What is the recommended regimen for Deep Vein Thrombosis (DVT) prophylaxis in patients undergoing orthopedic surgery?

DVT Prophylaxis in Orthopedic Surgery

For patients undergoing major orthopedic surgery, low molecular weight heparin (LMWH) is recommended as the preferred pharmacological agent for DVT prophylaxis, combined with intermittent pneumatic compression devices (IPCD) during hospitalization, with prophylaxis extended for up to 35 days post-surgery. 1

First-Line Pharmacological Prophylaxis

• LMWH (preferred first-line agent) 1:

  • For total hip/knee arthroplasty: 30 mg subcutaneously twice daily, starting 12 hours before or after surgery
  • Continue for 10-14 days, with extension up to 35 days recommended
  • If started preoperatively, administer 12 hours before surgery

• Alternative pharmacological options (if LMWH unavailable or contraindicated) 1:

  • Fondaparinux: 2.5 mg subcutaneously once daily
  • Rivaroxaban: 10 mg orally once daily, starting 6-10 hours after surgery
  • Apixaban: 2.5 mg orally twice daily
  • Dabigatran: 220 mg orally once daily (with 150 mg alternate lower dose available)
  • Unfractionated heparin: 5,000 units subcutaneously three times daily
  • Adjusted-dose warfarin: target INR 2.0-3.0

Mechanical Prophylaxis

• Intermittent pneumatic compression devices (IPCD) 1:
  • Recommended in combination with pharmacological prophylaxis
  • Use portable, battery-powered IPCDs capable of recording daily wear time
  • Target 18 hours of daily compliance
  • For patients with high bleeding risk, IPCD alone is recommended until bleeding risk decreases

Duration of Prophylaxis

• Minimum duration: 10-14 days post-surgery 1
• Extended duration: Up to 35 days from surgery (Grade 2B recommendation) 1
  • Particularly important for high-risk patients undergoing hip or knee replacement

Special Considerations

Patients at High Risk of Bleeding

• Use IPCD alone until bleeding risk diminishes 1
• Once hemostasis is achieved, add pharmacological prophylaxis 1

Patients Refusing Injections or IPCD

• Oral options (in order of preference) 1:
  1. Apixaban or dabigatran (Grade 1B)
  2. Rivaroxaban or adjusted-dose VKA (if apixaban/dabigatran unavailable)

IVC Filter Use

• Not recommended for primary prophylaxis in orthopedic surgery 1, 2
• Associated with complications including:
  • DVT at insertion site (1-3%)
  • Caval thrombosis (2.7%)
  • Filter migration and fracture (0.3%)
  • Long-term thrombosis of IVC or lower extremity veins (4-32%) 2

Efficacy Considerations

• Dual prophylaxis (pharmacological agent + IPCD) significantly reduces symptomatic DVT compared to pharmacological prophylaxis alone (RR 0.26) 1
• LMWH has been shown to be as effective as unfractionated heparin with fewer minor hemorrhagic complications 3
• The combination of LMWH and graduated elastic compression may provide increased efficacy compared to LMWH alone 4

Common Pitfalls to Avoid

1. Inadequate duration: Failing to extend prophylaxis beyond hospital stay (should continue for at least 10-14 days)
2. Improper IPCD use: Not achieving 18 hours of daily compliance
3. Delayed initiation: Pharmacological prophylaxis should begin 12 hours before surgery or 6-10 hours after surgery (depending on agent)
4. Inappropriate IVC filter use: Not recommended for primary prophylaxis
5. Poor patient adherence: Consider oral agents for outpatient prophylaxis if compliance with injections is a concern

By following these evidence-based recommendations, the risk of venous thromboembolism following orthopedic surgery can be significantly reduced while minimizing bleeding complications.