Impact of Perioperative Multimodal Blood Management of Bone Tumors of Hip on Early Postoperative Functional Recovery: A Retrospective Cohort Study

Impact of Perioperative Multimodal Blood Management of Bone Tumors of Hip on Early Postoperative Functional Recovery: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Perioperative Multimodal Blood Management of Bone Tumors of Hip on Early Postoperative Functional Recovery: A Retrospective Cohort Study zimin Zhang, yetian Ma, li Chu, wenquan Ding, leyu Zhao, huilin Yang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9059442/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background This study evaluated the efficacy of a perioperative multimodal blood management strategy—combining erythropoietin, iron supplementation, and restrictive transfusion protocols—in patients undergoing surgery for hip bone tumors, to optimize their perioperative care. Methods We conducted a retrospective analysis of 38 patients who underwent hip bone tumor surgery between January 2021 and February 2025. Based on inclusion and exclusion criteria, patients were divided into a control group (n = 24) and a multimodal management group (n = 14). We compared baseline characteristics, preoperative laboratory results, surgical and postoperative data, dynamic hemoglobin changes, FACIT-Fatigue scores, and Harris Hip Scores between the groups. Results Preoperative hemoglobin was lower and surgical duration was longer in the multimodal management group compared to the controls (both p < 0.05). At one month postoperatively, the multimodal group demonstrated significantly greater improvement in both FACIT-Fatigue scores (5.79 ± 2.01 vs. 3.00 ± 0.78, p < 0.05) and Harris Hip Scores (30.57 ± 6.03 vs. 25.25 ± 6.46, p 0.05). Conclusions Despite lower preoperative hemoglobin and more complex surgeries, the multimodal blood management strategy facilitated superior early functional recovery and accelerated rehabilitation at a critical postoperative time point. Bone Tumors of Hip Perioperative Period Multimodal Management Blood Management Functional Recovery Figures Figure 1 INTRODUCTION Surgery for hip bone tumors presents a significant challenge in orthopaedic oncology, with perioperative anemia being a particularly prominent issue. Existing research indicates that these procedures often require extensive soft tissue resection and subsequent bone reconstruction, leading to substantial intraoperative blood loss, typically ranging from 800 to 2200 mL( 1 ).onsequently, over half of these patients develop postoperative anemia. Unlike patients undergoing routine arthroplasty, those with bone tumors, especially malignant forms, frequently present with preoperative anemia. This pre-existing condition may stem from chronic inflammation or myelosuppression induced by chemotherapy. This iatrogenic blood loss, combined with pre-existing anemia, not only prolongs hospitalization but also significantly impedes postoperative functional recovery and diminishes patients' quality of life ( 2 ). Furthermore, studies have indicated a negative correlation between anemia and patient survival rates ( 3 ). Currently, there is no standardized consensus on perioperative blood management specifically for hip bone tumor surgery. The strategies employed are largely adapted from experiences in arthroplasty ( 4 – 6 ).This approach has two main shortcomings. First, it fails to provide individualized protocols tailored to the unique characteristics of oncology patients. Second, there is a lack of validated evidence concerning the optimal timing, appropriate strategies, and overall effectiveness of blood management in this specific patient population. Compared to conventional orthopaedic surgeries like arthroplasty, the field of oncologic hip surgery has yet to develop a systematic blood management protocol, with few relevant studies reported domestically or internationally. This evidence gap significantly lags behind the rapid advancements in the Enhanced Recovery After Surgery (ERAS) philosophy and fails to meet the demands of clinical practice. Therefore, this study aims to systematically evaluate the efficacy of a multimodal blood management strategy in hip tumor surgery. By investigating its clinical significance in mitigating postoperative anemia and promoting functional recovery, we seek to provide a crucial reference for the development of standardized perioperative blood management protocols for patients with hip bone tumors. 1 Materials and Methods 1.1 Patient Selection This single-center retrospective study reviewed 38 patients with hip bone tumors admitted to our hospital between January 2021 and February 2025. Based on the perioperative blood management strategy received, patients were divided into a multimodal management group and a control group. The multimodal management group received any two of the following interventions in combination: iron supplementation, erythropoietin (EPO), and a restrictive transfusion protocol. The control group received no perioperative anemia intervention, or only a single modality (iron supplementation alone, EPO alone, or restrictive transfusion alone). Inclusion criteria were: ( 1 ) age ≥ 18 years; ( 2 ) preoperative hemoglobin levels meeting the following criteria: 70–175 g/L for males, 70–150 g/L for females; ( 3 ) postoperative survival > 3 months; ( 4 ) diagnosis of primary or metastatic hip bone tumor; ( 5 ) underwent hip bone tumor resection (with or without reconstruction). Exclusion criteria were: ( 1 ) severe allergy to blood products, erythropoiesis-stimulating agents, or parenteral iron; ( 2 ) macrocytic anemia; ( 3 ) active infection requiring intravenous antibiotics; ( 4 ) receipt of intravenous iron or EPO therapy within 2 months prior to surgery; ( 5 ) contraindications to blood transfusion or refusal to receive transfusion; ( 6 ) prolonged bedridden status precluding functional assessment; ( 7 ) pregnancy or lactation; ( 8 ) loss to follow-up; ( 9 ) unplanned amputation during surgery. This study was approved by the Medical Ethics Committee of The First Affiliated Hospital of Soochow University. Due to the retrospective nature of the study, which involved only collection of medical records without any intervention, the requirement for informed consent was waived. 1.2 Blood Management Strategy Individualized blood management protocols were developed for patients with hip bone tumors, based on guidelines including the Chinese Expert Consensus on Enhanced Recovery After Surgery for Hip and Knee Arthroplasty: Perioperative Anemia Management and the Chinese Expert Consensus on Enhanced Recovery After Surgery in Orthopedics: Perioperative Blood Management. For all patients, topical application of tranexamic acid (1-3g/100mL normal saline) or hemocoagulase (10U/50mL normal saline) was used on the wound surface during surgery. For patients with anticipated large blood loss or postoperative anemia, EPO 10,000 IU was administered subcutaneously once on the day before surgery, followed by three additional doses of EPO 10,000 IU subcutaneously on alternate days postoperatively. Concurrently, intravenous or oral iron supplementation was provided to replenish hematopoietic raw materials. The specific administration methods and iron dosage calculation formulas were based on the Chinese Expert Consensus on Perioperative Blood Management for Enhanced Recovery After Surgery in Orthopedics, forming a comprehensive multimodal blood conservation pathway throughout the perioperative period. 1.3 Data Collection The following data were collected through retrospective review of patient medical records:1.Preoperative data: Age, sex, body mass index (BMI), tumor location, surgical approach, tumor type, preoperative comorbidities, preoperative chemotherapy use, and preoperative laboratory results (hemoglobin, renal function, coagulation function, albumin levels, etc.).2.Intraoperative data: Operative time, estimated blood loss, intraoperative blood transfusion, and anesthesia details.3.Postoperative data: Postoperative hemoglobin levels, time to first ambulation, and functional scores at follow-up visits at 1 week, 1 month, and 3 months post-surgery. 1.4 Outcome Measures To comprehensively assess the health status and treatment outcomes of patients from multiple dimensions, the following two scoring scales were employed as primary measurement tools in this study. The Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale is a specialized instrument designed to evaluate the degree of fatigue in patients with chronic illnesses. It comprises multiple items covering various aspects of fatigue, including its perception, severity, and impact on activities of daily living. Patients rate each item based on their actual condition, and the scores from all items are summed to obtain a total score. The total score ranges from 0 to 52, with higher scores indicating lower levels of fatigue, reflecting better physical and psychological tolerance to fatigue and a more favorable recovery status. The Harris Hip Score is a standardized scale specifically designed to assess hip joint function. It evaluates multiple dimensions, including pain, range of motion, functional capacity, and patient satisfaction with their hip condition. The score ranges from 0 to 100, with higher scores indicating better hip joint function. 1.5 Statistical Analysis Statistical analysis was performed using SPSS software (version 25.0, IBM Corp, Armonk, NY, USA). Categorical variables were presented as frequencies and percentages (%), and comparisons between groups were conducted using the chi-square (χ²) test. Continuous variables were first assessed for normality using the Kolmogorov-Smirnov test and for homogeneity of variance using Levene's test. Data that were normally distributed and met the assumption of homogeneity of variance were expressed as mean ± standard deviation, and intergroup comparisons were performed using the independent samples t-test. Data that were not normally distributed or did not meet the assumption of homogeneity of variance were expressed as median (interquartile range), and intergroup comparisons were performed using the Mann-Whitney U test. The significance level for all hypothesis tests was set at α = 0.05 (two-tailed), and P < 0.05 was considered statistically significant. 2 Results 2.1 Patient Selection and Baseline Characteristics A total of 98 patients undergoing hip bone tumor surgery were initially screened for this study. Based on the exclusion criteria, 60 patients were excluded, including 23 with skin and subcutaneous soft tissue masses, 16 aged under 18 years, 6 with macrocytic anemia, 2 with allergies to blood products, 3 with adverse reactions to EPO/iron therapy, 2 who were chronically bedridden and unable to undergo functional assessment, and 8 who were lost to follow-up. Ultimately, 38 patients undergoing hip bone tumor surgery were enrolled in this study and included in the final analysis, comprising 24 patients in the control group and 14 patients in the multimodal management group. The detailed patient selection process is illustrated in Fig. 1 . The comparison of baseline characteristics between the two groups is presented in Table 1 . No significant differences were observed between the control group and the multimodal management group with respect to sex distribution (male: 54.16% vs. 42.86%, χ²=0.452, P = 0.501), age (43.58 ± 14.04 years vs. 50.86 ± 14.56 years, t = 1.520, P = 0.137), or body mass index (BMI) (23.44 ± 2.53 kg/m² vs. 24.42 ± 4.84 kg/m², t = 0.824, P = 0.415). Regarding disease characteristics, the distribution of tumor location (femoral neck/femoral head/femoral trochanter/acetabulum and pelvis) was comparable between groups (χ²=0.613, P = 0.893). Surgical procedures, including lesion resection with bone grafting or cement, internal fixation, and hip arthroplasty, also showed no significant intergroup differences (χ²=5.300, P = 0.071). The distribution of tumor type (benign/borderline/malignant) was similar between groups (χ²=3.946, P = 0.140), with specific types and distributions detailed in Table 2 . The incidence of comorbidities (diabetes mellitus/hypertension/infectious diseases) did not differ significantly between groups (χ²=0.533, P = 0.766). It should be noted that only one patient in the multimodal management group received preoperative chemotherapy (doxorubicin + cisplatin), while no other patients in either group received preoperative chemotherapy. All patients underwent surgery under general anesthesia, and no deaths occurred during