Skip to main content
JDRS · Open access journal
Joint Diseases and
Related Surgery
Online manuscript submissionSubmit a manuscript e-ISSN 2687-4792

Original Article · Open access

Hidden blood loss and its risk factors after hip hemiarthroplasty for hip fracture in the elderly

PDF Cite this article

Jian-wei Zeng

Department of Orthopaedics, Chengdu First People’s Hospital, Chengdu, China

ORCID: 0009-0007-1525-3480

Xin Chen

Department of Orthopaedics, Chengdu First People’s Hospital, Chengdu, China

ORCID: 0009-0006-4937-3360

Li-ming Yang

Department of Orthopaedics, Chengdu First People’s Hospital, Chengdu, China

ORCID: 0009-0002-1181-4168

Cheng-jun Liu

Department of Orthopaedics, Chengdu First People’s Hospital, Chengdu, China

ORCID: 0009-0000-4923-0243

Fei Cao

Department of Orthopaedics, Chengdu First People’s Hospital, Chengdu, China

ORCID: 0000-0002-1180-4907

Abstract

Objectives: This study aims to evaluate hidden blood loss (HBL) and its determinants in elderly hip fracture patients undergoing this procedure via a posterolateral approach.

Patients and methods: Between January 2016 and June 2024, a total of 105 patients (52 males, 53 females; mean age: 78.5±5.6 years; range, 60 to 93 years) who underwent hip hemiarthroplasty through a posterolateral approach were retrospectively analyzed. Patient demographics and clinical data were obtained. Pre- and postoperative hematocrit (Hct), height, and weight were documented. Perioperative total blood loss (TBL) and HBL were quantified using the Gross and Sehat formulas, respectively. Risk factors linked to HBL were determined.

Results: The mean operative duration was 80.3±9.9 min. The mean HBL was 465.9±58.3 mL, accounting for 81.4% of TBL (571.1±149.6 mL). Multivariate linear regression revealed significant associations between increased HBL and lower preoperative albumin (β=–0.188, p=0.011), higher American Society of Anesthesiologists (ASA) classification (β=0.162, p=0.029), and perioperative blood transfusion (β=0.221, p=0.002).

Conclusion: Hidden blood loss constitutes a clinically significant consideration during hip hemiarthroplasty for geriatric hip fractures. Significantly greater HBL occurs in patients with preoperative hypoalbuminemia, elevated ASA classification, or perioperative transfusion. Recognizing and quantifying HBL enhances perioperative assessment precision and contributes to improved patient safety.

