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Updated systematic review assesses VTE prophylaxis for TJR, hip fracture surgery

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The Agency for Healthcare Research and Quality Effective Health Care Program recently released an updated systematic review that assessed prevention methods of venous thromboembolism following total hip replacement, total knee replacement and hip fracture surgery.

Researchers compared interventions used in 127 randomized controlled trials and 15 nonrandomized comparative studies on that examined venous thromboembolism (VTE), major bleeding and other adverse events after total hip replacement (THR), total knee replacement (TKR) and hip fracture surgery.

Results showed a lower risk of various VTE outcomes and major bleeding with low-molecular-weight heparin (LMWH) compared with unfractionated heparin for THR. Low-molecular-weight heparin had less major bleeding than direct thrombin inhibitors, vitamin K antagonists and factor Xa inhibitor, according to results, but direct thrombin inhibitors had lower deep venous thrombosis (DVT) risks. Researchers noted similar risks of total pulmonary embolism, symptomatic DVT and major bleeding among both LMWH and aspirin.

Compared with mechanical devices, researchers found a lower proximal DVT risk with vitamin K antagonists. A longer duration of LMWH led to a lower risk of various VTE outcome risks, while a higher dose led to a lower risk of total DVT but more major bleeding, researchers noted. Results showed a lower total risk of VTE with higher dose factor Xa inhibitor.

For TKR, while LMWH led to lower DVT risks vs. vitamin K antagonists, researchers noted vitamin K antagonists had less major bleeding. Compared with LMWH, results showed a lower risk of various venous thromboembolic outcomes with factor Xa inhibitor; however, LMWH had less major bleeding and more study-defined serious adverse events. A higher-dose direct thrombin inhibitor led to lower rates of DVT, but more major bleeding; while a lower risk of various VTE outcomes was found with a higher-dose factor Xa inhibitor.

Researchers also found a lower DVT risk with LMWH used in hip fracture surgery vs. factor Xa inhibitor. Researchers either had insufficient evidence to assess both benefits and harms or inconsistent findings for hip fracture surgery and other intervention comparisons. – by Casey Tingle

Reference:

Balk EM, et al. Venous thromboembolism prophylaxis in major orthopedic surgery: Systematic review update. Available at: www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2480. Accessed: June 28, 2017.