the follow-up period. These findings demonstrate that the baseline characteristics of the two groups were comparable (all P > 0.05). Table 1 Essential information Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t/χ 2 ) P Sex man 13 (54.17%) 6 (42.86%) 0.452 0.501 woman 11 (45.83%) 8 (57.14%) Age 43.58 ± 14.04 50.86 ± 14.56 1.520 0.137 BMI 23.44 ± 2.53 24.42 ± 4.84 0.824 0.415 Tumor site collum femoris 4 (16.67%) 2 (14.29%) 0.613 0.893 femoral head 1 (4.17%) 1 (7.14%) femoral trochanter 8 (33.33%) 6 (42.86%) acetabulum and pelvis 11 (45.83%) 5 (35.71%) Modus operandi Lesion resection + bone grafting 10 (41.66%) 6 (42.86%) 5.300 0.071 Resection of lesion + internal fixation 13 (54.17%) 4 (28.57%) hip replacement 1 (4.17%) 4 (28.57%) Tumor type benign 16 (66.67%) 5 (35.71%) 3.946 0.140 borderline 3 (12.50%) 2 (14.29%) malignancy 5 (20.83%) 7 (50.00%) Complication diabetes mellitus 3 2 0.533 0.766 hypertension 1 1 infectious diseases 1 2 Preoperative chemotherapy drug administration 0 1(Doribin + Cisplatin) Table 2 Specific tumor inclusion in each group Tumor character Control (n = 24) Multimodal management (n = 14) Malignant 5 7 metastatic cancer 0 2 osteosarcoma 2 1 chondrosarcoma 1 2 malignant peripheral nerve sheath tumor 0 1 Pleomorphic undifferentiated sarcoma 0 1 Spindle cell malignant tumor 1 0 multiple myeloma 1 0 Borderline 3 2 giant-cell tumor of bone 3 2 Benign 16 5 aneurysmal bone cyst 2 1 osteofibrous dysplasia 5 2 enchondroma 0 1 osteochondroma 4 1 hemangioma 2 0 non-ossifying fibroma 3 0 2.2 Preoperative Laboratory Parameters Comparison of preoperative laboratory parameters between the two groups is presented in Table 3 . No statistically significant differences were observed in baseline laboratory values. Specifically, albumin levels (control group: 42.08 ± 3.49 g/L vs. multimodal management group: 38.76 ± 2.68 g/L, t = 1.435, P = 0.156), creatinine levels (59.09 ± 12.63 µmol/L vs. 55.86 ± 14.62 µmol/L, t = 0.718, P = 0.477), prothrombin time (PT) (7.49 ± 5.18 s vs. 7.44 ± 4.95 s, t = 0.824, P = 0.415), and activated partial thromboplastin time (APTT) (28.52 ± 4.02 s vs. 27.53 ± 2.94 s, t = 0.811, P = 0.423) all showed no significant intergroup differences (all P > 0.05). These findings indicate that preoperative nutritional status, renal function, and coagulation function were comparable between the two groups. Table 3 Preoperative examination results Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t) p Albumin (g/L) 42.08 ± 3.49 38.76 ± 2.68 1.435 0.156 Creatinine (µmol/L) 59.09 ± 12.63 55.86 ± 14.62 0.718 0.477 Prothrombin time (s) 7.49 ± 5.18 7.44 ± 4.95 0.824 0.415 Activated partial thromboplastin time (s) 28.52 ± 4.02 27.53 ± 2.94 0.811 0.423 2.3 Surgical and Postoperative Parameters All patients underwent surgery under general anesthesia. Comparison of surgical and postoperative parameters between the two groups is presented in Table 4 . The multimodal management group had a significantly longer operative time compared to the control group (193.71 ± 93.66 min vs. 136.67 ± 67.57 min, t = 2.175, P = 0.036). Although the mean intraoperative blood loss was higher in the multimodal management group, this difference did not reach statistical significance (402.86 ± 280.64 mL vs. 313.04 ± 194.95 mL, t = 1.149, P = 0.258). The intraoperative transfusion rate was similar between groups (multimodal management group: 50.0% vs. control group: 45.8%). Regarding postoperative recovery, the time to first ambulation showed a trend toward prolongation in the multimodal management group (3.64 ± 1.74 days) compared to the control group (2.83 ± 0.92 days), although this difference did not achieve statistical significance (t = 1.888, P = 0.067). Table 4 Surgery and related postoperative indicators Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t) p Time of operation (min) 136.67 ± 67.57 193.71 ± 93.66 2.175 0.036 (*) Intraoperative blood loss (mL) 313.04 ± 194.95 402.86 ± 280.64 1.149 0.258 Intraoperative autotransfusion (person-time) 11 (45.83%) 7 (50.00%) Postoperative first time getting out of bed (d) 2.83 ± 0.92 3.64 ± 1.74 1.888 0.067 2.4 Dynamic Changes in Hemoglobin Levels Longitudinal assessment of hemoglobin levels revealed several notable findings between the two groups (Table 5 ). The multimodal management group had significantly lower preoperative hemoglobin levels compared to the control group (124.64 ± 14.62 g/L vs. 136.75 ± 18.30 g/L, t = 2.167, P = 0.037). On postoperative day 1, hemoglobin levels in the management group further decreased to 92.43 ± 16.99 g/L, which was significantly lower than those in the control group (110.50 ± 18.74 g/L, t = 2.965, P = 0.005). By postoperative day 4, hemoglobin levels in the management group (93.25 ± 21.96 g/L) remained lower than those in the control group (105.22 ± 21.95 g/L); however, this difference was no longer statistically significant (t = 1.512, P = 0.142), with missing data for 6 patients in the control group and 2 patients in the management group. By postoperative day 7, the intergroup difference further diminished (management group: 96.33 ± 14.87 g/L vs. control group: 100.91 ± 16.17 g/L, t = 0.652, P = 0.522), with missing data for 13 patients in the control group and 5 patients in the management group. These findings demonstrate that despite having lower preoperative and early postoperative hemoglobin levels, the multimodal management group exhibited a consistent trend of recovery throughout the observation period. Table 5 Dynamic monitoring results of hemoglobin(g/L) Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t) p Preoperative 136.75 ± 18.30 124.64 ± 14.62 2.167 0.037 (*) Postoperative Day 1 Mean 110.50 ± 18.74 92.43 ± 16.99 2.965 0.005 (**) Missing 0 0 Postoperative Day 4 Mean 105.22 ± 21.95 93.25 ± 21.96 1.512 0.142 Missing 6 2 Postoperative Day 7 Mean 100.91 ± 16.17 96.33 ± 14.87 0.652 0.522 Missing 13 5 2.5 FACIT-Fatigue Score Analysis Analysis of FACIT-Fatigue scores revealed significant differences in recovery patterns between the two groups (Table 6 ). At one week post-surgery, the multimodal management group exhibited significantly higher fatigue levels (indicated by lower scores) compared to the control group (FACIT score: 27.93 ± 5.94 vs. 32.08 ± 5.17, t = 2.180, P = 0.039). However, by one month post-surgery, the management group demonstrated significantly greater improvement in fatigue scores from baseline compared to the control group (change value: 5.79 ± 2.01 vs. 3.00 ± 0.78, t = 4.979, P = 0.0002). At three months post-surgery, no statistically significant differences were observed between the two groups, either in final fatigue scores (management group: 35.29 ± 8.01 vs. control group: 39.13 ± 5.80, t = 1.569, P = 0.132) or in the magnitude of improvement from baseline (management group: 7.36 ± 2.53 vs. control group: 7.04 ± 1.99, t = 0.400, P = 0.693). These findings indicate that although patients in the multimodal management group experienced increased fatigue levels early after surgery due to the greater surgical insult, the multimodal blood management strategy significantly accelerated fatigue recovery within the first postoperative month, ultimately achieving comparable fatigue relief to the control group by three months. Table 6 FACIT score and baseline changes based on postoperative scores Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t) p FACIT score 1 week after surgery 32.08 ± 5.17 27.93 ± 5.94 2.180 0.039 (*) 1 month after surgery 35.08 ± 5.22 33.71 ± 7.49 0.603 0.553 3 months after surgery 39.13 ± 5.80 35.29 ± 8.01 1.569 0.132 Baseline changes based on postoperative FACIT score 1 month after surgery 3.00 ± 0.78 5.79 ± 2.01 4.979 0.0002 (***) 3 months after surgery 7.04 ± 1.99 7.36 ± 2.53 0.400 0.693 2.6 Harris Hip Score Analysis Analysis of Harris Hip Scores revealed distinct patterns of functional recovery between the two groups (Table 7 ). Preoperatively, no significant difference in hip function was observed between groups (t = 0.210, P = 0.835). However, at one week post-surgery, the multimodal management group experienced a significantly greater decline in Harris Hip Scores attributable to surgical trauma (30.57 ± 10.19 points vs. 22.58 ± 9.79 points in the control group, t = 2.391, P = 0.022), resulting in correspondingly lower absolute scores (48.00 ± 12.15 points vs. 57.25 ± 13.03 points, t = 2.162, P = 0.037). Critically, the management group demonstrated significantly greater functional improvement at one month post-surgery compared to the control group (change value: 30.57 ± 6.03 points vs. 25.25 ± 6.46 points, t = 2.509, P = 0.017). This accelerated recovery effectively compensated for the greater early functional loss. By three months post-surgery, the overall magnitude of functional improvement was comparable between groups (management group: 40.00 ± 6.37 points vs. control group: 35.83 ± 9.24 points, t = 1.491, P = 0.145). These findings confirm that multimodal blood management, by accelerating mid-term functional recovery, enables patients undergoing more complex surgical procedures to ultimately achieve functional outcomes comparable to those of the control group. Table 7 Harris score and baseline changes based on postoperative scores Variable Control (n = 24) Multimodal management (n = 14) Statistical quantity (t/χ 2 ) p Harris score preoperative 79.83 ± 17.37 78.57 ± 18.82 0.210 0.835 1 week after surgery 57.25 ± 13.03 48.00 ± 12.15 2.162 0.037(*) 1 month after surgery 82.50 ± 11.47 78.67 ± 12.80 0.976 0.336 3 months after surgery 93.08 ± 11.29 88.00 ± 10.33 1.380 0.176 Postoperative Harris decline 22.58 ± 9.79 30.57 ± 10.19 2.391 0.022 (*) Baseline change value based on postoperative Harris score 1 month after surgery 25.25 ± 6.46 30.57 ± 6.03 2.509 0.017 (*) 3 months after surgery 35.83 ± 9.24 40.00 ± 6.37 1.491 0.145 4 Discussion 4.1 Preliminary Advantages of Multimodal Blood Management Perioperative blood management encompasses the entire continuum of care, including the preoperative, intraoperative, and postoperative phases. However, due to the unique characteristics of oncologic patients, intraoperative autologous blood transfusion is contraindicated, which inherently limits the options and implementation of intraoperative blood conservation strategies. Given this objective constraint, our study focused primarily on preoperative and postoperative blood management, aiming to achieve more precise and effective perioperative blood conservation in these critical windows, thereby improving overall treatment outcomes and patient prognosis. Although allogeneic blood transfusion can rapidly elevate hemoglobin levels in emergency situations or in anemic patients unresponsive to other therapies, it is associated with several risks, including viral transmission, immune-mediated allergic reactions, acute hemolytic reactions, and transfusion-related acute lung injury. Moreover, blood resources remain scarce in China. Given the inherent limitations of a restrictive transfusion strategy alone, there is a clear need to explore multimodal perioperative management approaches ( 7 , 8 ).The HiFIT team from the French Ministry of Health previously published findings in The Lancet Haematology demonstrating that single-modality blood management strategies are insufficient to reduce transfusion rates ( 9 ).Therefore, this study retrospectively evaluated a perioperative multimodal blood management strategy—combining erythropoietin (EPO), iron supplementation, and a restrictive transfusion protocol—specifically in the context of hip bone tumor surgery. We provide the first evidence that although this approach is employed in patients facing more complex surgical challenges, it effectively mitigates early postoperative functional disadvantages and facilitates enhanced recovery at critical time points. As a retrospective study, this research did not impose strict control over enrollment criteria. Although the two groups were comparable in terms of baseline demographics, disease characteristics, surgical procedure types, and preoperative laboratory parameters, patients in the multimodal management group presented with significantly lower preoperative hemoglobin levels compared to the control group (control group: 136.75 ± 18.30 g/L vs. multimodal group: 124.64 ± 14.62 g/L, P = 0.037). This difference suggests a distinct preoperative physiological profile in the multimodal group, potentially reflecting more aggressive tumor behavior or longer disease duration, leading to more pronounced anemia prior to surgery. This observation indirectly underscores the greater surgical complexity and diminished physiological reserve in this group, indicating that these patients faced a more arduous postoperative recovery trajectory. Furthermore, patients in the multimodal management group underwent relatively more complex surgical procedures, as evidenced by significantly longer operative times (193.71 ± 93.66 min vs. 136.67 ± 67.57 min, P = 0.036) and, although not statistically significant, numerically higher mean intraoperative blood loss (control group: 313.04 ± 194.95 mL vs. multimodal group: 402.86 ± 280.64 mL). Notably, hemoglobin assessment on postoperative day 1 confirmed greater blood loss in the multimodal group compared to controls. Despite this disadvantaged starting point, the multimodal management group demonstrated a robust recovery trajectory. Particularly at the critical one-month postoperative time point, both the magnitude of improvement in FACIT-Fatigue scores and Harris Hip Scores were significantly superior to those of the control group. This accelerated recovery suggests that multimodal blood management, by facilitating the restoration of physiological reserve, secured crucial opportunities for medium-to-long-term rehabilitation in these patients. These findings confirm the effectiveness of multimodal management strategies in promoting postoperative recovery, provide strong evidence to support their implementation in similar patient populations with hip bone tumors, and establish a preliminary foundation for further refinement of perioperative management protocols. 