Impact of Anemia on Outcomes Following Total Hip Replacement Surgery and Patient Prognosis

Abstract

Anemia is a prevalent comorbidity among patients undergoing total hip replacement (THR) surgery, significantly affecting surgical outcomes and patient prognosis. This review synthesizes current literature on the relationship between anemia and THR, with a focus on postoperative complications, recovery times, and overall patient satisfaction. While several recent meta-analyses have quantified the risks associated with anemia, our review offers a novel perspective by linking cellular mechanisms to clinical management strategies. We analyze various studies that highlight the prevalence of anemia in this patient population and its potential impact on surgical risks, including increased rates of transfusion, infection, and prolonged hospital stays. Furthermore, we explore the implications of anemia on functional recovery and long-term outcomes, emphasizing the necessity for preoperative screening and management strategies. Our findings suggest that addressing anemia before THR may improve surgical outcomes and enhance patients' quality of life. This review underscores the importance of a multidisciplinary approach in the preoperative assessment and management of patients with anemia undergoing total hip replacement surgery.

Keywords

anemia / patient prognosis / postoperative complications / preoperative management / surgical outcomes / total hip replacement

References

[1] Z. Zheng, S. Chen, X. Liu, et al., “A Bioactive Polymethylmethacrylate Bone Cement for Prosthesis Fixation in Osteoporotic Hip Replacement Surgery,” Materials & Design 209 (2021): 109966.

[2] J. Zhang, X. Wang, Q. Zhang, Z. Wang, and S. Zhu, “Application Effects of Remimazolam and Propofol on Elderly Patients Undergoing Hip Replacement,” BMC Anesthesiology 22, no. 1 (2022): 118.

[3] M. B. Held, A. J. deMeireles, S. S. Desai, and R. P. Shah, “Cemented Total Hip Replacement Through the ABMS Approach,” in The Anterior-Based Muscle-Sparing Approach to Total Hip Arthroplasty, ed. J. A. Geller and B. J. McGrory (Springer International Publishing, 2022), 77–94.

[4] S. Goyal, T. Tandon, D. Sangoi, and E. J. C. Dawe, “Total Joint Replacement,” in General Principles of Orthopedics and Trauma, ed. K. M. Iyer and W. S. Khan (Springer International Publishing, 2019), 429–489.

[5] J. Zajc and S. K. Fokter, “Bimodular Femoral Stems in Primary Total Hip Arthroplasty,” Expert Review of Medical Devices 20, no. 12 (2023): 1051–1064.

[6] A. Almaawi, F. S. Alabdullatif, N. Alabdulkarim, D. Benfaris, N. Alamari, and A. Alzuhair, “Different Types of Bearing Surfaces in Primary Total Hip Arthroplasty: A Systematic Review,” International Journal of Medical Research & Health Sciences 10 (2021): 153–167.

[7] S. Bahadori, J. M. Williams, S. Collard, and I. Swain, “Can a Purposeful Walk Intervention With a Distance Goal Using an Activity Monitor Improve Individuals' Daily Activity and Function Post Total Hip Replacement Surgery. A Randomized Pilot Trial,” Cyborg and Bionic Systems 4 (2023): 0069.

[8] K. Garfield, S. Noble, E. Lenguerrand, et al., “What Are the Inpatient and Day Case Costs Following Primary Total Hip Replacement of Patients Treated for Prosthetic Joint Infection: A Matched Cohort Study Using Linked Data From the National Joint Registry and Hospital Episode Statistics,” BMC Medicine 18, no. 1 (2020): 335.

[9] A. Green, A. Walsh, and O. Al-Dadah, “Comparison of Clinical Outcomes Between Total Hip Replacement and Total Knee Replacement,” World Journal of Orthopedics 14, no. 12 (2023): 853–867.

