Bridging Anticoagulation for Ankle Fracture Surgery

Key Decision Points

High thromboembolic risk patients, such as those with mechanical heart valves or atrial fibrillation with CHADS2 ≥5, may require bridging with therapeutic-dose LMWH, as recommended by the American College of Chest Physicians 1, 2
For patients undergoing orthopedic ankle fracture surgery, the American College of Chest Physicians suggests that orthopedic ankle fracture surgery is considered moderate-to-high bleeding risk due to bone and soft tissue trauma, potential for compartment syndrome complications, and need for adequate surgical hemostasis 3, 4

The American Society of Hematology recommends that if the patient was on warfarin, the last dose should have been 5 days before surgery, and the INR should be checked the day before surgery; proceed if INR ≤1.5 5
The American College of Chest Physicians recommends resuming oral anticoagulant without bridging, restarting warfarin at the usual maintenance dose on the evening of surgery or the next morning 5, 4

The American College of Chest Physicians suggests that if bridging were absolutely necessary for high-risk patients, delay LMWH resumption for 48-72 hours after surgery for high-bleeding-risk procedures, and use reduced-dose or prophylactic-dose LMWH initially rather than therapeutic dose 3, 4
Major bleeding occurs in 20% of patients when therapeutic LMWH is started 12-24 hours post-major surgery, as reported by the American College of Chest Physicians 3, 4

The American College of Chest Physicians recommends avoiding the initiation of therapeutic-dose LMWH within 24 hours post-surgery, as this dramatically increases major bleeding risk (20% incidence) 3, 4
The American College of Chest Physicians suggests not giving the last preoperative LMWH dose <24 hours before surgery, as 34% of patients have therapeutic anticoagulation at surgery when dosed 12 hours prior 2, 6