全髋关节置换术围术期失血量的相关影响因素分析

Analysis of Associated Risk Factors for Perioperative Blood Loss in Total Hip Arthroplasty

摘要: 目的：髋关节置换术(THA)围术期贫血将影响术后康复并延长住院时间。血液管理越来越受到重视，以尽量减少THA患者围术期的总失血量(TBL)，促进患者快速康复。近期有研究显示，腹主动脉钙化可能是影响围手术期失血的独立影响因素。心脑血管疾病在THA患者中尤为常见，本研究旨在探究THA围术期失血量的潜在独立影响因素以及心脑血管疾病是否为其中之一。方法：回顾性纳入2024年1月至2025年3月期间于青岛大学附属医院行初次单侧全髋关节置换术的患者。收集患者的人口统计学信息以及术前1周内的骨密度(BMD)测量结果，测量部位包括：股骨颈、Ward’s三角区、大转子以及腰椎，并记录患者是否合并心脑血管疾病，计算围手术期总出血量(TBL)，我们将术后24 h出血量 ≤ 20%总血容量(TBV)的患者纳入A组，其余患者(出血量 > 20%总血容量)纳入B组。我们分析了与TBL相关的因素并采用多重线性回归和逐步回归分析其独立影响因素。结果：本研究共纳入87名患者，平均术后24 h出血量为(890.4 ± 367.1) ml。A组平均年龄(66.3 ± 7.5)岁，显著大于B组(57.9 ± 9.9)岁(P < 0.001)；与A组相比，B组患者术前红细胞压积(HCT) (P < 0.001)、术前血红蛋白(HGB) (P = 0.002)、术前红细胞(RBC) (P = 0.002)较高，而术前血沉(ESR) (P = 0.03)较低。两组患者股骨以及腰椎骨密度T值无统计学差异。我们发现体重指数(BMI)、年龄、手术时间、TBV、HCT、HGB、RBC、ESR、D-二聚体与TBL有显著相关性(P < 0.05)，其中年龄(r = −0.488, P < 0.001)、ESR (r = −0.291, P = 0.006)、D-二聚体(r = −0.294, P = 0.006)与TBL呈负相关性；在骨密度中，股骨参数(包括股骨颈、Ward’s三角以及股骨大转子的T值)与TBL无显著相关性，而腰椎参数与TBL有显著相关性(r = 0.231, P = 0.031)。根据多重线性回归的结果，我们发现手术时间(β = 0.205, P = 0.022)、年龄(β = −0.344, P < 0.001)以及心脑血管病史(β = −0.146, P = 0.036)是TBL的独立影响因素，然而并未观察到骨密度指标腰椎T值(β = 0.159, P = 0.084)与TBL有显著性关联。结论：年龄、心脑血管病史以及手术时间为全髋关节置换术围术期出血量的独立影响因素，骨密度并未对全髋关节置换术围术期出血量产生显著影响。本研究将为高龄且合并心血管病史的THA患者围术期血液管理提供参考。

Abstract: Objective: Perioperative anemia in total hip arthroplasty (THA) affects postoperative recovery and prolongs hospital stay. Blood management is increasingly emphasized to minimize total blood loss (TBL) during the perioperative period in THA patients and promote rapid recovery. Recent studies suggest that abdominal aortic calcification may be an independent factor influencing perioperative blood loss. Cardiovascular and cerebrovascular diseases are particularly common in THA patients. This study aims to explore potential independent factors influencing perioperative blood loss in THA, including whether cardiovascular and cerebrovascular diseases are among them. Methods: Patients undergoing primary unilateral THA at the Affiliated Hospital of Qingdao University between January 2024 and March 2025 were retrospectively enrolled. Demographic data and bone mineral density (BMD) measurements taken within one week preoperatively at the femoral neck, Ward’s triangle, greater trochanter, and lumbar spine were collected. The presence of cardiovascular and cerebrovascular diseases was recorded. Total perioperative blood loss (TBL) was calculated. Patients with postoperative 24-hour blood loss ≤ 20% of total blood volume (TBV) were assigned to Group A; the remaining patients (blood loss > 20% TBV) were assigned to Group B. Factors associated with TBL were analyzed, and multiple linear regression with stepwise selection was used to identify independent influencing factors. Results: A total of eighty-seven patients were enrolled in this study. The mean postoperative 24-hour blood loss was (890.4 ± 367.1) ml. The mean age of Group A (66.3 ± 7.5 years) was significantly higher than that of Group B (57.9 ± 9.9 years) (P < 0.001). Compared to Group A, Group B had significantly higher preoperative hematocrit (HCT) (P < 0.001), hemoglobin (HGB) (P = 0.002), and red blood cell count (RBC) (P = 0.002), but significantly lower preoperative erythrocyte sedimentation rate (ESR) (P = 0.03). There were no significant differences in femoral or lumbar spine BMD T-scores between the groups. We found that body mass index (BMI), age, operative time, TBV, HCT, HGB, RBC, ESR, and D-dimer showed significant correlations with TBL (P < 0.05). Among these, age (r = −0.488, P < 0.001), ESR (r = −0.291, P = 0.006), and D-dimer (r = −0.294, P = 0.006) were negatively correlated with TBL. Regarding BMD, femoral parameters (T-scores for femoral neck, Ward’s triangle, and greater trochanter) showed no significant correlation with TBL, while the lumbar spine parameter did (r = 0.231, P = 0.031). Multiple linear regression analysis identified operative time (β = 0.205, P = 0.022), age (β = −0.344, P < 0.001), and history of cardiovascular/cerebrovascular disease (β = −0.146, P = 0.036) as independent influencing factors for TBL. However, the lumbar spine BMD T-score (β = 0.159, P = 0.084) did not show a significant association with TBL. Conclusion: Age, history of cardiovascular/cerebrovascular disease, and operative time are independent factors influencing perioperative blood loss in THA. Bone mineral density did not significantly affect perioperative blood loss. This study will provide a reference for perioperative blood management in elderly THA patients with a history of cardiovascular/cerebrovascular disease.