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International Orthopaedics

, Volume 42, Issue 7, pp 1517–1525 | Cite as

Quality of life of patients with osteonecrosis of the femoral head: a multicentre study

  • Yuko Uesugi
  • Takashi Sakai
  • Taisuke Seki
  • Shinya Hayashi
  • Junichi Nakamura
  • Yutaka Inaba
  • Daisuke Takahashi
  • Kan Sasaki
  • Goro Motomura
  • Naohiko Mashima
  • Tamon Kabata
  • Akihiro Sudo
  • Tetsuya Jinno
  • Wataru Ando
  • Satoshi Nagoya
  • Kengo Yamamoto
  • Satoshi Nakasone
  • Hiroshi Ito
  • Takuaki Yamamoto
  • Nobuhiko Sugano
Original Paper

Abstract

Purpose

Quality-of-life (QOL) assessments in patients with osteonecrosis of the femoral head (ONFH) have rarely been reported. This multicentre study aimed to elucidate the relationship between disease severity, including necrotic lesion type and radiological staging, and QOL, as well as between patients’ characteristics and QOL.

Methods

Two hundred seventy-four patients with ONFH (108 females, 166 males; median age, 46 years) were asked to complete self-assessment QOL questionnaires including the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Oxford Hip Score, and SF-12v2.

Results

Patients with large necrotic lesion type or collapsed ONFH had low QOL scores. Among patients with non-collapsed lesions, patients with alcohol-associated ONFH had lower QOL scores than those with steroid-associated ONFH, those with bilateral ONFH had lower mental scores, and male patients had worse social condition scores. Among patients with collapsed lesions, middle-aged patients exhibited lower mental QOL, and a strong correlation was observed between social activity and mental health.

Conclusion

Collapsed ONFH was associated with low QOL scores. Among patients with non-collapsed lesions, alcohol-associated ONFH, bilateral disease, and male sex were linked to low QOL scores.

Keywords

Osteonecrosis of the femoral head (ONFH) Quality of life (QOL) Radiological stage Steroid-associated Alcohol-associated 

Abbreviations

JIC

Japanese Investigating Committee

JHEQ

Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire

OHS

Oxford Hip Score

PCS

Physical component summary

MCS

Mental component summary

RCS

Role/social component summary

Introduction

Osteonecrosis of the femoral head (ONFH) causes severe hip pain due to femoral head collapse, and it leads to secondary osteoarthritis [1]. Accompanied by disease progression, hip pain increases as hip function deteriorates. The prognosis of ONFH depends on the disease severity, namely size and location of the necrotic lesion on plain radiograph and magnetic resonance imaging (MRI) [2, 3, 4, 5]. According to the type of necrotic lesion and radiological stage, treatment options include femoral osteotomy [6, 7], total hip arthroplasty (THA) [5], and recent regenerative medicine [8, 9, 10].

Quality-of-life (QOL) assessments have rarely been reported as part of surgical treatment outcomes in patients with ONFH [11, 12, 13], and these assessments have not been performed in large cohort. QOL assessments evaluated mental, physical, and social factors [14, 15, 16, 17]. QOL evaluation was first reported for patients in the 1940s [18]; subsequently, improvement in survival rate, physical function, and QOL scores have been evaluated for various diseases. At present, QOL evaluation is standard among patients undergoing orthopaedic surgery [14, 15, 16, 17].

Meanwhile, although steroid- and alcohol-associated ONFH comprise 51 and 31% of all cases of ONFH, respectively [1], the relationships of these associated factors with QOL remain unknown, and no QOL assessment has been reported in patients with ONFH who were not treated surgically in a large cohort. As most patients with ONFH are 30–50 years old [1] and most of them have occupational and social roles, it is important to elucidate QOL in patients with ONFH.

This study aimed to elucidate the relationship between disease severity, including necrotic lesion type and radiological staging, and QOL, as well as those of disease-associated factors and patient characteristics, with QOL, in a cohort of patients with ONFH.