[10] M. R. Whitehouse, R. Patel, J. M. R. French, et al., “The Association of Bearing Surface Materials With the Risk of Revision Following Primary Total Hip Replacement: A Cohort Analysis of 1,026,481 Hip Replacements From the National Joint Registry,” PLoS Medicine 21, no. 11 (2024): e1004478.

[11] X. Zhao, X.-. Z. Cai, W. Wang, et al., “MAKO Robotic Assisted Total Hip Replacement (THR) for Patients With Fused Hips,” International Journal of Medical Robotics and Computer Assisted Surgery 18, no. 3 (2022): e2369.

[12] M. Weißenberger, T. Heinz, D. Rak, et al., “Does Body Mass Index (BMI) Affect the Reconstruction of Biomechanical Parameters in Patients Undergoing Total Hip Replacement (THR) Through the Direct Anterior Approach (DAA)?,” Journal of Clinical Medicine 13, no. 2 (2024): 467.

[13] G. C. Duarte, A. P. Catanoce, J. L. Zabeu, et al., “Association of Preoperative Anemia and Increased Risk of Blood Transfusion and Length of Hospital Stay in Adults Undergoing Hip and Knee Arthroplasty: An Observational Study in a Single Tertiary Center,” Health Science Reports 4, no. 4 (2021): e448.

[14] Ø. Jans, C. Jørgensen, H. Kehlet, P. I. Johansson, and Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group, “Role of Preoperative Anemia for Risk of Transfusion and Postoperative Morbidity in Fast-Track Hip and Knee Arthroplasty,” Transfusion 54, no. 3 (2014): 717–726.

[15] F. Qian, T. M. Osler, M. P. Eaton, et al., “Variation of Blood Transfusion in Patients Undergoing Major Noncardiac Surgery,” Annals of Surgery 257, no. 2 (2013): 266–278.

[16] H. Gombotz, P. H. Rehak, A. Shander, and A. Hofmann, “The Second A Ustrian Benchmark Study for Blood Use in Elective Surgery: Results and Practice Change,” Transfusion 54, no. 10pt2 (2014): 2646–2657.

[17] S. Let, S. Tiwari, A. Singh, and M. Chakrabarty, “Prevalence and Determinants of Anaemia Among Women of Reproductive Age in Aspirational Districts of India: An Analysis of NFHS 4 and NFHS 5 Data,” BMC Public Health 24, no. 1 (2024): 437.

[18] E. Wacka, J. Nicikowski, P. Jarmuzek, and A. Zembron-Lacny, “Anemia and Its Connections to Inflammation in Older Adults: A Review,” Journal of Clinical Medicine 13, no. 7 (2024): 2049.

[19] K. Badura, J. Janc, J. Wąsik, et al., “Anemia of Chronic Kidney Disease—A Narrative Review of Its Pathophysiology, Diagnosis, and Management,” Biomedicine 12, no. 6 (2024): 1191.

[20] Effects of Interleukin-1β Inhibition on Incident Hip and Knee Replacement,” Annals of Internal Medicine 173, no. 7 (2020): 509–515.

[21] A. A. Pronskikh, K. N. Kharitonov, A. A. Korytkin, S. V. Romanova, and V. V. Pavlov, “Total Hip Arthroplasty in Patients With Acetabular Fractures,” Genij Ortopedii 27, no. 5 (2021): 620–627.

[22] K. Alsaleh, G. S. Alotaibi, H. S. Almodaimegh, A. A. Aleem, and C. T. Kouroukis, “The Use of Preoperative Erythropoiesis-Stimulating Agents (ESAs) in Patients Who Underwent Knee or Hip Arthroplasty: A Meta-Analysis of Randomized Clinical Trials,” Journal of Arthroplasty 28, no. 9 (2013): 1463–1472.

[23] Y. Li, P. Yin, H. Lv, Y. Meng, L. Zhang, and P. Tang, “A Meta-Analysis and Systematic Review Evaluating the Use of Erythropoietin in Total Hip and Knee Arthroplasty,” Therapeutics and Clinical Risk Management 14 (2018): 1191–1204.

