Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty. A total of 9482 patients (3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement) were evaluated prospectively from September 1996 through June 1997. Of those patients, 4409 (46 percent [57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement]) had a blood transfusion. Two thousand eight hundred and ninety patients (66 percent) received autologous blood, and 1519 patients (34 percent) received allogenic blood. Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood. Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood; however, inefficiencies in the procedures for obtaining autologous blood were identified. Sixty-one percent (5741) of the patients had predonated blood for autologous transfusion, but 4464 (45 percent) of the 9920 units of the predonated autologous blood were not used. Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units. Of the 5741 patients who had predonated blood, 503 (9 percent) needed a transfusion of allogenic blood. The frequency of allogenic blood transfusion varied with respect to the type of operative procedure (revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions) and with a baseline hemoglobin level of 130 grams per liter or less. Transfusion of allogenic blood was also associated with infection (p = 0.001), fluid overload (p = 0.001), and increased duration of hospitalization (p = 0.01). These latter findings warrant further evaluation in controlled studies.