VTE Prophylaxis

One high strength study (PE Prevention Trial Collaborative Group¹⁰⁷), three moderate strength studies (Moskovits et al¹⁶⁷; Xabregas et al¹⁶⁸; Morris et al¹⁶⁹), and eight low strength studies (Chatanaphutiet al ¹⁰⁸; Sasaki et al¹⁰⁹; Sasaki et al¹¹⁰; Checketts et al¹¹¹; Jorgensen et al¹¹²; Lahnborg et al¹¹³; Kew et al¹¹⁴; Eskeland et al¹¹⁵) were identified comparing various pharmacological prophylaxis interventions to placebo. One moderate strength study (Stranks et al¹¹⁵) compared mechanical prophylaxis to a group that received no mechanical prophylaxis.  These studies show the risk of DVT/VTE/PE complications is significantly less with VTE prophylaxis than control. Most general complications were not significantly different between treatment groups, with the exception of Lahnborg et al¹¹³ which found hematoma complications were higher in pharmacological prophylaxis groups. There was no difference in hospital stay and there is some evidence that mortality is less with prophylaxis.
 
Given the significant established risk factors for VTE present in this patient population including age, presence of hip fracture, major surgery, delays to surgery,  and the potential serious consequences of failure to provide prophylaxis in the hip fracture population,  it is the recommendation of the workgroup that VTE prophylaxis be used
 
Risks and Harms of Implementing this Recommendation
Patients with hip fracture are at high risk for deep venous thrombosis and pulmonary embolism. The consequences of symptomatic VTE are significant and include both increased morbidity and mortality. The harms associated with this recommendation include those associated with VTE prophylaxis, bleeding and thrombotic complications.
 
Future Research
The issue of VTE prophylaxis in patients who have sustained a hip fracture is complex. There are many unanswered questions that have the potential to have a significant impact on clinical outcomes for this patient population. A multi-armed randomized controlled study would be optimal. Such a study would potentially need to evaluate the comparative effectiveness of a multitude of chemical agents, at different dosages, with multiple time points (such as pre and post-op), and include assorted durations of therapy, while utilizing contemporary diagnostic methodologies. Barriers to such a study include the low incidence of the complication implicating a requirement for a substantially large sample size. Furthermore, such a study carries ethical concerns given the potential risks associated with under-treatment. Potentially, well organized patient outcome registries may ultimately help improve our knowledge in this area.