[24] M. Muñoz, A. G. Acheson, E. Bisbe, et al., “An International Consensus Statement on the Management of Postoperative Anaemia After Major Surgical Procedures,” Anaesthesia 73, no. 11 (2018): 1418–1431.

[25] F.-Q. Zhang, Y. Z. Yang, P. F. Li, et al., “Impact of Preoperative Anemia on Patients Undergoing Total Joint Replacement of Lower Extremity: A Systematic Review and Meta-Analysis,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 249.

[26] S. Nandhra, L. Boylan, J. Prentis, C. Nesbitt, and Northern Vascular Centre, “The Influence of Preoperative Anemia on Clinical Outcomes After Infrainguinal Bypass Surgery,” Annals of Vascular Surgery 66 (2020): 586–594.

[27] P. S. Myles, T. Richards, A. Klein, et al., “Postoperative Anaemia and Patient-Centred Outcomes After Major Abdominal Surgery: A Retrospective Cohort Study,” British Journal of Anaesthesia 129, no. 3 (2022): 346–354.

[28] X. Luo, F. Li, H. Hu, et al., “Anemia and Perioperative Mortality in Non-Cardiac Surgery Patients: A Secondary Analysis Based on a Single-Center Retrospective Study,” BMC Anesthesiology 20 (2020): 1–9.

[29] K. K. Mathew, R. M. Vakharia, H. S. Salem, et al., “Is Iron Deficiency Anemia a Risk Factor for Poorer Outcomes in Primary Total Knee Arthroplasty?,” Journal of Arthroplasty 35, no. 5 (2020): 1252–1256.

[30] T. Moon, A. Smith, T. Pak, et al., “Preoperative Anemia Treatment With Intravenous Iron Therapy in Patients Undergoing Abdominal Surgery: A Systematic Review,” Advances in Therapy 38 (2021): 1447–1469.

[31] A. L. Gianakos, B. N. Saad, R. Haring, et al., “Tranexamic Acid Lowers Transfusion Requirements and Hospital Length of Stay Following Revision Total Hip or Knee Arthroplasty,” Patient Safety in Surgery 15, no. 1 (2021): 21.

[32] D. E. DeMik, C. N. Carender, N. A. Glass, T. S. Brown, J. J. Callaghan, and N. A. Bedard, “Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?,” Journal of Arthroplasty 37, no. 6 (2022): S63–S69.e1.

[33] C. Pempe, R. Werdehausen, P. Pieroh, et al., “Predictors for Blood Loss and Transfusion Frequency to Guide Blood Saving Programs in Primary Knee- and Hip-Arthroplasty,” Scientific Reports 11, no. 1 (2021): 4386.

[34] E. Jeschke, M. Citak, A. M. Halder, et al., “Blood Transfusion and Venous Thromboembolism Trends and Risk Factors in Primary and Aseptic Revision Total Hip and Knee Arthroplasties: A Nationwide Investigation of 736,061 Cases,” Orthopaedics & Traumatology, Surgery & Research 108, no. 1 (2022): 102987.

[35] N. Shohat, L. Ludwick, G. S. Goh, M. Sherman, J. Paladino, and J. Parvizi, “Blood Transfusions Increase the Risk for Venous Thromboembolism Events Following Total Joint Arthroplasty,” Scientific Reports 11, no. 1 (2021): 21240.

[36] C. Pinilla-Gracia, J. Mateo-Agudo, A. Herrera, and M. Muñoz, “On the Relevance of Preoperative Haemoglobin Optimisation Within a Patient Blood Management Programme for Elective Hip Arthroplasty Surgery,” Blood Transfusion 18, no. 3 (2020): 182–190.

[37] K. W. Morse, N. K. Heinz, J. M. Abolade, et al., “Tranexamic Acid Does Not Reduce the Risk of Transfusion in Rheumatoid Arthritis Patients Undergoing Total Joint Arthroplasty,” Journal of Arthroplasty 35, no. 9 (2020): 2367–2374.

