Effect of preoperative lower-limb muscle strength on perioperative blood loss and early outcomes in total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Hang ¹ , ZHU Kejia ¹ , ZHANG Hui ¹ , WANG Junqing ¹ , WANG Biao ² ,  NIE Yong ¹ ,  SHEN Bin ¹

1. Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;
2. West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding?author：

NIE Yong, Email: nieyong1983@wchscu.cn; SHEN Bin, Email: shenbin_1971@163.com

Keywords：

Total knee arthroplasty; lower-limb muscle strength; perioperative blood loss; early outcomes

DOI：

10.7507/1002-1892.202512049

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Objective To investigate the effect of preoperative lower-limb muscle strength on perioperative blood loss, postoperative pain, and functional recovery in patients undergoing total knee arthroplasty (TKA).Methods A retrospective analysis was conducted on the clinical data of 380 patients who underwent TKA and met the selection criteria between February 2023 and December 2024. Based on the gender-specific median of standardized preoperative lower-limb extensor isokinetic muscle strength (IMS), the patients were divided into a low-extensor strength group and a high-extensor strength group, with 190 cases in each group. The following data of the two groups were collected and compared, including age, gender, body mass index, comorbidities, surgical side, length of hospital stay, Kellgren-Lawrence grade, perioperative parameters [including hematocrit (Hct) and hemoglobin (Hb) levels within 1 week preoperatively and 2-3 days postoperatively, with the calculation of Hct loss and Hb loss (the difference between the pre- and post-operative measurements), and whether intraoperative allogeneic blood transfusion was performed], preoperative knee flexion and extension IMS, 5-time sit-to-stand (5-STS) test within 2 weeks preoperatively, as well as visual analogue scale (VAS) score for pain and active range of motion (AROM) within 2 weeks preoperatively and 1 day postoperatively. Pearson correlation analysis was used to analyze the correlation between preoperative lower-limb extensor IMS and TBL. Through multiple linear regression analysis, the effect of IMS on TBL was further explored after adjusting for confounding factors such as age, body mass index, hypertension, diabetes mellitus, coronary atherosclerotic heart disease, and chronic obstructive pulmonary disease. Results There was no significant difference between the two groups in age, gender, body mass index, surgical side, Kellgren-Lawrence grade, comorbidities, length of hospital stay, preoperative Hct and Hb levels, intraoperative allogeneic blood transfusion rate, and changes in VAS scores (P>0.05). The high-extensor strength group was superior to the low-extensor strength group in preoperative VAS scores, AROM, 5-STS, as well as postoperative Hct and Hb loss, and the changes of AROM and TBL were less than those in the low-extensor strength group, with all differences being significant (P<0.05). Pearson correlation analysis showed a negative correlation between preoperative lower-limb extensor IMS and TBL (r=–0.460, P=0.043). Multiple linear regression analysis showed that after adjustment, a lower TBL was associated with a higher preoperative lower-limb extensor IMS. Specifically, for every 1 N·m increase in preoperative lower-limb extensor IMS, TBL decreased by 9.973 mL. TBL was not significantly affected by other factors such as age, body mass index, and comorbidities. Conclusion Higher preoperative lower-limb muscle strength is associated with reduced intraoperative blood loss during TKA and improved postoperative pain relief and functional recovery. These findings highlight the critical role of preoperative muscle strength management, providing scientific evidence for designing standardized postoperative rehabilitation protocols and offering guidance for optimizing surgical timing to maximize recovery outcomes.

