Back to all available

Efficacy and Safety of Pharmacological Antithrombotic and Mechanical Devices as Postoperative Thromboprophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-analysis of Randomized Trials

cardiology
orthopedics
pharmacology
surgery-and-surgical-specialties
sports-medicine

Abstract

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective procedures yet carry a risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thromboprophylaxis constitutes a cornerstone of clinical practice. Nevertheless, its efficacy and safety are difficult to ascertain given the inconsistency and limited robustness of the available evidence.

Methods: A network meta-analysis was performed evaluating randomized controlled trials (RCTs) identified from PubMed, ScienceDirect, Scopus, EuropePMC, and Cochrane (CENTRAL) through November 2024. Included studies assessed pharmacological and/or mechanical prophylaxis on VTE rates (DVT and PE) and bleeding outcomes (major and non-major bleeding). Odds ratios (OR) with 95% confidence intervals (CI) were calculated, using placebo/no intervention as reference. Treatments were ranked using average combined surface under the cumulative ranking curve (SUCRA) values.

Results: We included 116 studies encompassing 106,865 participants. When efficacy was averaged with major bleeding risk, apixaban 5 mg was the most favorable for DVT prevention (average SUCRA 69.59%), while nadroparin 3000 IU was optimal for PE (average SUCRA = 75.61%). When efficacy was averaged with non-major bleeding risk, fondaparinux 2.5 mg (average SUCRA 76.20%) and dabigatran 150 mg (average SUCRA 77.60%) were the most favorable for DVT and PE prevention, respectively. Evaluation of mechanical devices shows that IPCD combined with pharmacotherapy (average combined SUCRA = 59.97%) and IPCD-only (average SUCRA 61.74%) demonstrate optimal efficacy in preventing DVT and PE, respectively, while ensuring safety concerning major bleeding. GCS concomitant with VFP (average SUCRA 61.50%) and VFP only (average SUCRA 61.52%) were optimal for preventing DVT and PE, respectively, with minimal non-major bleeding.

Conclusions: This network meta-analysis suggests that for individuals at high risk of major bleeding, apixaban (5 mg) and nadroparin (3000 IU) are preferred for preventing DVT and PE, respectively. In those at risk of non-major bleeding, fondaparinux (2.5 mg) and dabigatran (150 mg) are most effective. Among mechanical methods, IPCD (with or without pharmacotherapy) is optimal for major bleeding risk, while GCS combined with VFP or VFP alone is favored in non-major bleeding risk groups.

Ask to review this manuscript

Notes for potential reviewers

  • Volunteering is not a guarantee that you will be asked to review. There are many reasons: reviewers must be qualified, there should be no conflicts of interest, a minimum of two reviewers have already accepted an invitation, etc.
  • This is NOT OPEN peer review. The review is single-blind, and all recommendations are sent privately to the Academic Editor handling the manuscript. All reviews are published and reviewers can choose to sign their reviews.
  • What happens after volunteering? It may be a few days before you receive an invitation to review with further instructions. You will need to accept the invitation to then become an official referee for the manuscript. If you do not receive an invitation it is for one of many possible reasons as noted above.
  • PeerJ does not judge submissions based on subjective measures such as novelty, impact or degree of advance. Effectively, reviewers are asked to comment on whether or not the submission is scientifically and technically sound and therefore deserves to join the scientific literature. Our Peer Review criteria can be found on the "Editorial Criteria" page - reviewers are specifically asked to comment on 3 broad areas: "Basic Reporting", "Experimental Design" and "Validity of the Findings".
  • Reviewers are expected to comment in a timely, professional, and constructive manner.
  • Until the article is published, reviewers must regard all information relating to the submission as strictly confidential.
  • When submitting a review, reviewers are given the option to "sign" their review (i.e. to associate their name with their comments). Otherwise, all review comments remain anonymous.
  • All reviews of published articles are published. This includes manuscript files, peer review comments, author rebuttals and revised materials.
  • Each time a decision is made by the Academic Editor, each reviewer will receive a copy of the Decision Letter (which will include the comments of all reviewers).

If you have any questions about submitting your review, please email us at [email protected].