JOA - 2026-04-24 - Journal Article
Antithrombotic Therapies and Their Associations with Periprosthetic Joint Infection Risk After Total Knee and Hip Arthroplasty: A 12-Year Review.
Khury F, Sarfraz A, Padon B, McCormick K, Rozell JC, Schwarzkopf R, Aggarwal VK
Topics
Key Takeaway
Aspirin monotherapy was associated with 40% lower odds of PJI after arthroplasty (OR 0.60, 95% CI 0.45–0.81) versus non-aspirin regimens, with warfarin carrying an 8-fold increased PJI risk in THA specifically.
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Summary
This retrospective study evaluated ATT trends and PJI risk across 36,452 primary TKA and THA patients over 12 years, using multivariate logistic regression adjusted for age, sex, BMI, smoking, and Charlson Comorbidity Index. Aspirin monotherapy rose from ~2–3% to 59–82% of prophylaxis use while LMWH fell from ~87% to <3%. Aspirin was independently associated with lower PJI odds (OR 0.60), whereas warfarin (OR 8.01) and LMWH (OR 1.89) were associated with increased PJI risk in THA, with no significant ATT-PJI association identified in the TKA cohort.
Key Limitation
Retrospective design with inherent confounding by indication—patients prescribed warfarin or LMWH likely had higher baseline thrombotic and comorbidity burden, which may independently elevate PJI risk regardless of ATT choice.
Original Abstract
BACKGROUND
The impact of postoperative antithrombotic therapy (ATT) on complications such as periprosthetic joint infection (PJI) after total knee and hip arthroplasty (TKA and THA, respectively) remains understudied. We aimed to evaluate temporal trends in ATT use and the association between ATT type and PJI following primary TKA and THA.
METHODS
We retrospectively reviewed 20,376 TKA and 16,076 THA patients receiving postoperative ATT between 2013 and 2025. Trends in ATT use were analyzed for all patients, but PJI incidence (2018 International Consensus Meeting definition) was assessed only in patients who had a minimum 90-day follow-up (14,663 TKA; 11,445 THA). Of these, 0.8% and 1.3% developed a PJI, respectively. Multivariate logistic regressions adjusted for age, sex, body mass index, smoking, and the Charlson Comorbidity Index were applied to assess the association between ATT and PJI.
RESULTS
From 2013 to 2025, aspirin monotherapy increased to account for the majority of prophylaxis (TKA: 2.0 to 59.4%;
THA
3.1 to 82.2%). In contrast, the use of low-molecular-weight heparin (LMWH) declined (TKA: 87.6 to 0.8%;
THA
86.7 to 2.3%), as did warfarin (TKA: 4.1 to 0.3%;
THA
3.4 to 0.9%) and rivaroxaban (TKA: 6.8 to 4.2%;
THA
8.9 to 2.8%). During the same period, apixaban use increased (TKA: 0 to 10.0%;
THA
0 to 12.7%). Aspirin monotherapy was associated with lower odds of PJI compared to non-aspirin regimens (adjusted odds ratio [OR] 0.60, 95% confidence interval [CI] 0.45 to 0.81, P = 0.001). Conversely, warfarin (OR 8.01, 95% CI 3.41 to 18.88, P < 0.001) and LMWH (OR 1.89, 95% CI 1.35 to 2.64, P < 0.001) were independently associated with increased PJI risk in THA.
CONCLUSION
Aspirin has become the dominant postoperative ATT agent. In THA, aspirin is associated with a significantly decreased risk of PJI compared to potent anticoagulants like warfarin and LMWH, while no such association was found in the TKA cohort. Surgeons should prioritize aspirin to minimize postoperative infection risk.