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Thromb Haemost 1998; 79(05): 902-906
DOI: 10.1055/s-0037-1615090
Review Article
Schattauer GmbH

Low Molecular Weight Heparin Decreases Proximal and Distal Deep Venous Thrombosis Following Total Knee Arthroplasty

A Meta-analysis of Randomized Trials
Andrew W. Howard
1   From the Division of Orthopaedics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
,
Shawn D. Aaron
2   From the Division of Respiratory Medicine, Ottawa General Hospital, Ottawa, Ontario, Canada
› Author Affiliations
Further Information

Publication History

Received 28 October 1997

Accepted after revision 14 January 1998

Publication Date:
07 December 2017 (online)

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Summary

Objectives: To assess the efficacy and safety of low molecular weight heparin (LMWH) as deep venous thrombosis (DVT) prophylaxis following total knee arthroplasty. Data sources: Medline 1986 to June 1997, Embase, and manufacturers were used to identify randomized controlled trials. Review methods: Trials included were randomized studies of LMWH with routine radiological screening for DVT. Placebo or active controls were included. Two reviewers independently screened trials for inclusion, and assessed their quality. Pooled relative risk estimates of DVT and proximal DVT rates were calculated using a DerSimonian and Laird random effects model. Sensitivity of the results to the type of control used and the quality of the trial was assessed. Results: The relative risk of DVT for a patient given LMWH is 0.73 (95% CI 0.66 to 0.80) when compared with patients treated with adjusted dose heparin or warfarin controls. The relative risk for proximal DVT is 0.58 (95% CI 0.38 to 0.90). The relative risk of pulmonary emboli in the LMWH group was 0.55 (95% C.I. 0.20 to 1.57). No excess of bleeding was recorded in the LMWH group. Conclusions: Low molecular weight heparin is more efficacious than either adjusted dose heparin or adjusted dose warfarin, when used to prevent DVT and proximal DVT following total knee arthroplasty.

 

