Should Deep Vein Thrombosis (DVT) prophylaxis be held in acute traumatic hip fracture patients undergoing orthopedic surgery?

From the Guidelines

DVT prophylaxis should not be held in acute traumatic hip fracture patients undergoing orthopedic surgery, as the benefits of preventing DVT outweigh the risks of bleeding complications, according to the most recent and highest quality study 1.

Key Considerations

• The risk of DVT in these patients is high due to immobilization and tissue injury, and prophylaxis is essential to minimize this risk.
• The choice of prophylaxis agent and timing are crucial, with low molecular weight heparin (LMWH) such as enoxaparin 40 mg subcutaneously once daily being a recommended option.
• If surgery is planned within 12 hours, consider using unfractionated heparin 5000 units subcutaneously every 8 hours instead, as it has a shorter half-life.
• Hold the last dose 12 hours before surgery for LMWH or 4-6 hours before for unfractionated heparin, and resume prophylaxis 6-8 hours post-operatively, once hemostasis is achieved.

Mechanical Prophylaxis

• Use mechanical prophylaxis with intermittent pneumatic compression devices throughout the perioperative period to provide additional DVT protection.
• This approach is supported by the American College of Chest Physicians evidence-based clinical practice guidelines 1, which recommend pharmacologic agent or IPCD for a minimum of 10 to 14 days.

Patient-Specific Factors

• Consider patient-specific factors, such as age, obesity, and presence of lower extremities fracture, when evaluating the risk of DVT and determining the best approach to prophylaxis, as outlined in the TESS score 1.
• Close communication between the orthopedic team and the medical team managing DVT prophylaxis is essential to optimize timing and ensure patient safety.

Evidence-Based Recommendations

• The Cochrane systematic review by Barrera et al. recommends prophylaxis to reduce the risk of DVT in severe trauma patients (RR 0.52), with pharmacological prophylaxis being more effective than mechanical prophylaxis (RR 0.48) 1.
• The Norwegian national prospective observational study found that post-operative prophylaxis decreased the risk of intraoperative bleeding complications for operations with hip compression screw, but not with intramedullary nail or screw osteosynthesis 1.

From the FDA Drug Label

2.2 Deep Vein Thrombosis Prophylaxis Following Hip Fracture, Hip Replacement, and Knee Replacement Surgery 5.1 Neuraxial Anesthesia and Post-operative Indwelling Epidural Catheter Use 5.2 Hemorrhage

DVT Prophylaxis in Acute Traumatic Hip Fracture Patients:

• The FDA drug label for fondaparinux does not provide direct guidance on holding DVT prophylaxis in acute traumatic hip fracture patients undergoing orthopedic surgery.
• However, it does mention the importance of considering the risk of hemorrhage and the use of neuraxial anesthesia when administering fondaparinux for DVT prophylaxis.
• Given the lack of direct information, a conservative clinical decision would be to consult the specific clinical guidelines for the management of acute traumatic hip fracture patients and to weigh the risks and benefits of holding DVT prophylaxis on a case-by-case basis 2.

From the Research

DVT Prophylaxis in Acute Traumatic Hip Fracture Patients

• The decision to hold Deep Vein Thrombosis (DVT) prophylaxis in acute traumatic hip fracture patients undergoing orthopedic surgery is complex and depends on various factors, including the timing of surgery and the patient's individual risk factors 3, 4.
• A study published in 2011 found that patients with hip and femur fractures who experienced a delay in surgery of more than 24 hours were at a higher risk of developing DVT, despite receiving preoperative prophylactic anticoagulation 3.
• Another study published in 2017 found that surgical delay of more than 2 days was associated with an increased risk of complications in patients undergoing non-total hip arthroplasty procedures for hip fractures 4.
• However, the optimal timing of surgery for hip fractures is still a topic of debate, and some studies suggest that achieving a stable medical condition is more important than early surgery 5.
• A systematic review and meta-analysis published in 2017 aimed to assess the impact of timing of surgery on health outcomes in patients aged 60 years or older with acute hip fracture, but the results are not available 5.
• More recent studies have focused on identifying the contextual determinants of time to surgery for patients with hip fracture, including factors such as operating room availability, care coordination, and improvement climate 6, 7.
• These studies suggest that the decision to hold DVT prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and the hospital's specific context and resources 6, 7.

Risk Factors for DVT and Complications

• The risk factors for DVT and complications in patients with hip fractures include delay in surgery, age, sex, physical status, and the use of anticoagulant medications 3, 4, 5.
• A study published in 2023 found that male patients were at a higher risk of postoperative complications and morbidity after hip fracture surgery 7.
• Another study published in 2017 found that patients with congestive heart failure and a body mass index of 40 or higher were at a higher risk of surgical delay and complications 4.

Timing of Surgery and Outcomes

• The timing of surgery for hip fractures has been shown to have an impact on outcomes, including mortality, perioperative complications, functional capacity, and quality of life 3, 4, 5.
• A study published in 2011 found that the incidence of DVT increased with each day of delay in surgery, from 14.5% if surgery was delayed by more than 1 day to 33.3% if surgery was delayed by more than 7 days 3.
• Another study published in 2023 found that delayed surgery was associated with an increased risk of postoperative complications and morbidity, as well as increased mortality among male patients 7.