Methods

This study was a multicentre study, and all analysis was performed under the permission of the Institutional Review Board of the authors’ institutions. Between February 2015 and March 2017, 290 patients with ONFH (age ≥ 16 years) in 17 medical centers were included. Among them, 16 patients were excluded due to histories of hip surgery, and 274 patients were investigated, including 108 females and 166 males with a median age of 46.0 years (interquartile range, 37–57; range, 17–84 years). The mean body mass index was 22.5 kg/m2 (interquartile range, 20.5–25.0; range, 14.3–35.2 kg/m2). The cohort consisted of 190 and 84 patients with bilateral and unilateral ONFH, respectively.

We categorized the location of the necrotic lesion at the weight-bearing portion using the Japanese Investigation Committee (JIC) type classification, which is divided into four types (A, B, C1, and C2) based on the mid-coronal images or anteroposterior plain radiograph [3]. Type A lesions occupy the medial one third or less of the weight-bearing portion, and type B lesions occupy the medial two thirds or less. Both types C1 and C2 lesions occupy more than the medial two thirds; however, type C2 lesions, unlike type C1 lesions, extend laterally to the acetabular edge. The weight-bearing portion is defined as the area lateral to the mid-vertical line of the line through the acetabular edge and the teardrop bottom. The worse hip side was evaluated in all assessments for patients with bilateral ONFH. In total, 0, 10, 87, and 177 patients had types A, B, C1, and C2 lesions, respectively.

The necrotic lesions were also evaluated using the JIC stage classification [3]. Stage 1 is defined by normal findings on plain radiographs and abnormal findings on MRI. Stage 2 is non-collapse with a band pattern, stage 3A features less than 3 mm of collapse, stage 3B features more than 3 mm of collapse, and stage 4 is typified by osteoarthritic changes. In total, 10, 23, 118, 76, and 47 patients were categorized into stages 1, 2, 3A, 3B, and 4, respectively. Regarding the associated factors, 126 patients had steroid-associated ONFH, 77 patients had alcohol-associated ONFH, 57 patients had both steroid- and alcohol-associated ONFH, and 14 patients had ONFH lacking associated factors (Table 1). According to the Japanese National Health and Nutrition Survey, alcohol-associated ONFH was defined as osteonecrosis in patients with histories of drinking ≥ 20 g of alcohol at least three days/week [19]. The underlying diseases in 126 patients with steroid-associated ONFH included systemic lupus erythematosus (SLE), dermatomyositis, Sjogren’s syndrome, other autoimmune diseases, blood tumor diseases, nephritis, idiopathic thrombocytopenic purpura, asthma, inflammatory bowel diseases, and eye diseases in 36, 11, 9, 17, 8, 7, 4, 3, 3, and 3 patients, respectively.
Table 1

ONFH patient characteristics

  

N (patients)

Percent

Sex

 Male

 

166

60.6

 Female

 

108

39.4

Age (years)

 Median (interquartile range)

46.(37–57)

  

 Range

17–84

  

BMI (kg/m2)

 Median (interquartile range)

22.5 (20.5–25.0)

  

 Range

14.3–35.2

  

Affected hip

 Unilateral

 

84

30.7

 Bilaterala

 

190

69.3

JIC type of the necrotic lesiona (patients)

 Type A

 

0

0.0

 Type B

 

10

3.6

 Type C1

 

87

31.8

 Type C2

 

177

64.6

JIC Stage of the necrotic lesiona (patients)

 Group Nb

  Stage 1

 

10

3.6

  Stage 2

 

23

8.4

 Group Cc

  Stage 3A

 

118

43.1

  Stage 3B

 

76

27.7

  Stage 4

 

47

17.2

Associated factors

 Steroid

 

126

46.0

 Alcohol

 

77

28.1

 Both

 

57

20.8

 None

 

