Total hip arthroplasty in patients with vertebral compression fracture is associated with poor clinical outcomes – retrospective analysis on 453 cases
Journal of Experimental Orthopaedics volume 10, Article number: 53 (2023)
Total hip arthroplasty (THA) is increasingly performed in older adults, and the prevalence of vertebral compression fracture (VCF) increases with age. We aimed to investigate the clinical outcomes of THA in patients with VCF.
We reviewed the records of 453 patients who underwent THA at our institution between 2015 and 2021. We classified patients into those with and without VCF. VCF was identified using preoperative upright whole-spine radiographs. Spinal parameters, preoperative and 1-year postoperative clinical outcomes of the Harris hip score (HHS), Oxford hip score (OHS), and visual analog scale (VAS) for low back pain (LBP) were assessed. Furthermore, propensity score-matched cohorts for age, sex, body mass index, and spinal parameters were created, and the clinical outcomes were compared between the two groups.
Among the 453 patients, 51 (11.3%) with VCF and 402 without VCF were identified. Before matching, patients with VCF were older (p < 0.01), had sagittal spinal imbalance (p < 0.01), and had worse clinical outcomes pre- and postoperatively. After matching 47 patients in both groups, patients with VCF had worse HHS (p < 0.05), especially regarding support and distance walked, and worse VAS scores for LBP (p < 0.05) pre- and postoperatively. However, the improvements in scores were not significantly different between the groups.
HHS, especially regarding support and distance walked, and VAS scores for LBP were poorer in patients with VCF preoperatively and 1-year postoperatively. Our findings suggest that hip surgeons should evaluate not only spinal alignment but also the presence of VCF before performing THA.
Level of evidence
Level III, Retrospective cohort study.
Total hip arthroplasty (THA) is an effective treatment for degenerative changes and pain in the hip joints. The volume of primary THAs performed has increased over the past several decades [15, 17, 25, 26] and will continue to increase until 2030 [16, 18, 26]. The number of THAs for older adults will rise by approximately twice as much in 2030 as in 2020 , but has a higher risk of complications, including dislocation, periprosthetic fracture, and infection [20, 28]. Hip surgeons should have greater knowledge of the characteristics of older adults who undergo THA.
Osteoporotic vertebral compression fractures (VCFs) are common in older adults. Globally, the prevalence of radiographic vertebral fractures has increased with age . Many studies have shown that VCFs lead to back pain, poor physical performance, and lower health-related quality of life (HRQoL) [1, 2, 13]. Recent studies have reported the relationship between spinal disorders and clinical outcomes of THA. Sagittal spinal imbalance, spinal fixation surgery, lumbar spinal disorders, and low back pain (LBP) have adverse effects on the clinical outcomes of THA [9, 19, 21, 23]. However, little evidence exists regarding the clinical outcomes of THA in patients with VCF. Furthermore, the number of THAs in patients with VCF will increase in the future owing to the increased number of THAs in older adults. Therefore, we aimed to investigate the clinical outcomes of THA in patients with VCF.
Patients and methods
This study was approved by the relevant Institutional Review Board and conducted in accordance with the World Medical Association Declaration of Helsinki. Written informed consent was obtained from the retrospective studies of all study participants.
This was a retrospective cohort study. We reviewed 529 consecutive patients who underwent primary THAs at our institution between November 2015 and July 2021. All patients were registered in our database. This study finally included 453 patients following the exclusion of 76 patients for the following reasons (Fig. 1): THA for femoral neck fracture, Crowe IV dysplasia , hip joint infection, severe lower limb trauma, metastasis of the hip, previous spinal fusion surgery, surgery of other joints or spine within 1 year, incomplete image study, poor image quality for measurement, simultaneous bilateral THAs, THA with intraoperative fracture, incomplete clinical functional assessment, loss to follow-up, or death within 12 months after THA.
Preoperative radiographs included antero-posterior (AP) pelvic images and upright whole-spine images in the AP and lateral views. We reviewed the spine radiographs and evaluated the presence and level of VCF, and the following sagittal spinal parameters: C7 sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and thoracic kyphosis (TK) (Fig. 2). Patients with low energy trauma or unrecognized VCFs were included. The definition of VCF on radiographs was based on the semiquantitative method proposed by Genant et al. . We included grade 1 or higher, which were 20% or more reduction in vertebral height, and 10% or more reduction in vertebral area. All the vertebral bodies were reviewed using lateral whole-spine images. We classified all patients into with or without VCF (Fig. 1).
All THAs were performed by five senior hip surgeons using an anterolateral approach. The types of THAs were: hybrid, 356; uncemented, 82; and cemented, 15. The Harris hip score (HHS), Oxford hip score (OHS), University of California, Los Angeles (UCLA) activity score, and visual analog scale (VAS) score for LBP (0 = no pain; 10 = maximum pain) were recorded preoperatively and 1 year after THA.
