What is the recommended prophylaxis for Venous Thromboembolism (VTE) in orthopedic surgery?

VTE Prophylaxis in Orthopedic Surgery

Low molecular weight heparin (LMWH) is the recommended first-line prophylaxis for venous thromboembolism (VTE) in patients undergoing orthopedic surgery, with administration beginning 12 hours before surgery or 12-24 hours after surgery. 1

First-Line Prophylaxis Recommendations

Major Orthopedic Surgery (Hip/Knee Replacement, Hip Fracture)

• First choice: LMWH (Grade 2B recommendation) 1
  • Timing: Start 12 hours before surgery or 12-24 hours after surgery 1
  • Duration: Minimum 10-14 days, with consideration for extending up to 35 days in high-risk patients 1

Dosing Considerations

• If started preoperatively, administer LMWH 12 hours before surgery
• If started postoperatively, administer 12-24 hours after surgery when hemostasis is established
• Avoid administration earlier than 6 hours post-surgery as this increases major bleeding risk 1

Alternative Options (When LMWH Unavailable or Contraindicated)

For patients who cannot receive LMWH (e.g., history of heparin-induced thrombocytopenia, formulary restrictions), alternative options include:

1. Direct oral anticoagulants (DOACs):

   • Apixaban 2.5 mg twice daily
   • Dabigatran 220 mg once daily (with 150 mg dose available for certain patients)
   • Rivaroxaban (FDA approved for orthopedic VTE prophylaxis) 1

2. Other pharmacologic options:

   • Fondaparinux 2.5 mg once daily (Grade 2B) 1, 2
   • Low-dose unfractionated heparin (LDUH) (Grade 2B) 1
   • Adjusted-dose vitamin K antagonist (VKA) (Grade 2C) 1
   • Aspirin (Grade 2C) 1

3. Mechanical prophylaxis:

   • Intermittent pneumatic compression device (IPCD) for 18 hours daily 1
   • Particularly useful when bleeding risk is high 1

Special Considerations

Bleeding Risk

• When bleeding risk is high, use IPCD alone initially until hemostasis is achieved 1
• IPCD has been shown to have lower bleeding rates compared to LMWH (RR 0.32) but may have slightly higher VTE risk 1

Patient Preferences

• Patients who prioritize avoiding daily injections may prefer oral options (apixaban, dabigatran, rivaroxaban) 1
• Patients who prioritize avoiding bleeding complications may prefer IPCD over pharmacologic options 1

Timing of Surgery

• For hip fracture patients with delayed surgery, initiate LMWH while awaiting surgery 1

Comparative Efficacy and Safety

• LMWH has demonstrated superior properties of effective thromboprophylaxis with minimal bleeding risk and extensive clinical experience 1
• DOACs do not offer clear advantages over LMWH in terms of clinical efficacy 3
• Perioperative LMWH regimens may lower the risk of postoperative thrombosis compared to preoperative regimens, but this benefit may be offset by increased bleeding risk 4

Duration of Prophylaxis

• Standard duration: 10-14 days post-surgery 1
• Extended prophylaxis (up to 35 days) recommended for:
  • Hip fracture surgery patients 1
  • High-risk patients undergoing hip or knee replacement 1

Monitoring

• Routine monitoring of platelet counts is recommended due to small risk of thrombocytopenia 2
• Monitor for signs of bleeding, particularly during the first 4 days after surgery when most major bleeding events occur 2

Remember that the choice of VTE prophylaxis should prioritize reduction in morbidity and mortality while balancing bleeding risk. LMWH remains the gold standard with the most extensive clinical experience and favorable risk-benefit profile.