14

5.1

aThe worse hip side was evaluated in all assessments for patients with bilateral ONFH

bNon-collapsed ONFH

cCollapsed ONFH

QOL evaluation included physical, mental, and social factors. Self-reported QOL questionnaires, including the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) [14], Oxford Hip Score (OHS) [15, 16, 17], and SF-12v2 [20], were given to all patients. Simultaneous evaluation of disease-specific assessment and comprehensive assessment has been recommended [21], and JHEQ and OHS are disease-specific assessments, whereas SF-12v2 is a comprehensive assessment. JHEQ evaluates pain, movement, and mental condition, and each subscale is scored on a range of 0–28 points in 21 items, with higher scores indicating better QOL. The current satisfaction status is also assessed by JHEQ satisfaction scores on a scale of 0–100, with higher scores indicating lower satisfaction. The validity of JHEQ for ONFH has been reported [22]. OHS valuate pain and the functional ability to perform home or yard work, and each scale is scored on a range of 0–48 points, with higher scores indicating better QOL. SF-12v2 is a short version of SF-36, a comprehensive QOL assessment tool, and it consists of physical component summary (PCS), mental component summary (MCS), and role/social component summary (RCS) scores. The national standard is 50 points, and a higher score indicates better QOL.

We investigated the relationships between QOL scores and disease severity (necrotic lesion type and radiological stage), between QOL scores and associated factors (steroid and alcohol), and between QOL scores and patients’ characteristics (bilateral/unilateral disease, sex, age).

The Kruskal-Wallis test, Wilcoxon rank sum test, and Holm method were used to compare QOL scores among the groups. Spearman’s correlation coefficient was used to evaluate the relationship between RCS and other domains. All statistical analyses were performed using JMP pro13 (SAS Institute Inc., Cary, NC, USA) and SPSS version 24 for Windows (IBM Corp., Armonk, NY, USA). Significance was established at a p value < 0.05.

Results

QOL score and disease severity (necrotic lesion type and radiological stage)

Worse QOL scores were associated with more severe necrotic lesion type and radiological stage. In particular, JHEQ scores for pain (p = 0.001), and movement (p < 0.0001) and the OHS (p = 0.019) were worse in the patients with type C2 lesions than in those with type C1 lesions (Table 2). Between radiological stages, there were significant differences in the JHEQ satisfaction score (p < 0.0001), the JHEQ pain score (p < 0.0001), the JHEQ movement score (p < 0.0001), the JHEQ mental score (p = 0.003), the OHS (p = 0.001), and the SF12v12 RCS score (p = 0.005) (Table 3). Although there were significant differences in QOL scores between necrotic lesion types as well as between radiological stages, there were no significant differences in QOL scores between necrotic lesion types in each radiological stage.
Table 2

QOL scores in JIC necrotic lesion type

 

Type B

Type C1

Type C2

Kruskal-Wallis

10 patients

87 patients

174 patients

p

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

70.5

30.8–98.5

82.0

50.0–99.0

91.0

70.0–100.0

0.021

 Pain

13.5

8.0–19.3

11.0

6.5–15.5

7.0

4.0–11.0

0.001*

 Movement

12.0

4.5–20.0

9.0

4.0–16.0

5.0

2.0–10.0

< 0.0001**

 Mental

12.5

5.0–17.8

10.0

5.8–18.0

9.0

5.0–14.0

0.374

 OHS

25.0

18.3–41.5

30.0

21.0–37.3

25.5

16.8–33.3

0.019***

SF-12v2

 PCS

25.2

18.7–40.9

26.6

16.1–36.5

23.8

13.4–33.3

0.245

 MCS

45.1

38.4–52.5

52.6

45.5–61.8

50.8

43.9–57.4

0.128

 RCS

42.1

23.1–56.4

36.5

25.5–50.4

34.4

23.5–45.5

0.440

Wilcoxon rank sum test with method of Holm was used to adjust the p values in multiple testing. Post-analysis of Kruskal-Wallis test was described

*p = 0.001 (types C1 and C2); **p < 0.0001 (types C1 and C2); ***p = 0.005 (types C1 and C2)

aLower score is better

Table 3

QOL scores in JIC radiological staging

 

