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. 2000;2002(2):CD000305.
doi: 10.1002/14651858.CD000305.

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures

H H Handoll  1 , M J Farrar, J McBirnie, G Tytherleigh-Strong, K A Awal, A A Milne, W J Gillespie
Affiliations

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures

H H Handoll et al. Cochrane Database Syst Rev. 2000.

Update in

Abstract

Background: Hip fracture patients have a high risk of thromboembolic complications following surgical management.

Objectives: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly.

Search strategy: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996.

Selection criteria: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture.

Data collection and analysis: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible.

Main results: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported.

Reviewer's conclusions: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

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Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 1: DVT ‐ any
1.2
1.2. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 2: DVT ‐ any: good quality trials
1.3
1.3. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 3: DVT ‐ proximal
1.4
1.4. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 4: DVT ‐ distal
1.5
1.5. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 5: Pulmonary embolism ‐ any
1.6
1.6. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 6: Pulmonary embolism ‐ non fatal
1.7
1.7. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 7: Pulmonary embolism ‐ fatal
1.8
1.8. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 8: Mortality
1.9
1.9. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 9: Death: other causes (not confirmed PE)
1.10
1.10. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 10: Wound haematoma
1.11
1.11. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 11: Wound infection
1.12
1.12. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 12: Blood loss (ml)
1.13
1.13. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 13: Transfusion ‐ amount
1.14
1.14. Analysis
Comparison 1: Any heparin vs Control/Placebo, Outcome 14: Transfusion ‐ no. patients receiving transfusion
2.1
2.1. Analysis
Comparison 2: Heparin vs Control/Placebo, Outcome 1: DVT ‐ any: by allocation concealment
2.2
2.2. Analysis
Comparison 2: Heparin vs Control/Placebo, Outcome 2: DVT ‐ any: by no treatment or placebo control
2.3
2.3. Analysis
Comparison 2: Heparin vs Control/Placebo, Outcome 3: DVT ‐ any: by timing overlap
3.1
3.1. Analysis
Comparison 3: LMW heparin vs Placebo, Outcome 1: DVT ‐ any: worst and best scenario
4.1
4.1. Analysis
Comparison 4: Physical device vs Control, Outcome 1: DVT ‐ any
4.2
4.2. Analysis
Comparison 4: Physical device vs Control, Outcome 2: DVT ‐ any: by device type
4.3
4.3. Analysis
Comparison 4: Physical device vs Control, Outcome 3: DVT ‐ any: by trial quality
4.4
4.4. Analysis
Comparison 4: Physical device vs Control, Outcome 4: DVT ‐ any: by allocation concealment
4.5
4.5. Analysis
Comparison 4: Physical device vs Control, Outcome 5: DVT ‐ any: worst and best case scenario
4.6
4.6. Analysis
Comparison 4: Physical device vs Control, Outcome 6: DVT ‐ proximal
4.7
4.7. Analysis
Comparison 4: Physical device vs Control, Outcome 7: DVT ‐ distal
4.8
4.8. Analysis
Comparison 4: Physical device vs Control, Outcome 8: Pulmonary embolism ‐ any
4.9
4.9. Analysis
Comparison 4: Physical device vs Control, Outcome 9: Pulmonary embolism ‐ fatal
4.10
4.10. Analysis
Comparison 4: Physical device vs Control, Outcome 10: Mortality
4.11
4.11. Analysis
Comparison 4: Physical device vs Control, Outcome 11: Bleeding complications
4.12
4.12. Analysis
Comparison 4: Physical device vs Control, Outcome 12: Transfusion ‐ mean volume (ml)
5.1
5.1. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 1: DVT ‐ any
5.2
5.2. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 2: DVT ‐ any: good quality trials
5.3
5.3. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 3: DVT ‐ any: worst scenario
5.4
5.4. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 4: DVT ‐ proximal
5.5
5.5. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 5: DVT ‐ distal
5.6
5.6. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 6: Pulmonary embolism ‐ any
5.7
5.7. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 7: Pulmonary embolism ‐ non fatal
5.8
5.8. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 8: Pulmonary embolism ‐ fatal
5.9
5.9. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 9: Mortality
5.10
5.10. Analysis
Comparison 5: LMW heparin vs U Heparin, Outcome 10: Wound haematoma
6.1
6.1. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 1: DVT ‐ any
6.2
6.2. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 2: DVT ‐ proximal
6.3
6.3. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 3: DVT ‐ distal
6.4
6.4. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 4: Pulmonary embolism ‐ fatal
6.5
6.5. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 5: Mortality
6.6
6.6. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 6: Bleeding complications
6.7
6.7. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 7: Transfusion ‐ no. patients receiving transfusion
6.8
6.8. Analysis
Comparison 6: LMW heparin vs Pneumatic intermittent compression (PIC), Outcome 8: Transfusion ‐ mean volume (ml)
7.1
7.1. Analysis
Comparison 7: LMW heparin vs Pneumatic intermittent compression (PIC) then LMW heparin, Outcome 1: DVT ‐ any
7.2
7.2. Analysis
Comparison 7: LMW heparin vs Pneumatic intermittent compression (PIC) then LMW heparin, Outcome 2: Pulmonary embolism ‐ non fatal
7.3
7.3. Analysis
Comparison 7: LMW heparin vs Pneumatic intermittent compression (PIC) then LMW heparin, Outcome 3: Transfusion ‐ no. patients receiving transfusion
8.1
8.1. Analysis
Comparison 8: Miscellaneous ‐ timing, dose management or type of LMW heparin, Outcome 1: LMW heparin ‐ 20mg 2xdaily vs 40mg 1xdaily
8.2
8.2. Analysis
Comparison 8: Miscellaneous ‐ timing, dose management or type of LMW heparin, Outcome 2: U heparin ‐ adjusted vs fixed
8.3
8.3. Analysis
Comparison 8: Miscellaneous ‐ timing, dose management or type of LMW heparin, Outcome 3: LMW heparin ‐ timing: pre‐operative vs post‐operative start
8.4
8.4. Analysis
Comparison 8: Miscellaneous ‐ timing, dose management or type of LMW heparin, Outcome 4: LMW heparins: Dalteparin vs Enoxaparin
See this image and copyright information in PMC

