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

Area of Science:

• Orthopedic Surgery
• Pharmacology
• Evidence-Based Medicine

Background:

• Venous thromboembolism (VTE) is a significant complication following total knee arthroplasty (TKA).
• The choice of pharmacological prophylaxis to prevent VTE after TKA is a subject of ongoing debate.
• Several non-vitamin K antagonist oral anticoagulants (NOACs) are commonly used for VTE prophylaxis post-TKA.

Purpose of the Study:

• To compare the efficacy and safety of various NOACs for VTE prophylaxis after TKA.
• To evaluate the rates of deep venous thrombosis (DVT), pulmonary embolism (PE), and major/minor hemorrhages.
• To identify the optimal anticoagulant agent balancing VTE prevention and bleeding risk.

Main Methods:

• A Bayesian network meta-analysis was conducted, adhering to PRISMA guidelines.
• Searches of PubMed, Web of Science, and Google Scholar were performed in March 2024.
• Included randomized controlled trials (RCTs) comparing two or more drugs for VTE prevention post-TKA.

Main Results:

• Data from 29,678 patients (67% women, mean age 66.8 years, mean BMI 29.2 kg/m²) were analyzed.
• Apixaban 5 mg, dabigatran 220 mg, and rivaroxaban 10 mg showed the highest efficacy in reducing DVT.
• Apixaban 5 mg, enoxaparin 60 mg, and rivaroxaban 40 mg were most effective for PE reduction.
• Apixaban (5 mg and 10 mg) and rivaroxaban 10 mg were associated with the lowest rates of major hemorrhage.
• Apixaban (5 mg and 20 mg) and dabigatran 220 mg showed the lowest rates of minor hemorrhage.

Conclusions:

• Apixaban 5 mg demonstrated a superior balance between VTE prevention and hemorrhage control post-TKA.
• This finding supports apixaban 5 mg as a preferred agent for pharmacological prophylaxis in TKA patients.
• The study provides valuable evidence for optimizing anticoagulant selection in orthopedic surgery.