Two orthopedic surgeons (CC and YO) independently evaluated the preoperative whole-spine radiographs to diagnose VCFs. In cases of discrepancy between the two surgeons, another senior surgeon (TK) evaluated and determined the presence or absence of VCFs. The κ coefficient was calculated as the inter-observer reliability. The spinal parameters were measured by two surgeons. The intra-class correlation coefficients (ICCs) of inter-observer reliability were calculated for randomly selected 30 patients. Student’s t-test or the Mann–Whitney U test was performed to compare the variables between the two groups based on the results of the Shapiro–Wilk test. Fisher’s exact test was used to detect differences between the two groups on a nominal scale. All components of the HHS are shown as mean ± standard deviation, although they were ordinal scales and analyzed using the Mann–Whitney U test as it was difficult for readers to recognize the differences in data shown as median (interquartile range). Propensity scores were obtained from the logistic regression analysis using the following covariates: age, sex, body mass index (BMI), SVA, and PI-LL. We matched SVA and PI-LL to clarify the clinical relevance of VCFs in THA because these parameters have been reported to affect the clinical outcomes of THA . A 1:1 propensity score in nearest-neighbor matching without replacement was performed to create matched pairs with the caliper set at 0.2 of a standard deviation of the logit of the propensity score. An absolute standardized difference (ASD) of < 0.20 was considered adequate. We further analyzed the demographics, sagittal spinal parameters, and pre-and postoperative changes in clinical assessments between patients with a single VCF and those with multiple VCFs. Statistical significance was set at p < 0.05. Statistical analyses were performed using the JMP Pro 15.0 software (SAS Institute, Cary, NC, USA).
The κ coefficient for the presence of VCF was 0.86, and the ICCs of the spinal parameters were greater than 0.85, indicating excellent consistency.
VCFs were identified in 51 (11.3%) patients. Patients with VCF were older, shorter, and had lower body weight than those without VCF (Table 1). Table 2 shows the relationship between the number of patients and VCFs. Single VCF was the most frequent, in 30 patients, and the most VCFs was four, in two patients. VCF occurred most frequently in the lumbo-thoracic transition areas of the Th12, L1, and L2 vertebrae (Table 3). Preoperative sagittal spinal parameters in patients with VCF showed lower LL and SS, larger PT and SVA, and greater PI-LL mismatch than those in patients without VCF, indicating sagittal spinal imbalance (Table 4). However, TK was higher in patients with VCF because of the kyphotic effects of VCFs on the thoracic vertebrae. Table 5 shows the clinical and VAS scores for LBP, which were significantly worse in patients with VCF, but not in those with postoperative OHS. The postoperative limp, support, distance walked, and stairs scores in the HHS were significantly poorer in patients with VCF. However, changes in the scores before and after THA were not significantly different between the groups.
After propensity score matching for age, sex, BMI, SVA, and PI-LL, 47 patients with and without VCF were established. The matched variables were considered adequate according to the ASDs. No significant differences in spinal parameters were found between the groups after matching (Table 4). Compared to patients without VCF, those with VCF showed worse HHS, especially regarding support and distance walked, and worse VAS scores for LBP pre- and postoperatively. However, no significant differences were found in the pre- and postoperative OHS and UCLA activity scores. The changes in clinical scores were not significantly different between the two groups after matching (Table 5).
Table 6 shows the results of the comparison between patients with a single VCF and those with multiple VCFs, comprising 30 and 21 patients, respectively. The postoperative HHS and UCLA activity scores were significantly lower in patients with multiple VCFs.
To the best of our knowledge, this is the first study to analyze the effects of VCF on the clinical outcomes of THA. Our study found that the approximately 11% of patients had VCF before THA, who were older, had sagittal spinal imbalance, and had worse clinical outcomes pre- and postoperatively. After propensity score matching, patients with VCF had worse HHS (p < 0.05), especially regarding support and distance walked, and worse VAS scores for LBP (p < 0.05), pre- and postoperatively. However, the changes in clinical scores were not significantly different between the groups, indicating that patients with VCFs showed similar improvement to patients without VCF. Furthermore, patients with multiple VCFs had lower clinical HHS and UCLA activity scores than those with a single VCF.