Declarations

Author Contributions

Wrote the draft of the manuscript, was a major contributor in design and revising: J.WZ.; Critically reviewed and revised the manuscript for important intellectual content: F.C.; Were involved in collecting data and design of the study: X.C., L.M.Y., C.J.L. All authors approved the final manuscript and agree to be accountable for all aspects of the work.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Guyen O. Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures? Orthop Traumatol Surg Res 2019;105(1S):S95-S101.
  2. Prestmo A, Hagen G, Sletvold O, Helbostad JL, Thingstad P, Taraldsen K, et al. Comprehensive geriatric care for patients with hip fractures: A prospective, randomised, controlled trial. Lancet 2015;385:1623-33. DOI: 10.1016/S0140-6736(14)62409-0.
  3. Mattesi L, Noailles T, Rosencher N, Rouvillain JL. Discontinuation of Plavix® (clopidogrel) for hip fracture surgery. A systematic review of the literature. Orthop Traumatol Surg Res 2016;102:1097-101. DOI: 10.1016/j.otsr.2016.08.022.
  4. Rudy MD, Grant PJ. The patient with hip fracture. Med Clin North Am 2024;108:1155-69. DOI: 10.1016/j.mcna.2024.04.004.
  5. Beauchamp-Chalifour P, Belzile ÉL, Michael R, Langevin V, Gaudreau N, Normandeau N, et al. The risk of venous thromboembolism in surgically treated hip fracture: A retrospective cohort study of 5184 patients. Orthop Traumatol Surg Res 2022;108:103142. DOI: 10.1016/j.otsr.2021.103142.
  6. Ringdal KG, Skaga NO, Steen PA, Hestnes M, Laake P, Jones JM, et al. Classification of comorbidity in trauma: The reliability of pre-injury ASA physical status classification. Injury 2013;44:29-35. DOI: 10.1016/j.injury.2011.12.024.
  7. Yin H, Zhang Y, Hou W, Wang L, Fu X, Liu J. Comparison of complications between total hip arthroplasty following failed internal fixation and primary total hip arthroplasty for femoral neck fractures: A meta-analysis. Jt Dis Relat Surg 2025;36:479-88. DOI: 10.52312/jdrs.2025.2230.
  8. Smith GH, Tsang J, Molyneux SG, White TO. The hidden blood loss after hip fracture. Injury 2011;42:133-5. DOI: 10.1016/j.injury.2010.02.015.
  9. Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee 2000;7:151-5. DOI: 10.1016/s0968-0160(00)00047-8.
  10. Lin S, Liu S, Li Y, Yan Y, Ye H. Hidden blood loss of minimally invasive transforaminal lumbar interbody fusion of lumbar degenerative diseases in patients with osteoporosis: A retrospective study. J Orthop Surg Res 2024;19:798. DOI: 10.1186/s13018-024-05297-4.
  11. Yuan G, Xiao Y, Li Z, Chen Z, Liu X. Impact of surgical approaches on stem position and hidden blood loss in total hip arthroplasty: Minimally invasive vs. posterolateral. BMC Musculoskelet Disord 2024;25:681. DOI: 10.1186/s12891-024-07806-2.
  12. Deng T, Liang Y, Xu C, Hao L, Fu J, Chen J. Factors associated with high hidden blood loss in patients undergoing primary total knee arthroplasty for osteoarthritis: A cross-sectional retrospective study of 1444 patients. BMC Musculoskelet Disord 2025;26:439. DOI: 10.1186/s12891-025-08698-6.
  13. Pala E, Trono M, Bitonti A, Lucidi G. Hip hemiarthroplasty for femur neck fractures: Minimally invasive direct anterior approach versus postero-lateral approach. Eur J Orthop Surg Traumatol 2016;26:423-7. DOI: 10.1007/s00590-016-1767-x.
  14. Kang JS, Moon KH, Kim BS, Yang SJ. Topical administration of tranexamic acid in hip arthroplasty. Int Orthop 2017;41:259-63. DOI: 10.1007/s00264-016-3195-2.
  15. Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br 2006;88:1053-9. DOI: 10.1302/0301-620X.88B8.17534.
  16. Guo WJ, Wang JQ, Zhang WJ, Wang WK, Xu D, Luo P. Hidden blood loss and its risk factors after hip hemiarthroplasty for displaced femoral neck fractures: A cross-sectional study. Clin Interv Aging 2018;13:1639-45. DOI: 10.2147/CIA.S174196.
  17. Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004;86:561-5.
  18. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery 1962;51:224-32.
