Rivaroxaban Utilization Without Perioperative Tranexamic Acid Is Associated With an Increased Risk of Bleeding Complications Following Total Joint Arthroplasty.

Abstract

Rivaroxaban provides effective venous thromboembolic prophylaxis, but there are concerns about associated bleeding in total joint arthroplasty (TJA) patients. This study aimed to investigate whether the perioperative administration of tranexamic acid (TXA) in TJA patients receiving rivaroxaban for thromboprophylaxis is associated with a reduced risk of postoperative bleeding complications. A healthcare database was utilized to identify all primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients between 2015 and 2021. Patients receiving rivaroxaban during their in-hospital admission who also received TXA on the day of surgery were compared to those who did not receive TXA. Univariate and multivariable regression analyses assessed differences in 90-day bleeding, thromboembolic, and medical postoperative outcomes between cohorts. In total, 161,585 TJA patients were identified (TKA: 67.3%; THA: 32.7%), of which 41,899 (25.9%) received rivaroxaban alone, and 119,686 (74.1%) received rivaroxaban plus TXA. Multivariable analyses found that patients who received rivaroxaban and TXA had a reduced risk of aggregate bleeding complications (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI]: 0.7 to 0.7, P < 0.001), transfusion (aOR 0.4, 95% CI: 0.4 to 0.4, P < 0.001), acute anemia (aOR 0.7, 95% CI: 0.7 to 0.8, P < 0.001), deep vein thrombosis (aOR 0.8, 95% CI: 0.7 to 0.9, P < 0.001), and pulmonary embolism (aOR 0.8, 95% CI: 0.7 to 0.9, P = 0.012). No differences between cohorts were observed for the risk of stroke (aOR 0.9, 95% CI: 0.7 to 1.1, P = 0.31) and myocardial infarction (aOR 0.9, 95% CI: 0.7 to 1.1, P = 0.305). Procedure-specific subanalysis demonstrated a reduced risk of aggregate bleeding complications, transfusion, and acute anemia following THA and TKA. Perioperative administration of TXA reduced the risk of bleeding complications without increasing thromboembolic risk among patients receiving rivaroxaban. Arthroplasty surgeons should consider administering TXA to primary THA and TKA patients receiving rivaroxaban.