JOA - 2026-08-03 - Journal Article
Outcomes of Total Knee Arthroplasty in Patients Receiving Chronic Antithrombotic Therapy: A Systematic Review.
Vosoughi F, Ramezanpour MR, Hashemi FS, Kazemivand S, Dorcheh SS, Oskouei IM
Topics
Key Takeaway
Among 104,182 TKA patients on chronic antithrombotic therapy, warfarin was associated with greater blood loss, higher transfusion rates, longer hospitalization, and elevated MI and PE risk compared to antiplatelet agents and DOACs, while DOAC use correlated with lower rates of PJI and wound dehiscence.
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Summary
This systematic review examined perioperative and longer-term TKA outcomes across antithrombotic drug classes (antiplatelet, warfarin, DOAC) versus non-anticoagulated controls across 17 retrospective studies through October 2025. Warfarin was consistently associated with increased blood loss, transfusion requirement, and prolonged hospitalization, while antiplatelet therapy showed no consistent perioperative harm. DOAC use was associated with lower PJI and wound dehiscence rates, though heterogeneous outcome reporting precluded meta-analytic pooling.
Key Limitation
All 17 included studies were retrospective, and heterogeneous outcome definitions across studies precluded meta-analysis, making it impossible to generate pooled effect sizes or adjust for confounders such as indication for anticoagulation, INR control quality, or bridging protocols.
Original Abstract
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 non-anticoagulated controls.
METHODS
A systematic literature search was conducted through October 2025. There were 17 retrospective studies, including 104,182 patients receiving chronic antithrombotic therapy and 261,139 controls, that 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.