Which Prophylaxis Strategy Is Best to Prevent DVT Following Knee Replacement?

Following elective total knee replacement, rivaroxaban monotherapy is the most effective therapy for the prevention of deep-vein thrombosis (DVT), according to the results of a recent meta-analysis.

Because hospital-associated venous thromboembolism is a major patient concern, providing prophylaxis to patients undergoing total knee replacement surgery has been proposed. The authors of a recent study sought to assess the various available prophylaxis strategies available to these patients.

They conducted a systematic review and Bayesian network meta-analysis of data from randomized controlled trials without outcomes including DVT, pulmonary embolism, and major bleeding. Overall, 25 randomized controlled trials were included, involving patients aged 16 years or older undergoing elective knee replacement, with prophylaxis including medications, mechanical interventions, and combinations of both.

They found that rivaroxaban ranked first for the prevention of DVT (relative risk [RR] 0.12), low molecular weight heparin (LMWH; standard prophylactic dose, 28–35 days) ranked first for the prevention of pulmonary embolism (RR 0.02), and LMWH (low prophylactic dose, 10–14 days) ranked first for the prevention of major bleeding (odds ratio 0.08). However, “the results for pulmonary embolism and major bleeding are highly uncertain,” the researchers wrote.

“Single prophylaxis strategies are more effective in prevention of deep vein thrombosis in the elective total knee replacement population than combination strategies, with rivaroxaban being the most effective. The results of the pulmonary embolism and major bleeding meta-analyses are uncertain and no clear conclusion can be made other than what is biologically plausible (eg, that no prophylaxis and mechanical prophylaxis strategies should have the lowest risk of major bleeding),” they concluded.

—Michael Potts


Lewis S, Glen J, Dawoud D, et al. Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis [published online August 20, 2019]. Lancet Hematol. DOI: