Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors

Abstract

Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7–14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

“…Moreover, current guidelines ( Chinese Orthopaedic Association, 2010 ; Falck-Ytter et al, 2012 ; Anderson et al, 2019 ; Gee, 2019 ) do not standardize the recommended duration of anticoagulation. In addition, the duration of prophylaxis can be influenced by factors such as the type of procedure and individual VTE risk, making it difficult to identify a standard for grouping anticoagulation durations for our analyses ( Jones and Al-Horani, 2023 ).…”

Geriatric proximal femur fracture updates

“…Early surgery may be safe, and no bridging therapy is generally recommended; however, some of these drugs requires reversal before surgical intervention. 15 , 16 Managing anticoagulants and antiplatelets requires close coordination according to the CGA. In addition, basic versus routine laboratory tests should be discussed on a case-by-case basis.…”

“…At discharge, DVT prophylaxis either with LMWH, oral anti-Xa agents or aspirin and pain control are recommended. 15 , 16 Adjustment of pain control using multimodal pain management strategies without opioid is preferable. If not possible, it is necessary to have a plan for reduction and discontinuation of opioids as the acute pain resolves.…”

The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review

“…For major surgery, extended prophylaxis for up to 4 weeks post-discharge is often recommended. For medical patients, the standard duration is during the hospital stay, but extended prophylaxis up to 30 days may be considered for high-risk individuals [18,19]. Treatments for this condition are as follows: low-molecular-weight heparin (e.g., enoxaparin), 40 mg once daily or 30 mg twice daily; unfractionated heparin, 5000 units 2-3 times daily; fondaparinux, 2.5 mg once daily; direct oral anticoagulants (e.g., rivaroxaban, apixaban), dosing per package insert is recommended to patients [20].…”