Citation： LI Hang, ZHU Kejia, ZHANG Hui, WANG Junqing, WANG Biao, NIE Yong, SHEN Bin. Effect of preoperative lower-limb muscle strength on perioperative blood loss and early outcomes in total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(4): 533-539. doi: 10.7507/1002-1892.202512049 Copy

1.	Liddle AD, Pegg EC, Pandit H. Knee replacement for osteoarthritis. Maturitas, 2013, 75(2): 131-136.
2.	Smilowitz NR, Oberweis BS, Nukala S, et al. Association between anemia, bleeding, and transfusion with long-term mortality following noncardiac surgery. Am J Med, 2016, 129(3): 315-323.
3.	Liu X, Zhang X, Chen Y, et al. Hidden blood loss after total hip arthroplasty. J Arthroplasty, 2011, 26(7): 1100-5. e1. doi: 10.1016/j.arth.2010.11.013.
4.	Lasocki S, Krauspe R, von Heymann C, et al. PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: a multicentre, observational study. Eur J Anaesthesiol, 2015, 32(3): 160-167.
5.	Koh IJ, Choi YJ, Kim MS, et al. Femoral nerve block versus adductor canal block for analgesia after total knee arthroplasty. Knee Surg Relat Res, 2017, 29(2): 87-95.
6.	Churchill L, John Bade M, Koonce RC, et al. The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review. Osteoarthr Cartil Open, 2023, 6(1): 100429. doi: 10.1016/j.ocarto.2023.100429.
7.	Chen TP, Chen YM, Jiao JB, et al. Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res, 2017, 12(1): 11. doi: 10.1186/s13018-017-0512-4.
8.	Chen S, Li J, Peng H, et al. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop, 2014, 38(2): 355-359.
9.	Stocks GW, Odoemene M, Gex J, et al. Quadriceps strain and TKA: Contribution of the tourniquet and intramedullary rod to postoperative thigh pain: A Randomized controlled trial. J Bone Joint Surg (Am), 2023, 105(6): 455-461.
10.	Hsu LI, Hsu HW, Chen JW, et al. The safety of tranexamic acid administration in total knee arthroplasty: a population-based study from Taiwan. Anaesthesia, 2023, 78(3): 303-314.
11.	Liao L, Chen Y, Tang Q, et al. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis. Int J Surg, 2018, 52: 334-341.
12.	Do K, Vachirakorntong B, Kawana E, et al. The use of bone wax in hemostatic control for total knee and hip arthroplasties: A systematic review. J Clin Med, 2024, 13(10): 2752. doi: 10.3390/jcm13102752.
13.	Dragosloveanu S, Dragosloveanu C, Petre M, et al. The impact of tourniquet usage on TKA outcome: A single-center prospective trial. Medicina (Kaunas), 2023, 59(5): 870. doi: 10.3390/medicina59050870.
14.	Domínguez-Navarro F, Silvestre-Mu?oz A, Igual-Camacho C, et al. A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 838-848.
15.	Husted RS, Juhl C, Troelsen A, et al. The relationship between prescribed pre-operative knee-extensor exercise dosage and effect on knee-extensor strength prior to and following total knee arthroplasty: a systematic review and meta-regression analysis of randomized controlled trials. Osteoarthritis Cartilage, 2020, 28(11): 1412-1426.
16.	Reeve TE, Craven TE, Goldman MP, et al. Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease. J Vasc Surg, 2021, 73(1): 250-257.