4.2 The Role of Iron Supplementation in Perioperative Blood Management Based on erythrocyte indices (MCV, MCH, MCHC), anemia is primarily classified into three categories: microcytic hypochromic anemia, normocytic normochromic anemia, and macrocytic anemia. Following acute surgical blood loss, the former two types are more commonly encountered. Given that macrocytic anemia is predominantly attributable to megaloblastic anemia resulting from folate and/or vitamin B 12 deficiency, patients with this condition were excluded from the present study to enable a more precise investigation of perioperative blood management in hip surgery. The Chinese Expert Consensus on Enhanced Recovery After Surgery for Hip and Knee Arthroplasty: Perioperative Anemia Management explicitly recommends iron supplementation for patients with preoperative iron deficiency anemia and anemia resulting from acute surgical blood loss, with the aim of rapidly elevating hemoglobin levels and correcting anemia. Iron serves as an essential micronutrient for hemoglobin synthesis; it combines with protoporphyrin Ⅸ to form heme, which subsequently binds with globin to constitute hemoglobin( 10 ).Furthermore, iron deficiency directly impedes heme synthesis, thereby impairing hemoglobin assembly( 11 ). A systematic review and meta-analysis examining preoperative intravenous iron administration in patients undergoing major surgery demonstrated significantly reduced transfusion requirements and markedly increased hemoglobin concentrations at four weeks postoperatively compared to placebo or oral iron( 12 ).Preoperative intravenous iron combined with tranexamic acid has been shown to substantially mitigate transfusion risk following arthroplasty procedures ( 9 , 13 , 14 ).A 2021 Danish study encompassing 210 elderly patients with hip fractures revealed that early postoperative iron supplementation was associated with reduced 30-day mortality ( 15 ).Moreover, an additional systematic review and meta-analysis addressing perioperative iron therapy in acute major non-cardiac surgery corroborated these findings, demonstrating lower 30-day mortality among patients receiving iron supplementation( 16 ).Although adverse reactions to iron therapy have been documented clinically, current third-generation intravenous iron formulations enable administration of sufficient iron doses while effectively mitigating complications such as oxidative stress, thereby offering safer and more efficacious options for clinical application( 17 ). In summary, iron supplementation occupies a pivotal position in perioperative anemia management. Third-generation intravenous iron formulations, in particular, effectively optimize hemoglobin levels, augment iron stores, reduce transfusion requirements, and ultimately contribute to improved patient prognosis. 4.3 The Role of Erythropoietin in Perioperative Blood Management Erythropoietin (EPO), a hormone primarily produced by the kidneys, serves as a critical regulator of erythropoiesis. It acts on erythroid progenitor cells, promoting their proliferation and differentiation into mature erythrocytes, thereby increasing red blood cell counts. EPO also activates intracellular signaling pathways, including the JAK2-STAT5 pathway ( 18 , 19 ),which inhibits apoptosis of erythroid precursors and facilitates hemoglobin synthesis, ultimately enhancing erythrocyte maturation and oxygen-carrying capacity. Furthermore, emerging evidence suggests that EPO possesses neurogenic and angiogenic properties, providing a theoretical rationale for its potential role in postoperative recovery ( 20 , 21 ). Given its multifaceted physiological effects, multiple guidelines and expert consensus statements have recommended EPO as a standard component of perioperative anemia management in orthopedic surgery( 22 – 24 ).A Spanish study involving 306 patients with hip fractures demonstrated that patients receiving EPO in combination with iron supplementation exhibited significantly improved hemoglobin levels at hospital discharge and at 60 days post-discharge compared to the placebo group ( 25 ).Moreover, at 60 days post-discharge, a higher proportion of anemic patients in the treatment group had achieved complete recovery. Additional research has robustly confirmed that preoperative administration of EPO effectively reduces perioperative transfusion requirements in patients with hip fractures( 26 ). In summary, erythropoietin plays a multifaceted role in regulating erythropoiesis, activating signaling pathways to inhibit apoptosis, and promoting cellular development. These properties confer substantial clinical value in the management of perioperative anemia in orthopedic surgery. 4.4 Multimodal Management Strategy: Mechanistic Complementarity and Synergistic Effects From the perspective of the underlying mechanisms of each component in multimodal management, the synergistic effect of combining EPO, iron supplementation, and a restrictive transfusion protocol plays a pivotal role. Iron serves as the essential raw material for hemoglobin synthesis, providing the necessary substrate for erythropoiesis. EPO accelerates red blood cell production through multiple mechanisms, including regulating the proliferation and differentiation of erythroid progenitor cells, promoting erythrocyte membrane development, and facilitating hemoglobin synthesis. The combination of these two interventions achieves comprehensive regulation—from providing fundamental building blocks to supporting cellular production and maturation—thereby offering more robust support for ameliorating perioperative anemia in patients undergoing hip bone tumor surgery. Previous studies have demonstrated that following iron or EPO administration, hemoglobin levels substantially increase within approximately 30 to 60 days( 26 , 27 ). Our findings revealed that at seven days post-surgery, although hemoglobin levels did not differ significantly between the multimodal management group and the control group, patients in the multimodal group had already begun to show improvement. Furthermore, due to the synergistic interaction between these two agents, both Harris Hip Scores and FACIT-Fatigue scores showed marked improvement at one month post-surgery. These observations align with previous research findings; although hemoglobin data at 30 days were not available in our study, the aforementioned functional improvements sufficiently demonstrate that the combination of EPO and iron supplementation can promote erythropoiesis and hemoglobin synthesis within a relatively short timeframe. This comprehensive strategy optimizes every aspect of the blood conservation process—from stimulating hematopoiesis and supplying raw materials to ensuring rational blood utilization—thereby enabling patients to progressively overcome the adverse effects of surgical trauma, accelerating the restoration of physical function and overall recovery. Ultimately, patients in the multimodal management group achieved rehabilitation outcomes comparable to, or even surpassing, those receiving conventional management. These findings provide novel insights for perioperative management in patients undergoing hip bone tumor surgery. 4.5 Study Limitations Several limitations of this study should be acknowledged. First, this was a single-center retrospective analysis with a relatively limited sample size (n = 38). Given that hip bone tumors represent a category of diseases with low incidence, collecting a large sample of highly homogeneous cases within a limited study period at a single center presents objective difficulties. This limitation may affect statistical power and limit the generalizability of the study conclusions. However, it is worth noting that the preliminary data obtained under strict inclusion criteria provide "real-world" evidence and trend-based insights into systematic blood management for this specific and high-risk surgical population. Future multicenter prospective studies with larger sample sizes are warranted to validate the generalizability of this strategy and further characterize the patient populations most likely to benefit. Another limitation of this study is the absence of hemoglobin data at 30 days post-surgery. As a retrospective analysis, the data were derived from routine clinical practice. In standard clinical follow-up, patients with stable postoperative recovery typically do not undergo routine blood tests, resulting in missing laboratory data at this time point. Consequently, we were unable to precisely delineate the complete kinetic curve of early postoperative anemia correction. However, this limitation also highlights the real-world perspective of our study: rather than evaluating the intervention under prespecified laboratory monitoring, we first observed significantly greater functional improvement at one month post-surgery in the management group within actual clinical practice, and subsequently traced back the differences in their management. These findings nonetheless robustly demonstrate an association between multimodal blood management and enhanced early functional recovery. Future prospective studies could build upon these findings by incorporating regular hematological monitoring to further elucidate the temporal and mechanistic relationship between anemia correction and functional recovery. Finally, the retrospective study design inherently carries certain limitations, including the potential presence of unrecorded or unmeasured confounding factors (e.g., tumor volume, extent of soft tissue involvement). Although we compared and verified all available key baseline characteristics in our statistical analysis, demonstrating comparability between the two groups, the possibility of residual confounding factors influencing the results cannot be completely excluded. It is noteworthy that this study observed significant early functional improvement in the management group despite their disadvantaged baseline status of lower preoperative hemoglobin levels and longer operative times. To some extent, this finding enhances the credibility of the results, as it suggests that the intervention may have overcome additional risks. However, retrospective analyses provide only correlational evidence. Establishing causal relationships will require well-designed prospective randomized controlled trials. 