探讨初次全膝关节置换术后隐性失血与溶血的相关性研究。

回顾性分析2015年7月至2015年12月在四川大学华西医院行初次全膝关节置换术的患者。纳入标准为膝关节重度骨关节炎、血沉及C-反应蛋白正常、24 h补液总量不超过2 000 ml的患者；排除非膝关节骨关节炎、有血液性疾病及自身免疫性疾病、体内有活动性感染灶、有深静脉血栓及肺栓塞以及病历资料不完整的患者。共有93例骨患者纳入本研究，其中男43例，女50例；年龄58～79岁，平均(67±9)岁。分别记录所有患者术前与术后1、3 d的血红蛋白(Hb)、红细胞压积(HCT)、结合珠蛋白，直接胆红素、间接胆红素及膝关节上、下周径。同时，根据Gross方程计算围术期总失血量，比较术后引流量；显微镜下观察术前与术后外周血涂片的变化(Wright染色)，根据术后第5天双下肢静脉彩超结果判断术后深静脉血栓及肌间静脉血栓发生率，记录患者术后皮下瘀斑发生率。计量资料符合正态分布的，组间比较采用配对t检验；计数资料行卡方检验。

93例患者均获得随访，随访时间1～3个月，平均(1.6±0.8)个月。研究结果发现：术后1、3 d HB值及HCT值明显高于术前，差异有统计学意义(t＝2.384、2.681、0.305、0.429，P均<0.05)；术后结合珠蛋白呈上升趋势，术后3 d相比术前具有统计学差异(t＝9.284，P<0.05)；术后1、3 d直接胆红素相比术前差异有统计学意义(t＝1.357、2.316，P均<0.05)，但是间接胆红素差异无统计学意义(t＝2.449、2.514，P均>0.05)；术后1、3 d膝上、下周径明显高于术前，差异具有统计学意义(t＝1.882、1.937、2.362、2.294，P<0.05)。围手术期总失血量为(979±192)ml,引流量为(165±41)ml；显微镜下观察术后外周血涂片的红细胞形态及大小较术前无明显变化，破碎的红细胞发生较少。术后有8例肌间静脉血栓，无深静脉血栓发生。17例发生皮下瘀斑。

术后隐性失血的原因主要与围手术期血液大量进入组织间隙以及积留在关节腔内有关，因溶血方面所造成的影响较小。

To analyze the correlation of hemolysis with hidden blood loss after primary TKA.

A total of 93 patients with primary total knee arthroplasty were retrospectively analyzed from the July 2015 to December 2015 in West China Hospital of Sichuan University. The inclusion criteria were patients with severe osteoarthritis of the knee, normal blood sedimentation and C-reactive protein values, and total fluid volume not exceeding 2 000 ml in 24 h. Patients with non-knee osteoarthritis, hematologic and autoimmune diseases, infection, deep vein thrombosis, pulmonary embolism and incomplete medical records were excluded. There were 43 males and 50 were females with an average age of(67±9)years (range, 58-79 years). Hemoglobin (Hb), hematocrit (HCT), haptoglobin, direct bilirubin, indirect bilirubin, peripheral blood picture, the upper and lower knee circumferences were compared respectively on the preoperative and postoperative day 1 and day 3. The perioperative blood loss according to the Gross equation was calculated. Based on the results of a double venous ultrasound performed on postoperative day 5, the incidences of deep vein thrombosis and calf muscular venous thrombosis were evaluated. The postoperative drainage and the incidence of subcutaneous ecchymosis were also measured, and using the microscope to observe changes in preoperative and postoperative peripheral blood pictures (Wright staining). The differences between the two groups were compared by paired t-test. The categorical variables were compared using chi-square test.

All the patients were followed up for one to three months, and the average follow-up time was (1.6±0.8) months. Values of Hb and HCT on postoperative day 1 and day 3 were significantly higher than the preoperative ones (t=2.384, 2.681, 0.305, 0.429, all P<0.05). Postoperative haptoglobin level compared with preoperative one showed a rising trend, and the difference between the data of postoperative day 3 and the preoperative period was statistically significant(t=9.284, P<0.05). The direct bilirubin on postoperative day 1 and day 3 were significantly higher than the preoperative period (t=1.357, 2.316, all P<0.05), but there was no statistically significant difference in indirect bilirubin (t=2.449, 2.514, all P>0.05). The upper and lower knee circumferences on postoperative day 1 and day 3 were significantly higher than the preoperative ones (t=1.882, 1.937, 2.362, 2.294, all P<0.05). The total blood loss and drainage respectively were (979±192) ml and (165±41) ml. There was no obvious difference in the red blood cell morphology, size nor broken red blood cells was observed in the postoperative peripheral blood erythrocyte compared with the preoperative period. There were 17 cases of postoperative subcutaneous ecchymosis, eight cases of calf muscular venous thrombosis, and no deep vein thrombosis occurred.

The reasons for hidden blood loss mainly relate to a large number of perioperative blood gathered in the tissue space and joint cavity, and the effect of hemolysis is small.