New oral anticoagulants after total knee arthroplasty: clinical considerations for orthopaedic surgeons

Patients who undergo total knee arthroplasty are at risk of developing venous thromboembolism. Thromboprophylaxis is widely accepted as standard of care in patients receiving total knee arthroplasty, but implementation of clinical practice guidelines is hampered by several barriers, including limitations of current agents. New anticoagulants in clinical development offer equivalent or superior efficacy and safety to existing anticoagulants and the added convenience of oral administration. To date, rivaroxaban is the only new oral anticoagulant with regulatory approval for total knee arthroplasty in the United States, although dabigatran and apixaban are approved in other countries. For total knee arthroplasty, neuraxial blockade offers advantages over general anesthesia and narcotic-based systemic analgesia, but it carries a risk of spinal hematoma if used in conjunction with antithrombotics. Clinical practice guidelines already exist for the use of neuraxial blockade with traditional antithrombotics, and similar evidence-based recommendations are required for the new oral anticoagulants.