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

From the Guidelines

DVT prophylaxis should not be withheld in patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day, and instead, prophylaxis with a pharmacologic agent or intermittent pneumatic compression device (IPCD) should be initiated as soon as possible post-operatively. According to the American College of Chest Physicians evidence-based clinical practice guidelines 1, all patients undergoing major orthopedic surgery should receive prophylaxis for a minimum of 10 to 14 days, and up to 35 days for high-risk patients. The guidelines suggest that the use of IPCD or no prophylaxis may be considered in patients at an increased risk of bleeding, but this does not apply to patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day.

Some key points to consider when initiating DVT prophylaxis in these patients include:

• Starting prophylaxis as soon as possible post-operatively, typically within 6-12 hours after surgery, assuming there are no contraindications such as active bleeding
• Using low molecular weight heparin (LMWH) such as enoxaparin 40 mg subcutaneously once daily, or fondaparinux 2.5 mg subcutaneously once daily as the recommended regimen
• Considering unfractionated heparin 5000 units subcutaneously every 8-12 hours for patients with renal impairment
• Continuing prophylaxis for at least 10-14 days and up to 35 days for high-risk patients
• Implementing early mobilization and mechanical prophylaxis (intermittent pneumatic compression devices) alongside pharmacological prophylaxis for optimal DVT prevention, as recommended by the guidelines 1.

The approach of initiating DVT prophylaxis post-operatively balances the need for DVT prevention with the risk of surgical bleeding, and is supported by the guidelines 1.

From the Research

DVT Prophylaxis in Acute Traumatic Hip Fractures

• The decision to withhold Deep Vein Thrombosis (DVT) prophylaxis in patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day is complex and depends on various factors.
• A study published in 2022 2 found that direct oral anticoagulants (DOACs) are associated with equivalent effectiveness and safety compared to low molecular weight heparin (LMWH) for thromboprophylaxis in trauma patients with hip fractures.
• However, another study from 2011 3 suggested that delayed surgery for patients with femur and hip fractures increases the risk of deep venous thrombosis, highlighting the importance of timely surgical intervention.
• The timing of surgery also impacts the efficacy of fascia iliaca blocks, with a 2022 study 4 finding that fascia iliaca compartment block (FICB) resulted in improved pain scores at the preoperative assessment among patients with earlier surgery.
• A systematic review protocol from 2017 5 aimed to assess the impact of timing of surgery on health outcomes in patients aged 60 years or older with acute hip fracture, including the use of anticoagulant medications.
• A retrospective study from 2023 6 found a statistically significant relationship between a delay in surgery and an increase in postoperative complications and morbidity, as well as increased morbidity among male patients.

Risk of DVT with Delayed Surgery

• The study from 2011 3 found that the incidence of thromboembolic disease increased with delayed surgery, from 14.5% if surgery was delayed >1 day to 33.3% if surgery was delayed >7 days.
• The average delay in surgery was 5.7 days for patients with DVT versus 3.2 days for those without (p = 0.021).
• The study suggests that all patients with delayed (>24 hours) surgical intervention undergo preoperative Doppler ultrasound to rule out DVT.

Timing of Surgery and Outcomes

• The study from 2023 6 found that earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality.
• The study from 2017 5 aimed 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.
• The study from 2022 2 found that DOACs are associated with equivalent effectiveness and safety compared to LMWH for thromboprophylaxis in trauma patients with hip fractures, regardless of the timing of surgery.