Elsevier

The Journal of Arthroplasty

Volume 32, Issue 9, September 2017, Pages 2911-2919.e6
The Journal of Arthroplasty

Review
Low-Molecular-Weight Heparin and the Relative Risk of Surgical Site Bleeding Complications: Results of a Systematic Review and Meta-Analysis of Randomized Controlled Trials of Venous Thromboprophylaxis in Patients After Total Joint Arthroplasty

https://doi.org/10.1016/j.arth.2017.04.010Get rights and content

Abstract

Background

Venous thromboembolism causes significant morbidity and mortality in patients after total joint arthroplasty. Although network meta-analyses have demonstrated a benefit of various thromboprophylactic agents, there remains a concern in the surgical community regarding the resulting wound complications. There is currently no systematic review of the surgical site bleeding complications of thromboprophylactic agents. The aim of this study was to systematically review the surgical site bleeding outcomes of venous thromboembolism prophylaxis in this population.

Methods

A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials comparing more than one of low-molecular-weight heparin (LMWH), warfarin, rivaroxaban, apixaban, dabigatran, aspirin, or no pharmacologic treatment in patients after total hip or knee arthroplasty were selected for inclusion. Five meta-analyses were performed to compare LMWH with control, warfarin, apixaban, rivaroxaban, and dabigatran.

Results

Forty-five randomized controlled trials of 56,730 patients were included. LMWH had a significantly increased relative risk of surgical site bleeding in comparison with control (relative risk, 2.32; 95% confidence interval, 1.40-3.85) and warfarin (1.54; 1.23-1.94). The relative risk of LMWH trended higher than apixaban (1.27; 1.00-1.63) and was similar to rivaroxaban (0.95; 0.74-1.23). Only 1 study reported the risk of surgical site bleeding in LMWH vs dabigatran (5.97; 2.08-17.11).

Conclusion

LMWH increased the risk of surgical site bleeding compared with control, warfarin. and dabigatran and trended toward an increased risk compared with apixaban. The risk of surgical site bleeding was similar with LMWH and rivaroxaban.

Section snippets

Methods

We considered RCTs investigating VTE prophylaxis in adult patients undergoing elective knee or hip arthroplasty. The included trials compared one or more of the following interventions: LMWH, warfarin, rivaroxaban, apixaban, dabigatran, aspirin, and placebo or no pharmacologic treatment (control).

Results

From January 1990 to December 2015, a total of 3617 potentially relevant citations were identified (Fig. 1); 3558 were excluded on the basis of title and abstract for not being related to clinical trials. A total of 77 relevant RCTs relating to interventions studied were selected for checking of full text; 28 trials were excluded on review of full text as they did not relate to the study question, and 4 were excluded as the outcomes were not adequately reported. The largest trial of aspirin vs

Discussion

This systematic review and meta-analysis, which included 45 RCTs and 56,730 total hip or total knee arthroplasty patients, is currently the only study in the existing literature comparing surgical site–specific bleeding complications in this population. In addition, this study included comparisons of newer oral anticoagulants as well as the more established LMWH and warfarin, and aspirin. We also included meta-analyses for the standard efficacy and safety outcomes as secondary outcomes. No

Conclusion

This systematic review and meta-analysis demonstrated that the risk of major and clinically relevant surgical site bleeding episodes was increased with LMWH compared with control, warfarin, and dabigatran. LMWH also demonstrated a trend toward an increased risk of surgical site bleeding episodes compared with apixaban and has an equivalent risk compared with rivaroxaban.

The meta-analysis for efficacy outcomes confirmed findings of earlier studies that LMWH was superior compared with control or

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    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.04.010.

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