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

From the Guidelines

For acute traumatic hip fracture patients undergoing same-day orthopedic surgery, DVT prophylaxis should not be withheld preoperatively, but rather modified to balance the risk of DVT with the risk of surgical bleeding. The most recent and highest quality study, 1, recommends low-molecular-weight heparin as the preferred choice, with the first dose given at least 12 hours from the time of surgery. Mechanical prophylaxis using intermittent pneumatic compression devices should be initiated immediately and used for a goal of 18 hours daily in addition to anticoagulant therapy. Some key points to consider when modifying DVT prophylaxis in this patient population include:

• The use of mechanical methods, such as graduated compression stockings or intermittent pneumatic compression devices, which are particularly important during the perioperative period when pharmacological prophylaxis is adjusted 1.
• The administration of pharmacological prophylaxis with low molecular weight heparin (LMWH), such as enoxaparin, with adjusted timing to minimize the risk of surgical bleeding 1.
• The consideration of alternative anticoagulants, such as rivaroxaban, in patients with a significant risk of bleeding or other contraindications to LMWH 1.
• The recommendation for a minimum duration of 10 to 14 days of thromboprophylaxis, with consideration of up to 35 days for patients at higher risk for VTE 1. Overall, the goal is to provide some protection against DVT while minimizing the risk of excessive surgical bleeding, and this approach is based on the understanding that hip fracture patients are at high risk for DVT due to immobility and tissue trauma, but also require careful management of bleeding risk during surgery.

From the FDA Drug Label

In patients undergoing hip fracture, hip replacement, or knee replacement surgery, the recommended dose of fondaparinux sodium injection is 2.5 mg administered by subcutaneous injection once daily after hemostasis has been established. Administer the initial dose no earlier than 6 to 8 hours after surgery. Administration of fondaparinux sodium injection earlier than 6 hours after surgery increases the risk of major bleeding.

The FDA drug label does not provide guidance on withholding DVT prophylaxis preoperatively in patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day. However, it recommends administering the initial dose of fondaparinux sodium injection no earlier than 6 to 8 hours after surgery to minimize the risk of major bleeding.

• The label does not address the specific scenario of administering DVT prophylaxis before surgery.
• It emphasizes the importance of establishing hemostasis before administering fondaparinux sodium injection.
• The label recommends administering the initial dose after surgery, which implies that DVT prophylaxis should not be initiated preoperatively in this context 2.

From the Research

Deep Vein Thrombosis Prophylaxis in Acute Traumatic Hip Fractures

• The decision to withhold Deep Vein Thrombosis (DVT) prophylaxis preoperatively in patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day should be guided by weighing the risk of thromboprophylaxis against the benefit in relation to each patient's medical history and age 3.
• Current international guidelines recommend routine pharmacological thromboprophylaxis for patients undergoing emergency hip fracture surgery, but the risk of VTE depends on the type and location of the lower limb injury 3.
• The nature and location of the fracture, operating times, and times before fracture fixation should be considered when deciding on thromboprophylaxis 3.
• There is no direct evidence to suggest that DVT prophylaxis should be withheld preoperatively in patients with acute traumatic hip fractures undergoing orthopedic surgery on the same day, but the risk of bleeding disorders and other complications should be taken into account 4, 5.
• Earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality in patients with acute hip fractures 6.
• The efficacy of fascia iliaca blocks may be impacted by the time to surgery for traumatic hip fracture, with improved pain scores and reduced opioid consumption in patients with earlier surgery 7.

Considerations for Thromboprophylaxis

• Patient risk profile, including medical history and age, should be considered when deciding on thromboprophylaxis 3, 4.
• The risk of bleeding disorders and other complications, such as transfusion, myocardial infarction, and pneumonia, should be taken into account 5.
• The nature and location of the fracture, operating times, and times before fracture fixation should be considered when deciding on thromboprophylaxis 3.
• Earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality in patients with acute hip fractures 6.