Stage 1

Stage 2

Stage 3A

Stage 3B

Stage 4

Kruskal-Wallis

10 patients

23 patients

118 patients

76 patients

47 patients

p

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

47.0

4.5–57.0

65.0

27.0–100.0

85.0

67.3–100.0

95.5

79.0–100.0

86.0

76.0–98.0

< 0.0001*

 Pain

24.0

11.5–28.0

14.0

9.0–24.0

9.0

5.0–14.0

7.0

3.0–10.8

7.0

4.0–11.0

< 0.0001**

 Movement

14.0

8.5–28.0

13.5

8.0–18.8

7.0

2.0–14.0

4.0

1.0–7.0

3.5

2.0–6.8

< 0.0001***

 Mental

15.0

11.0–25.5

10.0

7.0–17.0

11.0

5.0–18.0

7.0

4.0–13.0

10.0

5.8–14.0

0.003****

 OHS

35.0

21.5–48.0

36.0

23.0–42.0

27.0

17.3–36.8

23.0

15.0–31.0

27.0

19.0–31.0

0.001*****

SF-12v2

 PCS

31.9

16.4–49.9

30.2

21.9–41.2

24.1

15.7–35.0

19.6

12.4–31.8

24.9

16.7–32.6

0.070

 MCS

62.4

44.9–64.9

48.8

39.9–53.5

50.8

44.5–60.3

50.3

44.6–56.2

53.0

46.1–59.0

0.120

 RCS

50.4

37.6–60.9

40.8

24.1–51.2

37.2

27.2–48.5

31.8

19.4–41.1

38.0

25.4–48.7

0.005******

Wilcoxon rank sum test with method of Holm was used to adjust the p values in multiple testing. Post-analysis of Kruskal-Wallis test was described

*p = 0.0002, p < 0.0001, p = 0.0001 (stages 1 and 3A, 3B, 4), p = 0.007 (stages 2 and 3B); **p = 0.008, p = 0.001, p = 0.002 (stages 1 and 3A, 3B, 4), p = 0.001, p < 0.0001, p < 0.0001 (stages 2 and 3A, 3B, 4); ***p = 0.0007, p = 0.001 (stages 1 and 3B, 4), p = 0.003, p < 0.0001, p < 0.0001 (stages 2 and 3A, 3B, 4), p = 0.002, p = 0.054 (stage 3A and 3B, 4); ****p = 0.001 (stages 1 and 3B); *****p = 0.0003, p = 0.004 (stage 2 and 3B, 4); ******p = 0.002 (stages 1and 3B)

aLower score is better

QOL score and associated factors (steroid and alcohol)

Stages 1 and 2 comprised the non-collapsed group (group N, n = 33) whereas stages 3A, 3B, and 4 comprised the collapsed group (group C, n = 241). In group N, patient with alcohol-associated ONFH had lower satisfaction (p = 0.002), JHEQ mental scores (p = 0.010), OHS (p = 0.009), and SF12v2 RCS scores (p = 0.002) than those with steroid-associated ONFH (Table 4). There were no significant differences in QOL scores between patients with alcohol- and steroid-associated ONFH in group C.
Table 4

Associated factors and QOL scores in group N (non-collapsed osteonecrosis of the femoral head)

 

Steroid-associated

Alcohol-associated

Both

Kruskal-Wallis

19 patients

9 patients

5 patients

p

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

47.0

23.0–77.0

100.0

65.5–100.0

25.0

0.0–80.5

0.005*

 Pain

19.0

10.8–25.8

14.0

8.5–14.5

19.0

13.0–28.0

0.223

 Movement

16.0

7.8–21.3

12.0

8.5–13.8

16.0

9.5–28.0

0.250

 Mental

15.0

10.0–26.0

7.0

4.0–12.0

14.0

9.8–25.0

0.022**

 OHS

38.5

31.5–46.3

23.0

17.5–31.5

41.0

29.0–48.0

0.015***

SF-12v2

 PCS

32.4

21.6–45.0

26.0

15.1–30.0

49.4

25.7–55.6

0.074

 MCS

51.9

42.8–58.4

45.7

39.3–59.4

54.3

32.8–65.1

0.706

 RCS

50.5

35.1–56.6

27.6

20.4–33.6

50.4

42.2–50.7

0.032****

Wilcoxon rank sum test with method of Holm was used to adjust the p values in multiple testing. Post-analysis of Kruskal-Wallis test was described

*p = 0.002 (steroid associated and alcohol associated); **p = 0.010 (steroid associated and alcohol associated); ***p = 0.009 (steroid associated and alcohol associated); ****p = 0.002 (steroid associated and alcohol associated)

aLower score is better

QOL score and patients’ characteristics (bilateral/unilateral ONFH, sex, and age)

