Venous thromboembolism prophylaxis after total knee arthroplasty (TKA): aspirin vs. rivaroxaban

Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty

Aims

We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty.

Methods

A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes.

Results

Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile.

Conclusion

We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty.

Antithrombotic prophylaxis following total knee arthroplasty: a level I Bayesian network meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) is a major concern following total knee arthroplasty (TKA). The optimal pharmacological prophylaxis remains, however, controversial. The present investigation compared several non-vitamin K antagonist oral anticoagulants commonly employed as VTE prophylaxis following TKA. A Bayesian network meta-analysis was conducted to compare apixaban, aspirin, dabigatran, edoxaban, enoxaparin, fondaparinux, and rivaroxaban. The outcomes of interest were to compare the rate of deep venous thrombosis (DVT), pulmonary embolism (PE), and major and minor haemorrhages.

METHODS

This study was conducted according to the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions. In March 2024, PubMed, Web of Science, and Google Scholar were accessed with no time constraints. All randomised controlled trials (RCTs) comparing two or more drugs for the prevention of VTE following TKA were considered for inclusion.

RESULTS

Data from 29,678 patients were collected. Of them, 67% (19,884 of 29,678 patients) were women. The mean age of the patients was 66.8 ± 2.8 years, and the mean BMI was 29.2 ± 1.5 kg/m2. There was comparability in age, sex, and BMI at baseline. Apixaban 5 mg, dabigatran 220 mg, and rivaroxaban 10 mg were the most effective in reducing the rate of DVT. Apixaban 5 mg, enoxaparin 60 mg, and rivaroxaban 40 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, rivaroxaban 10 mg, and apixaban 10 mg were associated with the lowest rate of major haemorrhages. Apixaban 5 mg and 20 mg, and dabigatran 220 mg were associated with the lowest rate of minor haemorrhages.

CONCLUSION

Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following TKA.

LEVEL OF EVIDENCE

Level I, network meta-analysis of RCTs.

Comparative efficacy of aspirin versus direct oral anticoagulants for venous thromboembolism prophylaxis following primary total hip arthroplasty or total knee arthroplasty: A systematic review and meta-analysis of randomised controlled trials

Introduction

Venous thromboembolisms (VTEs), including deep vein thrombosis (DVT) and pulmonary embolisms (PE), are common after total knee (TKA) and hip arthroplasty (THA). Recent studies suggest that aspirin effectively prevents VTE following major orthopaedic surgery. This meta-analysis compares randomised controlled trials (RCTs) evaluating aspirin versus direct oral anticoagulants (DOACs) for VTE prevention after primary THA and TKA.

Methods

We included RCTs from 2017 to 2023 that looked at aspirin versus DOACs for VTE prophylaxis in primary THA and TKA. A search strategy was conducted which used Boolean operators and MESH terms. Primary outcomes included VTE rates, symptomatic, asymptomatic DVT and PE. Secondary outcomes were mortality and bleeding complications. Statistical analysis was performed using REVMAN software. An odds ratio with a 95% confidence interval was generated for the pooled studies. Heterogeneity was assessed using the I 2 variable, and publication bias was evaluated with a funnel plot.

Results

Seven RCTs with 3967 patients were included for analysis. Rivaroxaban 10 mg OD was compared to varying doses of aspirin (81-300 mg). There were no significant differences between the groups in the incidence of VTE (OR: 1.21, 95% CI: 0.72-2.01), PE (OR: 1.01, 95% CI: 0.39-2.61), asymptomatic DVT (OR: 1.39, 95% CI: 0.64-3.00), suspected DVT (OR: 1.13, 95% CI: 0.49-2.61) and major bleeding (OR: 0.84, 95% CI: 0.55-1.27).

Discussion

Aspirin is as effective as rivaroxaban for primary thromboprophylaxis post-THA and TKA, without increased incidence of complications. Further research is needed to determine the optimal dosing regimen of aspirin and its long-term efficacy in preventing VTE.

Level of Evidence

Level I.

Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis

BACKGROUND

Several clinical investigations have compared different pharmacologic agents for the prophylaxis of venous thromboembolism (VTE). However, no consensus has been reached. The present investigation compared enoxaparin, fondaparinux, aspirin and non-vitamin K antagonist oral anticoagulants (NOACs) commonly used as prophylaxis following total hip arthroplasty (THA). A Bayesian network meta-analysis was performed, setting as outcomes of interest the rate of deep venous thrombosis (DVT), pulmonary embolism (PE) and major and minor haemorrhages.

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. All randomised controlled trials (RCTs) comparing two or more drugs used for the prophylaxis of VTE following THA were accessed. PubMed, Web of Science and Google Scholar databases were accessed in March 2023 with no time constraint.

RESULTS

Data from 31,705 patients were extracted. Of these, 62% (19,824) were women, with age, sex ratio, and body mass index (BMI) being comparable at baseline. Apixaban 5 mg, fondaparinux, and rivaroxaban 60 mg were the most effective in reducing the rate of DVT. Dabigatran 220 mg, apixaban 5 mg, and aspirin 100 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, ximelagatran 2 mg and aspirin 100 mg were associated with the lowest rate of major haemorrhages, while rivaroxaban 2.5 mg, apixaban 5 mg and enoxaparin 40 mg were associated with the lowest rate of minor haemorrhages.