17.	Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18.	Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
19.	Wang XF, Ma ZH, Teng XR. Isokinetic strength test of muscle strength and motor function in total knee arthroplasty. Orthop Surg, 2020, 12(3): 878-889.
20.	Knight K, Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. Philadelphia: Lippincott Williams & Wilkins, 2012: 125-128.
21.	Aplin AC, Nicosia RF. Tissue oxygenation stabilizes neovessels and mitigates hemorrhages in human atherosclerosis-induced angiogenesis. Angiogenesis, 2023, 26(1): 63-76.
22.	de Vries MR, Parma L, Peters HAB, et al. Blockade of vascular endothelial growth factor receptor 2 inhibits intraplaque haemorrhage by normalization of plaque neovessels. J Intern Med, 2019, 285(1): 59-74.
23.	Hiyama Y, Kamitani T, Wada O, et al. Effects of group-based exercise on range of motion, muscle strength, functional ability, and pain during the acute phase after total knee arthroplasty: A controlled clinical trial. J Orthop Sports Phys Ther, 2016, 46(9): 742-748.
24.	Mizner RL, Petterson SC, Stevens JE, et al. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol, 2005, 32(8): 1533-1539.
25.	AL-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Relat Res, 2002(396): 152-162.
26.	Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther, 2005, 35(7): 424-436.
27.	Lord SR, Murray SM, Chapman K, et al. Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. J Gerontol A Biol Sci Med Sci, 2002, 57(8): M539-M543.
28.	Zhang H, Wang J, Wang B, et al. Effect of lower-limb isokinetic muscle strengthening on knee function and joint contact force in knee osteoarthritis patients awaiting total knee arthroplasty: study protocol for a randomized controlled trial. J Orthop Surg Res, 2024, 19(1): 677. doi: 10.1186/s13018-024-05125-9.
29.	Fielden JM, Cumming JM, Horne JG, et al. Waiting for hip arthroplasty: economic costs and health outcomes. J Arthroplasty, 2005, 20(8): 990-997.
30.	Mizner RL, Petterson SC, Stevens JE, et al. Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg (Am), 2005, 87(5): 1047-1053.
31.	Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part Ⅱ: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage, 2008, 16(2): 137-162.
32.	Zhang H, Shuai T, Wang J, et al. Relationship between 2 years of muscle strength decrease and volume loss of menisci and cartilage according to knee pain in mild and moderate knee osteoarthritis. Am J Phys Med Rehabil, 2024, 104(1): 1-7.
33.	Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage, 2019, 27(11): 1578-1589.
34.	Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth, 2016, 117(suppl 3): iii62-iii72.
35.	Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS^?) Society recommendations. Acta Orthop, 2020, 91(1): 3-19.
36.	Morrell AT, Layon DR, Scott MJ, et al. Enhanced recovery after primary total hip and knee arthroplasty: A systematic review. J Bone Joint Surg (Am), 2021, 103(20): 1938-1947.