Patients with bilateral ONFH in group N had significantly lower SF12v2 MCS scores (p = 0.013) (Table 5). Male patients in group N showed significantly worse SF12v2 RCS scores (p = 0.035) (Table 6), whereas no significant differences were noted between males and females in group C (Table 7). Middle-aged patients (40–64 years) in group C showed significantly lower SF-12v2 MCS scores (p = 0.022) (Table 7) whereas no significant differences were found among the ages in group N (Table 6).
Table 5

Unilateral/bilateral ONFH and QOL scores

 

Group N*

Group C**

Unilateral

Bilateral

p

Unilateral

Bilateral

p

9 patients

24 patients

75 patients

166 patients

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

50.0

20.0–100.0

49.5

25.5–86.3

1.000

86.0

70.0–98.0

90.5

74.0–100.0

0.147

 Pain

14.0

11.5–28.0

17.0

8.0–24.0

0.833

7.0

3.0–12.3

8.0

5.0–12.0

0.670

 Movement

14.0

12.0–24.5

13.5

7.8–21.0

0.486

4.5

2.0–11.3

5.0

2.0–11.0

0.673

 Mental

11.0

10.0–14.3

14.0

7.3–22.3

1.000

9.0

5.0–15.0

9.0

5.0–14.3

0.770

 OHS

30.0

18.5–44.0

36.0

30.0–45.0

0.502

26.0

17.5–35.5

26.0

17.0–33.0

0.651

SF-12v2

 PCS

25.4

20.6–43.5

32.1

23.5–44.4

0.526

25.8

15.4–36.8

23.4

13.5–32.5

0.181

 MCS

62.7

47.4–64.3

48.3

39.3–53.5

0.013

50.2

43.7–56.2

51.3

45.0–59.2

0.423

 RCS

35.9

24.3–50.5

50.4

32.1–54.1

0.189

33.7

22.7–42.8

36.5

23.2–47.6

0.326

Wilcoxon rank sum test

aLower score is better

bNon-collapsed ONFH

cCollapsed ONFH

Table 6

Sex, age, and QOL scores in group N (non-collapsed osteonecrosis of the femoral head)

 

Sex

Age

Male

Female

p

Under 39 years

Over 40 years

p

21 patients

12 patients

9 patients

24 patients

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

65.0

31.5–97.0

44.0

22.5–70.0

0.230

52.0

44.5–100.0

84.0

62.5–99.0

0.216

 Pain

14.0

9.0–27.0

18.0

14.0–24.8

0.569

14.0

11.5–26.0

8.0

4.0–14.0

0.983

 Movement

14.0

8.0–13.0

14.0

8.5–25.5

0.640

15.0

11.0–24.0

5.0

2.0–11.0

0.486

 Mental

11.0

7.5–21.0

15.0

9.0–20.0

0.751

11.0

8.5–25.0

9.0

5.0–14.0

0.614

 OHS

30.0

20.0–43.0

37.0

34.0–46.0

0.080

35.0

30.0–41.5

25.0

17.5–36.5

0.965

SF-12v2

 PCS

30.7

19.4–44.2

31.2

22.5–44.6

0.763

26.5

17.3–38.6

24.1

13.8–33.8

0.428

 MCS

45.5

40.3–60.4

51.0

48.3–61.6

0.389

53.4

48.7–62.2

50.1

43.7–56.0

0.130

 RCS

39.5

22.5–50.4

50.8

36.1–56.1

0.035

32.2

25.8–53.4

37.2

23.2–49.7

0.483

Wilcoxon rank sum test

aLower score is better

Table 7

Sex, age, and QOL scores in group C (collapsed osteonecrosis of the femoral head)

 

