Management of patients on long-term oral anticoagulant therapy during primary total hip or knee replacement arthroplasty : A prospective non-interventional comparative study

Article Article scientifique Article Management of patients on long-term oral anticoagulant therapy during primary total hip or knee replacement arthroplasty : A prospective non-interventional comparative study eng 2025-12-03 author Biau David Université Paris-Cité, INSERM U1153, AP-HP, Hôpital Cochin, Service de Chirurgie Orthopédique, 27, rue du Fbg-St-Jacques, 123 bd de Port-Royal, 75014 Paris, France. Electronic address: david.biau@aphp.fr. author Godier Anne Université Paris Cité, Inserm, The Paris Cardiovascular Research Center Team Endotheliopathy and Hemostasis Disorders, Service d'anesthésie Réanimation, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France. author Viste Anthony Service de Chirurgie Orthopédique, Hôpital Lyon Sud - Hospices Civils de Lyon, 165 chemin du Grand Revoyet, 69495 Oullins-Pierre-Bénite, France. author Hannouche Didier 0000-0003-2060-2394 Service de Chirurgie Orthopédique, Service de Chirurgie Orthopédique et Traumatologie de l'appareil Moteur, Hôpitaux Universitaires de Genève, rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland. 842478 Département de chirurgie (CHIRU) author Jenny Jean-Yves ELSAN Clinique Sainte Odile, 6 rue des Premontres, 67500 Haguenau, France. author Le Baron Marie Service de Chirurgie Orthopédique, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France. author Marmor Simon Service de Chirurgie Orthopédique, Groupe Hospitalier Diaconesses Croix Saint-Simon, 125 rue d'Avron, 75020 Paris, France. author Petit Pierre-Yves Service de Chirurgie Orthopédique, Hôpital Lyon Sud - Hospices Civils de Lyon, 165 chemin du Grand Revoyet, 69495 Oullins-Pierre-Bénite, France. author Rodriguez Pablo Pierre David Service de Chirurgie Orthopédique, Service de Chirurgie Orthopédique et Traumatologie de l'appareil Moteur, Hôpitaux Universitaires de Genève, rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland. 980820 Pablo Rodriguez author Bentzinger Pierre Unité d'anesthésie, Institut de Cancérologie Strasbourg Europe, 17 rue Albert Calmette, 67200 Strasbourg, France. author Delahaye David Service d'anesthésie Réanimation, Hôpital Sainte-Marguerite, 270 bd de Sainte-Marguerite, 13009 Marseille, France. author Braham Wiem Service de Chirurgie Orthopédique, Groupe Hospitalier Diaconesses Croix Saint-Simon, 125 rue d'Avron, 75020 Paris, France. author Coré Maxime Cinique Ambroise Paré, 25-27 bd Victor Hugo, 92200 Neuilly-sur-Seine, France. author Flecher Xavier Service de Chirurgie Orthopédique, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France. author Hamadouche Moussa Service de Chirurgie Orthopédique, Hôpital Cochin, 27, rue du Fbg-St-Jacques, 123 Bd de Port-Royal, 75014 Paris, France. 104561 10.1016/j.otsr.2025.104561 41349866 1877-0568 https://www.sciencedirect.com/science/article/pii/S1877056825004104 Background: Patients scheduled for primary hip or knee replacement are frequently treated with long-term curative oral anticoagulants (LT-COA), vitamin K antagonists (VKA) or direct oral anticoagulants (DOA). We conducted a prospective, controlled study comparing patients treated with LT-COA undergoing total hip replacement (THR) or total knee replacement (TKR) with patients not treated with LT-COA undergoing the same procedure, in order to estimate the adjusted and unadjusted risks of postoperative haemorrhagic or thrombotic complications associated with LT-COA. Hypothesis: The rate of post-operative complications was higher in the group treated with LT-COA. Patients and methods: This was a prospective, comparative, non-interventional study comparing patients undergoing primary THR or TKR arthroplasty who were treated with LT-COA with those who were not treated with curative-dose oral anticoagulants (control group). A total of 325 patients were assessed at 3 months, 215 (66%) in the control group, 123 with THR and 92 with TKR, and 110 (34%) in the LT-COA group, 68 with THR and 42 with TKR. Patients in the control group were more likely to be female, and were also slightly younger and in better pre-operative health. In the LT-COA group, 55 (50%) patients were treated with VKA and 55 (50%) with DOA. The surgical technique, implants and management of perioperative anticoagulants were left to the discretion of the practitioners. The primary endpoint was the occurrence of a HTR (haemorrhagic or thrombotic complications, or revision surgery) complication within 3 months of surgery. Results: Of the 325 patients analysed, 77 (24%) had a HTR complication, 50 (23%) in the control group and 27 (25%) in the LT-COA group (OR = 0.93; 95% CI: 0.54-1.59 (p = 0.80)). In multivariable analysis, the risk of a HTR complication was not significantly different between the groups (adjusted OR = 0.85; 95% CI: 0.45-1.61 (p = 0.62)). Age (p = 0.99) and sex (p = 0.97) were not associated with the occurrence of a HTR complication. In contrast, ASA score (p = 0.017), and type of surgery (THR or TKR, p = 0.019) were significantly associated with the occurrence of a HTR complication in the multivariable analyses. In the LT-COA group, the rate of HTR complications during hospitalisation was significantly higher (p = 0.0076) for patients who had undergone preoperative relay (discontinuation of anticoagulants and initiation of LMWH (Low Molecular Weight Heparin)) (n = 15 out of 41 patients, 37%) compared with those who had not (n = 9 out of 69 patients, 13%). Similarly, HTR complications during hospitalisation were significantly more frequent (p = 0.0363, Fisher's exact test) for patients treated with VKA (n = 19 out of 55 patients, 35%) compared with those treated with DOA (n = 8 out of 55 patients, 15%). Discussion: The rate of HTR complications was not significantly different between the control and LT-COA groups. The use of LMWH as a relay was associated with a significant increase in the HTR complication rate. The increased risk of haemorrhage associated with the use of LMWH may be due to residual anticoagulation at the time of surgery, earlier postoperative anticoagulation, or dual transitory anticoagulation with VKA and LMWH. Level of evidence: III; comparative prospective study. Complications Curative oral anticoagulants Direct oral anticoagulants Total hip arthroplasty Total knee arthroplasty Dewey 617 57 Département de chirurgie 222 false 955 Mécanismes physiopathologiques de l'arthrose 960 Orthopaedics & traumatology: surgery & research 4a7ea81f-2674-4e74-8623-29e1e4776e9c Article (Published version) Public 1-s2.0-S1877056825004104-main.pdf 635094 application/pdf CC BY-NC-4.0 e263c92cd2e29b09a6bb26e6a00f82032da743d48ffe05070ec26d395cf680d4 openAccess Faculté de médecine / Section de médecine clinique / Département de chirurgie

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Rodriguez, Pablo