5 Conclusion This study compared the effects of a perioperative multimodal blood management strategy (combining EPO, iron supplementation, and a restrictive transfusion protocol) with conventional management in patients undergoing hip bone tumor surgery. The following conclusions were drawn: Although the multimodal management group presented with lower preoperative hemoglobin levels and underwent more complex surgical procedures—constituting multiple disadvantageous factors—this strategy, through the synergistic interaction of EPO, iron supplementation, and restrictive transfusion, significantly accelerated the improvement of fatigue and hip joint function during the critical postoperative recovery phase (particularly at one month post-surgery). This approach effectively compensated for early functional deficits, enabling patients to ultimately achieve rehabilitation outcomes comparable to those of the control group, thereby demonstrating substantial clinical value. Clinically, reliance on traditional transfusion alone should be superseded by the establishment of a multimodal blood management system centered on the concept of "physiological reserve reconstruction." Declarations Ethics approval and consent to participate The experimental procedures were performed under the approval of the Ethics Committee of First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China. Approval number is 2025552. They were in strict accordance with the Declaration of Helsinki (1964). Written informed consents were obtained from all participants and their parents. Competing interests The authors declared no conflicts of interest. Funding This article was partially supported by the National Natural Science Foundation of China (82402857), Natural Science Foundation of Jiangsu Province (BK20240369) and Suzhou Basic Research Pilot Project (Interdisciplinary, SSD2025064). Author Contribution Zhang ZM, Ma YT and Ge J contributed to manuscript writing and editing, and data collection; Chu L, Ding WQ, Zhao LY and Ge J contributed to literature review; Zou J, Yang HL and Lu J contributed to conceptualization and supervision; all authors have read and approved the final manuscript.#Zhang ZM and Ma YT contributed equally to the work. Acknowledgements Not applicable. Data Availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. References Zan P, Ma X, Wang H, Cai Z, Shen J, Sun W. Feasibility and preliminary efficacy of tantalum components in the management of acetabular reconstruction following periacetabular oncologic resection in primary malignancies. (2047-783X (Electronic)). Smilowitz NR, Oberweis BS, Nukala S, Rosenberg A, Zhao S, Xu J et al. Association Between Anemia, Bleeding, and Transfusion with Long-term Mortality Following Noncardiac Surgery. (1555–7162 (Electronic)). Connor JP, Destrampe E, Robbins D, Hess AS, McCarthy D, Maloney J. Pre-operative anemia and peri-operative transfusion are associated with poor oncologic outcomes in cancers of the esophagus: potential impact of patient blood management on cancer outcomes. (1471–2407 (Electronic)). Reinke JM, Meybohm P, Weber P. [Diagnosis and treatment of perioperative anaemia in elective primary hip and knee arthroplasty: Consensus statement of the Committee for Perioperative Management of the Working Group for Endoprosthetics]. (2731–7153 (Electronic)). Hourlier H, Fricault G, Fennema P. Blood management protocol for baseline anemic patients undergoing hip arthroplasty. (1434–3916 (Electronic)). Zongke Z, Xisheng W, Bing X, Tiebing QU, Xianlong Z, Peifu T et al. Expert consensus in enhanced recovery after total hip and knee arthroplasty in China:diagnosis and treatment of perioperative anemia. Chinese Journal of Bone and Joint Surgery. Carson JL, Stanworth Sj Fau - Roubinian N, Roubinian N, Fau - Fergusson DA. Fergusson Da Fau - Triulzi D, Triulzi D Fau - Doree C, Doree C Fau - Hebert PC, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. (1469-493X (Electronic)). Bansal N, Raturi M, Singh C, Bansal Y. Immunological complications of blood transfusion: current insights and advances. Curr Opin Immunol. 2025;96:102617. Lasocki S, Capdevila X, Vielle B, Bijok B, Lahlou-Casulli M, Collange V et al. Ferric derisomaltose and tranexamic acid, combined or alone, for reducing blood transfusion in patients with hip fracture (the HiFIT trial): a multicentre, 2 × 2 factorial, randomised, double-blind, controlled trial. (2352–3026 (Electronic)). Lipiński P, Starzyński RR, Styś A, Gajowiak A, Staroń R. [Heme metabolism as an integral part of iron homeostasis]. Postepy Hig Med Dosw (Online). 2014;68:557–70. Perutz MF. Regulation of oxygen affinity of hemoglobin: influence of structure of the globin on the heme iron. Annu Rev Biochem. 1979;48:327–86. Elhenawy AA-O, Meyer SR, Bagshaw SM, MacArthur RG, Carroll LJ. Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis. (2046–4053 (Electronic)). Suh DW, Han SB, Park JH, Cheong K, Kyung BS. Intravenous iron supplementation with intra-articular administration of tranexamic acid reduces the rate of allogeneic transfusions after simultaneous bilateral total knee arthroplasty. (2385 – 2070 (Electronic)). Jung HJ, Kang MW, Lee JA-O, Lee JK, Kim JA-O. The Association of Intravenous Iron Administered the Day before Total Knee Arthroplasty with Postoperative Anemia and Functional Recovery. LID – 10.3390/medicina59071212 [doi] LID – 1212. (1648–9144 (Electronic)). Clemmensen SA-O, Kragholm KH, Melgaard D, Hansen LT, Riis J, Cavallius C et al. Association between intravenous iron therapy and short-term mortality risk in older patients undergoing hip fracture surgery: an observational study. (1749-799X (Electronic)). Schack AA-O, Berkfors AA, Ekeloef S, Gögenur I, Burcharth J. The Effect of Perioperative Iron Therapy in Acute Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin Levels: A Systematic Review and Meta-analysis. (1432–2323 (Electronic)). Kwak SG, Kwon JB, Bae JW, Bae DJ, Kim DK, Choi WK. Effects of intraoperative or postoperative administration of intravenous iron supplements on hemoglobin recovery in patients with total knee arthroplasty: A systematic review and meta-analysis. Med (Baltim). 2023;102(43):e35744. Tóthová Z, Tomc J, Debeljak NA-OX. Solár PA-O. STAT5 as a Key Protein of Erythropoietin Signalization. LID – 10.3390/ijms22137109 [doi] LID – 7109. (1422-0067 (Electronic)). Tóthová Z, Šemeláková M, Solárová Z, Tomc J, Debeljak NA-OX, Solár PA-O. The Role of PI3K/AKT and MAPK Signaling Pathways in Erythropoietin Signalization. LID – 10.3390/ijms22147682 [doi] LID – 7682. (1422-0067 (Electronic)). Wang Y, Li Y, Liu D. Erythropoietin promoted intraplaque angiogenesis by PI3K/AKT/mTOR signaling pathway in atherosclerosis. (1532–3072 (Electronic)). Sergio CM, Rolando CA. Erythropoietin regulates signaling pathways associated with neuroprotective events. (1432 – 1106 (Electronic)). Rineau E, Campfort M, Lasocki S. Managing preoperative anemia: EPO is needed. Blood Transfus. 2025;23(1):28–32. Goodnough LT, Maniatis A, Earnshaw P, Benoni G, Beris P, Bisbe E, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106(1):13–22. Rineau E, Stoyanov A, Samson E, Hubert L, Lasocki S. Patient Blood Management in Major Orthopedic Surgery: Less Erythropoietin and More Iron? Anesth Analg. 2017;125(5):1597–9. Bernabeu-Wittel M, Romero M, Ollero-Baturone M, Aparicio R, Murcia-Zaragoza J, Rincón-Gómez M et al. Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. (1537–2995 (Electronic)). García-Erce JA, Cuenca J, Fau - Haman-Alcober S, Haman-Alcober S, Fau - Martínez AA. Martínez Aa Fau - Herrera A, Herrera A Fau - Muñoz M, Muñoz M. Efficacy of preoperative recombinant human erythropoietin administration for reducing transfusion requirements in patients undergoing surgery for hip fracture repair. An observational cohort study. (1423 – 0410 (Electronic)). Yoo S, Bae J, Fau - Ro DH, Fau - Han RD H-S, Han Hs Fau -, Lee MC. Lee Mc Fau - Park S-K, Park Sk Fau - Lim Y-J, Efficacy of intra-operative administration of iron isomaltoside for preventing postoperative anaemia after total knee arthroplasty: A randomised controlled trial. (1365–2346 (Electronic)). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9059442","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618252246,"identity":"b24d89b9-5d17-4b8a-b7e2-7a80ac9e63f2","order_by":0,"name":"zimin Zhang","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"zimin","middleName":"","lastName":"Zhang","suffix":""},{"id":618252247,"identity":"3e3750a9-f018-46f7-b06e-96b4606926e4","order_by":1,"name":"yetian Ma","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"yetian","middleName":"","lastName":"Ma","suffix":""},{"id":618252248,"identity":"ff417d23-870c-4d28-94eb-f06da65528fb","order_by":2,"name":"li Chu","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"li","middleName":"","lastName":"Chu","suffix":""},{"id":618252249,"identity":"6f560b55-7afa-428d-8aaf-030eea95fc69","order_by":3,"name":"wenquan Ding","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"wenquan","middleName":"","lastName":"Ding","suffix":""},{"id":618252250,"identity":"ffd03186-4d5b-4691-83f3-abc008e4aac7","order_by":4,"name":"leyu Zhao","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"leyu","middleName":"","lastName":"Zhao","suffix":""},{"id":618252251,"identity":"a991e5a5-2c79-41cf-a06c-ff9aa82ebab8","order_by":5,"name":"huilin Yang","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"huilin","middleName":"","lastName":"Yang","suffix":""},{"id":618252252,"identity":"94a8cd28-b338-4131-97db-b6fb7a299ee0","order_by":6,"name":"jun Zou","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"jun","middleName":"","lastName":"Zou","suffix":""},{"id":618252253,"identity":"e0aff9e7-223a-4238-b116-983e72ad5fea","order_by":7,"name":"jian Lu","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"jian","middleName":"","lastName":"Lu","suffix":""},{"id":618252254,"identity":"0d76a976-7ba3-44a8-9a4f-fffa0083e1c3","order_by":8,"name":"jun Ge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYHCCBAYGA4l6fiBLAogZG4jTUmCRINlAghYg+FCRYHCAWC3y7g3PpAsMJPKMz58xvPGDwUZ2wwHmZw/waTE8cyBNeoaBRLHZjRxjyx6GNOMNB9jMDfBqmZGQJs1jIMG47QaPmQQPw+HEDQd42CTwapn/AKJlc/8ZM8k/DP8Ja5GXYABrSdzAkGMmzcNwgLAWA56EZGugFmOJG2nF1jIGycYzD7OZ4bel/UzibZ4/dXL8/Yc33nxTYSfbd7z5GX5bDvAkIHOBmBmfepAtDewHCCgZBaNgFIyCEQ8ASN9E69ohYQ0AAAAASUVORK5CYII=","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"jun","middleName":"","lastName":"Ge","suffix":""}],"badges":[],"createdAt":"2026-03-07 15:23:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9059442/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9059442/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106468624,"identity":"28a9dabf-7705-4084-87f0-93246e0566c4","added_by":"auto","created_at":"2026-04-09 00:42:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172651,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9059442/v1/cac671028cb3b5cfa31060de.png"},{"id":106724518,"identity":"17ccc785-401c-4042-9bf6-93daa90c6caf","added_by":"auto","created_at":"2026-04-12 18:28:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1607434,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9059442/v1/2352ba09-f45c-42f1-a3d5-3e8059acbabd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Perioperative Multimodal Blood Management of Bone Tumors of Hip on Early Postoperative Functional Recovery: A Retrospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSurgery for hip bone tumors presents a significant challenge in orthopaedic oncology, with perioperative anemia being a particularly prominent issue. Existing research indicates that these procedures often require extensive soft tissue resection and subsequent bone reconstruction, leading to substantial intraoperative blood loss, typically ranging from 800 to 2200 mL(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).onsequently, over half of these patients develop postoperative anemia. Unlike patients undergoing routine arthroplasty, those with bone tumors, especially malignant forms, frequently present with preoperative anemia. This pre-existing condition may stem from chronic inflammation or myelosuppression induced by chemotherapy. This iatrogenic blood loss, combined with pre-existing anemia, not only prolongs hospitalization but also significantly impedes postoperative functional recovery and diminishes patients' quality of life (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, studies have indicated a negative correlation between anemia and patient survival rates (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrently, there is no standardized consensus on perioperative blood management specifically for hip bone tumor surgery. The strategies employed are largely adapted from experiences in arthroplasty (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).This approach has two main shortcomings. First, it fails to provide individualized protocols tailored to the unique characteristics of oncology patients. Second, there is a lack of validated evidence concerning the optimal timing, appropriate strategies, and overall effectiveness of blood management in this specific patient population. Compared to conventional orthopaedic surgeries like arthroplasty, the field of oncologic hip surgery has yet to develop a systematic blood management protocol, with few relevant studies reported domestically or internationally. This evidence gap significantly lags behind the rapid advancements in the Enhanced Recovery After Surgery (ERAS) philosophy and fails to meet the demands of clinical practice.