Male

Female

p value

Under 39 years

40–64 years

Over 65 years

Kruskal-Wallis

145 patients

96 patients

82 patients

125 patients

33 patients

p

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

Median

Interquartile range

JHEQ

 Satisfactiona

87.0

73.0–100.0

89.5

70.3–100.0

0.787

93.5

74.8–100.0

88.0

73.8–100.0

82.0

51.0–98.0

0.065

 Pain

8.0

5.0–12.0

8.0

3.0–12.0

0.250

9.0

5.0–12.0

7.0

3.0–11.0

8.0

4.0–12.8

0.563

 Movement

5.0

2.0–12.0

4.0

1.0–10.0

0.188

6.5

2.0–14.0

5.0

2.0–9.8

4.0

1.0–9.0

0.064

 Mental

10.0

5.0–15.0

9.0

4.0–15.0

0.334

10.0

5.0–16.0

9.0

5.0–14.0

7.5

3.3–14.0

0.353

 OHS

26.0

18.0–34.0

24.0

16.0–33.0

0.320

27.0

18.0–33.5

25.0

17.3–35.0

22.0

13.0–33.0

0.342

SF-12v2

 PCS

24.5

14.1–34.6

21.5

14.1–32.4

0.298

24.8

16.0–35.9

23.8

13.4–33.8

22.2

12.4–28.7

0.390

 MCS

50.9

44.2–59.8

50.8

46.0–56.3

0.636

55.3

45.8–62.7

49.7

44.4–55.2

52.5

44.5–58.0

0.022

 RCS

36.6

24.4–45.2

32.5

22.5–48.7

0.614

34.2

25.4–43.6

37.2

23.5–49.7

32.6

21.4–44.4

0.243

Wilcoxon rank sum test with method of Holm was used to adjust the p values in multiple testing. Post-analysis of Kruskal-Wallis was described

*p = 0.007 (under 39 and 40–64 years)

aLower score is better

Correlation coefficients between SF12v2 RCS scores and other QOL scores

Because most patients with ONFH were middle-aged and have occupational and social activities, we investigated the correlation coefficients between SF12v2 RCS scores and other QOL scores in each radiological stage (Spearman’s correlation coefficient) (Table 8). There were significant correlations (r ≥ 0.5) for OHS (r = 0.61, p = 0.004) in stage 2, JHEQ mental scores (r = 0.70, p < 0.0001), OHS (r = 0.55, p < 0.0001) in stage 3A, JHEQ mental scores (r = 0.58, p < 0.0001), OHS (r = 0.58, p < 0.0001) in stage 3B, and JHEQ mental scores (r = 0.67, p < 0.0001), OHS (r = 0.57, p < 0.0001) in stage 4. In particular, JHEQ mental scores exhibited the strongest correlation with SF12v2 RCS scores in the collapsed stage.
Table 8

Correlation coefficient between SF-12v2 RCS and JHEQ, OHS, SF-12v2 PCS, and SF-12v2 MCS in each JIC radiological staging

 

Stage 2

Stage 3A

Stage 3B

Stage 4

23 patients

118 patients

76 patients

47 patients

r

p

r

p

r

p

r

p

JHEQ

 Satisfactiona

− 0.43

0.057

− 0.39

< 0.0001

− 0.22

0.063

− 0.38

0.011

 Pain

0.42

0.067

0.41

< 0.0001

0.39

0.001

0.26

0.079

 Movement

0.40

0.092

0.45

< 0.0001

0.43

0.000

0.44

0.003

 Mental

0.47

0.035

0.70

< 0.0001

0.58

< 0.0001

0.67

< 0.0001

 OHS

0.61

0.004

0.55

< 0.0001

0.58

< 0.0001

0.57

< 0.0001

SF-12v2

 PCS

0.16

0.490

0.25

0.008

0.16

0.182

0.23

0.134

 MCS

− 0.03

0.915

0.32

0.000

0.08

0.498

0.12

0.429

Spearman’s correlation coefficient

aLower score is better

Discussion

This was the first large cohort study of QOL evaluation in patients with ONFH. Patients with large necrotic lesions and collapsed ONFH had low QOL scores. In patients with non-collapsed ONFH, patients with alcohol-associated ONFH had lower QOL scores than those with steroid-associated ONFH, patients with bilateral ONFH had low mental scores, and males had worse social condition scores. Among patients with collapsed ONFH, middle-aged patients exhibited lower mental QOL, and a strong correlation was observed between role/social-related QOL and mental condition.

