Perioperative Outcomes With Direct Oral Anticoagulants in Orthopaedic Trauma Surgery: A Systematic Review and Meta-Analysis.

Abstract

The perioperative management of direct oral anticoagulants (DOACs) in orthopaedic trauma is variably practised. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-concordant systematic review and meta-analysis of adult trauma surgery comparing DOAC exposure with vitamin K antagonists or no anticoagulation. MEDLINE, Embase, and CENTRAL were searched (2010-October 2025) for randomised and observational studies. Pre-injury DOAC use informed analyses of mortality, transfusion, and operative delay, whereas postoperative prophylaxis trials addressed venous thromboembolism (VTE); these represent two distinct clinical questions that were analysed separately. Risk of bias (Risk of Bias 2/Risk of Bias in Non-randomized Studies - of Interventions), random-effects pooling, and GRADE were used. In total, 15 studies (4 randomised, 11 observational; >6,000 patients) were included. DOAC exposure was not associated with higher mortality (risk ratio (RR) = 0.98, 95% confidence interval (CI) = 0.66-1.45), transfusion (RR = 1.20, 95% CI = 0.96-1.49), or VTE (RR = 0.41, 95% CI = 0.16-1.05). DOAC users more often experienced operative delay beyond 24-36 hours (RR = 2.43, 95% CI = 0.93-6.33), which may reflect institutional caution. Evidence certainty ranged from low to moderate. In orthopaedic trauma, DOAC use is not linked to increased perioperative bleeding, transfusion, VTE, or mortality, but is associated with modest surgical delay. Where renal function is adequate and no active bleeding exists, early fixation without routine pharmacological reversal appears safe. Standardised early-surgery pathways and education on DOAC pharmacokinetics may reduce avoidable delays.