Health Education England-North West, Manchester, United Kingdom.
Blackpool Teaching Hospital NHS Trust, Blackpool, Lancashire, United Kingdom.
JBJS Rev. 2020 Dec 18;8(12):e20.00021. doi: 10.2106/JBJS.RVW.20.00021.
Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty.
A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups.
Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023).
These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
关节置换术后感染可能对患者造成毁灭性影响，并需要进一步手术。静脉血栓栓塞症（VTE）的预防是必要的，以尽量降低深静脉血栓和肺栓塞的风险。抗凝治疗已被证明会干扰伤口愈合并增加感染的风险。我们假设不同的抗凝方案会对假体周围关节感染的发生率产生不同的影响。本研究旨在比较华法林、低分子肝素（LMWH）和阿司匹林在全膝关节或髋关节置换术后预防 VTE 中的应用对手术部位感染风险的影响。
2018 年 11 月，我们使用 PubMed、CINAHL 和 Cochrane 中心对照试验注册库（CENTRAL）数据库进行了系统文献检索，以确定比较华法林、LMWH 和/或阿司匹林在髋关节或膝关节置换术后手术部位感染发生率方面的研究。进行了荟萃分析以比较组间感染和 VTE 风险。
纳入了 9 项涉及 184037 名患者的研究。荟萃分析显示，华法林预防与深感染（或需要再次手术的感染）（比值比[OR] = 1.929，95%置信区间[CI] = 1.197 至 3.109，p = 0.007）和手术部位总体感染（OR = 1.610，95%CI = 1.028 至 2.522，p = 0.038）的风险更高相比，阿司匹林在原发性全关节置换术中，当将原发性和修订手术结合在一起时，也发现了类似的结果。华法林与 LMWH 之间以及 LMWH 与阿司匹林之间的感染风险无显著差异。与阿司匹林治疗相比，华法林在原发性手术中 VTE 风险有升高的趋势（OR = 1.600，95%CI = 0.875 至 2.926，p = 0.127），当包括原发性和修订病例时，这一点具有统计学意义（OR = 2.674，95%CI = 1.143 至 6.255，p = 0.023）。
这些发现提醒人们不要将华法林用于髋关节和膝关节置换术的 VTE 预防。需要进一步进行随机对照头对头试验和机制研究，以确定特定抗凝剂如何影响感染风险。
治疗性 III 级。请参阅作者说明以获取完整的证据水平描述。
