What is the recommended DVT (Deep Vein Thrombosis) prophylaxis protocol post ORIF (Open Reduction Internal Fixation) surgery?

DVT Prophylaxis Protocol Post ORIF Surgery

For patients undergoing ORIF surgery, DVT prophylaxis should be tailored based on risk stratification, with pharmacological prophylaxis using LMWH (enoxaparin 40 mg daily) recommended for most patients, combined with mechanical prophylaxis when appropriate. 1

Risk Stratification Approach

The appropriate DVT prophylaxis after ORIF depends on the patient's risk level:

Very Low Risk (Caprini score 0)

• Early ambulation only
• No specific pharmacological or mechanical prophylaxis needed 1

Low Risk (Caprini score 1-2)

• Mechanical prophylaxis, preferably intermittent pneumatic compression (IPC)
• Early ambulation 1

Moderate Risk (Caprini score 3-4)

• LMWH (enoxaparin 40 mg subcutaneously daily) or
• Low-dose unfractionated heparin (5000 units subcutaneously every 12 hours)
• If high bleeding risk: mechanical prophylaxis with IPC until bleeding risk diminishes 1

High Risk (Caprini score ≥5)

• LMWH (enoxaparin 40 mg subcutaneously daily) or
• Low-dose unfractionated heparin (5000 units subcutaneously every 8 hours)
• Add mechanical prophylaxis with elastic stockings or IPC 1
• If high bleeding risk: mechanical prophylaxis until bleeding risk diminishes 1

Very High Risk

• Enoxaparin 40 mg subcutaneously daily plus pneumatic compression device
• If high bleeding risk: pneumatic compression device only 1

Timing and Duration

• Pharmacological prophylaxis should be started 2-12 hours preoperatively when possible 1
• Continue for at least 7-10 days postoperatively 1
• For high-risk patients (especially those with cancer), consider extended prophylaxis for 4 weeks 1

Special Considerations

Dosing Adjustments

• For patients >150 kg: Consider increasing enoxaparin to 40 mg twice daily 1
• For patients with renal impairment (CrCl <30 ml/min): Reduce enoxaparin to 30 mg daily 1

Epidural/Spinal Anesthesia

• Hold enoxaparin for 24 hours before planned manipulation of epidural/spinal catheter
• Resume no earlier than 2 hours following manipulation 1

Contraindications to Pharmacological Prophylaxis

• Active bleeding
• High bleeding risk
• History of heparin-induced thrombocytopenia (consider fondaparinux as alternative) 1

Mechanical Prophylaxis Options

• Intermittent pneumatic compression (IPC) - preferred mechanical method
• Graduated compression stockings
• Early ambulation (essential for all patients when possible)

Important Caveats

• IVC filters are not recommended for primary VTE prevention 1
• Routine surveillance with venous compression ultrasonography is not recommended 1
• The risk of bleeding must be carefully weighed against the benefits of prophylaxis 1
• Patients with previous DVT history are at significantly higher risk and should receive more aggressive prophylaxis

The evidence strongly supports that appropriate DVT prophylaxis significantly reduces morbidity and mortality following orthopedic procedures like ORIF. While there is some variation in guidelines, risk stratification using validated tools like the Caprini score provides a practical framework for determining the appropriate prophylactic approach.