What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients following ORIF (Open Reduction Internal Fixation) surgery?

DVT Prophylaxis Following ORIF Surgery

Low molecular weight heparin (LMWH) is the preferred pharmacological agent for DVT prophylaxis following ORIF surgery, with prophylaxis beginning 6-8 hours postoperatively and continuing for 7-10 days or until full mobilization. 1

Risk Assessment for VTE Following ORIF

The risk of venous thromboembolism (VTE) following orthopedic surgery is significant, with several factors increasing this risk:

• Age ≥65 years (2 points on TESS score) 1
• Lower extremity fractures (2 points on TESS score) 1
• Obesity (BMI >30) (1 point on TESS score) 1
• Limited mobility post-surgery
• History of previous VTE (independent risk factor) 1, 2

According to the TESS score from the 2023 WSES guidelines, patients with scores of 3-6 are at moderate risk, while those with scores of 7-14 are at high risk for VTE 1.

Recommended Prophylaxis Protocol

Timing of Initiation

• Begin prophylaxis 6-8 hours after surgery once hemostasis has been established 1, 3
• Starting earlier than 6 hours post-surgery significantly increases bleeding risk 3

Pharmacological Options

1. First-line: LMWH (e.g., enoxaparin)

   • Standard dosing: 40 mg subcutaneously once daily 2
   • For patients >65 years: 30 mg every 12 hours 1
   • For patients with renal impairment (CrCl <30 mL/min): 30 mg daily or consider UFH 2
   • For patients >150 kg: Consider increasing to 40 mg twice daily 2

2. Alternative: Unfractionated Heparin (UFH)

   • Dosing: 5,000 units subcutaneously every 8 hours 4
   • Consider for patients with severe renal impairment 1, 2

3. Alternative: Fondaparinux

   • Dosing: 2.5 mg subcutaneously once daily 3
   • Particularly effective for hip fracture, hip replacement, and knee replacement surgeries 3
   • Avoid in patients with CrCl <30 mL/min 2, 3

Duration of Prophylaxis

• Standard duration: 7-10 days or until fully mobile 1, 2
• For hip fracture ORIF: Extended prophylaxis for up to 24-32 additional days is recommended 1, 3
• For major abdominal or pelvic surgery with high-risk features: Consider extended prophylaxis for up to 4 weeks 1

Mechanical Prophylaxis

• Intermittent pneumatic compression (IPC) is preferred over graduated compression stockings 1, 2
• Use as monotherapy only when pharmacological methods are contraindicated due to active bleeding or high bleeding risk 1, 2
• Consider combining mechanical with pharmacological methods for highest-risk patients 1

Special Considerations

Contraindications to Pharmacological Prophylaxis

• Active bleeding
• Coagulopathy
• Hemodynamic instability
• Recent intracranial hemorrhage
• History of heparin-induced thrombocytopenia 2

In these cases, use mechanical prophylaxis until the contraindication resolves 1, 2.

Comparative Efficacy and Safety

• LMWH is superior to UFH in preventing VTE events with fewer bleeding complications 1
• LMWH offers the advantage of once-daily dosing versus twice or three times daily for UFH 5
• Minor hemorrhagic complications like wound hematoma and surgical site bleeding are significantly more common with UFH compared to LMWH 5

Monitoring

• Daily reassessment of VTE and bleeding risk is recommended as risk can change during hospitalization 2
• Routine surveillance with venous compression ultrasonography is not recommended 2

Conclusion

For DVT prophylaxis following ORIF surgery, LMWH starting 6-8 hours postoperatively and continuing for 7-10 days (or longer for hip fractures) represents the optimal approach based on current evidence. Mechanical methods should be added for highest-risk patients or used alone when pharmacological prophylaxis is contraindicated.