Radiological stage, which represents the extent of femoral head collapse, more closely influenced QOL scores than the necrotic lesion type, because there were no significant differences in QOL scores between necrotic lesion types in each radiological stage. There were significant differences in JHEQ pain scores between stages 2 and 3A, in other words, non-collapsed and collapsed stages, whereas JHEQ movement scores gradually worsened during the progression from stages 2 to 3A and 3B. Therefore, JHEQ pain and JHEQ movement scores do not worsen simultaneously; specifically, pain rapidly worsen between stages 2 and 3A, whereas movement deteriorates gradually accompanied by femoral head collapse. In a previous study, JHEQ pain, movement, and mental scores in 100 patients with pre-operative hip osteoarthritis were 8.4, 6.7, and 10.7 [23], respectively, compared with 7.7, 5.1, and 9.6, respectively, in patients with stage 4 ONFH that had osteoarthritic changes in the current study. ONFH may have lower QOL scores than hip osteoarthritis.

QOL scores in patients with ONFH displayed similar trends as observed in previous small cohort studies [12, 13]. Seki et al. reported that SF-12v2 PCS and MCS scores of 27.8 and 48.3, respectively, in patients with ONFH, more than half of whom had stage 3B lesions [12] (Table 9). In the present study, the SF-12v2 PCS and MCS scores were 22.0 and 50.0, respectively, in patients with stage 3B ONFH. Kubo et al. reported a comparative study of 9 patients with ONFH who underwent anterior rotational osteotomy (ARO) of the femoral head and 11 patients with ONFH who underwent THA and indicated the differences in pre-operative QOL scores between ARO and THA patients [13] (Table 9). QOL scores may be useful for identifying patients suitable for surgery and selecting the optimal surgical strategy.
Table 9

OHS and SF-12/36 scores in non-operative patients with ONFH (mean value)

 

Seki [12]

Kubo [13]

Current study

Subgroup

Pre-operative ARO

Pre-operative THA

Stage 1

Stage 2

Stage 3A

Stage 3B

Stage 4

21 patients

9 patients

11 patients

10 patients

23 patients

118 patients

76 patients

47 patients

OHS

 

29.1 ± 10.9

21.9 ± 9.6

34.2

33.3

27.2

23.1

25.8

SF-12/36

 PCS

27.8

30.8

17.8

32.7

29.8

25.8

22.0

25.1

 MCS

48.3

48

48.6

54.8

46.9

52.0

50.0

52.9

Among patients with non-collapsed ONFH, patients with alcohol-associated ONFH had lower satisfaction, JHEQ mental, OHS, and SF12v2 RCS scores than those with steroid-associated ONFH. A prior study of patients with histories of alcohol abuse reported poor mental health scores using SF-12 (PCS, 44.7; MCS, 46.6) [24]. Additionally, patients with SLE had poor scores (PCS, 35.9; MCS, 42.3) [25]. These studies mentioned that both groups had low QOL scores, and that patients with SLE had lower scores than alcohol abuse. In the present study, patients with alcohol-associated ONFH had SF12v2 PCS and MCS scores of 25.3 and 52.5, respectively, compared with 24.0 and 51.1, respectively, for patients with steroid-associated ONFH. Compared with patients with histories of alcohol abuse [24] or SLE [25], the PCS score was lower in the current cohort due to hip joint symptoms, whereas the MCS score was higher.

Among patients with non-collapsed ONFH, males had worse SF12v2 RCS scores, and patients with bilateral ONFH patients had worse SF12v2 MCS scores. Middle-aged patients with collapsed ONFH had worse SF-12v2 MCS. Medical personnel should confirm these findings and support patients who return to work. In patients with collapsed ONFH, a strong correlation coefficient was observed between SF-12v2 RCS and JHEQ mental scores. These findings suggest that physical deterioration influenced the patients’ social roles and mental condition. In patients with stage 3A lesions, we must consider the social situation of patients and the timing of surgical treatment.

There were some limitations in the present study. First, the number of patients with non-collapsed ONFH was small (33 patients). However, there are no QOL reports regarding patients with non-collapsed ONFH and analyses in non-collapsed ONFH were available in the current study. Second, the examination regarding multiple osteonecrosis was not sufficient to permit analysis. Third, the investigation of bone marrow oedema of the femoral head on MRI is important from the point of view of pain evaluation; we cannot evaluate completely in this multicentre study.

