Multifactorial Risk Assessment and Anticoagulation Strategy Optimization for Deep Vein Thrombosis After Major Joint Surgery: A Retrospective Study

Summary

This multicenter retrospective cohort study compares rivaroxaban and low molecular weight heparin for deep vein thrombosis (DVT) prevention after total hip arthroplasty and total knee arthroplasty. Rivaroxaban reduced DVT risk but increased bleeding, underscoring the importance of individualized prophylaxis and patient-specific decision-making.

Abstract

Deep vein thrombosis (DVT) is a major concern following total hip arthroplasty (THA) and total knee arthroplasty (TKA), with prophylactic anticoagulation being the cornerstone of postoperative care. This multicenter retrospective cohort study evaluated the relative effectiveness and safety of rivaroxaban and low molecular weight heparin (LMWH) in DVT prevention after joint replacement surgery. It also aimed to identify patient-related risk factors for thrombotic and hemorrhagic events. It was hypothesized that rivaroxaban would reduce DVT incidence compared with LMWH but may increase bleeding risk, and that patient-specific factors would influence these outcomes. The study included 32,512 patients undergoing elective TKA or THA. Categorization of patients was based on the postoperative anticoagulation strategy, and propensity scores were used to match them using nearest-neighbor propensity score matching based on baseline covariates, including age, sex, body mass index, smoking status, comorbidities (e.g., diabetes, prior venous thromboembolism [VTE]), American Society of Anesthesiologists (ASA) class, and type of surgery (THA/TKA). All patients underwent standardized duplex ultrasonography to detect DVT. Results showed that rivaroxaban was less likely to be associated with DVT at 30 days than LMWH (2.3% vs. 3.6%) with an adjusted odds ratio of 0.62 (p < 0.001). These values represent the cumulative incidence of DVT within 30 days postoperatively. However, rivaroxaban use was associated with a higher incidence of major bleeding (1.48% vs. 1.08%) and a postoperative hemoglobin drop. No significant differences were observed in 30-day pulmonary embolism (PE), readmissions, or mortality between the two groups. Subgroup analysis demonstrated benefit across key patient groups, including obese, elderly, diabetic, and TKA patients. Multivariable modeling established that pre-existing VTE, obesity, and age above 75 years were predictors of DVT, whereas baseline anemia and rivaroxaban use were independent predictors of major bleeding. These findings highlight the need for individualized prophylaxis strategies that balance thrombotic and hemorrhagic risks in patients undergoing major joint arthroplasty.

Introduction

Deep vein thrombosis (DVT) remains one of the most important postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Together with pulmonary embolism (PE), it contributes significantly to postoperative morbidity, mortality, and healthcare utilization. Patients undergoing lower‑limb joint arthroplasty are particularly vulnerable to venous thromboembolism (VTE) due to venous stasis, endothelial injury, and postoperative hypercoagulability. Despite modern prophylaxis, symptomatic VTE occurs in approximately 0.6–1.5% of patients within 30 days postoperatively¹. Given the high procedural volu....

Protocol

This study was conducted using de-identified, routinely collected clinical data. In accordance with institutional policies and national regulations, formal ethical approval and informed consent were waived as no identifiable patient information was used and no intervention was performed. The study adhered to the principles of the Declaration of Helsinki.

Study design

This multicenter retrospective cohort study was conducted using data from institutional joint replacement registries and electronic health records across several high-volume orthopedic centers. The study utilized prospectively collect....

Results

Patient cohort and baseline characteristics

A total of 38,745 patients were screened across participating centers. Of these, 6,233 patients were excluded due to preoperative anticoagulation, known coagulopathy, trauma-related arthroplasty, revision surgery, or incomplete data. This resulted in a final cohort of 32,512 patients included in the comparative propensity score–adjusted analysis. The patient selection process is illustrated in Figure 2.<.......

Discussion

This cohort study evaluated the comparative effectiveness and safety of rivaroxaban versus LMWH for VTE prophylaxis following total hip and knee arthroplasty, providing clinically relevant real-world evidence that complements and extends findings from controlled trials by incorporating patient-level heterogeneity and risk stratification. This study’s findings demonstrate a significantly lower 30-day incidence of DVT with rivaroxaban compared with LMWH, consistent with prior randomized and observational studies. It .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automated Hematology Analyzer	Sysmex Corporation	XN-Series	Hemoglobin and hematocrit monitoring pre- and postoperatively (POD 1, 3, 5).
CT Pulmonary Angiography Systems	Siemens Healthineers AG	SOMATOM Force	Confirmatory imaging for symptomatic PE events.
D-Dimer ELISA Kit	BioMedica Diagnostics Inc.	BI-20752	Plasma D-dimer measured on POD 1, 3, 5; used for trend analysis and thrombotic risk assessment.
Duplex Ultrasonography Machines	GE HealthCare Technologies Inc.	LOGIQ E9	Used for standardized DVT screening between POD 7–10, regardless of symptoms.
Electronic Medical Record System	Epic Systems Corporation	N/A	Data extracted retrospectively using standard templates from EMRs and joint registries.
Enoxaparin (LMWH)	Sanofi S.A.	Institutional Protocols	Subcutaneous injection; 30 mg BID or 40 mg OD depending on site protocol.
Rivaroxaban (10 mg tablets)	Bayer Aktiengesellschaft (Bayer AG)	NDC 50419-576-01	Oral factor Xa inhibitor; administered once daily postoperatively (14 days for TKA, 35 days for THA).
SPSS Statistical Software	International Business Machines Corporation (IBM)	Version 27	Used for all statistical analyses including logistic regression, PSM, and survival curves.
Tranexamic Acid (TXA)	Pfizer Inc.	NDC 0143-9684-01	Used intraoperatively via IV or topical route to reduce bleeding.