Patients with VCFs have sagittal spinal imbalance [5, 10, 12]. The VCFs and sagittal spinal parameters were closely related. Furthermore, Ochi et al.  reported that preoperative sagittal spinopelvic alignment affects hip function after THA. Therefore, we consider that a patient cohort with or without VCF after matching only for age, sex, and BMI, may mislead the results regarding whether VCFs or sagittal spinal imbalance affect the results. Our study featured propensity score matching for not only age, sex, and BMI but also spinal parameters to clarify the relationship between VCFs and clinical outcomes, regardless of sagittal spinal parameters. We found that VCFs independently affected the clinical outcomes of THA. Therefore, hip surgeons should assess not only spinal alignment but also the presence of VCFs, when spine radiographs are routinely examined.
Some studies showed that VCFs were associated with poor physical function [4, 14]. Similarly, vertebral deformities are associated with functional impairment [3, 22]. Our study revealed that the functional components of HHS, support and walking distance, were significantly lower in the VCF group, which is consistent with the results of previous studies. The other HHS components did not differ significantly between the two groups. Therefore, although patients with VCF may not show sufficient improvement in support and distance walked after THA, hip surgeons and patients with VCF can expect similar improvements in other components of the HHS as compared to patients without VCF.
The postoperative HHS and UCLA activity scores in patients with multiple VCFs were significantly poorer than those in patients with a single VCF, although no significant difference was noted between the two groups before THA. A previous study demonstrated that the number of VCFs correlated with the global sagittal alignment, which was further correlated with the Oswestry Disability Index and Short-Form-12 . Another study found that community-dwelling women with multiple VCFs had poorer physical function, including slower walking speed, shorter chair stand time, and shorter functional reach than those with a single VCF . The number of VCFs should also be evaluated to predict the clinical scores, activities of daily living, and HRQoL of patients.
VCFs are also closely related to sarcopenia [27, 30], with different criteria for sarcopenia [6, 8] such as poor physical performance. One study reported that patients with sarcopenia showed poor functional scores on THA pre- and postoperatively . In our study, some patients with VCF also had sarcopenia, however, we did not investigate grip strength, which is a major criterion of sarcopenia. Therefore, clinical outcomes of THA may have been affected by sarcopenia. This is a limitation of this study; patients with sarcopenia or VCF overlap. In this study, we focused on VCFs, however, its definition remains complex. The identification of patients with sarcopenia among many THA candidates is difficult, whereas a spine radiograph is a relatively easy way to check VCFs to identify patients with poor functional outcomes.
This study has some limitations. First, this was a retrospective study performed at a single institution. Selection bias or other biases may have been present for THA in this study. Second, this study lacked data on medication, bone mineral density, bone metabolism markers, and diagnosis of sarcopenia, which may be covariates of the clinical outcomes of THA. The relationships between these factors should be investigated in future studies. Third, this study included a small number of patients with VCF and a 1-year follow-up period. A prospective, large-scale, long-term follow-up study is required to further clarify the association between VCF and THA.
This study found that 11.3% of the patients had VCF before THA. HHS, especially regarding support and distance walked, and VAS for LBP were worse in patients with VCF preoperatively and 1-year postoperatively, after matching for age, sex, BMI, SVA, and PI-LL. However, the improvements in the clinical scores were similar between the two groups with or without VCF. Our findings suggest that hip surgeons should evaluate not only spinal alignment but also the presence of VCF before performing THA.
Availability of data and materials
The datasets analyzed in this study are available from the corresponding author upon reasonable request.
Total hip arthroplasty
Vertebral compression fracture
Health-related quality of life
Low back pain
Sagittal vertical axis
Harris hip score
Oxford hip score
University of California, Los Angeles
Visual analog scale
Body mass index
Absolute standardized difference
Al-Sari UA, Tobias J, Clark E (2016) Health-related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis. Osteoporos Int 27:2891–2900
Arima K, Abe Y, Nishimura T, Okabe T, Tomita Y, Mizukami S et al (2017) Association of vertebral compression fractures with physical performance measures among community-dwelling Japanese women aged 40 years and older. BMC Musculoskelet Disord 18:176
Burger H, Van Daele PL, Grashuis K, Hofman A, Grobbee DE, Schütte HE et al (1997) Vertebral deformities and functional impairment in men and women. J Bone Miner Res 12:152–157
Cawthon PM, Blackwell TL, Marshall LM, Fink HA, Kado DM, Ensrud KE et al (2014) Physical performance and radiographic and clinical vertebral fractures in older men. J Bone Miner Res 29:2101–2108
