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Outcomes of Total Knee Arthroplasty in Patients Receiving Chronic Antithrombotic Therapy: A Systematic Review
Fardis Vosoughi1, Mohammad Reza Ramezanpour2, Fatemeh Sadat Hashemi3
1Department of Orthopaedics and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Sports Orthopaedics and Arthroscopy Research (SOAR) Center, Tehran University of Medical Sciences, Tehran, Iran.
Insights
Patients undergoing total knee arthroplasty (TKA) on warfarin face higher risks of blood loss and longer hospital stays. Antiplatelet and direct oral anticoagulants show better outcomes, but careful management is key for all antithrombotic therapies.
Area of Science:
- Orthopedic Surgery
- Cardiovascular Medicine
- Pharmacology
Background:
- Aging populations and cardiovascular comorbidities increase the need for antithrombotic therapy in total knee arthroplasty (TKA) patients.
- The impact of long-term antithrombotic use on TKA outcomes is not well understood.
- This review examines perioperative and long-term outcomes of TKA in patients on chronic antithrombotic therapy.
Purpose of the Study:
- To summarize postoperative outcomes in TKA patients receiving chronic antithrombotic therapy.
- To compare outcomes across different antithrombotic classes (antiplatelet, warfarin, direct oral anticoagulants).
- To compare outcomes against non-anticoagulated control groups.
Main Methods:
- Systematic literature search conducted up to October 2025.
- Analysis of 17 retrospective studies involving 104,182 patients on antithrombotics and 261,139 controls.
- Outcomes included perioperative parameters, medical complications, thromboembolic events, and longer-term results, categorized by antithrombotic class.
Main Results:
- Warfarin use correlated with increased blood loss, higher transfusion rates, and prolonged hospitalization.
- Antiplatelet therapy demonstrated no consistent adverse perioperative effects.
- Direct oral anticoagulant therapy was linked to reduced periprosthetic joint infection and wound dehiscence rates.
Conclusions:
- Warfarin use in TKA is associated with greater blood loss, longer hospitalization, and increased risks of wound complications, myocardial infarction, and pulmonary embolism compared to other antithrombotics.
- TKA is feasible with chronic antithrombotic therapy, but warfarin patients need closer monitoring.
- Further research is necessary to clarify outcomes for various antithrombotic regimens in TKA.
Background:
With population aging and increasing cardiovascular comorbidity, more patients undergoing total knee arthroplasty (TKA) require chronic antithrombotic therapy. The impact of long-term anticoagulant or antiplatelet use on perioperative and longer-term outcomes after TKA remains unclear. This systematic review summarizes postoperative outcomes in patients receiving chronic antithrombotic therapy, examines differences by antithrombotic class, and compares outcomes with nonanticoagulated controls.
Methods:
A systematic literature search was conducted through October 2025. There were 17 retrospective comparative studies, including 104,182 patients receiving chronic antithrombotic therapy and 261,139 controls, which were analyzed. Studies reporting outcomes of primary TKA in patients receiving long-term antithrombotic therapy were included. Extracted outcomes comprised perioperative parameters, medical complications, thromboembolic events, and longer-term outcomes. Antithrombotic regimens were categorized as antiplatelet therapy, warfarin, direct oral anticoagulants or mixed regimen (outcomes were not reported separately by anticoagulant class in this group), and findings were synthesized descriptively.
Results:
Warfarin use was associated with greater blood loss, higher transfusion rates, and longer hospitalization, whereas antiplatelet therapy showed no consistent adverse perioperative effects. Direct oral anticoagulant therapy was related to lower rates of periprosthetic joint infection and wound dehiscence. Reporting of thromboembolic, infectious, wound, and revision outcomes was heterogeneous.
Conclusion:
Warfarin use in TKA, compared with antiplatelet and direct oral anticoagulant therapy, is associated with greater blood loss, longer hospitalization, and higher risk of wound complications, myocardial infarction, and pulmonary embolism, while other outcomes show no difference or remain inconclusive. Despite this, TKA is feasible under chronic antithrombotic therapy with proper perioperative management, though warfarin patients require closer monitoring and further research is needed.
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