Analysis of independent risk factors for high hidden blood loss following total knee arthroplasty
Kaige Xu, Weipeng Shi, Tianyu Guo, Jiaqi Dong, Tianlong Gao, Yaping Jiang
Abstract
Hidden blood loss (HBL) constitutes a substantial proportion of total perioperative blood loss after total knee arthroplasty (TKA) and may adversely affect postoperative recovery, yet factors associated with high-level HBL remain insufficiently defined.
Introduction
Knee osteoarthritis (KOA) is the most prevalent musculoskeletal disorder among individuals over 60 years old and represents a leading cause of chronic pain and functional limitation [1–3]. Total knee arthroplasty (TKA) remains the definitive treatment for end-stage KOA, offering substantial pain relief and marked improvement in joint function [4–6].
Materials and methods
This study was conducted at the Affiliated Hospital of Qingdao University, a tertiary referral center for joint arthroplasty. We performed a retrospective observational cohort study to investigate factors associated with HBL following primary unilateral TKA.
Results
All patients successfully underwent surgery without intraoperative complications or the need for postoperative blood transfusion. In the low-HBL group (n = 116), the mean HBL was 330.00 ± 171.67 mL. In the high-HBL group (n = 38), the mean HBL was 972.95 ± 243.29 mL
Discussion
In recent years, HBL has received increasing clinical attention. Multiple studies have confirmed that HBL constitutes a substantial proportion of total perioperative blood loss in orthopedic procedures [26–28]. The magnitude of HBL is influenced by a variety of factors, including patient-specific characteristics, the severity of KOA, surgical technique, and postoperative management.
Conclusion
HBL following TKA represented a clinically significant contributor to perioperative morbidity. This study identified BMI > 26.34 kg/m² as an independent predictor of high HBL and further demonstrated that hypertension was independently associated with an increased risk of high HBL.
Citation: Xu K, Shi W, Guo T, Dong J, Gao T, Jiang Y, et al. (2026) Analysis of independent risk factors for high hidden blood loss following total knee arthroplasty. PLoS One 21(9): e0356264. https://doi.org/10.1371/journal.pone.0356264
Editor: Robert Jeenchen Chen, Stanford University School of Medicine, UNITED STATES OF AMERICA
Received: December 4, 2025; Accepted: August 2, 2026; Published: September 3, 2026
Copyright: © 2026 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was supported by grants from National Natural Science Foundation of China; Grant number: 82272489, 82203588; TaiShan Scholars Project Special Fund; Grant number: NO.tsqn202306396; Qingdao Science and Technology Benefiting the People Demonstration Special Project; Grant number: 24-1-8-smjk-3-nsh. The funding body played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. There was no additional external funding received for this study.
Competing interests: The authors have declared that no competing interests exist.
