What is the best Deep Vein Thrombosis (DVT) prophylaxis regimen for patients undergoing hip fracture surgery?

Best DVT Prophylaxis for Hip Fracture Surgery

For patients undergoing hip fracture surgery, fondaparinux is the preferred DVT prophylaxis, followed by low molecular weight heparin (LMWH) as an effective alternative. 1, 2

Recommended Prophylactic Options

First-line Option: Fondaparinux

• Recommended dose: 2.5 mg subcutaneously once daily 3
• Timing: Initial dose should be administered 6-8 hours after surgery once hemostasis has been established 3
• Duration: 7-10 days standard course, with extended prophylaxis recommended for up to 24 additional days (total of 32 days) 3
• Extended prophylaxis with fondaparinux has shown a 95.9% relative risk reduction in VTE compared to placebo (1.4% vs 35.0%) 3

Alternative Option: Low Molecular Weight Heparin (LMWH)

• Enoxaparin 40 mg subcutaneously once daily 1
• Timing: Should be administered between 18:00 and 20:00 to minimize bleeding risk related to neuraxial anesthesia during daytime trauma lists 1
• Duration: Minimum 7-10 days, with extended prophylaxis for high-risk patients for at least 4 weeks post-discharge 1
• For elderly patients (>65 years), consider reduced dosing of 30 mg every 12 hours 1

Special Considerations

Timing Considerations

• Fondaparinux should be started 6-8 hours after surgery; earlier administration increases major bleeding risk 3
• LMWH should be timed appropriately if neuraxial anesthesia is planned 1
• Pre-operative prophylaxis has not shown to influence mortality or reoperation risk in hip fracture patients 1

Extended Prophylaxis

• Extended prophylaxis (up to 32 days total) is recommended for hip fracture patients due to continued VTE risk 3
• The SAVE-HIP3 trial showed extended semuloparin (a LMWH) reduced VTE from 18.6% to 3.9% compared to placebo after initial 7-10 day treatment 1

Mechanical Prophylaxis

• Thromboembolism stockings or intermittent compression devices should be employed intra-operatively 1
• Mechanical prophylaxis should be used in conjunction with pharmacological methods, not as sole therapy 1
• Early mobilization and regional anesthesia may further reduce DVT risk 1

Bleeding Risk Considerations

• Monitor patients for signs of bleeding, particularly those with renal dysfunction 3
• For patients at high risk of bleeding, consider mechanical prophylaxis until bleeding risk diminishes 1
• LMWH has shown fewer bleeding complications compared to unfractionated heparin in elderly trauma patients 1

Comparative Efficacy

• Fondaparinux has demonstrated superior efficacy compared to enoxaparin in hip fracture surgery with similar bleeding risk 3
• LMWH has shown significantly lower rates of DVT (0.6-1.2% for proximal DVT) compared to unfractionated heparin (4.8%) 4, 5
• Meta-analysis of orthopedic surgery trials showed semuloparin (a LMWH) reduced VTE by almost one-third compared to enoxaparin 1

Monitoring and Follow-up

• Regular assessment for signs and symptoms of DVT/PE is essential 1
• In patients with renal failure, consider unfractionated heparin (5000 U every 8 hours) instead of LMWH 1
• For patients receiving fondaparinux, monitor for signs of neurologic impairment if neuraxial anesthesia was used 3

Practical Algorithm

1. Assess bleeding risk and renal function
2. If no contraindications: Use fondaparinux 2.5 mg SC once daily starting 6-8 hours post-surgery
3. If fondaparinux contraindicated: Use enoxaparin 40 mg SC once daily (or 30 mg twice daily for elderly)
4. Continue prophylaxis for minimum 7-10 days
5. Extend prophylaxis to 32 days total for hip fracture patients
6. Add mechanical prophylaxis (intermittent compression devices) for all patients
7. Ensure early mobilization when possible