Thromboprophylactic Efficacy and Safety of Anticoagulants After Arthroscopic Knee Surgery: A Systematic Review and Meta-Analysis

Abstract

To examine the efficacy and safety of anticoagulants after knee arthroscopy (KA), PubMed, EMBASE, databases of Cochrane Central Register of Controlled Trials, and Chinese National Knowledge Infrastructure were searched up to August 2019 for randomized controlled trials (RCT). Seven RCTs including 4097 patients were demonstrated eligible according to the inclusion and exclusion criteria. The efficacy and safety of thromboprophylaxis were assessed and expressed using relative risk (RR) and 95% confidence intervals (95% CIs). The analysis of pooled data showed that anticoagulants group exhibited significant lower overall incidence of symptomatic and asymptomatic venous thromboembolism (VTE; RR = 0.35, 95% CIs: 0.22-0.55, P < .00001), significant higher incidence of all bleeding events (RR = 1.42, 95% CIs: 1.08-1.86, P = .01) compared to control group. However, no significant difference was found in terms of incidence of symptomatic VTE (RR = 0.43, 95% CIs: 0.15-1.21, P = .11) and incidence of major bleeding events (RR = 1.87, 95% CIs: 0.40-8.67, P = .42). The pooled number needed to treat to prevent one symptomatic or asymptomatic VTE was 26, while the pooled number needed to harm to cause one major bleeding event was 869. These results show that anticoagulants can effectively reduce the overall risk of VTE after KA; however, the increased risk of bleeding should be fully considered. Further studies are required to address the risk–benefit calculus and cost-effectiveness of anticoagulants after KA.

Recommendations from the ICM-VTE: Sports

“…Overall, there is a paucity of research on the optimal VTE prophylaxis regime for patients undergoing non-weight-bearing KA procedures, and thus the current recommendations are based on expert consensus on general KA literature. Due to the significantly increased incidence of DVT in non-weight-bearing patients (3.0% vs. 0.7%), the NNT and NNH can be assumed to be much smaller for non-weight-bearing patients relative to data on overall KA (NNT = 26, NNH = 869) 64 . Until further evidence is available, clinicians should consider utilizing LMWH, rivaroxaban or ASA after non-weight-bearing KA procedures such as autologous chondrocyte implantation (ACI), OATS, microfracture, or meniscal repair in order to limit the thrombotic risk associated with prolonged non-weight-bearing.…”

“…In evaluating the efficacy and safety of anticoagulants after KA, Yu et al 41 , performed another systematic review and meta-analysis, which included 4,097 patients. They concluded that anticoagulants could effectively reduce the overall risk of VTE after KA, although the increased risk of bleeding should be considered.…”

“…This question still remains valid when encountering patients with procoagulant comorbidities, or those who are taking oral contraceptives (e.g., younger patients undergoing anterior cruciate ligament reconstruction). More research is needed to clarify if routine prophylaxis should be indicated in this group of individuals 38,41 , and prophylactic measures should be individualized, taking into account all the risk factors present at the time of the surgical intervention.…”

“…A recent Cochrane Systematic Review and four separate meta-analyses concluded that the incidence of PE and symptomatic DVT following KA was not reduced with the use of low-molecularweight heparin (LMWH), aspirin (ASA) or rivaroxaban (moderate-to low-evidence) 43,[60][61][62][63] . On the other hand, LMWH use may reduce the risk of asymptomatic DVT when compared to no treatment, and a meta-analysis of randomized controlled trials (RCT) concluded that anticoagulants could reduce the overall incidence of VTE in patients undergoing KA 42,43,47,[64][65][66][67][68] . The authors estimated that, in order to prevent one symptomatic or asymptomatic VTE, the Number Needed to Treat (NNT) was 26, and one major or fatal bleeding event could occur with every 869 patients treated with VTE prophylaxis (Number Needed to Harm [NNH] = 869) 64 .…”

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost

“…12 Cost-effectiveness has been called into question within the ongoing debate regarding the utility of VTE chemoprophylaxis after knee arthroscopy. 26 Knowledge remains extremely limited on the cost-effectiveness of aspirin or LMWH chemoprophylaxis after knee arthroscopy. Therefore, this study aimed to examine the cost-effectiveness of using aspirin and LMWH to prevent VTE after knee arthroscopy.…”