Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing
Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty.
A total of 258 patients undergoing elective total hip or knee arthroplasty within one NHS Trust were included. A total of 202 subjects (mean age, 70.7 years ± 10.0, 43 % men) received a daily dose of 10 mg of oral rivaroxaban and 56 (mean age, 70.9 years ± 9.8, 39 % men) had a daily subcutaneous injection of 40 mg of enoxaparin as thromboprophylaxis. Endpoints included VTE (deep vein thrombosis and pulmonary embolism), haemorrhagic wound complications, hospital re-admission, requirement for blood transfusion, minor and major bleeding and death.
There were no significant differences in the incidence of VTE, requirement for blood transfusion and readmission rate between rivaroxaban and enoxaparin-treated patients. The incidence of minor bleeding (2.0 vs. 0 %) and haemorrhagic wound complications (5.0 vs. 1.8 %) were non-significantly higher in the rivaroxaban-treated group. There were no cases of pulmonary embolism, major bleeding or death in either group.
Our experience with rivaroxaban in elective hip and knee arthroplasty showed no significant difference in the incidence of VTE or major bleeding. There was, however, a tendency to greater risk of minor bleeding and wound complications that were largely haemorrhagic in nature, which may have reached significance in a larger study.
KeywordsRivaroxaban Enoxaparin Thromboprophylaxis Thromboembolism Wound healing
- 3.Cardiovascular Disease Educational and Research Trust, Cyprus Cardiovascular Disease Educational and Research Trust, European Venous Forum, International Surgical Thrombosis Forum, International Union of Angiology, Union Internationale de Phlébologie (2006) Prevention and treatment of venous thromboembolism. International consensus statement (guidelines according to scientific evidence). Int Angiol 25:101–161Google Scholar
- 5.Eriksson BI, Borris LC, Friedman RJ, Haas S, Huisman MV, Kakkar AK, et al (2008) Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 358(26):2765–2775Google Scholar
- 6.Kakkar AK, Brenner B, Dahl OE, Eriksson BI, Mouret P, Muntz J et al (2008) Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. The Lancet. Elsevier 372(9632):31–39CrossRefGoogle Scholar
- 7.Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, et al (2008) Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N. Engl. J. Med 358(26):2776–2786Google Scholar
- 8.Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, et al (2009) Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial. The Lancet 373(9676):1673–1680Google Scholar
- 11.Jensen C, Steval A, Partington P, Reed M, Muller S (2011) Return to theatre following total hip and knee replacement, before and after the introduction of rivaroxaban: a retrospective cohort study. J Bone Joint Surg Br 93(1):91Google Scholar
- 12.Lotke PA (2008) Rivaroxaban for thromboprophylaxis. N Engl J Med 359(20):2174; author reply 2175–3176Google Scholar
- 18.McCullagh L, Tilson L, Walsh C, Barry M (2009) A cost-effectiveness model comparing rivaroxaban and dabigatran etexilate with enoxaparin sodium as thromboprophylaxis after total hip and total knee replacement in the Irish healthcare setting. Pharmacoeconomics 27(10):829–846PubMedCrossRefGoogle Scholar
- 19.Turpie A, Jamal W, Schmidt A, Lassen M, Mantovani L, Kreutz R, et al (2011) XAMOS: a non-interventional study of rivaroxaban in the prophylaxis of venous thromboembolism after hip or knee surgery. J Thromb Haemost 9(Suppl 2):961Google Scholar