[38] A. Vaish, R. J. Belbase, and R. Vaishya, “Is Blood Transfusion Really Required in Simultaneous Bilateral Total Knee Replacement: A Retrospective Observational Study,” Journal of Clinical Orthopaedics and Trauma 11 (2020): S214–S218.

[39] Z. Chen, W. Zhang, M. Wang, L. J. Backman, and J. Chen, “Effects of Zinc, Magnesium, and Iron Ions on Bone Tissue Engineering,” ACS Biomaterials Science & Engineering 8, no. 6 (2022): 2321–2335.

[40] A. M. Silva and M. Rangel, “The (Bio) Chemistry of Non-Transferrin-Bound Iron,” Molecules 27, no. 6 (2022): 1784.

[41] S. Hu, W. He, and G. Wu, “Hydroxyproline in Animal Metabolism, Nutrition, and Cell Signaling,” Amino Acids 54, no. 4 (2022): 513–528.

[42] W. Zhu, C. Li, M. Yao, et al., “Advances in Osseointegration of Biomimetic Mineralized Collagen and Inorganic Metal Elements of Natural Bone for Bone Repair,” Regenerative Biomaterials 10 (2023): rbad030.

[43] Y. Yang, Y. Wang, L. Guo, W. Gao, T. L. Tang, and M. Yan, “Interaction Between Macrophages and Ferroptosis,” Cell Death & Disease 13, no. 4 (2022): 355.

[44] Q. Qin, Y. Liu, Z. Yang, et al., “Hypoxia-Inducible Factors Signaling in Osteogenesis and Skeletal Repair,” International Journal of Molecular Sciences 23, no. 19 (2022): 11201.

[45] F. N. von Brackel and R. Oheim, “Iron and Bones: Effects of Iron Overload, Deficiency and Anemia Treatments on Bone,” JBMR Plus 8, no. 8 (2024): ziae064.

[46] S. Entezari, S. M. Haghi, N. Norouzkhani, et al., “Iron Chelators in Treatment of Iron Overload,” Journal of Toxicology 2022, no. 1 (2022): 4911205.

[47] C. S. Olver, “Erythropoiesis,” in Schalm's Veterinary Hematology (Wiley-Blackwell (John Wiley & Sons), 2022), 149–157.

[48] C. Camaschella, A. Pagani, L. Silvestri, and A. Nai, “The Mutual Crosstalk Between Iron and Erythropoiesis,” International Journal of Hematology 116, no. 2 (2022): 182–191.

[49] P. Tang and H. Wang, “Regulation of Erythropoiesis: Emerging Concepts and Therapeutic Implications,” Hematology 28, no. 1 (2023): 2250645.

[50] R. M. Hanna, E. Streja, and K. Kalantar-Zadeh, “Burden of Anemia in Chronic Kidney Disease: Beyond Erythropoietin,” Advances in Therapy 38, no. 1 (2021): 52–75.

[51] M. R. Hanudel, S. Wong, G. Jung, et al., “Amelioration of Chronic Kidney Disease-Associated Anemia by Vadadustat in Mice Is Not Dependent on Erythroferrone,” Kidney International 100, no. 1 (2021): 79–89.

[52] M. J. Koury, R. Agarwal, G. M. Chertow, et al., “Erythropoietic Effects of Vadadustat in Patients With Anemia Associated With Chronic Kidney Disease,” American Journal of Hematology 97, no. 9 (2022): 1178–1188.

[53] N. Behranvand, F. Nasri, R. Zolfaghari Emameh, et al., “Chemotherapy: A Double-Edged Sword in Cancer Treatment,” Cancer Immunology, Immunotherapy 71, no. 3 (2022): 507–526.