CONCLUSION

Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following THA. Level of evidence Level I, network meta-analysis of RCTs.

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used. Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS). Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration's tool. Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053-1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499-1.815), all-cause mortality (RR = 1.208, 95% CI 0.459-3.177), and wound-related events (RR = 0.618, 95% CI 0.333-1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552-0.850) events and total bleeding (RR = 0.726, 95% CI 0.590-0.892). Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants.

RESULTS

Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61).

CONCLUSION

Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Prevention of venous thromboembolism with aspirin following knee surgery: A systematic review and meta-analysis

Venous thromboembolism (VTE) is a well-known complication following orthopaedic surgery. The incidence of this complication has decreased substantially since the introduction of routine thromboprophylaxis. However, concerns have been raised about increased bleeding complications caused by aggressive thromboprophylaxis.Attention has grown for aspirin as a safer thromboprophylactic agent following orthopaedic surgery.A systematic review using MEDLINE, Embase and Web of Science databases was undertaken to compare the effectiveness of aspirin prophylaxis following knee surgery with the current standard prophylactic agents (low molecular weight heparin [LMWH], vitamin K antagonists and factor Xa inhibitors).No significant difference in effectiveness of VTE prevention was found between aspirin, LMWH and warfarin. Factor Xa inhibitors were more effective, but increased bleeding complications were reported.As evidence is limited and of low quality with substantial heterogeneity, further research with high-quality, adequately powered trials is needed. Cite this article: EFORT Open Rev 2021;6:892-904. DOI: 10.1302/2058-5241.6.200120.

Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review

Although total hip and knee arthroplasty are effective methods for treating arthritis, they have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including aspirin, low-molecular-weight Heparin, vitamin K antagonists, and direct oral anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of aspirin for VTE prophylaxis compared to anticoagulants. An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional studies identified during the review process were also included. The final studies meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme tool. A total of 12 (60%) studies (two meta-analyses, three randomised trials, seven retrospective studies) favoured aspirin over anticoagulants for VTE prophylaxis. A total of 15 (75%) studies (two meta-analyses, three randomised trials, nine retrospective, one matched cohort) reported that aspirin had better bleeding profiles and complication rates, which was statistically significant in seven (46.7%) studies (one randomised trial, six retrospective studies). A total of eight studies (one randomised trial, six retrospective studies, one matched cohort) reported statistically significant results for aspirin. Five (62.5%) studies reported aspirin to be superior for VTE prophylaxis, while seven (87.5%) reported aspirin to be superior in terms of bleeding complications. The current evidence indicates that aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis in terms of their bleeding profiles.

Rivaroxaban versus aspirin in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery: a meta-analysis

Objective

To evaluates the efficacy and safety of rivaroxaban versus aspirin in prevention of venous thromboembolism (VTE) following total hip (THA) or knee arthroplasty (TKA) or hip fracture surgery.

Methods

Major databases were systematically searched for all relevant studies published in English up to October 2020. The meta-analysis was conducted using RevMan 5.3 software.

Results

In total, 7 studies were retrieved which contained 5133 patients. Among these patients, 2605 patients (50.8%) received rivaroxaban, whereas 2528 patients (49.2%) received aspirin. There were no statistical difference between aspirin and rivaroxaban for reducing VTE (RR = 0.75, 95% CI 0.50–1.11, I² = 36%, p = 0.15), major bleeding (RR = 0.94, 95% CI 0.45–2.37, I² = 21%, p = 0.95), and all-cause mortality (RR = 0.88, 95% CI 0.12–6.44, I² = 0%, p = 0.90) between the two groups. Compared with aspirin, rivaroxaban significantly increased nonmajor bleeding (RR = 1.29, 95% CI 1.05–1.58, I² = 0%, p = 0.02).

Conclusion

There was no significant difference between aspirin and rivaroxaban in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery. Aspirin may be an effective, safe, convenient, and cheap alternative for prevention of VTE. Further large randomized studies are required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02274-z.

Venous thromboembolism prophylaxis in patients undergoing knee replacements: comparison of real-world outcomes

