Should Deep Vein Thrombosis (DVT) prophylaxis be withheld in patients with acute traumatic hip fractures undergoing orthopedic surgery?

From the Guidelines

DVT prophylaxis should not be withheld in patients with acute traumatic hip fractures undergoing orthopedic surgery, as the risk of venous thromboembolism remains high in these patients. The most recent and highest quality study, 1, recommends low-molecular-weight heparin as the preferred agent, with the first dose given at least 12 hours from the time of surgery, and intermittent pneumatic compression for a goal of 18 hours daily in addition to anticoagulant therapy. When patients have a significant risk of bleeding, IPC may be used alone, but a minimum duration of 10 to 14 days of thromboprophylaxis is recommended, with consideration of up to 35 days for patients at higher risk for VTE. Key points to consider include:

• The use of low molecular weight heparin, such as enoxaparin 40 mg subcutaneously once daily, with the last dose given 12 hours before the planned surgery time
• The use of mechanical prophylaxis with intermittent pneumatic compression devices throughout the pre-operative period and continued post-operatively
• Resuming DVT prophylaxis as soon as hemostasis is achieved, usually within 6-12 hours post-operatively, and continuing for at least 10-14 days, and up to 35 days in high-risk patients
• The importance of minimizing the risk of excessive surgical bleeding while still providing protection during most of the pre-operative period, as recommended by 1 and 1. This approach is supported by the studies 1, which emphasize the need for thromboprophylaxis in patients undergoing major orthopedic surgery, including those with acute traumatic hip fractures.

From the FDA Drug Label

2.2 Deep Vein Thrombosis Prophylaxis Following Hip Fracture, Hip Replacement, and Knee Replacement Surgery 14.1 Prophylaxis of Thromboembolic Events Following Hip Fracture Surgery

DVT Prophylaxis should not be withheld in patients with acute traumatic hip fractures undergoing orthopedic surgery. The fondaparinux label provides guidance on DVT prophylaxis following hip fracture surgery, indicating its use in this setting 2.

From the Research

DVT Prophylaxis in Patients with Acute Traumatic Hip Fractures

• The decision to withhold Deep Vein Thrombosis (DVT) prophylaxis in patients with acute traumatic hip fractures 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 of more than 24 hours from the time of injury until the time of surgery were at a higher risk of developing DVT, despite receiving preoperative prophylactic anticoagulation 3.
• Another study published in 2024 found that initiating venous thromboembolism pharmacologic prophylaxis (VTEp) more than 12 hours after primary orthopedic surgery was associated with an increased risk of VTE, and that earlier initiation of prophylaxis was not associated with an increased risk of surgical reintervention 4.
• The timing of surgery for traumatic hip fracture can also impact the efficacy of fascia iliaca blocks, with one study finding that the use of fascia iliaca compartment block (FICB) resulted in improved pain scores at the preoperative assessment among patients with earlier surgery, whereas FICB reduced opioid consumption over the preoperative period only when surgery was later than 24 hours from arrival 5.
• A retrospective cohort study published in 2019 found that surgical management of hip fractures performed within 24 hours of injury minimized hospital stay, but did not detect significant differences in the spectrum or number of complications regarding delay of surgery 6.
• A systematic review and meta-analysis protocol 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, and to investigate differences in beneficial or harmful effects of timing of surgery in subgroups of patients based on demographic characteristics, physical status, and the use of anticoagulant medications 7.

Risk Factors for DVT

• Delayed surgery is a significant risk factor for DVT in patients with acute traumatic hip fractures, with the risk increasing each day from 14.5% if surgery is delayed more than 1 day to 33.3% if surgery is delayed more than 7 days 3.
• The use of anticoagulant therapy and age do not appear to affect postoperative complications, including DVT 6.
• The timing of VTEp initiation is also an important factor, with earlier initiation associated with a decreased risk of VTE 4.

Clinical Implications

• Clinicians should consider the timing of surgery and the patient's individual risk factors when deciding whether to withhold DVT prophylaxis in patients with acute traumatic hip fractures undergoing orthopedic surgery 3, 4.
• Earlier initiation of VTEp and surgical management of hip fractures within 24 hours of injury may help minimize the risk of DVT and other complications 4, 6.
• Further research is needed to fully understand the relationship between the timing of surgery and the risk of DVT in patients with acute traumatic hip fractures, and to inform clinical practice guidelines concerning timing of surgery in hip fractures 7.