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to systematically evaluate the efficacy of a multimodal blood management strategy in hip tumor surgery. By investigating its clinical significance in mitigating postoperative anemia and promoting functional recovery, we seek to provide a crucial reference for the development of standardized perioperative blood management protocols for patients with hip bone tumors.\u003c/p\u003e"},{"header":"1 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Patient Selection\u003c/h2\u003e \u003cp\u003e This single-center retrospective study reviewed 38 patients with hip bone tumors admitted to our hospital between January 2021 and February 2025. Based on the perioperative blood management strategy received, patients were divided into a multimodal management group and a control group. The multimodal management group received any two of the following interventions in combination: iron supplementation, erythropoietin (EPO), and a restrictive transfusion protocol. The control group received no perioperative anemia intervention, or only a single modality (iron supplementation alone, EPO alone, or restrictive transfusion alone).\u003c/p\u003e \u003cp\u003eInclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) preoperative hemoglobin levels meeting the following criteria: 70\u0026ndash;175 g/L for males, 70\u0026ndash;150 g/L for females; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) postoperative survival\u0026thinsp;\u0026gt;\u0026thinsp;3 months; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) diagnosis of primary or metastatic hip bone tumor; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) underwent hip bone tumor resection (with or without reconstruction).\u003c/p\u003e \u003cp\u003eExclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) severe allergy to blood products, erythropoiesis-stimulating agents, or parenteral iron; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) macrocytic anemia; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) active infection requiring intravenous antibiotics; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) receipt of intravenous iron or EPO therapy within 2 months prior to surgery; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) contraindications to blood transfusion or refusal to receive transfusion; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) prolonged bedridden status precluding functional assessment; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) pregnancy or lactation; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) loss to follow-up; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) unplanned amputation during surgery.\u003c/p\u003e \u003cp\u003e This study was approved by the Medical Ethics Committee of The First Affiliated Hospital of Soochow University. Due to the retrospective nature of the study, which involved only collection of medical records without any intervention, the requirement for informed consent was waived.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Blood Management Strategy\u003c/h2\u003e \u003cp\u003e Individualized blood management protocols were developed for patients with hip bone tumors, based on guidelines including the Chinese Expert Consensus on Enhanced Recovery After Surgery for Hip and Knee Arthroplasty: Perioperative Anemia Management and the Chinese Expert Consensus on Enhanced Recovery After Surgery in Orthopedics: Perioperative Blood Management.\u003c/p\u003e \u003cp\u003eFor all patients, topical application of tranexamic acid (1-3g/100mL normal saline) or hemocoagulase (10U/50mL normal saline) was used on the wound surface during surgery. For patients with anticipated large blood loss or postoperative anemia, EPO 10,000 IU was administered subcutaneously once on the day before surgery, followed by three additional doses of EPO 10,000 IU subcutaneously on alternate days postoperatively. Concurrently, intravenous or oral iron supplementation was provided to replenish hematopoietic raw materials. The specific administration methods and iron dosage calculation formulas were based on the Chinese Expert Consensus on Perioperative Blood Management for Enhanced Recovery After Surgery in Orthopedics, forming a comprehensive multimodal blood conservation pathway throughout the perioperative period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Data Collection\u003c/h2\u003e \u003cp\u003eThe following data were collected through retrospective review of patient medical records:1.Preoperative data: Age, sex, body mass index (BMI), tumor location, surgical approach, tumor type, preoperative comorbidities, preoperative chemotherapy use, and preoperative laboratory results (hemoglobin, renal function, coagulation function, albumin levels, etc.).2.Intraoperative data: Operative time, estimated blood loss, intraoperative blood transfusion, and anesthesia details.3.Postoperative data: Postoperative hemoglobin levels, time to first ambulation, and functional scores at follow-up visits at 1 week, 1 month, and 3 months post-surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Outcome Measures\u003c/h2\u003e \u003cp\u003eTo comprehensively assess the health status and treatment outcomes of patients from multiple dimensions, the following two scoring scales were employed as primary measurement tools in this study.\u003c/p\u003e \u003cp\u003eThe Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale is a specialized instrument designed to evaluate the degree of fatigue in patients with chronic illnesses. It comprises multiple items covering various aspects of fatigue, including its perception, severity, and impact on activities of daily living. Patients rate each item based on their actual condition, and the scores from all items are summed to obtain a total score. The total score ranges from 0 to 52, with higher scores indicating lower levels of fatigue, reflecting better physical and psychological tolerance to fatigue and a more favorable recovery status.\u003c/p\u003e \u003cp\u003eThe Harris Hip Score is a standardized scale specifically designed to assess hip joint function. It evaluates multiple dimensions, including pain, range of motion, functional capacity, and patient satisfaction with their hip condition. The score ranges from 0 to 100, with higher scores indicating better hip joint function.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS software (version 25.0, IBM Corp, Armonk, NY, USA). Categorical variables were presented as frequencies and percentages (%), and comparisons between groups were conducted using the chi-square (χ\u0026sup2;) test. Continuous variables were first assessed for normality using the Kolmogorov-Smirnov test and for homogeneity of variance using Levene's test. Data that were normally distributed and met the assumption of homogeneity of variance were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and intergroup comparisons were performed using the independent samples t-test. Data that were not normally distributed or did not meet the assumption of homogeneity of variance were expressed as median (interquartile range), and intergroup comparisons were performed using the Mann-Whitney U test. The significance level for all hypothesis tests was set at α\u0026thinsp;=\u0026thinsp;0.05 (two-tailed), and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient Selection and Baseline Characteristics\u003c/h2\u003e \u003cp\u003eA total of 98 patients undergoing hip bone tumor surgery were initially screened for this study. Based on the exclusion criteria, 60 patients were excluded, including 23 with skin and subcutaneous soft tissue masses, 16 aged under 18 years, 6 with macrocytic anemia, 2 with allergies to blood products, 3 with adverse reactions to EPO/iron therapy, 2 who were chronically bedridden and unable to undergo functional assessment, and 8 who were lost to follow-up. Ultimately, 38 patients undergoing hip bone tumor surgery were enrolled in this study and included in the final analysis, comprising 24 patients in the control group and 14 patients in the multimodal management group. The detailed patient selection process is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe comparison of baseline characteristics between the two groups is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No significant differences were observed between the control group and the multimodal management group with respect to sex distribution (male: 54.16% vs. 42.86%, χ\u0026sup2;=0.452, P\u0026thinsp;=\u0026thinsp;0.501), age (43.58\u0026thinsp;\u0026plusmn;\u0026thinsp;14.04 years vs. 50.86\u0026thinsp;\u0026plusmn;\u0026thinsp;14.56 years, t\u0026thinsp;=\u0026thinsp;1.520, P\u0026thinsp;=\u0026thinsp;0.137), or body mass index (BMI) (23.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53 kg/m\u0026sup2; vs. 24.42\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84 kg/m\u0026sup2;, t\u0026thinsp;=\u0026thinsp;0.824, P\u0026thinsp;=\u0026thinsp;0.415). Regarding disease characteristics, the distribution of tumor location (femoral neck/femoral head/femoral trochanter/acetabulum and pelvis) was comparable between groups (χ\u0026sup2;=0.613, P\u0026thinsp;=\u0026thinsp;0.893). Surgical procedures, including lesion resection with bone grafting or cement, internal fixation, and hip arthroplasty, also showed no significant intergroup differences (χ\u0026sup2;=5.300, P\u0026thinsp;=\u0026thinsp;0.071). The distribution of tumor type (benign/borderline/malignant) was similar between groups (χ\u0026sup2;=3.946, P\u0026thinsp;=\u0026thinsp;0.140), with specific types and distributions detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The incidence of comorbidities (diabetes mellitus/hypertension/infectious diseases) did not differ significantly between groups (χ\u0026sup2;=0.533, P\u0026thinsp;=\u0026thinsp;0.766). It should be noted that only one patient in the multimodal management group received preoperative chemotherapy (doxorubicin\u0026thinsp;+\u0026thinsp;cisplatin), while no other patients in either group received preoperative chemotherapy. All patients underwent surgery under general anesthesia, and no deaths occurred during the follow-up period. These findings demonstrate that the baseline characteristics of the two groups were comparable (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEssential information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t/χ\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (54.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (42.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (57.14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.58\u0026thinsp;\u0026plusmn;\u0026thinsp;14.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.86\u0026thinsp;\u0026plusmn;\u0026thinsp;14.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.42\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor site\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecollum femoris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (14.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemoral head\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemoral trochanter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (33.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (42.86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eacetabulum and pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.71%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModus operandi\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion resection\u0026thinsp;+\u0026thinsp;bone grafting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (41.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (42.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e5.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResection of lesion\u0026thinsp;+\u0026thinsp;internal fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (54.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (28.57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehip replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (28.57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (66.