Background Increasing evidence for the use of the aspirin in patients undergoing an orthopaedic surgery for venous thromboembolism prophylaxis has led to a change in the national guidelines substituting anticoagulants with aspirin. Little is known about the impact of such substitution on real-world outcomes from clinical practice. Objective The study was designed to examine clinical outcomes associated with the use of aspirin and apixaban. Setting Two large-scale general hospitals in West Yorkshire region of England. Method A 1-year observational study among adults who underwent elective knee replacements and received venous thromboembolism prophylaxis within the first 14 days post replacements. Main outcome measure The incidence of postoperative venous thromboembolism, leaking wounds during the hospital stay, and 30-day any readmission for the two drugs. Results A total of 420 patients were included. There was a significant drop in apixaban prescribing (from 80.37 to 10.51%) and increase in aspirin use (from 19.02 to 81.71%) after the implementation of the revised guidelines. There were 52 (12.38%) cases of leaking wound, 16 (3.81%) cases of postoperative venous thromboembolism, 45 (10.71%) cases of 30-day readmission and no case of 30-day major bleeding. The leaking wounds and 30-day readmissions were almost twice more frequent in obese compared to non-obese patients. Multivariate logistic regression found an increased risk of leaking wound with apixaban and postoperative venous thromboembolism and 30-day readmission with aspirin use but the differences were not statistically significant. Conclusion The results suggest aspirin to be as effective as apixaban in preventing venous thromboembolism and readmission. Apixaban usage decreased with a corresponding increase in Aspirin use. The impact of obesity and length of hospital stay need further investigations.

Analysis of the quality of reporting of randomized controlled trials in anticoagulant versus antiplatelet medication for venous thromboembolism prophylaxis as governed by the CONSORT statement

Randomized controlled trials (RCTs) are the gold standard research in evaluating healthcare interventions. The CONSORT (Consolidated Standards of Reporting Trials) statement improves the quality of RCTs in an evidence-based approach. To evaluate the reporting quality of published RCTs concerning the use of anticoagulants versus antiplatelet agents for venous thromboembolism prophylaxis according to the CONSORT statement. Electronic databases were searched for English-language RCTs involving patients who received either anticoagulant or antiplatelet medication for prophylaxis of deep vein thrombosis and pulmonary embolism published from 2000 to 2019. Trials were considered eligible when the included patients received either anticoagulant or antiplatelet medication for primary and secondary prevention of deep vein thrombosis or pulmonary embolism and were randomly assigned to at least two treatment arms. Quality of reporting was assessed using a 37-item questionnaire based on the CONSORT 2010 checklist. Reporting was assessed in 2 publication periods (2000-2009) and (2010-2019). The effect of CONSORT statement in high- and low-ranked medical journals, according to their impact factor, has also been evaluated. The search identified 13 eligible articles for analysis. Only 12 of the 37 items of the checklist were addressed in 75% or more of the studies. Most items concerning the methodological issues were reported by fewer than 50% of the studies. Improvements over time were seen for items that assessed the methodological quality with no statistically significant difference. RCTs published in high-ranked journals showed better quality of reporting. Quality of reporting in RCTs focusing on the use of anticoagulants versus antiplatelet agents for venous thromboembolism prophylaxis remains unsatisfactory. Further improvement of reporting is necessary to assess the validity of clinical research.

Aspirin alleviates orthopedic implant‑associated infection

Implant-associated infection (IAI), a common condition marked by progressive inflammation and bone destruction, is mentally and financially devastating to those it affects, causing severe morbidity, prolonged hospital admissions, significant hospital costs and, in certain cases, mortality. Aspirin, a popular synthetic compound with a history of >100 years, is antipyretic, anti-inflammatory and analgesic. It is the most active component of non-steroidal anti-inflammatory drugs. However, the effects of aspirin on IAI remain unknown. In the present study, an IAI animal model was used, in which a stainless steel pin coated with Staphylococcus aureus was implanted through the left shaft of the tibia in mice. The animals were then randomized into five groups and subjected respectively to IAI, IAI + 15 mg aspirin treatment, IAI + 30 mg aspirin treatment, IAI + 60 mg aspirin treatment and IAI + 120 mg aspirin treatment groups. Aspirin was injected intraperitoneally twice daily for 11 days. Micro-CT and histological assays were performed to assess the effects of aspirin on IAI. It was found that aspirin reduced osteolysis and periosteal reaction, inhibited the activation of osteoclasts, promoted the activation of osteoblasts and facilitated healing of the infected fracture.

Aspirin versus rivaroxaban in postoperative bleeding after total knee arthroplasty: a retrospective case-matched study

BACKGROUND

Venous thromboembolic disease (VTE) is a complication not uncommon following total knee arthroplasty. Postoperative bleeding-related complications are a concern in many guidelines. The authors aimed to compare the amount of postoperative drainage from closed suction drainage, transfusion rate, and postoperative complications between aspirin and rivaroxaban as VTE prophylaxes after total knee arthroplasty.

METHODS

This study was a retrospective case-matched study of 155 patients. The data were collected between 2008 and 2015 from patients who had total knee arthroplasty using aspirin or rivaroxaban as the VTE prophylaxis. Seventy-nine patients received aspirin, and 76 patients received rivaroxaban. A single surgeon operated on all patients with the same surgical technique and patient care protocol.

RESULTS

The total closed suction drainage outputs at 48 h were not significantly different between the aspirin and rivaroxaban groups (p = 0.10). Eighteen percent of patients in the aspirin group and 25% of patients in the rivaroxaban group received blood transfusions (p = 0.37). There were no bleeding-related complications or VTE in either group.

CONCLUSIONS

Aspirin and rivaroxaban were effective and safe as VTE chemoprophylaxis in total knee arthroplasty.