Key result
Direct factor Xa inhibitors significantly reduced the rates of deep vein thrombosis compared to conventional VTE prophylaxis after nonelective lower limb fracture surgery (OR 0.59; 95% CI 0.46-0.76; P<0.0001).
Why the study?
DOACs are well-established for thromboprophylaxis after major elective orthopaedic surgery, but their effectiveness and safety in the nonelective setting after lower limb fracture surgery remained unclear.
Do direct oral anticoagulants reduce venous thromboembolism and adverse events compared to conventional thromboprophylaxis in patients undergoing nonelective lower limb fracture surgery?
Meta-Analysis
Do direct oral anticoagulants reduce venous thromboembolism and adverse events compared to conventional thromboprophylaxis in patients undergoing nonelective lower limb fracture surgery?
Odds Ratio: 0.59 (95% CI 0.46–0.76)
p-value: p=< 0.0001
Direct oral anticoagulants, particularly factor Xa inhibitors, appear effective and safe for VTE prophylaxis following nonelective lower limb fracture surgery, reducing DVT without increasing bleeding.
Supports preferential use of factor Xa inhibitors for VTE prophylaxis after nonelective lower limb fracture surgery; extends Level 1 evidence to this population.
OBJECTIVES: Venous thromboembolism (VTE) is a well-established complication after many orthopaedic injuries, such as hip and lower limb fractures. The use of direct oral anticoagulants (DOACs, previously termed novel oral anticoagulants) is well-established as thromboprophylaxis after major elective orthopaedic surgery, but not in the nonelective setting. The aim of this study was to investigate the effectiveness and safety of DOACs after nonelective lower limb fracture surgery. DATA SOURCES: A systematic literature search of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases was conducted. No limitation was placed on publication date, with only manuscripts printed in English were eligible. STUDY SELECTION: Included studies were either randomized controlled trials or prospective and retrospective comparative studies. Included studies compared DOACs to conventional methods of thromboprophylaxis in the postoperative period after surgical management of lower limb fractures. DATA EXTRACTION: Outcomes included VTE, bleeding, wound complications, mortality, and adverse events. Eight studies met inclusion criteria, of which 7 compared direct factor Xa inhibitors (XaIs) with conventional VTE prophylaxis and one study compared a direct thrombin inhibitor with conventional VTE prophylaxis. DATA SYNTHESIS: Revman 5.3 (Nordic Cochrane Centre, Denmark) was used to complete the meta-analysis and generate forest plots. CONCLUSIONS: XaIs were shown to have lower rates of deep vein thrombosis (Odds ratio 0.59; 95% confidence interval, 0.46-0.76; P < 0.0001) and less pharmacologically attributable adverse events (Odds ratio 0.62; 95% confidence interval, 0.46-0.82; P = 0.0007). There was difference between DOACs and conventional VTE prophylaxis regarding mortality, PE, symptomatic deep vein thrombosis, or bleeding events. The results generally support the use of DOACs for VTE prophylaxis after nonelective lower limb fracture surgery, such after hip fracture. The results more strongly support the use of XaIs; however, more evidence is needed to fully assess DOACs' role in clinical practice. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Wæver et al. (2020) conducted a meta-analysis in Nonelective lower limb fracture surgery. Direct factor Xa inhibitors (XaIs) vs. Conventional methods of thromboprophylaxis was evaluated on Deep vein thrombosis (OR 0.59, 95% CI 0.46-0.76, p=< 0.0001). Direct factor Xa inhibitors significantly reduced the rates of deep vein thrombosis compared to conventional VTE prophylaxis after nonelective lower limb fracture surgery (OR 0.59; 95% CI 0.46-0.76; P<0.0001).
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