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    Another Use for Aspirin after TKA: Treatment of Infrapopliteal DVT

    Aspirin is well established as a preventive agent for deep vein thrombosis (DVT) in patients undergoing total hip and total knee arthroplasty. [1-6]

    Now, a paper from Hackensack Meridian Health in New Jersey offers insight into the use of aspirin in the management of another type of blood clot that can occur post-total knee arthroplasty, infrapopliteal DVT (IDVT). The researchers found that aspirin administration can effectively treat IDVT and is associated with a low rate of clot progression and stroke or thromboembolic events. 

    The paper, published by The Bone & Joint Journal, received the 2021 John N. Insall Award Winner from the Knee Society. The award, recognizing outstanding papers on clinical results and techniques, established to honor the pioneering contributions to the field of orthpaedics by orthopedic surgeon John N. Insall, MD. Dr. Insall – often considered to be the father of total knee arthroplasty in the US – was a past president of the Knee Society and a founding member of Insall Scott Kelly Institute in New York.

    “The optimal management of an infrapopliteal deep venous thrombosis, located in veins below the knee, following total knee arthroplasty has never been clear-cut for the clinicians managing postoperative care,” said study co-author Gregg R. Klein, MD. Dr. Klein is Vice-Chairperson of the Department of Orthopaedic Surgery at Hackensack University Medical Center and an Associate Professor at the Hackensack Meridian School of Medicine at Seton Hall.

    “This study, to the best of the authors’ knowledge, is the first to show that patients undergoing total knee replacement who developed blood clots below the knee can be effectively treated with aspirin,” he continued. “While the optimal management of these types of clots following knee replacement surgery needs further prospective study, treatment with aspirin could be a new standard of care in orthopedics.” 

    For the study, Dr. Klein and his colleagues the researchers examined the medical records of 5078 patients who underwent primary or revision total knee arthroplasty between January 1, 2014, and January 1, 2019, at Hackensack University Medical Center. All patients who had the surgery during the study period received DVT prophylaxis that included early mobilization, mechanical prophylaxis, and prophylaxis with aspirin, heparin, or warfarin based on their risk profile.

    The researchers identified 532 patients from this cohort who developed an IDVT, which was diagnosed by Doppler ultrasound at the first postoperative visit. Most patients (91%) were prescribed aspirin, 325 mg taken twice daily for 3 months. The remaining patients with IDVT were treated with anticoagulants other than aspirin.

    Follow-up ultrasound was performed on 94% (459/486) of the IDVT patients treated with aspirin, and in 97% of those patients (445/459), IDVT had resolved. Ten patients (2%) showed propagation of the IDVT to the popliteal vein. Only 1 patient (0.2%) treated with aspirin developed a pulmonary embolism 6 weeks after surgery. No significant bleeding episodes, wound-related complications, or other adverse events were noted.

    “The findings of this study are encouraging and provide impetus to consider treating patients with acute IDVT with aspirin, which appears to be an effective treatment for this type of blood clot,” Dr. Klein said.  “It is inexpensive and well tolerated in patients and lacks the major bleeding and wound-related complications that can occur with more potent anticoagulant therapy.

    “Once thought to be inconsequential, IDVT propagation has shown to be a real risk in multiple studies. Therefore, until prospective studies can be performed regarding treatment for IVDT, we recommend the use of aspirin therapy when IDVT is diagnosed.”

    Source

    Omari AM, Parcells BW, Levine HB, Seidenstein A, Parvizi J, Klein GR. 2021 John N. Insall Award: Aspirin is effective in preventing propagation of infrapopliteal deep venous thrombosis following total knee arthroplasty. Bone Joint J. 2021 Jun;103-B(6 Supple A):18-22. doi: 10.1302/0301-620X.103B6.BJJ-2020-2436.R1.

    Aspirin photo by Sauligno, from Wikipedia.com, provided under an Attribution-ShareAlike 3.0 Unported (CC BY-SA 3.0) license. Photo was duplicated and cropped.

    References

    1. Shohat N, Ludwick L, Goel R, Ledesma J, Streicher S, Parvizi J. Thirty days of aspirin for venous thromboembolism prophylaxis is adequate following total knee arthroplasty, regardless of the dose used. J Arthroplasty. 2021 Sep;36(9):3300-3304. doi: 10.1016/j.arth.2021.05.002. Epub 2021 May 8.
    2. Ren Y, Cao S-L, Li Z, Luo T, Feng B, Weng X-S. Comparable efficacy of 100 mg aspirin twice daily and rivaroxaban for venous thromboembolism prophylaxis following primary total hip arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2021 Jan 5;134(2):164-172. doi: 10.1097/CM9.0000000000001305.
    3. Tang A, Zak SG, Waren D, et al. Low-dose aspirin is safe and effective for venous thromboembolism prevention in patients undergoing revision total knee arthroplasty: a retrospective cohort study. J Knee Surg. 2020 Sep 8. doi: 10.1055/s-0040-1716377. Online ahead of print.
    4. Tang A, Zak S, Iorio R, Slover J, Bosco J, Schwarzkopf R. Low-dose aspirin is safe and effective for venous thromboembolism prevention in patients undergoing revision total hip arthroplasty: a retrospective cohort study. J Arthroplasty. 2020 Aug;35(8):2182-2187. doi: 10.1016/j.arth.2020.03.040. Epub 2020 Mar 30.
    5. Faour M, Piuzzi NS, Brigati DP, Klika AK, Mont MA, Barsoum WK, Higuera CA. No Difference Between Low- and Regular-dose Aspirin for Venous Thromboembolism Prophylaxis After THA. Clin Orthop Relat Res. 2019 Feb;477(2):396-402. doi: 10.1097/CORR.0000000000000613.
    6. Faour M, Piuzzi NS, Brigati DP, Klika AK, Mont MA, Barsoum WK, Higuera CA. Low-dose aspirin is safe and effective for venous thromboembolism prophylaxis following total knee arthroplasty. J Arthroplasty. 2018 Jul;33(7S):S131-S135. doi: 10.1016/j.arth.2018.03.001. Epub 2018 Mar 8