Real World Adherence with Thromboprophylaxis Guidelines After Lower Limb Fracture Surgery: Rates, Barriers, and Complications- A Cross Sectional Study

• Non-adherence to anticoagulants was 22.4% after fracture surgery. • Main barrier was misunderstanding of treatment duration (63.2%). • Adherence increased with age, particularly after age 50. • DVT incidence was 0.8%, all cases occurred in adherent patients. • Pharmacist education was associated with lower adherence rates. To investigate adherence rates, barriers, and complication profiles associated with thromboprophylaxis following lower limb fracture surgery, and to identify factors contributing to non-adherence in routine orthopedic practice. A cross-sectional study was conducted involving 254 patients aged ≥18 years who underwent surgical fixation of lower extremity fractures and attended outpatient follow-up ≥6 weeks postoperatively at a tertiary trauma center between October 2023 and December 2024. Data were collected through structured questionnaires. Patient-reported barriers were classified according to the World Health Organization (WHO) five-dimension adherence framework. Non-adherence was defined according to ACCP-9 guidelines (<14 days for minor or <35 days for major surgeries, or irregular use). Appropriate statistical analyses were performed. Overall, 22.4% of patients were non-adherent to anticoagulant therapy. The most common reason was misunderstanding the intended treatment duration (63.2%). Injection-related pain (8.8%) and difficulties accessing healthcare (5.3%) were additional barriers. Adherence increased with age (p = 0.007) and was higher among hip fracture patients (p = 0.039). Pharmacist education was linked to lower adherence. Educational level showed a non-linear association (p = 0.019). DVT was rare (0.8%) and occurred only in adherent patients. Findings were consistent in sensitivity analyses. Despite established guidelines, many patients remain non-adherent to thromboprophylaxis after lower limb fracture surgery, mainly due to misunderstanding of treatment duration. Targeted education, simplified prescribing regulations, and multidisciplinary support are warranted to improve adherence and reduce preventable thromboembolic complications in orthopedic trauma care.