What type and duration of Deep Vein Thrombosis (DVT) prophylaxis is recommended for patients post hip replacement surgery?

DVT Prophylaxis Post Hip Replacement: Type and Duration

Low molecular weight heparin (LMWH) is the preferred method of DVT prophylaxis for patients undergoing hip replacement surgery, with recommended duration of at least 10-14 days and extended up to 35 days (5 weeks) postoperatively. 1, 2

Recommended Pharmacological Agents

First-Line Options

• LMWH is the preferred agent for DVT prophylaxis in hip replacement patients due to superior efficacy in preventing asymptomatic VTE compared to adjusted-dose warfarin 1
• LMWH should be started either 12 hours before surgery, 12-24 hours after surgery, or 4-6 hours after surgery (starting with half-dose and continuing with usual high-risk dose the following day) 1, 2
• Fondaparinux is considered an equal alternative to LMWH according to more recent guidelines 1

Alternative Options

• Adjusted-dose warfarin (target INR 2.5, range 2.0-3.0) is an acceptable alternative but more complex to manage and potentially less effective than LMWH 1
• Direct oral anticoagulants (DOACs) like rivaroxaban (10 mg once daily) and apixaban have shown efficacy in VTE prevention after hip replacement 1, 3, 4
• Rivaroxaban has demonstrated reduced DVT, PE, or death without increased bleeding rates compared to enoxaparin in the RECORD trials 1

Not Recommended

• Low-dose unfractionated heparin, aspirin alone, or dextran are not recommended as sole prophylactic agents 1
• Aspirin is not recommended as the sole method of thromboprophylaxis according to ACCP and French guidelines (Grade A and B evidence, respectively) 1

Duration of Prophylaxis

• Minimum duration of 7-10 days is recommended for all patients undergoing hip replacement 1, 5
• Extended prophylaxis beyond hospital discharge is strongly recommended as the risk of DVT persists for up to 2-3 months following hip replacement 1, 5
• Extended prophylaxis (approximately 5 weeks total) has been shown to significantly reduce the continuing risk of DVT (12-37%) in six randomized double-blind trials 1
• The RECORD 2 trial demonstrated that extended rivaroxaban (31-39 days) was more effective than shorter-duration enoxaparin (10-14 days) without increased bleeding complications 1
• Extended prophylaxis with LMWH reduces the frequency of post-discharge VTE by approximately two-thirds after hip replacement 5

Mechanical Prophylaxis

• Intermittent pneumatic compression (IPC) devices or elastic stockings may provide additional efficacy when used in conjunction with pharmacological prophylaxis (Grade 2C) 1, 2
• Mechanical prophylaxis alone is recommended only in patients with high bleeding risk 1, 2
• Combined use of mechanical and pharmacological methods may offer superior protection compared to either method alone 1, 2

Special Considerations

• Risk of bleeding at the surgical site and wound hematoma may be greater with LMWH than with adjusted-dose warfarin, so the choice should be individualized based on bleeding risk 1
• Major bleeding occurred in 3.3% of warfarin recipients versus 5.3% of LMWH recipients in pooled data from five large clinical trials 1
• For patients at high risk of bleeding, mechanical prophylaxis should be used until the bleeding risk decreases 1, 2
• Patients with additional risk factors for VTE (previous VTE, cancer) should definitely receive extended prophylaxis 5

Implementation Challenges

• Despite strong evidence and guidelines, compliance with recommended DVT prophylaxis after hip replacement varies geographically 1
• In the US, approximately 84-93% of hip replacement patients receive some form of VTE prophylaxis, though not always according to guidelines 1
• European surgeons tend to favor LMWH while US surgeons more commonly use warfarin or mechanical prophylaxis 1
• Clinical decision support tools and standardized order sets have been shown to improve compliance with VTE prophylaxis guidelines 1