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3.946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eborderline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (14.29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (50.00%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ediabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einfectious diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative chemotherapy drug administration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(Doribin\u0026thinsp;+\u0026thinsp;Cisplatin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpecific tumor inclusion in each group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor character\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emetastatic cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eosteosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003echondrosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emalignant peripheral nerve sheath tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleomorphic undifferentiated sarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpindle cell malignant tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emultiple myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBorderline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egiant-cell tumor of bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBenign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eaneurysmal bone cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eosteofibrous dysplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eenchondroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eosteochondroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehemangioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-ossifying fibroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Preoperative Laboratory Parameters\u003c/h2\u003e \u003cp\u003eComparison of preoperative laboratory parameters between the two groups is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. No statistically significant differences were observed in baseline laboratory values. Specifically, albumin levels (control group: 42.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49 g/L vs. multimodal management group: 38.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68 g/L, t\u0026thinsp;=\u0026thinsp;1.435, P\u0026thinsp;=\u0026thinsp;0.156), creatinine levels (59.09\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63 \u0026micro;mol/L vs. 55.86\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62 \u0026micro;mol/L, t\u0026thinsp;=\u0026thinsp;0.718, P\u0026thinsp;=\u0026thinsp;0.477), prothrombin time (PT) (7.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18 s vs. 7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95 s, t\u0026thinsp;=\u0026thinsp;0.824, P\u0026thinsp;=\u0026thinsp;0.415), and activated partial thromboplastin time (APTT) (28.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02 s vs. 27.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94 s, t\u0026thinsp;=\u0026thinsp;0.811, P\u0026thinsp;=\u0026thinsp;0.423) all showed no significant intergroup differences (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings indicate that preoperative nutritional status, renal function, and coagulation function were comparable between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative examination results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin (g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e38.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreatinine (\u0026micro;mol/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e59.09\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e55.86\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProthrombin time (s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eActivated partial thromboplastin time (s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e28.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Surgical and Postoperative Parameters\u003c/h2\u003e \u003cp\u003eAll patients underwent surgery under general anesthesia. Comparison of surgical and postoperative parameters between the two groups is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The multimodal management group had a significantly longer operative time compared to the control group (193.71\u0026thinsp;\u0026plusmn;\u0026thinsp;93.66 min vs. 136.67\u0026thinsp;\u0026plusmn;\u0026thinsp;67.57 min, t\u0026thinsp;=\u0026thinsp;2.175, P\u0026thinsp;=\u0026thinsp;0.036). Although the mean intraoperative blood loss was higher in the multimodal management group, this difference did not reach statistical significance (402.86\u0026thinsp;\u0026plusmn;\u0026thinsp;280.64 mL vs. 313.04\u0026thinsp;\u0026plusmn;\u0026thinsp;194.95 mL, t\u0026thinsp;=\u0026thinsp;1.149, P\u0026thinsp;=\u0026thinsp;0.258). The intraoperative transfusion rate was similar between groups (multimodal management group: 50.0% vs. control group: 45.8%). Regarding postoperative recovery, the time to first ambulation showed a trend toward prolongation in the multimodal management group (3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74 days) compared to the control group (2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 days), although this difference did not achieve statistical significance (t\u0026thinsp;=\u0026thinsp;1.888, P\u0026thinsp;=\u0026thinsp;0.067).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgery and related postoperative indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime of operation (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136.67\u0026thinsp;\u0026plusmn;\u0026thinsp;67.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193.71\u0026thinsp;\u0026plusmn;\u0026thinsp;93.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036 (*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative blood loss (mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313.04\u0026thinsp;\u0026plusmn;\u0026thinsp;194.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e402.86\u0026thinsp;\u0026plusmn;\u0026thinsp;280.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative autotransfusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(person-time)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (50.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative first time getting out of bed (d)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Dynamic Changes in Hemoglobin Levels\u003c/h2\u003e \u003cp\u003eLongitudinal assessment of hemoglobin levels revealed several notable findings between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The multimodal management group had significantly lower preoperative hemoglobin levels compared to the control group (124.64\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62 g/L vs. 136.75\u0026thinsp;\u0026plusmn;\u0026thinsp;18.30 g/L, t\u0026thinsp;=\u0026thinsp;2.167, P\u0026thinsp;=\u0026thinsp;0.037). On postoperative day 1, hemoglobin levels in the management group further decreased to 92.43\u0026thinsp;\u0026plusmn;\u0026thinsp;16.99 g/L, which was significantly lower than those in the control group (110.50\u0026thinsp;\u0026plusmn;\u0026thinsp;18.74 g/L, t\u0026thinsp;=\u0026thinsp;2.965, P\u0026thinsp;=\u0026thinsp;0.005). By postoperative day 4, hemoglobin levels in the management group (93.25\u0026thinsp;\u0026plusmn;\u0026thinsp;21.96 g/L) remained lower than those in the control group (105.22\u0026thinsp;\u0026plusmn;\u0026thinsp;21.95 g/L); however, this difference was no longer statistically significant (t\u0026thinsp;=\u0026thinsp;1.512, P\u0026thinsp;=\u0026thinsp;0.142), with missing data for 6 patients in the control group and 2 patients in the management group. By postoperative day 7, the intergroup difference further diminished (management group: 96.33\u0026thinsp;\u0026plusmn;\u0026thinsp;14.87 g/L vs. control group: 100.91\u0026thinsp;\u0026plusmn;\u0026thinsp;16.17 g/L, t\u0026thinsp;=\u0026thinsp;0.652, P\u0026thinsp;=\u0026thinsp;0.522), with missing data for 13 patients in the control group and 5 patients in the management group. These findings demonstrate that despite having lower preoperative and early postoperative hemoglobin levels, the multimodal management group exhibited a consistent trend of recovery throughout the observation period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDynamic monitoring results of hemoglobin(g/L)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136.75\u0026thinsp;\u0026plusmn;\u0026thinsp;18.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124.64\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037 (*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Day 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110.50\u0026thinsp;\u0026plusmn;\u0026thinsp;18.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.43\u0026thinsp;\u0026plusmn;\u0026thinsp;16.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005 (**)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Day 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105.22\u0026thinsp;\u0026plusmn;\u0026thinsp;21.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.25\u0026thinsp;\u0026plusmn;\u0026thinsp;21.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Day 7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.91\u0026thinsp;\u0026plusmn;\u0026thinsp;16.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.33\u0026thinsp;\u0026plusmn;\u0026thinsp;14.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.5 FACIT-Fatigue Score Analysis\u003c/h2\u003e \u003cp\u003eAnalysis of FACIT-Fatigue scores revealed significant differences in recovery patterns between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). At one week post-surgery, the multimodal management group exhibited significantly higher fatigue levels (indicated by lower scores) compared to the control group (FACIT score: 27.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94 vs. 32.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17, t\u0026thinsp;=\u0026thinsp;2.180, P\u0026thinsp;=\u0026thinsp;0.039). However, by one month post-surgery, the management group demonstrated significantly greater improvement in fatigue scores from baseline compared to the control group (change value: 5.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01 vs. 3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78, t\u0026thinsp;=\u0026thinsp;4.979, P\u0026thinsp;=\u0026thinsp;0.0002). At three months post-surgery, no statistically significant differences were observed between the two groups, either in final fatigue scores (management group: 35.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.01 vs. control group: 39.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.80, t\u0026thinsp;=\u0026thinsp;1.569, P\u0026thinsp;=\u0026thinsp;0.132) or in the magnitude of improvement from baseline (management group: 7.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53 vs. control group: 7.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99, t\u0026thinsp;=\u0026thinsp;0.400, P\u0026thinsp;=\u0026thinsp;0.693). These findings indicate that although patients in the multimodal management group experienced increased fatigue levels early after surgery due to the greater surgical insult, the multimodal blood management strategy significantly accelerated fatigue recovery within the first postoperative month, ultimately achieving comparable fatigue relief to the control group by three months.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFACIT score and baseline changes based on postoperative scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eFACIT score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 week after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.039 (*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.71\u0026thinsp;\u0026plusmn;\u0026thinsp;7.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline changes based on postoperative FACIT score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0002 (***)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Harris Hip Score Analysis\u003c/h2\u003e \u003cp\u003eAnalysis of Harris Hip Scores revealed distinct patterns of functional recovery between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Preoperatively, no significant difference in hip function was observed between groups (t\u0026thinsp;=\u0026thinsp;0.210, P\u0026thinsp;=\u0026thinsp;0.835). However, at one week post-surgery, the multimodal management group experienced a significantly greater decline in Harris Hip Scores attributable to surgical trauma (30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;10.19 points vs. 22.