[54] H. Van Remoortel, J. Laermans, B. Avau, et al., “Effectiveness of Iron Supplementation With or Without Erythropoiesis-Stimulating Agents on Red Blood Cell Utilization in Patients With Preoperative Anaemia Undergoing Elective Surgery: A Systematic Review and Meta-Analysis,” Transfusion Medicine Reviews 35, no. 2 (2021): 103–124.

[55] J. Yang, Q. Li, Y. Feng, and Y. Zeng, “Iron Deficiency and Iron Deficiency Anemia: Potential Risk Factors in Bone Loss,” International Journal of Molecular Sciences 24, no. 8 (2023): 6891.

[56] R. S. Zeidan, S. M. Han, C. Leeuwenburgh, and R. Xiao, “Iron Homeostasis and Organismal Aging,” Ageing Research Reviews 72 (2021): 101510.

[57] C. Peyssonnaux, V. Nizet, and R. S. Johnson, “Role of the Hypoxia Inducible Factors HIF in Iron Metabolism,” Cell Cycle 7, no. 1 (2008): 28–32.

[58] S. G. Azarnier, M. Esmkhani, Z. Dolatkhah, and S. Javanshir, “Collagen-Coated Superparamagnetic Iron Oxide Nanoparticles as a Sustainable Catalyst for Spirooxindole Synthesis,” Scientific Reports 12, no. 1 (2022): 6104.

[59] Z. Hussain, I. Ullah, X. Liu, et al., “Tannin-Reinforced Iron Substituted Hydroxyapatite Nanorods Functionalized Collagen-Based Composite Nanofibrous Coating as a Cell-Instructive Bone-Implant Interface Scaffold,” Chemical Engineering Journal 438 (2022): 135611.

[60] S. Jiang, W. Dong, Z. Zhang, et al., “A New Iron Supplement: The Chelate of Pig Skin Collagen Peptide and Fe2+ Can Treat Iron-Deficiency Anemia by Modulating Intestinal Flora,” Frontiers in Nutrition 9 (2022): 1055725.

[61] L. He, D. di, X. Chu, et al., “Photothermal Antibacterial Materials to Promote Wound Healing,” Journal of Controlled Release 363 (2023): 180–200.

[62] C. Añazco, P. G. Ojeda, and M. Guerrero-Wyss, “Common Beans as a Source of Amino Acids and Cofactors for Collagen Biosynthesis,” Nutrients 15, no. 21 (2023): 4561.

[63] F. Azizi-Soleiman, M. Vafa, B. Abiri, and M. Safavi, “Effects of Iron on Vitamin D Metabolism: A Systematic Review,” International Journal of Preventive Medicine 7, no. 1 (2016): 126.

[64] L. Toxqui, A. M. Pérez-Granados, R. Blanco-Rojo, I. Wright, C. González-Vizcayno, and M. P. Vaquero, “Effects of an Iron or Iron and Vitamin D–Fortified Flavored Skim Milk on Iron Metabolism: A Randomized Controlled Double-Blind Trial in Iron-Deficient Women,” Journal of the American College of Nutrition 32, no. 5 (2013): 312–320.

[65] D. R. Fraser, “Regulation of the Metabolism of Vitamin D,” Physiological Reviews 60, no. 2 (1980): 551–613.

[66] W. Xie, S. Lorenz, S. Dolder, and W. Hofstetter, “Extracellular Iron Is a Modulator of the Differentiation of Osteoclast Lineage Cells,” Calcified Tissue International 98 (2016): 275–283.

[67] E. Balogh, G. Paragh, and V. Jeney, “Influence of Iron on Bone Homeostasis,” Pharmaceuticals 11, no. 4 (2018): 107.

[68] V. Jeney, “Clinical Impact and Cellular Mechanisms of Iron Overload-Associated Bone Loss,” Frontiers in Pharmacology 8 (2017): 77.

