What are the next steps for an elderly patient 4 days post total knee arthroplasty (TKA) with increased pain, bleeding, and blisters next to the incision site, who is taking tramadol, rivaroxaban, clonazepam, and Acetylsalicylic Acid (ASA)?

Immediate Management of Post-TKA Wound Complications

This patient requires urgent surgical evaluation and immediate cessation of rivaroxaban due to active bleeding at the incision site with concerning wound complications 4 days post-TKA. 1

Critical First Steps

Immediate Anticoagulation Management

• Stop rivaroxaban immediately due to active bleeding at the surgical site 2
• Stop ASA immediately to minimize further bleeding risk 2
• Rivaroxaban has no specific reversal agent readily available in most settings, but activated charcoal may reduce absorption if overdose is suspected; plasma products can provide partial reversal of anticoagulation 2
• The combination of rivaroxaban plus ASA significantly increases bleeding risk, particularly in the early postoperative period 3, 4

Urgent Surgical Consultation

• Contact the orthopedic surgeon immediately for evaluation of wound dehiscence, hematoma, or early infection 1
• The combination of increased pain, bleeding, and blisters adjacent to the incision represents a surgical emergency requiring same-day evaluation 1
• Patients requiring early surgical intervention for wound complications within 30 days post-TKA have a 6.0% two-year cumulative probability of developing deep infection and 5.3% probability of requiring major subsequent surgery (component resection, muscle flap coverage, or amputation) 1

Diagnostic Workup

Initial Imaging

• Obtain knee radiographs immediately if not already performed, as this is the first-line imaging for any patient with pain after TKA 5
• Radiographs should be obtained prior to any joint aspiration to evaluate for hardware complications, fracture, or other structural issues 5

Infection Evaluation

• Perform joint aspiration with culture if infection cannot be excluded clinically, but only after reviewing radiographs 5
• The ACR Appropriateness Criteria rate aspiration as "usually appropriate" (rating 9/9) for pain after TKA when infection cannot be excluded 5
• If aspiration cultures are positive, patients typically proceed directly to surgery without additional imaging 5
• If aspiration is negative but infection still suspected, reaspiration is usually appropriate 5

Risk Factors and Prognosis

High-Risk Features Present

• Diabetes mellitus is significantly associated with early wound complications requiring surgical intervention after TKA 1
• The trauma (twisting injury) 4 days post-op may have disrupted the surgical wound, increasing infection and dehiscence risk 1
• Blisters adjacent to the incision suggest significant soft tissue compromise and potential skin necrosis 1

Poor Prognostic Indicators

• Early wound complications requiring surgical treatment carry dramatically worse outcomes compared to uncomplicated TKA 1
• Two-year cumulative probability of deep infection: 6.0% (vs 0.8% in uncomplicated cases, p<0.001) 1
• Two-year cumulative probability of major subsequent surgery: 5.3% (vs 0.6% in uncomplicated cases, p<0.001) 1

Pain Management Adjustments

Continue Safe Analgesics

• Continue tramadol for pain control as it does not increase bleeding risk and is appropriate for postoperative orthopedic pain 6
• Avoid NSAIDs entirely given active bleeding and elderly status; NSAIDs increase bleeding risk and must be used with extreme caution in elderly trauma/surgical patients 7, 8
• Consider adding acetaminophen as first-line adjunct, which provides equivalent pain relief without bleeding risk 7

Sedative Medication Caution

• Reassess clonazepam necessity given increased fall risk in elderly patients with acute pain and mobility limitations 8
• Benzodiazepines worsen cognitive function and increase fall risk in elderly patients 8

When to Resume Anticoagulation

Timing Considerations

• Do not restart rivaroxaban until wound shows evidence of healing (typically ~14 days), all sutures/staples are removed, there is no significant swelling, erythema, or drainage, and no clinical evidence of infection 5
• Given active bleeding and wound complications, this timeline will likely be extended beyond the typical 14 days 5
• The decision to restart must be made in consultation with the orthopedic surgeon based on wound assessment 5

Critical Pitfalls to Avoid

• Do not delay surgical evaluation thinking this will resolve spontaneously; early wound complications require aggressive management to prevent catastrophic outcomes 1
• Do not restart anticoagulation prematurely even if concerned about VTE risk; active bleeding takes priority 2
• Do not add NSAIDs for pain control given active bleeding, elderly age, and concurrent anticoagulation 7, 8
• Do not perform imaging before obtaining radiographs; plain films are the mandatory first step 5