Low-dose erythropoietin in anemic arthroplasty patients within contemporary patient blood management pathways.

Preoperative anemia remains a major determinant of transfusion risk in total joint arthroplasty (TJA), even within contemporary patient blood management (PBM) pathways. Although erythropoietin (EPO) increases preoperative hemoglobin (Hb) levels, its role in modern low-transfusion arthroplasty practice remains debated. This study evaluated the real-world effectiveness of a selective, low-dose preoperative EPO protocol in anemic patients undergoing TJA within a comprehensive PBM program. We retrospectively analyzed 2462 primary TJA procedures performed between 2013 and 2024 and identified 188 patients with baseline Hb < 12 g/dL. Of these, 80 received low-dose EPO and 108 served as controls. The EPO regimen consisted of two weekly subcutaneous injections of 20,000 IU administered preoperatively, combined with oral iron supplementation. All patients were managed under a standardized PBM protocol. The primary outcome was the bleeding index at postoperative day 7 (BI-7), defined as the sum of Hb decline between admission and postoperative day 7 and the number of transfused red-blood-cell units. Patients receiving EPO had lower baseline Hb levels than controls (10.9 vs. 11.5 g/dL). EPO treatment increased preoperative Hb by a mean of 1.3 g/dL and resulted in higher Hb levels at hospital admission, postoperative day 1, and postoperative day 7. No blood transfusions were administered during the observation period. BI-7 values were low and comparable between groups (2.1 vs. 2.3; p = 0.30). No thromboembolic events were observed. Within a contemporary PBM framework, selective low-dose preoperative EPO safely optimized perioperative Hb levels and was associated with a transfusion-free perioperative course despite higher baseline hematologic risk. These findings suggest that modern low-transfusion PBM strategies can be effectively extended to selected anemic arthroplasty patients by improving preoperative Hb reserve.