Venous thromboembolism and fractured neck of femur

Summary

The post-operative incidence of venous thromboembolism (VTE) is high for patients undergoing hip fracture surgery. Proven prophylactic measures are available although underutilized due to concern on post-operative bleeding with use of anticoagulants. This study retrospectively reviewed the clinical incidence of VTE and utilisation of thromboprophylactic protocols over an eight year period. Demographic details, mechanism of injury, VTE risk factors, prophylactic modalities (mechanical and pharmacological), operation duration, mode of anaesthesia, hospital length of stay (LOS) and post-operative complications with particular attention to suspected deep vein thrombosis (DVT) and/or pulmonary embolism (PE) were analysed. Male to female ratio was 1: 2.7 with a median age of 78 years (IQR: 70–86 years) and 83 years (IQR: 77–87 years) respectively (p<0.001). Median hospital LOS was 8 days (IQR: 5–13 days) and differed with mechanism of injury. The in-hospital incidence of VTE was 1.6% (95% CI:1.1–2.5%) with a probably underestimated three month rate of 8.2% (95% CI:5.3–12.4%). Non fatal PE was 0.5% (95% CI: 0.2–1.0%) in-hospital and 2.6% (95% CI: 1.2–5.5%) at three months. Fatal PE was 0.5% (95% CI: 0.2–1.0%) with a three month incidence of 0.4% (95% CI: 0.1–2.4%). The in-hospitalVTE incidence was kept relatively low with use of prophylactic protocols with almost all patients receiving prophylaxis by the end of the study period. Given the five-fold out of hospital increase in incidence, consideration should be given to continue prophylaxis beyond hospital discharge in this high risk group of patients.

Keywords

Aspirin - hip fractures - unfractionated heparin - low-molecular weight heparin - warfarin

• References

• 1 Nicolaides AN, Breddin HK, Fareed J. et al. Prevention of venous thromboembolism. International Consensus Statement. Guidelines compiled in accordance with the scientific evidence. Int Angiol 2001; 20: 1-37.
• 2 Geerts WH, Heit JA, Clagett GP. et al. Prevention of venous thromboembolism. Chest 2001; 119: 132S-175S.
• 3 Haake DA, Berkman SA. Venous thromboembolic disease after hip surgery. Risk factors, prophylaxis, and diagnosis. Clin Orthop Relat Res. 1989: 212-31.
• 4 Geerts WH, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 338S-400S.
• 5 Bounameaux H. Integrating pharmacologic and mechanical prophylaxis of venous thromboembolism. Thromb Haemost 1999; 82: 931-7.
• 6 Eskander MB, Limb D, Stone MH. et al. Sequential mechanical and pharmacological thromboprophylaxis in the surgery of hip fractures. A pilot study. Int Orthop 1997; 21: 259-61.
• 7 Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355: 1295-302.
• 8 Gent M, Hirsh J, Ginsberg JS. et al. Low-molecularweight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996; 93: 80-4.
• 9 Eriksson BI, Bauer KA, Lassen MR. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001; 345: 1298-304.
• 10 Fisher CG, Blachut PA, Salvian AJ. et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma 1995; 9: 1-7.
• 11 Thromboprophylaxis in hip fracture surgery: a pilot study comparing danaparoid, enoxaparin and dalteparin. The TIFDED Study Group. Haemostasis 1999; 29: 310-7.
• 12 Fletcher JP, Koutts J, Ockelford PA. Deep vein thrombosis prophylaxis: a survey of current practice in Australia and New Zealand. Aust N Z J Surg 1992; 62: 601-5.
• 13 Gibbs H, Cardiff L, Coombes J. et al. Deep vein thrombosis prophylaxis in a tertiary referral hospital. Aust N Z J Surg 1998; 68: A155.
• 14 Silverstein MD, Heit JA, Mohr DN. et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158: 585-93.
• 15 Rodgers A, Gray H, MacMahon S. Pharmacological thromboprophylaxis in hip and knee surgery: a survey of New Zealand orthopaedic surgeons. Aust N Z J Surg 1994; 64: 167-72.
• 16 Todd CJ, Freeman CJ, Camilleri-Ferrante C. et al. Differences in mortality after fracture of hip: the east Anglian audit. Bmj 1995; 310: 904-8.
• 17 Williams HR, Macdonald DA. Audit of thromboembolic prophylaxis in hip and knee surgery. Ann R Coll Surg Engl 1997; 79: 55-7.
• 18 Lumpkin MM. FDA public health advisory. Anesthesiology 1998; 88: 27A-28A.
• 19 Wan S, Ting J, Olsen A. et al. Thromboprophylaxis practice patterns in hip fracture surgery patients: experience in Perth, Western Australia. ANZ J Surg 2003; 73: 826-9.
• 20 White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost 2003; 90: 446-55.
• 21 Anderson Jr. FA, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003; 107: I9-16.
• 22 Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107: I22-30.
• 23 Di Minno G, Tufano A. Challenges in the prevention of venous thromboembolism in the elderly. J Thromb Haemost 2004; 2: 1292-8.
• 24 Mismetti P, Laporte-Simitsidis S, Navarro C. et al. Aging and venous thromboembolism influence the pharmacodynamics of the anti-factor Xa and antithrombin activities of a low molecular weight heparin (nadroparin). Thromb Haemost 1998; 79: 1162-5.
• 25 Horlocker TT, Heit JA. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 1997; 85: 874-85.
• 26 Wysowski DK, Talarico L, Bacsanyi J. et al. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med 1998; 338: 1774-5.
• 27 Bergqvist D, Lindblad B, Matzsch T. Risk of combining low molecular weight heparin for thromboprophylaxis and epidural or spinal anesthesia. Semin Thromb Hemost 1993; 19 (Suppl. 01) 147-51.
• 28 Fletcher JP. Venous thromboembolism prophylaxis: applying evidence-based guidelines. ANZ J Surg 2002; 72: 320.
• 29 Wilson D, Cooke EA, McNally MA. et al. Changes in coagulability as measured by thrombelastography following surgery for proximal femoral fracture. Injury 2001; 32: 765-70.
• 30 Lassen MR, Eriksson BI. Efficacy of fondaparinux (Arixtra) in extended thromboprophylaxis in hip fracture surgery is irrespective of patient and surgical characteristics: subgroup analyses of the Penthifra-Plus study. Thromb Haemost 2003; 1: P2062.
• 31 Eriksson BI, Lassen MR. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med 2003; 163: 1337-42.