Meta-analysis of low molecular weight heparin versus placebo in patients undergoing total hip replacement and post-operative morbidity and mortality since their introduction.
OBJECTIVE
1) To establish the clinical validity for in-patient low molecular weight heparin (LMWH) following total hip replacement (THR) through a meta-analysis of peer reviewed and published randomised placebo controlled trials (RCTs). 2) To establish whether modern peri-operative practices were associated with changes in rates of clinical venous thromboembolic (VTE) and all-cause mortality after THR by review of series of patients receiving in-patient LMWH published between 1985 and 2000. DATASOURCES: Medline and Embase (from 1980 to 2005), Datastar and Proquest databases were searched and references from bibliographies traced.


METHODS
Studies of adult patients receiving in-patient LMWH following elective primary or revision THR were sought and data abstracted. The first part of our analysis included only randomised placebo controlled trials. For the second part, randomised control trials were included and divided by their year of completion into three groups.


RESULTS
We found no difference between LMWH and placebo in the risk of fatal pulmonary embolism (PE), other deaths, all cause mortality or major bleeding. LMWH reduced non-fatal PE (OR=0.14, 95%CI 0.03 to 0.74, p=0.029) at the expense of haematoma formation (7/147 vs 0/149, p=0.015). 35 studies were included in the second part of our analysis. Point estimates of rates of fatal and non-fatal pulmonary embolism and other deaths suggest a decline over time but fell short of statistical significance.


CONCLUSIONS
Clinically relevant VTEs are a rare complication following THR. The lower risk of VTE narrows the risk benefit of potent pharmacological thromboprophylaxis. We do not support their use in patients undergoing THR without additional thromboembolic risk factors.
Tasker
Andrew
A
Department of Orthopaedics, Avon Orthopaedic Centre, Bristol, UK.
Harbord
Roger
R
Bannister
Gordon C
GC
D000925:Anticoagulants / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D006801:Humans; D010919:Placebos / Q000627:therapeutic use; D054556:Venous Thromboembolism / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D010919:Placebos