1. Liddle AD, Pegg EC, Pandit H. Knee replacement for osteoarthritis. Maturitas, 2013, 75(2): 131-136.
2. Smilowitz NR, Oberweis BS, Nukala S, et al. Association between anemia, bleeding, and transfusion with long-term mortality following noncardiac surgery. Am J Med, 2016, 129(3): 315-323.
3. Liu X, Zhang X, Chen Y, et al. Hidden blood loss after total hip arthroplasty. J Arthroplasty, 2011, 26(7): 1100-5. e1. doi: 10.1016/j.arth.2010.11.013.
4. Lasocki S, Krauspe R, von Heymann C, et al. PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: a multicentre, observational study. Eur J Anaesthesiol, 2015, 32(3): 160-167.
5. Koh IJ, Choi YJ, Kim MS, et al. Femoral nerve block versus adductor canal block for analgesia after total knee arthroplasty. Knee Surg Relat Res, 2017, 29(2): 87-95.
6. Churchill L, John Bade M, Koonce RC, et al. The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review. Osteoarthr Cartil Open, 2023, 6(1): 100429. doi: 10.1016/j.ocarto.2023.100429.
7. Chen TP, Chen YM, Jiao JB, et al. Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res, 2017, 12(1): 11. doi: 10.1186/s13018-017-0512-4.
8. Chen S, Li J, Peng H, et al. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop, 2014, 38(2): 355-359.
9. Stocks GW, Odoemene M, Gex J, et al. Quadriceps strain and TKA: Contribution of the tourniquet and intramedullary rod to postoperative thigh pain: A Randomized controlled trial. J Bone Joint Surg (Am), 2023, 105(6): 455-461.
10. Hsu LI, Hsu HW, Chen JW, et al. The safety of tranexamic acid administration in total knee arthroplasty: a population-based study from Taiwan. Anaesthesia, 2023, 78(3): 303-314.
11. Liao L, Chen Y, Tang Q, et al. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis. Int J Surg, 2018, 52: 334-341.
12. Do K, Vachirakorntong B, Kawana E, et al. The use of bone wax in hemostatic control for total knee and hip arthroplasties: A systematic review. J Clin Med, 2024, 13(10): 2752. doi: 10.3390/jcm13102752.
13. Dragosloveanu S, Dragosloveanu C, Petre M, et al. The impact of tourniquet usage on TKA outcome: A single-center prospective trial. Medicina (Kaunas), 2023, 59(5): 870. doi: 10.3390/medicina59050870.
14. Domínguez-Navarro F, Silvestre-Mu?oz A, Igual-Camacho C, et al. A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 838-848.
15. Husted RS, Juhl C, Troelsen A, et al. The relationship between prescribed pre-operative knee-extensor exercise dosage and effect on knee-extensor strength prior to and following total knee arthroplasty: a systematic review and meta-regression analysis of randomized controlled trials. Osteoarthritis Cartilage, 2020, 28(11): 1412-1426.
16. Reeve TE, Craven TE, Goldman MP, et al. Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease. J Vasc Surg, 2021, 73(1): 250-257.
17. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
19. Wang XF, Ma ZH, Teng XR. Isokinetic strength test of muscle strength and motor function in total knee arthroplasty. Orthop Surg, 2020, 12(3): 878-889.
20. Knight K, Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. Philadelphia: Lippincott Williams & Wilkins, 2012: 125-128.
21. Aplin AC, Nicosia RF. Tissue oxygenation stabilizes neovessels and mitigates hemorrhages in human atherosclerosis-induced angiogenesis. Angiogenesis, 2023, 26(1): 63-76.
22. de Vries MR, Parma L, Peters HAB, et al. Blockade of vascular endothelial growth factor receptor 2 inhibits intraplaque haemorrhage by normalization of plaque neovessels. J Intern Med, 2019, 285(1): 59-74.
23. Hiyama Y, Kamitani T, Wada O, et al. Effects of group-based exercise on range of motion, muscle strength, functional ability, and pain during the acute phase after total knee arthroplasty: A controlled clinical trial. J Orthop Sports Phys Ther, 2016, 46(9): 742-748.
24. Mizner RL, Petterson SC, Stevens JE, et al. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol, 2005, 32(8): 1533-1539.
25. AL-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Relat Res, 2002(396): 152-162.
26. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther, 2005, 35(7): 424-436.
27. Lord SR, Murray SM, Chapman K, et al. Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. J Gerontol A Biol Sci Med Sci, 2002, 57(8): M539-M543.
28. Zhang H, Wang J, Wang B, et al. Effect of lower-limb isokinetic muscle strengthening on knee function and joint contact force in knee osteoarthritis patients awaiting total knee arthroplasty: study protocol for a randomized controlled trial. J Orthop Surg Res, 2024, 19(1): 677. doi: 10.1186/s13018-024-05125-9.
29. Fielden JM, Cumming JM, Horne JG, et al. Waiting for hip arthroplasty: economic costs and health outcomes. J Arthroplasty, 2005, 20(8): 990-997.
30. Mizner RL, Petterson SC, Stevens JE, et al. Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg (Am), 2005, 87(5): 1047-1053.
31. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part Ⅱ: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage, 2008, 16(2): 137-162.
32. Zhang H, Shuai T, Wang J, et al. Relationship between 2 years of muscle strength decrease and volume loss of menisci and cartilage according to knee pain in mild and moderate knee osteoarthritis. Am J Phys Med Rehabil, 2024, 104(1): 1-7.
33. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage, 2019, 27(11): 1578-1589.
34. Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth, 2016, 117(suppl 3): iii62-iii72.
35. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS^?) Society recommendations. Acta Orthop, 2020, 91(1): 3-19.
36. Morrell AT, Layon DR, Scott MJ, et al. Enhanced recovery after primary total hip and knee arthroplasty: A systematic review. J Bone Joint Surg (Am), 2021, 103(20): 1938-1947.

Chinese Journal of Reparative and Reconstructive Surgery

Effect of preoperative lower-limb muscle strength on perioperative blood loss and early outcomes in total knee arthroplasty

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