy in hand surgery involves striking a delicate balance between the risk of thromboembolism associated with discontinuing treatment and a risk of bleeding that is generally low but sometimes a cause for concern in clinical practice. This issue is even more critical in emergency situations, where the urgency of the procedure does not always allow for treatment to be adjusted in line with the standard protocols for elective surgery. The primary objective was to assess whether simple emergency hand surgery in patients on uninterrupted antithrombotic therapy was associated with an increased risk of postoperative local hemorrhagic events compared with elective carpal tunnel surgery. The secondary objective was to identify the factors associated with the occurrence of such an event. This was a prospective, observational, single-center study conducted between January 2024 and December 2025. The study included 390 patients on antithrombotic therapy who underwent either elective carpal tunnel surgery or simple emergency hand surgery, under peripheral nerve block or WALANT anesthesia. In the carpal tunnel control group, antiplatelet agents were continued, direct oral anticoagulants were discontinued in accordance with local protocol, and vitamin K antagonists were maintained or adjusted according to the INR. In the emergency group, treatments were neither discontinued nor modified. The primary endpoint was the occurrence, within 30 days of a postoperative local hemorrhagic event, classified as minor or clinically significant. Of the patients included, 241 were in the carpal tunnel group and 149 in the emergency group. Fifty-eight postoperative bleeding events were observed, representing 14.9% of the cohort, of which 57 were minor and 1 was clinically significant. No reoperation was required. The rate of bleeding events did not differ between the carpal tunnel group and the emergency group, at 14.5% and 15.4% respectively (p = 0.92). In exploratory multivariate analysis, the emergency setting was not associated with the occurrence of a bleeding event (adjusted OR 1.23; 95% CI 0.65-2.32; p = 0.52). In this single-center cohort, simple hand surgery performed as an emergency in patients on uninterrupted antithrombotic therapy was not associated with an increased risk of postoperative local bleeding compared with elective carpal tunnel surgery. The events observed were almost exclusively minor. These results suggest that prompt surgical management in an emergency setting may be considered without systematic deferral based solely on antithrombotic status, provided the procedure is simple and carries a low risk of bleeding.