EP 526 Timelines of Surgery in Neck of Femur Fractures in Patients on DOACS: Are Anti-Xa Levels being used Appropriately?

Introduction/Aims

Neck of femur (NOF) fractures are one of the most common orthopaedic emergencies, affecting frail, elderly patients with multiple comorbidities. Timely surgery is critical - delays beyond 36 hrs are associated with higher rates of morbidity, mortality, and hospital stay.

Direct Oral Anticoagulants (DOACs), such as apixaban, rivaroxaban, and edoxaban, are widely used for atrial fibrillation and venous thromboembolism prophylaxis. Their anticoagulant effect complicates surgical planning, as premature surgery may increase bleeding risk.

Anti-Xa assays can measure residual anticoagulant activity and help guide safe timing for surgery. However, inconsistent or unnecessary testing may introduce avoidable delays. Hence, optimising peri-operative decision-making is essential to improve clinical outcome.

Method

The audit design used retrospective methodology to assess the delay in accessing surgery in NOF fracture in patients with comorbidities that require use of DOACs within August 2024 to August 2025 in the Southampton General Hospital.

Results

Types of Surgery: Hemiarthroplasty-52.9%, IM Nail-38.5%, Total Hip Replacement- 4.7%, DHS- 3.9%

Age of Patients: Age 60-100

Gender: Female 50%, Male 49.2%, unknown 0.8%

Anti-Xa Measured?

Yes- 41

No- 77

Surgery within 36h?

98- No

21- Yes

Guidelines followed?

99 - Yes

19- No

Conclusion

Common Mistakes in Current Practice:Postponing surgery automatically >48 hours after the last DOAC dose without checking anti-Xa levels.Repeated anti-Xa testing even after 48 hours since last DOAC dose

Recommendations:Perform Anti-Xa testing during clerking for all patients on DOACs last dose < 48 hrs or unknown doseCreate Awareness about anti xa levelsRe-audit in six months