Venous Thromboembolism Prophylaxis with Low Molecular Weight Heparin Versus Unfractionated Heparin for Patients Undergoing Operative Treatment of Closed Femoral Shaft Fractures

Overview

Journal J Clin Orthop Trauma

Specialty Orthopedics

Date 2022 Jul 25

PMID 35874319

Authors

Nicholas C Danford

Sanket Mehta

Venkat Boddapati

Justin E Hellwinkel

Charles M Jobin

Justin K Greisberg

Affiliations

Soon will be listed here.

Abstract

Background: The objective of this study was to compare inpatient mortality rates for patients with operatively treated closed femoral shaft fractures (AO/OTA 32 A-C) who received venous thromboembolism (VTE) prophylaxis with either low molecular weight heparin (LMWH) or unfractionated heparin.

Methods: This was a retrospective cohort study of a national database of patients presenting to Level I through IV trauma centers in the United States. All patients ≥18 years of age who sustained an operatively treated closed femoral shaft fracture were included. The primary outcome of inpatient mortality was compared between two groups: those who received LMWH or unfractionated heparin for VTE prophylaxis. Secondary outcomes were complications including VTE and bleeding events. Groups were compared using a multivariate regression model.

Results: There were 2058 patients included in the study. Patients who received VTE prophylaxis with LMWH had lower odds of inpatient mortality compared to patients who received VTE prophylaxis with unfractionated heparin (OR 0.19; 95% CI 0.05 to 0.68, p = 0.011).

Conclusions: VTE prophylaxis with LMWH is associated with lower inpatient mortality compared to VTE prophylaxis with unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures. To our knowledge this is the first study to report these associations for a specific subset of orthopedic trauma patients.

Citing Articles

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures.

Tischler E, McDermott J, Wolfert A, Krasnyanskiy B, Ibrahim I, Malik A J Orthop. 2024; 55:91-96.

PMID: 38665991 PMC: 11039340. DOI: 10.1016/j.jor.2023.10.020.

References

DAlleyrand J, OToole R . The evolution of damage control orthopedics: current evidence and practical applications of early appropriate care. Orthop Clin North Am. 2013; 44(4):499-507. DOI: 10.1016/j.ocl.2013.06.004. View

Heit J, OFallon W, Petterson T, Lohse C, Silverstein M, Mohr D . Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002; 162(11):1245-8. DOI: 10.1001/archinte.162.11.1245. View

Hashmi Z, Kaji A, Nathens A . Practical Guide to Surgical Data Sets: National Trauma Data Bank (NTDB). JAMA Surg. 2018; 153(9):852-853. DOI: 10.1001/jamasurg.2018.0483. View

Delate T, Jones A, Clark N, Witt D . Assessment of the coding accuracy of warfarin-related bleeding events. Thromb Res. 2017; 159:86-90. DOI: 10.1016/j.thromres.2017.10.004. View

Nahm N, Como J, Wilber J, Vallier H . Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma. 2011; 71(1):175-85. DOI: 10.1097/TA.0b013e3181fc93a2. View

Thorson C, Ryan M, Van Haren R, Curia E, Barrera J, Guarch G . Venous thromboembolism after trauma: a never event?*. Crit Care Med. 2012; 40(11):2967-73. DOI: 10.1097/CCM.0b013e31825bcb60. View

OToole R, Stein D, Frey K, OHara N, Scharfstein D, Slobogean G . PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients. BMJ Open. 2021; 11(3):e041845. PMC: 7993181. DOI: 10.1136/bmjopen-2020-041845. View

Nguyen R, Rizor J, Damiani M, Powers A, Fagnani J, Monie D . The Impact of Anticoagulation on Trauma Outcomes : An National Trauma Data Bank Study. Am Surg. 2020; 86(7):773-781. DOI: 10.1177/0003134820934419. View

Lakomkin N, Zuckerman S, Stannard B, Montejo J, Sussman E, Virojanapa J . Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score. Spine (Phila Pa 1976). 2019; 44(13):E782-E787. DOI: 10.1097/BRS.0000000000002970. View

10.

Bergqvist D, Lindblad B . A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1274 surgical patients. Br J Surg. 1985; 72(2):105-8. DOI: 10.1002/bjs.1800720211. View

11.

Lowe J, Mitchell S, Agarwal S, Jones C . The Incidence of Venous Thromboembolism Following Pelvic and Lower Extremity Trauma Despite Adherence to Modern Prophylactic Protocols. J Orthop Trauma. 2020; 34(8):418-421. DOI: 10.1097/BOT.0000000000001790. View

12.

Singer G, Riggi G, Karcutskie C, Vaghaiwalla T, Lieberman H, Ginzburg E . Anti-Xa-guided enoxaparin thromboprophylaxis reduces rate of deep venous thromboembolism in high-risk trauma patients. J Trauma Acute Care Surg. 2016; 81(6):1101-1108. DOI: 10.1097/TA.0000000000001193. View

13.

Malinoski D, Jafari F, Ewing T, Ardary C, Conniff H, Baje M . Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients. J Trauma. 2010; 68(4):874-80. DOI: 10.1097/TA.0b013e3181d32271. View

14.

Sagi H, Ahn J, Ciesla D, Collinge C, Molina C, Obremskey W . Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations. J Orthop Trauma. 2015; 29(10):e355-62. DOI: 10.1097/BOT.0000000000000387. View

15.

Morshed S, Miclau 3rd T, Bembom O, Cohen M, Knudson M, Colford Jr J . Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009; 91(1):3-13. PMC: 2663326. DOI: 10.2106/JBJS.H.00338. View

16.

DHoore W, Bouckaert A, Tilquin C . Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol. 1996; 49(12):1429-33. DOI: 10.1016/s0895-4356(96)00271-5. View

17.

Tran A, Fernando S, Carrier M, Siegal D, Inaba K, Vogt K . Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-analysis. Ann Surg. 2021; 275(1):19-28. DOI: 10.1097/SLA.0000000000005157. View

18.

Cushman M, Tsai A, White R, Heckbert S, Rosamond W, Enright P . Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004; 117(1):19-25. DOI: 10.1016/j.amjmed.2004.01.018. View

19.

Cantu R, Graves S, Spratt K . In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006. J Trauma Acute Care Surg. 2014; 76(6):1433-40. PMC: 4537793. DOI: 10.1097/TA.0000000000000230. View

20.

Jacobs B, Cain-Nielsen A, Jakubus J, Mikhail J, Fath J, Regenbogen S . Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma. J Trauma Acute Care Surg. 2017; 83(1):151-158. PMC: 7055932. DOI: 10.1097/TA.0000000000001494. View