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Background: Allogenic blood transfusions increase the risk of multiple complications. We evaluated the influence of restricting transfusions in adults with osteoarthritis that underwent total hip or knee arthroplasty (THA/TKA) with severe postoperative anemia. Material and methods: Patients that underwent THA/TKA for osteoarthritis with postoperative hemoglobin (Hb) ≤ 8 g/dl were retrospectively identified. We evaluated characteristics and adverse postoperative outcomes of patients not transfused and compared them to those of patients who received postoperative transfusion. Adverse outcomes were 90-day readmission, reoperation, infection, and falls, as well as inpatient cardiovascular events and deaths. Results: One thousand eighty-seven patients meeting inclusion criteria underwent THA and TKA. The 399 patients (36.7%) who did not undergo transfuion were younger (67.4 vs 69.5 years, P = .008), healthier (American Society of Anesthesiologist ≤ 2: 64.2% vs 56%, P = .006), comprised a lower proportion of cardiovascular disease patients (13.8% vs 24.7%, P < .001), a lower proportion of patients with Medicare/Medicare Managed Care (57.2% vs 65.5%, P = .05), received tranexamic acid more frequently (66.4% vs 52.9%, P < .01), had a shorter procedure time (92.7 vs 103.1, P < .01), a lower postoperative drop in Hb (4.0 vs 4.2 g/dl, P = .022), a later drop in Hb (2.6 vs 2.2 days, P = .003), and a shorter length of stay (3.5 vs 4.8, P < .01). TKA patients underwent transfusion more frequently than THA patients (67.5% vs 59%, P = .004). There were no postoperative deaths. Adverse events were similar between the 2 groups. Conclusion: Findings suggest that younger and healthier patients that have lower Hb later during their hospital stay need not undergo transfusion solely based on Hb levels. Routine transfusion triggers can be avoided even in more anemic patients.