[69] D. Dong, J. Yang, G. Zhang, T. Huyan, and P. Shang, “16 T High Static Magnetic Field Inhibits Receptor Activator of Nuclear Factor Kappa-Β Ligand-Induced Osteoclast Differentiation by Regulating Iron Metabolism in Raw264. 7 Cells,” Journal of Tissue Engineering and Regenerative Medicine 13, no. 12 (2019): 2181–2190.

[70] P. Dao and P. Massin, “Blood Management in Enhanced Recovery After Hip and Knee Replacement,” Orthopaedics & Traumatology, Surgery & Research 106, no. 1 (2020): S1–S5.

[71] X. Wang, Y. Chen, J. Zhao, B. Wang, and Z. Chen, “Enhanced Recovery After Surgery for Primary Total Hip Arthroplasty: Analysis of Post-Operative Blood Indexes,” International Orthopaedics 47, no. 1 (2023): 125–129.

[72] S. B. Sequeira, N. D. Quinlan, A. D. Althoff, and B. C. Werner, “Iron Deficiency Anemia Is Associated With Increased Early Postoperative Surgical and Medical Complications Following Total Hip Arthroplasty,” Journal of Arthroplasty 36, no. 3 (2021): 1023–1028.

[73] M. M. Sylla, L. Gruffi, E. S. Roth, F. E. Rosato, C. H. J. Wong, and A. E. Razi, “How Does Iron Deficiency Anemia Impact Outcomes Following Revision Total Hip Arthroplasty?,” Hip and Pelvis 33, no. 3 (2021): 140–146.

[74] J. Cao, Y. Zhou, W. Xin, et al., “Natural Outcome of Hemoglobin and Functional Recovery After the Direct Anterior Versus the Posterolateral Approach for Total Hip Arthroplasty: A Randomized Study,” Journal of Orthopaedic Surgery and Research 15, no. 1 (2020): 200.

[75] C. S. Sicat, N. Muthusamy, V. Singh, R. I. Davidovitch, J. D. Slover, and R. Schwarzkopf, “Impact of Preoperative Anemia Severity on Primary Total Hip Arthroplasty Outcomes,” Journal of Arthroplasty 37, no. 4 (2022): 721–726.

[76] R. Frangie, K. Z. Masrouha, R. Abi-Melhem, H. Tamim, and M. al-Taki, “The Association of Anaemia and Its Severity With Composite Morbidity After Total Hip Arthroplasty,” Hip International 31, no. 2 (2021): 201–206.

[77] D. R. Spahn, “Anemia and Patient Blood Management in Hip and Knee Surgery: A Systematic Review of the Literature,” Anesthesiology 113, no. 2 (2010): 482–495.

[78] A. Bailey, I. Eisen, A. Palmer, et al., “Preoperative Anemia in Primary Arthroplasty Patients—Prevalence, Influence on Outcome, and the Effect of Treatment,” Journal of Arthroplasty 36, no. 7 (2021): 2281–2289.

[79] K. S. Gill, A. D. Antigua, A. K. Barnett, A. J. Hall, and C. T. Klodell, “Evaluation of Erythropoietin Stimulating Agents (ESA) and Their Effect on Blood Optimization for Cardiac Surgery,” Journal of Pharmacy Practice 35, no. 2 (2022): 263–267.

[80] L. T. Goodnough, A. Manaitis, P. Earnshaw, and the NATA Consensus Development Working Group, “Management of Preoperative Anaemia in Patients Undergoing Elective Surgery,” ISBT Science Series 5, no. n1 (2010): 120–124.

[81] I. Pabjańczyk, R. Owczuk, H. Kutaj-Wąsikowska, et al., “Standards of Perioperative Management in Total Knee and Hip Arthroplasty Procedures. A Survey-Based Study. Part I: Preoperative Management,” Anaesthesiology Intensive Therapy 55, no. 4 (2023): 262–271.

[82] C. Mosieri, D. Chandler, D. S. Reed, et al., “Managing Preoperative Anemia: Evolving Concepts and Strategies for Improving Patient Outcomes,” Best Practice & Research. Clinical Anaesthesiology 34, no. 2 (2020): 183–197.

