# Restrictive versus Liberal blood transfusion strategies for patients undergoing orthopedic surgery: a meta-analysis of randomised trials with trial sequential analysis

## TL;DR

This study compares restrictive and liberal blood transfusion strategies in orthopedic surgery patients, finding that restrictive transfusion increases cardiovascular risks but does not affect other adverse outcomes.

## Contribution

The study provides a meta-analysis and trial sequential analysis to evaluate the effectiveness of blood transfusion strategies in orthopedic surgery.

## Key findings

- Restrictive blood transfusion increases cardiovascular events, particularly myocardial infarction.
- There is no significant difference in infection rates, thrombotic events, mortality, or delirium between transfusion strategies.
- Restrictive transfusion is associated with shorter hospital stays and lower infection rates in joint replacement surgeries.

## Abstract

A meta-analysis was conducted to explore the prognostic differences of restrictive blood transfusion (RBT) versus liberal blood transfusion (LBT) strategies in orthopedic patients.

A comprehensive search was performed in PubMed, Embase, Cochrane Central Register of Controlled Trials, Embase, and clinicaltrials.gov up to 20 October 2024. The quality of included studies was assessed according to Cochrane risk of bias, and quality of evidence was assessed using the GRADE system. We performed sensitivity and publication bias analyses and used trial sequential analysis (TSA) to assess the risk of random error in the analysis results.

19 studies involving 7833 patients were included in the analysis. Compared with LBT, RBT reduced transfusion rate and increased the occurrence of cardiovascular events (RR = 1.44; 95% CI: 1.15–1.80, P = 0.001; I2 = 0%), mainly increased myocardial infarction (RR = 1.70; 95% CI: 1.16–2.48, P = 0.006; I2 = 0%) rather than congestive heart failure. There were no significant differences between transfusion strategies in infection, thrombotic events, mortality, delirium and length of hospitalization. Results of subgroup analyses indicate that in patients at high risk for cardiovascular disease, RBT increases the risk of myocardial infarction and length of hospitalization. In addition, RBT are associated with lower overall infection rates and shorter length of hospitalization after joint replacement or revision surgery; and are associated with an increased risk of myocardial infarction after fracture repair surgery (RR = 1.79; 95% CI: 1.21–2.65, P = 0.004). The TSA results show that transfusion rate and mortality (≥ 60 days) have reached the required information size. However, the evidence regarding the efficacy for the remaining outcomes analyzed remains inconclusive, likely due to insufficient numbers of patients in the existing studies.

Compared with LBT, RBT increases the risk of cardiovascular events in orthopedic patients but does not affect adverse outcomes such as infection, thrombotic events, mortality, and delirium.

No patients were involved in this study.

The online version contains supplementary material available at 10.1186/s13018-025-05883-0.