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79 points in the control group, t\u0026thinsp;=\u0026thinsp;2.391, P\u0026thinsp;=\u0026thinsp;0.022), resulting in correspondingly lower absolute scores (48.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.15 points vs. 57.25\u0026thinsp;\u0026plusmn;\u0026thinsp;13.03 points, t\u0026thinsp;=\u0026thinsp;2.162, P\u0026thinsp;=\u0026thinsp;0.037). Critically, the management group demonstrated significantly greater functional improvement at one month post-surgery compared to the control group (change value: 30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03 points vs. 25.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46 points, t\u0026thinsp;=\u0026thinsp;2.509, P\u0026thinsp;=\u0026thinsp;0.017). This accelerated recovery effectively compensated for the greater early functional loss. By three months post-surgery, the overall magnitude of functional improvement was comparable between groups (management group: 40.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.37 points vs. control group: 35.83\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24 points, t\u0026thinsp;=\u0026thinsp;1.491, P\u0026thinsp;=\u0026thinsp;0.145). These findings confirm that multimodal blood management, by accelerating mid-term functional recovery, enables patients undergoing more complex surgical procedures to ultimately achieve functional outcomes comparable to those of the control group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHarris score and baseline changes based on postoperative scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultimodal management\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical quantity\u003c/p\u003e \u003cp\u003e(t/χ\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eHarris score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.83\u0026thinsp;\u0026plusmn;\u0026thinsp;17.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.57\u0026thinsp;\u0026plusmn;\u0026thinsp;18.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 week after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.25\u0026thinsp;\u0026plusmn;\u0026thinsp;13.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.037(*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.67\u0026thinsp;\u0026plusmn;\u0026thinsp;12.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.08\u0026thinsp;\u0026plusmn;\u0026thinsp;11.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Harris decline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;10.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.022 (*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline change value based on postoperative Harris score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.017 (*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.83\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Preliminary Advantages of Multimodal Blood Management\u003c/h2\u003e \u003cp\u003ePerioperative blood management encompasses the entire continuum of care, including the preoperative, intraoperative, and postoperative phases. However, due to the unique characteristics of oncologic patients, intraoperative autologous blood transfusion is contraindicated, which inherently limits the options and implementation of intraoperative blood conservation strategies. Given this objective constraint, our study focused primarily on preoperative and postoperative blood management, aiming to achieve more precise and effective perioperative blood conservation in these critical windows, thereby improving overall treatment outcomes and patient prognosis.\u003c/p\u003e \u003cp\u003eAlthough allogeneic blood transfusion can rapidly elevate hemoglobin levels in emergency situations or in anemic patients unresponsive to other therapies, it is associated with several risks, including viral transmission, immune-mediated allergic reactions, acute hemolytic reactions, and transfusion-related acute lung injury. Moreover, blood resources remain scarce in China. Given the inherent limitations of a restrictive transfusion strategy alone, there is a clear need to explore multimodal perioperative management approaches (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).The HiFIT team from the French Ministry of Health previously published findings in The Lancet Haematology demonstrating that single-modality blood management strategies are insufficient to reduce transfusion rates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).Therefore, this study retrospectively evaluated a perioperative multimodal blood management strategy\u0026mdash;combining erythropoietin (EPO), iron supplementation, and a restrictive transfusion protocol\u0026mdash;specifically in the context of hip bone tumor surgery. We provide the first evidence that although this approach is employed in patients facing more complex surgical challenges, it effectively mitigates early postoperative functional disadvantages and facilitates enhanced recovery at critical time points.\u003c/p\u003e \u003cp\u003eAs a retrospective study, this research did not impose strict control over enrollment criteria. Although the two groups were comparable in terms of baseline demographics, disease characteristics, surgical procedure types, and preoperative laboratory parameters, patients in the multimodal management group presented with significantly lower preoperative hemoglobin levels compared to the control group (control group: 136.75\u0026thinsp;\u0026plusmn;\u0026thinsp;18.30 g/L vs. multimodal group: 124.64\u0026thinsp;\u0026plusmn;\u0026thinsp;14.62 g/L, P\u0026thinsp;=\u0026thinsp;0.037). This difference suggests a distinct preoperative physiological profile in the multimodal group, potentially reflecting more aggressive tumor behavior or longer disease duration, leading to more pronounced anemia prior to surgery. This observation indirectly underscores the greater surgical complexity and diminished physiological reserve in this group, indicating that these patients faced a more arduous postoperative recovery trajectory. Furthermore, patients in the multimodal management group underwent relatively more complex surgical procedures, as evidenced by significantly longer operative times (193.71\u0026thinsp;\u0026plusmn;\u0026thinsp;93.66 min vs. 136.67\u0026thinsp;\u0026plusmn;\u0026thinsp;67.57 min, P\u0026thinsp;=\u0026thinsp;0.036) and, although not statistically significant, numerically higher mean intraoperative blood loss (control group: 313.04\u0026thinsp;\u0026plusmn;\u0026thinsp;194.95 mL vs. multimodal group: 402.86\u0026thinsp;\u0026plusmn;\u0026thinsp;280.64 mL). Notably, hemoglobin assessment on postoperative day 1 confirmed greater blood loss in the multimodal group compared to controls.\u003c/p\u003e \u003cp\u003eDespite this disadvantaged starting point, the multimodal management group demonstrated a robust recovery trajectory. Particularly at the critical one-month postoperative time point, both the magnitude of improvement in FACIT-Fatigue scores and Harris Hip Scores were significantly superior to those of the control group. This accelerated recovery suggests that multimodal blood management, by facilitating the restoration of physiological reserve, secured crucial opportunities for medium-to-long-term rehabilitation in these patients. These findings confirm the effectiveness of multimodal management strategies in promoting postoperative recovery, provide strong evidence to support their implementation in similar patient populations with hip bone tumors, and establish a preliminary foundation for further refinement of perioperative management protocols.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The Role of Iron Supplementation in Perioperative Blood Management\u003c/h2\u003e \u003cp\u003eBased on erythrocyte indices (MCV, MCH, MCHC), anemia is primarily classified into three categories: microcytic hypochromic anemia, normocytic normochromic anemia, and macrocytic anemia. Following acute surgical blood loss, the former two types are more commonly encountered. Given that macrocytic anemia is predominantly attributable to megaloblastic anemia resulting from folate and/or vitamin B\u003csub\u003e12\u003c/sub\u003e deficiency, patients with this condition were excluded from the present study to enable a more precise investigation of perioperative blood management in hip surgery.\u003c/p\u003e \u003cp\u003eThe Chinese Expert Consensus on Enhanced Recovery After Surgery for Hip and Knee Arthroplasty: Perioperative Anemia Management explicitly recommends iron supplementation for patients with preoperative iron deficiency anemia and anemia resulting from acute surgical blood loss, with the aim of rapidly elevating hemoglobin levels and correcting anemia. Iron serves as an essential micronutrient for hemoglobin synthesis; it combines with protoporphyrin Ⅸ to form heme, which subsequently binds with globin to constitute hemoglobin(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).Furthermore, iron deficiency directly impedes heme synthesis, thereby impairing hemoglobin assembly(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA systematic review and meta-analysis examining preoperative intravenous iron administration in patients undergoing major surgery demonstrated significantly reduced transfusion requirements and markedly increased hemoglobin concentrations at four weeks postoperatively compared to placebo or oral iron(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).Preoperative intravenous iron combined with tranexamic acid has been shown to substantially mitigate transfusion risk following arthroplasty procedures (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).A 2021 Danish study encompassing 210 elderly patients with hip fractures revealed that early postoperative iron supplementation was associated with reduced 30-day mortality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).Moreover, an additional systematic review and meta-analysis addressing perioperative iron therapy in acute major non-cardiac surgery corroborated these findings, demonstrating lower 30-day mortality among patients receiving iron supplementation(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).Although adverse reactions to iron therapy have been documented clinically, current third-generation intravenous iron formulations enable administration of sufficient iron doses while effectively mitigating complications such as oxidative stress, thereby offering safer and more efficacious options for clinical application(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, iron supplementation occupies a pivotal position in perioperative anemia management. Third-generation intravenous iron formulations, in particular, effectively optimize hemoglobin levels, augment iron stores, reduce transfusion requirements, and ultimately contribute to improved patient prognosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3 The Role of Erythropoietin in Perioperative Blood Management\u003c/h2\u003e \u003cp\u003eErythropoietin (EPO), a hormone primarily produced by the kidneys, serves as a critical regulator of erythropoiesis. It acts on erythroid progenitor cells, promoting their proliferation and differentiation into mature erythrocytes, thereby increasing red blood cell counts. EPO also activates intracellular signaling pathways, including the JAK2-STAT5 pathway (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e),which inhibits apoptosis of erythroid precursors and facilitates hemoglobin synthesis, ultimately enhancing erythrocyte maturation and oxygen-carrying capacity. Furthermore, emerging evidence suggests that EPO possesses neurogenic and angiogenic properties, providing a theoretical rationale for its potential role in postoperative recovery (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven its multifaceted physiological effects, multiple guidelines and expert consensus statements have recommended EPO as a standard component of perioperative anemia management in orthopedic surgery(\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).A Spanish study involving 306 patients with hip fractures demonstrated that patients receiving EPO in combination with iron supplementation exhibited significantly improved hemoglobin levels at hospital discharge and at 60 days post-discharge compared to the placebo group (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).Moreover, at 60 days post-discharge, a higher proportion of anemic patients in the treatment group had achieved complete recovery. Additional research has robustly confirmed that preoperative administration of EPO effectively reduces perioperative transfusion requirements in patients with hip fractures(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, erythropoietin plays a multifaceted role in regulating erythropoiesis, activating signaling pathways to inhibit apoptosis, and promoting cellular development. These properties confer substantial clinical value in the management of perioperative anemia in orthopedic surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Multimodal Management Strategy: Mechanistic Complementarity and Synergistic Effects\u003c/h2\u003e \u003cp\u003eFrom the perspective of the underlying mechanisms of each component in multimodal management, the synergistic effect of combining EPO, iron supplementation, and a restrictive transfusion protocol plays a pivotal role. Iron serves as the essential raw material for hemoglobin synthesis, providing the necessary substrate for erythropoiesis. EPO accelerates red blood cell production through multiple mechanisms, including regulating the proliferation and differentiation of erythroid progenitor cells, promoting erythrocyte membrane development, and facilitating hemoglobin synthesis. The combination of these two interventions achieves comprehensive regulation\u0026mdash;from providing fundamental building blocks to supporting cellular production and maturation\u0026mdash;thereby offering more robust support for ameliorating perioperative anemia in patients undergoing hip bone tumor surgery.