  19. Gross JB. Estimating allowable blood loss: Corrected for dilution. Anesthesiology 1983;58:277-80. DOI: 10.1097/00000542-198303000-00016.
  20. Morrell AT, Lindsay SE, Schabel K, Parker MJ, Griffin XL. Surgical approaches for inserting hemiarthroplasty of the hip in people with hip fractures. Cochrane Database Syst Rev 2025;6:CD016031. DOI: 10.1002/14651858.CD016031.
  21. van den Bekerom MP, Hilverdink EF, Sierevelt IN, Reuling EM, Schnater JM, Bonke H, et al. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: A randomised controlled multicentre trial in patients aged 70 years and over. J Bone Joint Surg Br 2010;92:1422-8. DOI: 10.1302/0301-620X.92B10.24899.
  22. Suarez JC, Arguelles W, Saxena A, Rivera P, Parris D, Veledar E. Hemiarthroplasty vs total hip arthroplasty for femoral neck fractures: 2010-2017 Trends in complication rates. J Arthroplasty 2020;35:S262-7. DOI: 10.1016/j.arth.2020.02.040.
  23. Lee C, Freeman R, Edmondson M, Rogers BA. The efficacy of tranexamic acid in hip hemiarthroplasty surgery: An observational cohort study. Injury 2015;46:1978-82. DOI: 10.1016/j.injury.2015.06.039.
  24. Lawrence VA, Silverstein JH, Cornell JE, Pederson T, Noveck H, Carson JL. Higher Hb level is associated with better early functional recovery after hip fracture repair. Transfusion 2003;43:1717-22. DOI: 10.1046/j.0041-1132.2003.00581.x.
  25. Micicoi G, de Geofroy B, Chamoux J, Ghabi A, Gauci MO, Bernard de Dompsure R, et al. Total blood loss after hip hemiarthroplasty for femoral neck fracture: Anterior versus posterior approach. Orthop Traumatol Surg Res 2024;110:103911. DOI: 10.1016/j.otsr.2024.103911.
  26. Xu K, Anwaier D, He R, Zhang X, Qin S, Wang G, et al. Hidden blood loss after hip hemiarthroplasty using the superPATH approach: A retrospective study. Injury 2019;50:2282-6. DOI: 10.1016/j.injury.2019.10.013.
  27. Miao K, Ni S, Zhou X, Xu N, Sun R, Zhuang C, et al. Hidden blood loss and its influential factors after total hip arthroplasty. J Orthop Surg Res 2015;10:36. DOI: 10.1186/s13018-015-0185-9.
  28. Pattison E, Protheroe K, Pringle RM, Kennedy AC, Dick WC. Reduction in haemoglobin after knee joint surgery. Ann Rheum Dis 1973;32:582-4. DOI: 10.1136/ard.32.6.582.
  29. Karkouti K, Callum JL, Acker JP, Yip P, Rao V. Red Cell transfusion-associated hemolysis in cardiac surgery: An observational cohort study. Anesth Analg 2017;124:1986-91. DOI: 10.1213/ANE.0000000000001807.
  30. Lou L, Xu L, Wang X, Xia C, Dai J, Hu L. Comprehensive assessment of risk factors and development of novel predictive tools for perioperative hidden blood loss in intertrochanteric femoral fractures: A multivariate retrospective analysis. Eur J Med Res 2024;29:626. DOI: 10.1186/s40001-024-02244-1.
  31. Zhu J, Hu H, Deng X, Cheng X, Li Y, Chen W, et al. Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty. Int Orthop 2022;46:1637-45. DOI: 10.1007/s00264-022-05347-8.
  32. Markl-Le Levé A, Haller I, Bachler M. Fluid management in hemorrhagic shock. Curr Opin Anaesthesiol 2025;38:316-22. DOI: 10.1097/ACO.0000000000001481.
  33. Tan Y, Jiang L, Liu H, Pan Z, Wang H, Chen L. The effect of preoperative hypoalbuminemia on complications after primary hip arthroplasty. J Orthop Surg Res 2021;16:562. DOI: 10.1186/s13018-021-02702-0.
  34. Garcia-Martinez R, Caraceni P, Bernardi M, Gines P, Arroyo V, Jalan R. Albumin: Pathophysiologic basis of its role in the treatment of cirrhosis and its complications. Hepatology 2013;58:1836-46. DOI: 10.1002/hep.26338.
  35. Venker BT, Ganti BR, Lin H, Lee ED, Nunley RM, Gage BF. Safety and efficacy of new anticoagulants for the prevention of venous thromboembolism after hip and knee arthroplasty: A meta-analysis. J Arthroplasty 2017;32:645- 52. DOI: 10.1016/j.arth.2016.09.033.
  36. Xie J, Hu Q, Ma J, Huang Q, Pei F. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss and the inflammatory response following enhancedrecovery primary total hip arthroplasty: A andomised clinical trial. Bone Joint J 2017;99-B:1442-9. DOI: 10.1302/0301-620X.99B11.BJJ-2017-0488.R1.