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Joint Diseases and
Related Surgery
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Original Article · Open access

Hidden blood loss in total hip arthroplasty: A comparison of the direct anterior versus posterolateral approach

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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

Yun-jie Wang

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

ORCID: 0009-0009-3656-7985

Xie Jiang

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

ORCID: 0009-0006-8243-8533

Xiao-ke Yao

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

ORCID: 0009-0009-0856-7478

Abstract

Objectives: This study aims to compare the volume and impact of hidden blood loss (HBL) following total hip arthroplasty (THA) performed via the direct anterior approach (DAA) versus the posterolateral approach (PLA).

Patients and methods: Between January 2016 and January 2024, a total of 134 patients (63 males, 71 females; mean age: 69.7 ± 7.7 years; range, 48 to 79 years) who underwent primary THA were retrospectively analyzed. The patients were stratified into two cohorts according to surgical approach: DAA group (n = 63) and PLA group (n = 71). Preoperative blood volume and visible blood loss (VBL) were quantified for both cohorts. Total blood loss (TBL) was derived from hematocrit (Hct) levels measured preoperatively and on postoperative Day 3, which subsequently allowed calculation of HBL and its proportion relative to TBL. Intergroup comparisons were performed for these parameters.

Results: The most common etiology for THA was hip osteoarthritis. The mean operative time was 120.4 ± 10.2 min in the DAA group and 117.7 ± 8.2 min in the PLA group, indicating no statistically significant difference between the two groups (p = 0.093). The mean TBL was 366.3 ± 54.3 mL in the DAA group and 477.0 ± 71.6 mL in the PLA group (p < 0.001), while the mean HBL was 206.3 ± 40.4 mL and 318.9 ± 44.9 mL, respectively (p < 0.001). The reductions in Hb and Hct were significantly lower in the DAA group compared to the PLA group (p < 0.001 for both).

Conclusion: During the perioperative period of THA, HBL represents a considerable clinical concern regardless of the surgical approach employed. Compared to the PLA, the DAA is associated with a significant reduction in both HBL and TBL.

Declarations

Author Contributions

J.W.Z.: Wrote the draft of the manuscript, was a major contributor in design and revising; X.K.Y.: Critically reviewed and revised the manuscript for important intellectual content; X.C., Y.J.W., X.J.: Were involved in collecting data and design of the study. 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.

AI Disclosure

The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

References

  1. Learmonth ID, Young C, Rorabeck C. The operation of the century: Total hip replacement. Lancet 2007;370:1508-19. DOI: 10.1016/S0140-6736(07)60457-7.
  2. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: Updated projections to 2021. J Bone Joint Surg Am 2014;96:624-30. DOI: 10.2106/JBJS.M.00285.
  3. Young SW, Marsh DJ, Akhavani MA, Walker CG, Skinner JA. Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: A national survey. Int Orthop 2008;32:325-9. DOI: 10.1007/s00264-007-0330-0.
  4. Kim JL, Park JH, Han SB, Cho IY, Jang KM. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: A meta-analysis. J Arthroplasty 2017;32:320-5. DOI: 10.1016/j.arth.2016.08.026.
  5. Ponnusamy KE, Kim TJ, Khanuja HS. Perioperative blood transfusions in orthopaedic surgery. J Bone Joint Surg Am 2014;96:1836-44. DOI: 10.2106/JBJS.N.00128.
  6. 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.
  7. 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.
  8. Zha GC, Zhu XR, Wang L, Li HW. Tranexamic acid reduces blood loss in primary total hip arthroplasty performed using the direct anterior approach: A one-center retrospective observational study. J Orthop Traumatol 2022;23:12. DOI: 10.1186/s10195-022-00638-7.
  9. Cai L, Chen L, Zhao C, Wang Q, Kang P. Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: A retrospective study. BMC Musculoskelet Disord 2023;24:582. DOI: 10.1186/s12891-023-06716-z.
  10. Bao N, Zhou L, Cong Y, Guo T, Fan W, Chang Z, et al. Free fatty acids are responsible for the hidden blood loss in total hip and knee arthroplasty. Med Hypotheses 2013;81:104-7. DOI: 10.1016/j.mehy.2013.03.038.
  11. Akti S, Zeybek H, Bilekli AB, Çelebi NÖ, Erdem Y, Çankaya D. The effect of tranexamic acid on hidden blood loss in total hip arthroplasty. Jt Dis Relat Surg 2022;33:102-8. DOI: 10.52312/jdrs.2022.446.
  12. Awad ME, Farley BJ, Mostafa G, Saleh KJ. Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty: A metaanalysis of functional outcomes and cost. Bone Joint J 2021;103-B:1078-87. DOI: 10.1302/0301-620X.103B6.BJJ-2020-1271.R1.
  13. You J, Zheng Y, Ruan B, Zheng B, Fan J. Effects of the direct anterior approach and Orthopadisehe Chirurgie Munchen on early joint function after primary hip arthroplasty in young adults. Am J Transl Res 2022;14:2013-20.
  14. Nogler M, Mayr E, Krismer M. The direct anterior approach to the hip revision. Oper Orthop Traumatol 2012;24:153-64. DOI: 10.1007/s00064-011-0113-z.
  15. Gross JB. Estimating allowable blood loss: Corrected for dilution. Anesthesiology 1983;58:277-80. DOI: 10.1097/00000542-198303000-00016.
  16. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery 1962;51:224-32.
  17. Martin CT, Pugely AJ, Gao Y, Clark CR. A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty 2013;28:849-54. DOI: 10.1016/j.arth.2012.10.029.
  18. Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin North Am 2009;40:321-8. DOI: 10.1016/j.ocl.2009.01.003.
  19. Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin North Am 2009;40:321-8. DOI: 10.1016/j.ocl.2009.01.003.
  20. Manhas V, Meena R, Sehrawat S, Lakhtakia A, Gupta V, Pandey S. Direct anterior vs. posterior approach in hip arthroplasty: A systematic review and meta-analysis for Asian demographics. J Clin Orthop Trauma 2025;70:103170. DOI: 10.1016/j.jcot.2025.103170.
  21. Stryker LS, Gilliland JM, Odum SM, Mason JB. Femoral vessel blood flow is preserved throughout direct anterior total hip arthroplasty. J Arthroplasty 2015;30:998-1001. DOI: 10.1016/j.arth.2015.01.012.
  22. Schmitt-Sody M, Pilger V, Gerdesmeyer L. Rehabilitation and sport following total hip replacement. Orthopade 2011;40:513-9. DOI: 10.1007/s00132-011-1761-2.
  23. Yue C, Kang P, Yang P, Xie J, Pei F. Topical application of tranexamic acid in primary total hip arthroplasty: A randomized double-blind controlled trial. J Arthroplasty 2014;29:2452-6. DOI: 10.1016/j.arth.2014.03.032.
  24. Li Y, Yin P, Lv H, Meng Y, Zhang L, Tang P. A metaanalysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty. Ther Clin Risk Manag 2018;14:1191-204. DOI: 10.2147/TCRM.S159134.