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that following iron or EPO administration, hemoglobin levels substantially increase within approximately 30 to 60 days(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings revealed that at seven days post-surgery, although hemoglobin levels did not differ significantly between the multimodal management group and the control group, patients in the multimodal group had already begun to show improvement. Furthermore, due to the synergistic interaction between these two agents, both Harris Hip Scores and FACIT-Fatigue scores showed marked improvement at one month post-surgery. These observations align with previous research findings; although hemoglobin data at 30 days were not available in our study, the aforementioned functional improvements sufficiently demonstrate that the combination of EPO and iron supplementation can promote erythropoiesis and hemoglobin synthesis within a relatively short timeframe.\u003c/p\u003e \u003cp\u003eThis comprehensive strategy optimizes every aspect of the blood conservation process\u0026mdash;from stimulating hematopoiesis and supplying raw materials to ensuring rational blood utilization\u0026mdash;thereby enabling patients to progressively overcome the adverse effects of surgical trauma, accelerating the restoration of physical function and overall recovery. Ultimately, patients in the multimodal management group achieved rehabilitation outcomes comparable to, or even surpassing, those receiving conventional management. These findings provide novel insights for perioperative management in patients undergoing hip bone tumor surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Study Limitations\u003c/h2\u003e \u003cp\u003eSeveral limitations of this study should be acknowledged. First, this was a single-center retrospective analysis with a relatively limited sample size (n\u0026thinsp;=\u0026thinsp;38). Given that hip bone tumors represent a category of diseases with low incidence, collecting a large sample of highly homogeneous cases within a limited study period at a single center presents objective difficulties. This limitation may affect statistical power and limit the generalizability of the study conclusions. However, it is worth noting that the preliminary data obtained under strict inclusion criteria provide \"real-world\" evidence and trend-based insights into systematic blood management for this specific and high-risk surgical population. Future multicenter prospective studies with larger sample sizes are warranted to validate the generalizability of this strategy and further characterize the patient populations most likely to benefit.\u003c/p\u003e \u003cp\u003eAnother limitation of this study is the absence of hemoglobin data at 30 days post-surgery. As a retrospective analysis, the data were derived from routine clinical practice. In standard clinical follow-up, patients with stable postoperative recovery typically do not undergo routine blood tests, resulting in missing laboratory data at this time point. Consequently, we were unable to precisely delineate the complete kinetic curve of early postoperative anemia correction. However, this limitation also highlights the real-world perspective of our study: rather than evaluating the intervention under prespecified laboratory monitoring, we first observed significantly greater functional improvement at one month post-surgery in the management group within actual clinical practice, and subsequently traced back the differences in their management. These findings nonetheless robustly demonstrate an association between multimodal blood management and enhanced early functional recovery. Future prospective studies could build upon these findings by incorporating regular hematological monitoring to further elucidate the temporal and mechanistic relationship between anemia correction and functional recovery.\u003c/p\u003e \u003cp\u003eFinally, the retrospective study design inherently carries certain limitations, including the potential presence of unrecorded or unmeasured confounding factors (e.g., tumor volume, extent of soft tissue involvement). Although we compared and verified all available key baseline characteristics in our statistical analysis, demonstrating comparability between the two groups, the possibility of residual confounding factors influencing the results cannot be completely excluded. It is noteworthy that this study observed significant early functional improvement in the management group despite their disadvantaged baseline status of lower preoperative hemoglobin levels and longer operative times. To some extent, this finding enhances the credibility of the results, as it suggests that the intervention may have overcome additional risks. However, retrospective analyses provide only correlational evidence. Establishing causal relationships will require well-designed prospective randomized controlled trials.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study compared the effects of a perioperative multimodal blood management strategy (combining EPO, iron supplementation, and a restrictive transfusion protocol) with conventional management in patients undergoing hip bone tumor surgery. The following conclusions were drawn: Although the multimodal management group presented with lower preoperative hemoglobin levels and underwent more complex surgical procedures\u0026mdash;constituting multiple disadvantageous factors\u0026mdash;this strategy, through the synergistic interaction of EPO, iron supplementation, and restrictive transfusion, significantly accelerated the improvement of fatigue and hip joint function during the critical postoperative recovery phase (particularly at one month post-surgery). This approach effectively compensated for early functional deficits, enabling patients to ultimately achieve rehabilitation outcomes comparable to those of the control group, thereby demonstrating substantial clinical value. Clinically, reliance on traditional transfusion alone should be superseded by the establishment of a multimodal blood management system centered on the concept of \"physiological reserve reconstruction.\"\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The experimental procedures were performed under the approval of the Ethics Committee of First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China. Approval number is 2025552. They were in strict accordance with the Declaration of Helsinki (1964). Written informed consents were obtained from all participants and their parents.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declared no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis article was partially supported by the National Natural Science Foundation of China (82402857), Natural Science Foundation of Jiangsu Province (BK20240369) and Suzhou Basic Research Pilot Project (Interdisciplinary, SSD2025064).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZhang ZM, Ma YT and Ge J contributed to manuscript writing and editing, and data collection; Chu L, Ding WQ, Zhao LY and Ge J contributed to literature review; Zou J, Yang HL and Lu J contributed to conceptualization and supervision; all authors have read and approved the final manuscript.#Zhang ZM and Ma YT contributed equally to the work.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZan P, Ma X, Wang H, Cai Z, Shen J, Sun W. 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(1365\u0026ndash;2346 (Electronic)).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bone Tumors of Hip, Perioperative Period, Multimodal Management, Blood Management, Functional Recovery","lastPublishedDoi":"10.21203/rs.3.rs-9059442/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9059442/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study evaluated the efficacy of a perioperative multimodal blood management strategy\u0026mdash;combining erythropoietin, iron supplementation, and restrictive transfusion protocols\u0026mdash;in patients undergoing surgery for hip bone tumors, to optimize their perioperative care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis of 38 patients who underwent hip bone tumor surgery between January 2021 and February 2025. Based on inclusion and exclusion criteria, patients were divided into a control group (n\u0026thinsp;=\u0026thinsp;24) and a multimodal management group (n\u0026thinsp;=\u0026thinsp;14). We compared baseline characteristics, preoperative laboratory results, surgical and postoperative data, dynamic hemoglobin changes, FACIT-Fatigue scores, and Harris Hip Scores between the groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePreoperative hemoglobin was lower and surgical duration was longer in the multimodal management group compared to the controls (both p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At one month postoperatively, the multimodal group demonstrated significantly greater improvement in both FACIT-Fatigue scores (5.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01 vs. 3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and Harris Hip Scores (30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03 vs. 25.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). By three months postoperatively, scores between the two groups were comparable (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite lower preoperative hemoglobin and more complex surgeries, the multimodal blood management strategy facilitated superior early functional recovery and accelerated rehabilitation at a critical postoperative time point.\u003c/p\u003e","manuscriptTitle":"Impact of Perioperative Multimodal Blood Management of Bone Tumors of Hip on Early Postoperative Functional Recovery: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 00:42:27","doi":"10.21203/rs.3.rs-9059442/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-30T14:27:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-06T12:40:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191808891663583805916362161274583802750","date":"2026-04-06T07:53:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186784287538101595204687246758678418258","date":"2026-04-04T19:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T07:22:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-09T08:36:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T06:25:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T06:24:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-03-07T15:16:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4686ddb5-258f-4380-acfa-ca5d6319bab1","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-04-30T14:27:01+00:00","index":60,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T00:42:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 00:42:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9059442","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9059442","identity":"rs-9059442","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}