  • References

  • 1 National Centre for Health Statistics.. Vital and Health Statistics. 1997 13 (127)
    PubMedSearch in Google Scholar
  • 2 Naylor CD, DeBoer DP, Goel V, Williams JI, Anderson GM, Blackstein-Hirsch P, Fooks C, Naylor CD. eds. 4 Patterns of Health Care in Ontario. The ICES Practice Atlas. 2nd ed. Ottawa: Canadian Medical Association; 1996: 5 Total Hip and Knee Replacement, Variations is Selected Surgical Procedures and Medical Diagnoses by Year and Region. pp. 54-63.
    Search in Google Scholar
  • 3 Lieberman JR, Geerts WH. Prevention of venous thromboembolism after total hip and knee arthroplasty. [Review]. J Bone Joint Surg Am 1994; 76 A (8) 1239-50.
    CrossrefPubMedSearch in Google Scholar
  • 4 Hull R, Raskob G, Pineo G, Rosenbloom D, Evans W, Mallory T, Anquist K, Smith F, Hughes G. et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation [see comments]. N Engl J Med 1993; 329 (19) 1370-6.
    CrossrefPubMedSearch in Google Scholar
  • 5 Hull R, Delmore TJ, Hirsh J, Gent M, Armstrong P, Lofthouse R. Effectiveness of Intermittent Pulsatile Elastic Stockings for the Prevention of Calf and Thigh Vein Thrombosis in Patients Undergoing Elective Knee Surgery. Thromb Res 1979; 16: 37-45.
    CrossrefPubMedSearch in Google Scholar
  • 6 McKenna R, Galante J, Bachmann F, Wallace DL, Kaushal SP, Meredith P. Prevention of Venous Thromboembolism after Total Knee Replacement by High-dose Aspirin or Intermittent Calf and Thigh Compression. BMJ 1980; 280: 514-7.
    CrossrefPubMedSearch in Google Scholar
  • 7 Francis CW, Pelligrini VD, Stulberg BN, Miller ML, Totterman S, Marder VJ. Prevention of Venous Thrombosis after Total Knee Arthroplasty. Comparison of Antithrombin III and Low-dose Heparin with Dextran. J Bone Joint Surg Am 1990; 72-A: 976-82.
    PubMedSearch in Google Scholar
  • 8 Hodge WA. Prevention of Deep Venous Thrombosis after Total Knee Arthroplasty. Coumadin versus Pneumatic Compression. Clin Orthop 1991; 271: 101-5.
    PubMedSearch in Google Scholar
  • 9 Leclerc JR, Geerts WH, Desjardins L, Jobin F, Laroche F, Delorme F, Haviernick S, Atkinson S, Bourgouin J. Prevention of deep vein thrombosis after major knee surgery–a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost 1992; 67 (04) 417-23.
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, McQuay HJ. Assessing the Quality of Reports of Randomized Clinical Trials: Is Blinding Necessary?. Controlled Clinical Trials 1996; 17: 1-12.
    CrossrefPubMedSearch in Google Scholar
  • 11 Kramer MS, Feinstein AR, Clinical Biostatistics LIV. The Biostatistics of Concordance. Clinical Pharmacological Therapy 1981; 29 (01) 111-23.
    CrossrefPubMedSearch in Google Scholar
  • 12 Berlin JA, Laird NM, Sacks HS, Chalmers TC. A Comparison of Statistical Methods for Combining Event Rates from Clinical Trials. Statistics in Medicine 1989; 8: 141-51.
    CrossrefPubMedSearch in Google Scholar
  • 13 Orwin RG. A Fail-Safe N for Effect Size in Meta-Analysis. Journal of Educational Statistics 1983; 8 (02) 157-9.
    PubMedSearch in Google Scholar
  • 14 Barsotti J, Rosset P, Planes A, Marchal C, Robert C, Bertrand P. Prophylaxie de la maladie thromboembolique par les heparines de bas poids moleculaire en orthopedie et traumatologie. Annales Françaises d’Anesthesie et de Reanimation 1992; 11: 318-24.
    PubMedSearch in Google Scholar
  • 15 Hamulyak K, Lensing AW, van der Meer J, Smid WM, van Ooy A, Hoek JA. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement? Fraxiparine Oral Anticoagulant Study Group. Thromb Haemost 1995; 74 (06) 1428-31.
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Levine MN, Gent M, Hirsh J, Weitz J, Turpie AG, Powers P, Neemeh J, Willan A, Skingley P. Ardeparin (low-molecular-weight heparin) vs graduated compression stockings for the prevention of venous thromboembolism. A randomized trial in patients undergoing knee surgery. Arch Internal Med 1996; 156 (08) 851-6.
    CrossrefPubMedSearch in Google Scholar
  • 17 Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, L’Esperance B, Demers C, Kassis J, Cruickshank M, Whitman L, Delorme F. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Annals Internal Med 1996; 124 (07) 619-26.
    PubMedSearch in Google Scholar
  • 18 Colwell Jr. CW, Spiro TE, Trowbridge AA, Stephens JW, Gardiner Jr. GA, Ritter MA. Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Enoxaparin Clinical Trial Group. Clin Orthop 1995; 321: 19-27.
    PubMedSearch in Google Scholar
  • 19 Fitzgerald Jr. RH. Preventing DVT following total knee replacement: a review of recent clinical trials. Orthopedics 1995; 18 (Suppl): 10-1.
    PubMedSearch in Google Scholar
  • 20 Fauno P, Suomalainen O, Rehnberg V, Hansen TB, Kroner K, Soimakallio S, Nielsen E. Prophylaxis for the prevention of venous thromboembolism after total knee arthroplasty. A comparison between unfractionated and low-molecular-weight heparin. J Bone Joint Surg Am 1994; 76 A (12) 1814-8.
    CrossrefPubMedSearch in Google Scholar
  • 21 RD Heparin Arthroplasty Group.. RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. RD Heparin Arthroplasty Group. J Bone Joint Surg Am 1994; 76 A (8) 1174-85.
    CrossrefPubMedSearch in Google Scholar
  • 22 Heit JA, Berkowitz SD, Bona R, Cabanas V, Corson JD, Elliott CG, Lyons R. Efficacy and Safety of Low Molecular Weight Heparin (Ardeparin Sodium) Compared to Warfarin for the Prevention of Venous Thromboembolism after Total Knee Replacement Surgery: A Double-blind, Dose-ranging Study. Thromb Haemost 1997; 77 (01) 32-8.
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Anderson DR, O’Brien BJ, Levine MN, Roberts R, Wells PS, Hirsh J. Efficacy and Cost of Low Molecular Weight Heparin Compared with Standard Heparin for the Prevention of Deep Vein Thrombosis after Total Hip Arthroplasty. Annals Internal Med 1993; 119: 1105-12.
    PubMedSearch in Google Scholar
  • 24 Eriksson BI, Wille-Jorgensen P, Kalebo P, Mouret P, Rosencher N, Bosch P, Baur M, Ekman S, Bach D, Lindbratt S. et al. A Comparison of Recombinant Hirudin with a Low-Molecular-Weight-Heparin to Prevent Thromboembolic Complications after Total Hip Replacement. N Engl J Med 1997; 337 (19) 1329-35.
    CrossrefPubMedSearch in Google Scholar
  • 25 Eriksson BI, Ekman S, Lindbratt S, Baur M, Bach D, Torholm C, Kalebo P, Close P. Prevention of Thromboembolism with the use of Recombinant Hirudin. Results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement. J Bone Joint Surg A 1997; 79-A 3: 326-33.
    PubMedSearch in Google Scholar