Does femoral Open Reduction Internal Fixation (ORIF) require Deep Vein Thrombosis (DVT) prophylaxis (ppx)?

DVT Prophylaxis for Femoral ORIF

Yes, femoral ORIF requires DVT prophylaxis—this is a high-risk orthopedic procedure that mandates pharmacologic prophylaxis with LMWH or LDUH combined with mechanical prophylaxis (IPC) unless contraindicated by bleeding risk. 1

Risk Stratification

Femoral fracture surgery falls into the high-risk category for VTE, similar to hip fracture surgery and major orthopedic procedures. 1

• Baseline VTE risk without prophylaxis: The risk of DVT in major orthopedic surgery without prophylaxis ranges from 20-32%, with pulmonary embolism rates of 0.93% at 90 days. 1, 2
• Patient-specific risk factors that further elevate risk include: age >60 years, prior VTE history, active malignancy, obesity, limited mobility, smoking, and hypercoagulable states. 3
• Procedure-specific factors: Operative time, blood loss requiring transfusion, and reoperation for bleeding all increase VTE risk. 1

Recommended Prophylaxis Regimen

Pharmacologic Prophylaxis (First-Line)

For patients NOT at high bleeding risk:

• LMWH (preferred): Enoxaparin 40 mg subcutaneously once daily, starting 12-24 hours postoperatively. 1, 3
• LDUH (alternative): 5,000 IU subcutaneously every 8-12 hours. 1, 2
• Fondaparinux: An equally effective alternative to LMWH, particularly useful in patients with history of heparin-induced thrombocytopenia. 1, 3

The evidence strongly supports pharmacologic prophylaxis in this population—pooled data from major trials show LMWH reduces DVT rates from 20.7% to 13.7% compared to warfarin, and most importantly, significantly reduces fatal postoperative pulmonary embolism. 1, 2

Mechanical Prophylaxis (Adjunctive or Alternative)

• Add IPC devices to pharmacologic prophylaxis for all high-risk femoral ORIF patients. 1
• If high bleeding risk exists: Use IPC or graduated compression stockings as sole prophylaxis until bleeding risk diminishes, then add pharmacologic agents. 1, 3

Mechanical methods alone have not been shown to prevent fatal pulmonary embolism, which is why combined therapy is recommended for high-risk surgery. 2

Duration of Prophylaxis

• Minimum duration: 7-10 days or until hospital discharge, whichever is longer. 1, 4
• Extended prophylaxis: Consider 4 weeks total duration for patients with additional risk factors (prior VTE, cancer, prolonged immobility). 1, 4

Extended prophylaxis with LMWH reduces post-discharge VTE by approximately two-thirds after major orthopedic surgery, though the absolute reduction in fatal PE is small (1 per 2,500 patients). 4

Timing of Initiation

• Start pharmacologic prophylaxis 12-24 hours postoperatively to balance efficacy against surgical bleeding risk. 1
• Begin mechanical prophylaxis immediately in the operating room or recovery room. 1

Special Considerations and Dose Adjustments

• Renal impairment (CrCl <30 mL/min): Reduce enoxaparin to 30 mg once daily. 3
• Active bleeding or high bleeding risk: Use mechanical prophylaxis only until bleeding risk resolves. 1
• Aspirin alone is NOT recommended as sole prophylaxis—it is less effective than LMWH or LDUH and has not been adequately studied in this population. 1, 5

Common Pitfalls to Avoid

• Do not withhold prophylaxis based solely on concern about bleeding—the VTE risk in femoral ORIF far exceeds bleeding risk in most patients. 2
• Do not use aspirin alone—this is inadequate for high-risk orthopedic surgery despite some guidelines suggesting it for elective joint replacement. 1
• Do not stop prophylaxis at hospital discharge if the patient remains non-weight-bearing or has additional risk factors—extend to 4 weeks. 1, 4
• Do not rely on mechanical prophylaxis alone unless pharmacologic agents are absolutely contraindicated—combined therapy is superior. 1, 2
• Avoid routine screening ultrasound before discharge, as this leads to unnecessary anticoagulation of asymptomatic DVTs without reducing symptomatic VTE. 5