Suen Kary, Westh Roger N, Churilov Leonid, Hardidge Andrew J
Department of Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia.
Department of Statistics and Decision Support, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia.
J Arthroplasty. 2017 Sep;32(9):2911-2919.e6. doi: 10.1016/j.arth.2017.04.010. Epub 2017 Apr 14.
Venous thromboembolism causes significant morbidity and mortality in patients after total joint arthroplasty. Although network meta-analyses have demonstrated a benefit of various thromboprophylactic agents, there remains a concern in the surgical community regarding the resulting wound complications. There is currently no systematic review of the surgical site bleeding complications of thromboprophylactic agents. The aim of this study was to systematically review the surgical site bleeding outcomes of venous thromboembolism prophylaxis in this population.
A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials comparing more than one of low-molecular-weight heparin (LMWH), warfarin, rivaroxaban, apixaban, dabigatran, aspirin, or no pharmacologic treatment in patients after total hip or knee arthroplasty were selected for inclusion. Five meta-analyses were performed to compare LMWH with control, warfarin, apixaban, rivaroxaban, and dabigatran.
Forty-five randomized controlled trials of 56,730 patients were included. LMWH had a significantly increased relative risk of surgical site bleeding in comparison with control (relative risk, 2.32; 95% confidence interval, 1.40-3.85) and warfarin (1.54; 1.23-1.94). The relative risk of LMWH trended higher than apixaban (1.27; 1.00-1.63) and was similar to rivaroxaban (0.95; 0.74-1.23). Only 1 study reported the risk of surgical site bleeding in LMWH vs dabigatran (5.97; 2.08-17.11).
LMWH increased the risk of surgical site bleeding compared with control, warfarin. and dabigatran and trended toward an increased risk compared with apixaban. The risk of surgical site bleeding was similar with LMWH and rivaroxaban.
静脉血栓栓塞在全关节置换术后患者中会导致显著的发病率和死亡率。尽管网状Meta分析已证明各种血栓预防药物有一定益处，但手术界仍对由此产生的伤口并发症存在担忧。目前尚无关于血栓预防药物手术部位出血并发症的系统评价。本研究的目的是系统评价该人群中静脉血栓栓塞预防的手术部位出血结局。
按照系统评价和Meta分析的首选报告项目指南进行系统评价和Meta分析。纳入比较全髋关节或膝关节置换术后患者使用低分子肝素（LMWH）、华法林、利伐沙班、阿哌沙班、达比加群、阿司匹林中的一种以上药物或不进行药物治疗的随机对照试验。进行了五项Meta分析，以比较LMWH与对照组、华法林、阿哌沙班、利伐沙班和达比加群。
纳入了45项针对56730例患者的随机对照试验。与对照组（相对风险，2.32；95%置信区间，1.40 - 3.85）和华法林（1.54；1.23 - 1.94）相比，LMWH手术部位出血的相对风险显著增加。LMWH的相对风险高于阿哌沙班（1.27；1.00 - 1.63）且呈上升趋势，与利伐沙班相似（0.95；0.74 - 1.23）。仅有1项研究报告了LMWH与达比加群相比手术部位出血的风险（5.97；2.08 - 17.11）。
与对照组、华法林和达比加群相比，LMWH增加了手术部位出血的风险，与阿哌沙班相比风险呈上升趋势。LMWH和利伐沙班的手术部位出血风险相似。
