Navigating the antithrombotic challenge in hip-fracture care: A framework to avoid delays and optimise patient outcomes.

INTRODUCTION: Hip fractures are a critical surgical emergency in older adults, frequently complicated by chronic antithrombotic therapy. Balancing expedited surgery with haemostatic and anaesthetic safety remains a major multidisciplinary challenge, with direct implications for survival and functional recovery.

OBJECTIVE: To propose an evidence-based decision-making framework for the perioperative management of anticoagulated patients with hip fractures, prioritising early surgery through an active clinical approach.

FRAMEWORK: This review proposes a pragmatic multidisciplinary framework, derived from practice in a Level 1 Trauma Centre and informed by current international guidelines (NICE, AAOS, Association of Anaesthetists, ESAIC/ESRA, and ASRA). It integrates recent evidence on antithrombotic management, regional anaesthesia safety, reversal strategies, and Patient Blood Management.

MAIN RECOMMENDATIONS: Early surgery-ideally within 24 h and no later than 48 h-is the overriding objective. Decision-making is guided by active haemostatic assessment, including drug-specific assays where available. A foundational principle is the clinical decoupling of safety thresholds for surgery and anaesthesia, recognising that the haemostatic requirements for surgery are distinct from the more stringent criteria for neuraxial or deep regional techniques. When neuraxial safety thresholds are not met, general anaesthesia, supplemented where appropriate by low-bleeding-consequence peripheral nerve blocks, should be considered to avoid unnecessary surgical delay. Reversal strategies and Patient Blood Management measures are integrated in parallel to optimise the patient's physiological status without postponing intervention. While this allows for an expedited pathway, surgical intervention remains contingent on achieving a baseline haemostatic profile to mitigate procedural bleeding risk.

CONCLUSION: This framework replaces passive drug-clearance waiting times with a structured, active strategy. By adapting haemostatic and anaesthetic tracks to the clinical urgency, it ensures that antithrombotic therapy is managed as a treatable condition rather than an automatic barrier to life-saving surgery.