Wound complications and bleeding with new oral anticoagulants in patients undergoing total joint arthroplasty: A systematic review and meta-analysis of randomized controlled trials

Aims The results of associations between new oral anticoagulants (NOACs) and wound complications after total joint arthroplasty remain inconsistent. We conducted a systematic review and meta-analysis of randomized controlled trials to make comparisons with low molecular weight heparins (LMWH) on the clinical outcomes of total wound complications, together with other efficacy and safety endpoints to further evaluate the safety and efficacy of NOACs. Methods This meta-analysis was conducted based on a published protocol (PROSPERO: CRD42019140841). We searched for available articles in PubMed, Embase, and Cochrane Library through Jun 6 2021. Random-effects meta-analyses, including subgroup analyses, were conducted to estimate the pooled relative risk (RR) and 95% confidence interval (CI) for specific doses of NOACs. Results We retrieved 1683 studies, of which 20 studies were eligible for inclusion. We found that apixaban was associated with a lower incidence of total wound complications compared with LMWH (RR=0.81; 95% CI: 0.65-1.00), while dabigatran and rivaroxaban did not increase the risk of total wound complications. In addition, apixaban was associated with a reduction in the risk of major/clinically relevant non-major (CRNM) bleeding events compared to LMWH (RR=0.80, 95% CI: 0.65-0.99), while rivaroxaban increased the risk for major/CRNM bleeding events (RR=1.23, 95% CI: 1.02-1.50). Moreover, all of four new oral anticoagulants were associated with lower incidences of major venous thromboembolism compared with LMWH. Conclusion A lower risk of wound complications was detected for apixaban, while dabigatran and rivaroxaban did not increase the risk when compared with LMWH. The efficacy of four NOACs was broadly similar.