[83] G. S. Matharu, S. K. Kunutsor, A. Judge, A. W. Blom, and M. R. Whitehouse, “Clinical Effectiveness and Safety of Aspirin for Venous Thromboembolism Prophylaxis After Total Hip and Knee Replacement: A Systematic Review and Meta-Analysis of Randomized Clinical Trials,” JAMA Internal Medicine 180, no. 3 (2020): 376–384.

[84] G. J. Hong, L. A. Wilson, J. Liu, and S. G. Memtsoudis, “Tranexamic Acid Administration Is Associated With a Decreased Odds of Prosthetic Joint Infection Following Primary Total Hip and Primary Total Knee Arthroplasty: A National Database Analysis,” Journal of Arthroplasty 36, no. 3 (2021): 1109–1113.

[85] T. W. Wainwright, M. Gill, D. A. McDonald, et al., “Consensus Statement for Perioperative Care in Total Hip Replacement and Total Knee Replacement Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations,” Acta Orthopaedica 91, no. 1 (2020): 3–19.

[86] X.-D. Wu, Z. L. Zhu, P. C. Xiao, J. C. Liu, J. W. Wang, and W. Huang, “Are Routine Postoperative Laboratory Tests Necessary After Primary Total Hip Arthroplasty?,” Journal of Arthroplasty 35, no. 10 (2020): 2892–2898.

[87] X.-D. Wu, J. C. Liu, Y. J. Li, J. W. Wang, G. X. Qiu, and W. Huang, “The Necessity of Routine Postoperative Laboratory Tests After Total Hip Arthroplasty for Hip Fracture in a Semi-Urgent Clinical Setting,” Journal of Orthopaedics and Traumatology 21, no. 1 (2020): 19.

[88] A. Gu, M. A. Malahias, N. A. Selemon, et al., “Increased Severity of Anaemia Is Associated With 30-Day Complications Following Total Joint Replacement,” Bone & Joint Journal 102-B, no. 4 (2020): 485–494.

[89] S. Hamaway, B. Hadid, R. M. Vakharia, et al., “The Association of Iron Deficiency Anemia and Perioperative Complications Following Revision Total Knee Arthroplasty,” Art 4, no. 1 (2022): 34.

[90] A. Delaforce, L. Galeel, E. Poon, et al., “Preoperative Anemia Screening and Treatment Practices in Patients Having Total Joint Replacement Surgery: A Retrospective, Observational Audit,” Journal of Blood Medicine 11 (2020): 259–265.

[91] H. Dömötör, Á. L. Varga, R. Sződy, F. Tóth, and G. Nardai, “Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery,” Advances in Orthopedics 2021, no. 1 (2021): 2235600.

[92] D. A. Kolin, S. Lyman, A. G. Della Valle, M. P. Ast, D. C. Landy, and B. P. Chalmers, “Predicting Postoperative Anemia and Blood Transfusion Following Total Knee Arthroplasty,” Journal of Arthroplasty 38, no. 7 (2023): 1262–1266.e2.

[93] E. Grandone, G. L. Tiscia, A. Ostuni, F. Marongiu, and D. Barcellona, “Navigating Anemia and Anticoagulation in Elderly Patients Undergoing Orthopedic Surgery: Strategies for Preventing Complications and Implementing Treatments,” Blood Transfusion 22, no. 5 (2024): 450–458.

[94] C. C. Dlott, A. Moore, C. Nelson, et al., “Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients,” Journal of Arthroplasty 35, no. 6 (2020): 1508–1515.e2.

[95] J. M. Forslund, P. H. Chan, H. A. Prentice, A. C. Purdy, and M. Khatod, “Preoperative Patient Optimization: Outcomes From Elective Total Joint Arthroplasty in a Large US Healthcare System,” Journal of the American Academy of Orthopaedic Surgeons 31, no. 14 (2023): 746–753.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.