Preoperative or Postoperative Start of Prophylaxis for Venous Thromboembolism With Low-Molecular-Weight Heparin in Elective Hip Surgery?

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Abstract
MULTIPLE RANDOMIZED clinical trials have established that treatment with low-molecular-weight heparin (LMWH) is an effective and safe method for preventing venous thromboembolism after elective orthopedic surgery. It is believed that the surgical procedure itself (and the associated immobility) is the primary initiator of the thrombotic process. This notion of pathogenesis has led to the widely held European view that, to be optimally effective, prophylaxis should be initiated preoperatively. On the other hand, concerns about the risk of bleeding during surgery and the interference with regional anesthesia led to the North American approach of initiating LMWH after surgery. Therefore, for years, clinical practice relating to the time of initiation of prophylaxis has differed in Europe and North America. In the typical European regimen, prophylaxis is started 12 hours prior to surgery, whereas in North America, prophylaxis is usually started 12 to 24 hours after the operation. An alternative approach, which has recently been reinvestigated, is to start prophylaxis several hours before or shortly after surgery with adapted doses. All 3 regimens have been shown to be effective in preventing postoperative deep vein thrombosis (DVT), but there are no definitive data about the relative efficacy and safety of these 3 strategies.

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