Conclusion

Patients with large necrotic lesions (types C1 and C2) or collapsed ONFH (radiological stages 3A, 3B, and 4) had lower QOL scores. Among patients with non-collapsed ONFH, patients with alcohol-associated lesions had lower QOL scores than those with steroid-associated lesions, those with bilateral ONFH had low mental scores, and male patients had worse social condition scores. Among patients with collapsed lesions, middle-aged patients had lower mental QOL and a strong correlation was observed between role/social related QOL and mental condition.

Notes

Acknowledgements

We thank Prof Wakaba Fukushima and Mr. Kazuya Ito for their helpful advices. We also thank Drs Hiromasa Tanino, Toshiyuki Tateiwa, Yusuke Kubo, Daisuke Inoue, Satoshi Kubota, Hiroyuki Ike, Yohei Naito, Masaki Takao, and Hidetoshi Hamada for their helpful support.

Funding information

The principal investigator (NS) of the Japanese Investigation Committee under the auspices of the Ministry of Health Labour and Welfare received a research grant from the Ministry of Health and Welfare of Japan (Research on Measures for Intractable Diseases).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Yuko Uesugi
    • 1
  • Takashi Sakai
    • 2
  • Taisuke Seki
    • 3
  • Shinya Hayashi
    • 4
  • Junichi Nakamura
    • 5
  • Yutaka Inaba
    • 6
  • Daisuke Takahashi
    • 7
  • Kan Sasaki
    • 8
  • Goro Motomura
    • 9
  • Naohiko Mashima
    • 10
  • Tamon Kabata
    • 11
  • Akihiro Sudo
    • 12
  • Tetsuya Jinno
    • 13
  • Wataru Ando
    • 14
  • Satoshi Nagoya
    • 15
  • Kengo Yamamoto
    • 16
  • Satoshi Nakasone
    • 17
  • Hiroshi Ito
    • 18
  • Takuaki Yamamoto
    • 19
  • Nobuhiko Sugano
    • 20
  1. 1.Department of International Health, Graduate School of Health ScienceKobe UniversityKobeJapan
  2. 2.Department of Orthopaedic Surgery, Graduate School of MedicineOsaka UniversitySuitaJapan
  3. 3.Department of Orthopaedic Surgery, Graduate School of MedicineNagoya UniversityNagoyaJapan
  4. 4.Department of Orthopaedic Surgery, Graduate School of MedicineKobe UniversityKobeJapan
  5. 5.Department of Orthopaedic Surgery, Graduate School of MedicineChiba UniversityChibaJapan
  6. 6.Department of Orthopaedic Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
  7. 7.Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
  8. 8.Department of Orthopaedic Surgery, Faculty of MedicineYamagata UniversityYamagataJapan
  9. 9.Department of Orthopaedic Surgery, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
  10. 10.Department of Orthopaedic Surgery, Graduate School of MedicineEhime UniversityToonJapan
  11. 11.Department of Orthopaedic Surgery, Graduate School of Medical scienceKanazawa UniversityKanazawaJapan
  12. 12.Department of Orthopaedic Surgery, Graduate School of MedicineMie UniversityTsuJapan
  13. 13.Department of Orthopaedic Surgery, Graduate School of MedicineTokyo Medical and Dental UniversityBunkyo-KuJapan
  14. 14.Department of Orthopaedic SurgeryKansai-Rosai HospitalAmagasakiJapan
  15. 15.Department of Orthopaedic SurgerySapporo Medical UniversitySapporoJapan
  16. 16.Department of Orthopaedic Surgery, School of MedicineTokyo Medical UniversityTokyoJapan
  17. 17.Department of Orthopaedic Surgery, Graduate School of MedicineUniversity of the RyukusNishiharaJapan
  18. 18.Department of Orthopaedic Surgery, School of MedicineAsahikawa Medical UniversityAsahikawaJapan
  19. 19.Department of Orthopaedic Surgery, Faculty of MedicineFukuoka UniversityFukuokaJapan
  20. 20.Department of Orthopaedic Medical Engineering, Graduate School of MedicineOsaka UniversitySuitaJapan

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