What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients undergoing ORIF (Open Reduction Internal Fixation)?

From the Guidelines

The recommended DVT prophylaxis for patients undergoing ORIF typically includes low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or 30mg twice daily, starting 12-24 hours postoperatively and continuing for 2-4 weeks depending on patient risk factors, as supported by the most recent guidelines 1. The rationale for DVT prophylaxis in ORIF patients is that orthopedic surgery, particularly of the lower extremities, significantly increases thromboembolism risk due to venous stasis from immobilization, endothelial injury during surgery, and hypercoagulability from the inflammatory response to trauma and surgery. Some key points to consider when determining the appropriate DVT prophylaxis regimen include:

• Patient risk factors, such as previous DVT/PE, known thrombophilia, or multiple risk factors
• The type of surgery being performed, with orthopedic surgery carrying a higher risk of thromboembolism
• The use of mechanical prophylaxis, such as intermittent pneumatic compression devices, for patients with contraindications to anticoagulants
• The importance of early mobilization, which should begin as soon as medically appropriate after surgery Proper risk assessment using tools like the Caprini score should be performed preoperatively to determine the appropriate prophylaxis regimen for each individual patient, as recommended by the American College of Chest Physicians 1 and the American Society of Hematology 1. In terms of specific medications, LMWH and fondaparinux are commonly used for DVT prophylaxis, with the choice of medication depending on patient-specific factors, such as renal function and bleeding risk, as outlined in the guidelines from the National Institute for Health and Care Excellence 1. Overall, the goal of DVT prophylaxis is to reduce the risk of thromboembolism and improve patient outcomes, while also minimizing the risk of bleeding complications, as supported by the evidence from the American Society of Clinical Oncology 1.

From the FDA Drug Label

A number of well-controlled clinical trials have demonstrated that low-dose heparin prophylaxis, given just prior to and after surgery, will reduce the incidence of postoperative deep vein thrombosis in the legs (as measured by the I-125 fibrinogen technique and venography) and of clinical pulmonary embolism The most widely used dosage has been 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for seven days or until the patient is fully ambulatory, whichever is longer.

DVT Prophylaxis Recommendation:

• Yes, DVT prophylaxis is recommended after an ORIF.
• Heparin (SQ) is a suitable option.
• Dosage: 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter.
• Duration: for seven days or until the patient is fully ambulatory, whichever is longer 2.

From the Research

DVT Prophylaxis after ORIF

• The use of DVT prophylaxis after ORIF is recommended to prevent venous thromboembolism (VTE) in patients undergoing orthopedic surgery 3.
• Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are both effective options for VTE prophylaxis, with LMWH being associated with a lower risk of VTE compared to UFH 4, 5.
• The American College of Chest Physicians (ACCP) recommends a minimum of 7 to 10 days of prophylaxis after hip and knee replacement surgery, with extended prophylaxis considered for patients at high risk for postoperative VTE 3.

Choice of Prophylaxis

• Enoxaparin, a type of LMWH, has been shown to be effective in reducing the risk of VTE in medical patients compared to UFH 4, 5.
• Aspirin and pneumatic compression devices (PCD) may also be considered for VTE prophylaxis in orthopedic oncology patients, although the efficacy of this combination is similar to LMWH and PCD 6.
• The choice of prophylaxis should be individualized based on patient risk factors and the type of surgery being performed.

Duration of Prophylaxis

• The duration of prophylaxis after ORIF surgery is typically 7 to 10 days, although extended prophylaxis may be considered for patients at high risk for postoperative VTE 3.
• The use of extended prophylaxis with LMWH has been shown to reduce the frequency of postdischarge VTE after hip replacement surgery 3.
• The optimal duration of prophylaxis after ORIF surgery may vary depending on the individual patient's risk factors and the type of surgery being performed.