A comparison of the efficacy and safety of direct oral anticoagulants with low molecular weight heparin for venous thromboembolism prophylaxis after total hip arthroplasty

Aims: To evaluate differences in the efficacy and safety of low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) used for venous thromboembolism (VTE) prophylaxis after elective total hip arthroplasty (THA). Methods: This systematic review and meta-analysis reviewed MEDLINE, Embase, and CENTRAL from conception to 13 December 2025, for any randomized controlled trials (RCTs) comparing the efficacy (VTE risk) and safety (bleeding risk) of LMWH and DOACs after elective THA. Pooled odds ratios (ORs) of VTE, bleeding, reoperation, and mortality risks were assessed. Results: A total of 22 RCTs involving 28,112 participants were included. The risk of VTE in the DOAC group was lower compared with the LMWH group (OR 0.62 (95% CI 0.47 to 0.82); p = 0.002), driven by a reduction in deep vein thrombosis (DVT) risk (OR 0.60 (95% CI 0.42 to 0.86); p = 0.008). The findings remained consistent in the subgroup analysis restricted to anticoagulants and dosages licensed for use in the UK. Overall bleeding risk was higher in the DOAC group (OR 1.19 (95% CI 1.03 to 1.38); p = 0.023), but no difference was seen when comparing only UK-licensed anticoagulants and doses (OR 1.06 (95% CI 0.95 to 1.18); p = 0.279). Reoperation risk (OR 1.21 (95% CI 0.75 to 1.93); p = 0.351) and mortality (OR 1.03 (95% CI 0.46 to 2.33); p = 0.937) did not differ between groups. Conclusion: DOACs reduce the risk of VTE and DVT following elective THA compared with LMWH without increasing bleeding risk, for UK-licensed agents and doses. Switching to DOACs could save the NHS £8.6 million per year. New clinical trials are needed to compare the safety and efficacy of UK-licensed DOACs and LWMH with modern postoperative rehabilitation protocols.