Graham Goh, Leanne Ludwick, Andrea Baldini.
Response/Recommendation: Patients undergoing SBTKA are at a higher risk of venous thromboembolism (VTE) compared to those undergoing unilateral total knee arthroplasty (TKA). Chemical prophylaxis should be considered for these patients.
Strength of Recommendation: Limited.
Rationale: A SBTKA is an effective surgical option for patients with bilateral knee osteoarthritis as it imparts several benefits including a decreased cumulative operative time and lower economic burden1–3. Although SBTKA provides several advantages for the patient, it is associated with a higher rate of complications such as VTE.
A vast body of literature has reported an increased risk of VTE following SBTKA compared to unilateral TKA4–11. This heightened risk may be the result of increased operative time, blood loss, and longer recovery period associated with the operation. Current VTE prophylaxis guidelines presented by the American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) do not provide guidance on the most appropriate prophylactic agent to prescribe to patients undergoing SBTKA12,13. Consequently, it is common practice for surgeons to prescribe more aggressive anticoagulation for these higher-risk patients.
Although aspirin has shown to be as effective as other chemoprophylactic agents with a more favorable safety profile for patients undergoing TKA14–21, existing studies examined heterogenous cohorts containing both unilateral and bilateral procedures22–24. Furthermore, other studies compared aspirin with potent anticoagulants only after risk-stratifying patients based on VTE risk, prescribing aspirin only to “low-risk” unilateral TKA and potent anticoagulants to “high-risk” bilateral TKA25,26. As a result, current literature still lacks consensus regarding the most appropriate VTE prophylactic agent for patients undergoing SBTKA.
Two retrospective studies compared the efficacy of various chemoprophylactic agents for the prevention of VTE following SBTKA27,28. Goel et al., evaluated the incidence of VTE in patients undergoing SBTKA and compared the efficacy of aspirin and warfarin for VTE prevention27. Employing a validated VTE risk calculator to control for confounding risk factors, the study found that aspirin was as protective as warfarin for these high-risk patients. Similarly, Nam et al., compared the efficacy of a multimodal regimen (mobile compression device with aspirin) and warfarin in patients undergoing SBTKA, reporting no symptomatic VTE events in the aspirin cohort compared to one in the warfarin cohort28.
Although it is widely recognized that SBTKA is associated with an increased risk of VTE, current literature lacks robust data evaluating the optimal prophylactic agent for these higher-risk patients. In the absence of such data, it is the recommendation of this workgroup that chemical prophylaxis, which includes aspirin, should be considered for patients undergoing SBTKA.
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