References

References to studies included in this review

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Jorgensen 1998 {published and unpublished data}
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Sourmelis 1995b {published data only}
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References to studies excluded from this review

Anglen 1998 {published data only}
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Arrington 1997 {published data only}
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Eriksson 2001 {published data only}
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Geerts 1996 {published data only}
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Knudsen 1989 {published data only}
    1. Knudsen JB, Torholm C, Jorgensen PK, Hagen K, Broeng L, Josefson L, et al. Effect on coagulation parameters of low molecular weight heparin (fragmin) in elective and acute hip surgery [Abstract]. Thrombosis and Haemostasis 1989;62:523.
Knudson 1994 {published data only}
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Wilson 1999 {published data only}
    1. Wilson D, Cooke EA, McNally MA, Mollan RA. Whole blood thromboelastographic profiles following hip fracture - a comparison of low molecular weight heparin, dextran 70 and mechanical prophylaxis [Abstract]. Journal of Bone and Joint Surgery. British Volume 1999;81 Suppl 3:296.

References to studies awaiting assessment

Haentjens 1996 {published data only}
    1. Haentjens P, Buffels R. Thromboembolic prophylaxis in trauma patients: A comparison between a fixed dose and an individually adjusted dose of a low molecular weight heparin (CY216). Journal of Bone and Joint Surgery. British Volume 1995;77 Suppl 2:173.
    1. Haentjens P. Thromboembolic prophylaxis in orthopaedic trauma patients: A comparison between a fixed dose and an individually adjusted dose of a low molecular weight heparin (nadroparin calcium). Injury 1996;27(6):385-90. - PubMed
Krska 2001 {published data only}
    1. Krska Z, Kudrna K, Kvasnicka J, Zeman M, Peskova M. Prostheses of the hip joint in orthopaedics and traumatology - thromboembolics complications [Nahrady kycelniho kloubu v ortopedii a tramatologii - tromboembolicke komplikace]. Prakticky Lehar 2001;81(4):192-6.
Monreal 1991 {published data only}
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Additional references

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References to other published versions of this review

Handoll 2002
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Protocol
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