Chau LTC, Hu Z, Ko KSY, Man GCW, Yeung KH, Law YY et al (2021) Global sagittal alignment of the spine, pelvis, lower limb after vertebral compression fracture and its effect on quality of life. BMC Musculoskelet Disord 22:476
Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K et al (2020) Asian working group for sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc 21:300-307.e302
Crowe JF, Mani VJ, Ranawat CS (1979) Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 61:15–23
Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T et al (2019) Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 48:16–31
Ellenrieder M, Bader R, Bergschmidt P, Fröhlich S, Mittelmeier W (2015) Coexistent lumbar spine disorders have a crucial impact on the clinical outcome after total hip replacement. J Orthop Sci 20:1046–1052
Fechtenbaum J, Etcheto A, Kolta S, Feydy A, Roux C, Briot K (2016) Sagittal balance of the spine in patients with osteoporotic vertebral fractures. Osteoporos Int 27:559–567
Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148
Hu Z, Man GCW, Kwok AKL, Law SW, Chu WWC, Cheung WH et al (2018) Global sagittal alignment in elderly patients with osteoporosis and its relationship with severity of vertebral fracture and quality of life. Arch Osteoporos 13:95
Jinbayashi H, Aoyagi K, Ross PD, Ito M, Shindo H, Takemoto T (2002) Prevalence of vertebral deformity and its associations with physical impairment among Japanese women: The Hizen-Oshima Study. Osteoporos Int 13:723–730
Johansson L, Sundh D, Nilsson M, Mellström D, Lorentzon M (2018) Vertebral fractures and their association with health-related quality of life, back pain and physical function in older women. Osteoporos Int 29:89–99
Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M (2005) Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 87:1487–1497
Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89:780–785
Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA et al (2015) Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 97:1386–1397
Matsuoka H, Nanmo H, Nojiri S, Nagao M, Nishizaki Y (2021) Projected numbers of knee and hip arthroplasties up to the year 2030 in Japan. J Orthop Sci;https://doi.org/10.1016/j.jos.2021.09.002
Ochi H, Homma Y, Baba T, Nojiri H, Matsumoto M, Kaneko K (2017) Sagittal spinopelvic alignment predicts hip function after total hip arthroplasty. Gait Posture 52:293–300
Ogino D, Kawaji H, Konttinen L, Lehto M, Rantanen P, Malmivaara A et al (2008) Total hip replacement in patients eighty years of age and older. J Bone Joint Surg Am 90:1884–1890
Okuzu Y, Goto K, Kuroda Y, Kawai T, Matsuda S (2022) Preoperative factors associated with low back pain improvement after total hip arthroplasty in a Japanese Population. J Arthroplasty 37:69–74
Pluijm SM, Tromp AM, Smit JH, Deeg DJ, Lips P (2000) Consequences of vertebral deformities in older men and women. J Bone Miner Res 15:1564–1572
Prather H, Van Dillen LR, Kymes SM, Armbrecht MA, Stwalley D, Clohisy JC (2012) Impact of coexistent lumbar spine disorders on clinical outcomes and physician charges associated with total hip arthroplasty. Spine J 12:363–369
Schousboe JT (2016) Epidemiology of Vertebral Fractures. J Clin Densitom 19:8–22
Singh JA (2011) Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J 5:80–85
Sloan M, Premkumar A, Sheth NP (2018) Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 100:1455–1460
Takahashi K, Kubo A, Ishimura K, Fukui T, Tamura T (2018) Correlation among sarcopenia, malnutrition and activities of daily living in patients with vertebral compression fractures: a comparison based on admission and discharge parameters evaluating these conditions. J Phys Ther Sci 30:1401–1407
Toro G, Bothorel H, Saffarini M, Jacquot L, Chouteau J, Rollier JC (2019) Uncemented total hip arthroplasty in octogenarian and nonagenarian patients. Eur J Orthop Surg Traumatol 29:103–110
Ueoka K, Kabata T, Kajino Y, Inoue D, Ohmori T, Ueno T et al (2022) The prevalence and impact of sarcopenia in females undergoing total hip arthroplasty: a prospective study. Mod Rheumatol 32:193–198
Wang WF, Lin CW, Xie CN, Liu HT, Zhu MY, Huang KL et al (2019) The association between sarcopenia and osteoporotic vertebral compression refractures. Osteoporos Int 30:2459–2467
This work was supported by Japan Orthopaedics and Traumatology Foundation, Inc. [grant number 463].
Ethics approval and consent to participate
This retrospective chart review study involving human participants was conducted in accordance with the ethical standards of the Institutional and National Research Committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Kyoto University approved this study (reference number: E884-2). Written informed consent was obtained from all patients in this study to participate retrospective studies at our institution.
Consent for publication
Not applicable due to a retrospective study.
Shuichi Matsuda received speaker and consultant honoraria from Kyocera. The other authors have no relevant financial or non-financial interests to disclose.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Chen, CH., Okuzu, Y., Goto, K. et al. Total hip arthroplasty in patients with vertebral compression fracture is associated with poor clinical outcomes – retrospective analysis on 453 cases. J EXP ORTOP 10, 53 (2023). https://doi.org/10.1186/s40634-023-00618-8