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Journal of Peking University (Health Sciences) ›› 2025, Vol. 57 ›› Issue (6): 1081-1088. doi: 10.19723/j.issn.1671-167X.2025.06.010

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A follow-up study on total hip arthroplasty in patients with systemic lupus erythematosus combined with osteonecrosis of femoral head

Xiaolin WANG1, Shaoyi GUO2, Dazhao CHEN2, Xijie WEN3, Yong HUA4, Liang ZHANG2,*(), Qin ZHANG5,*()   

  1. 1. Department of Anesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
    2. Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
    3. Department of Orthopedics, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine of Hebei Province, Cangzhou 061000, Hebei, China
    4. Department of Orthopedics, Gaotang County Hospital of Traditional Chinese Medicine, Liaocheng 252800, Shandong, China
    5. Department of Rheumatology and Immunology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing 100010, China
  • Received:2025-08-12 Online:2025-12-18 Published:2025-11-25
  • Contact: Liang ZHANG, Qin ZHANG

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Abstract:

Objective: To evaluate the clinical results of total hip arthroplasty (THA) for the treatment of patients with systemic lupus erythematosus (SLE) with end-stage osteonecrosis of femoral head (ONFH). Methods: Between March 2002 and June 2024, 235 SLE patients with end-stage ONFH who underwent 340 THAs were retrospectively reviewed. Before operation and at the last follow-up visit, the patient demographics, disease-related, hip and surgery-related, and laboratory parameters were collected via outpatient questionnaire, telephone, and online questionnaire. Objective clinical results were evaluated using the Harris hip score (HHS) system and subjective clinical results were evaluated using the short form-12 (SF-12) outcome score. The patient satisfaction at the last follow-up was evaluated by using a four-point scale with the options "very unsatisfied", "unsatisfied", "satisfied", or "very satisfied". Results: The median duration of follow-up was 58.0 (34.7, 101.2) months (12.4-283.2 months). At the last follow-up, the HHS increased from 32.0 (23.8, 39.3) before surgery to 88.0 (84.0, 91.0), the SF-12 mental component score (MCS) increased from 42.3(35.7, 48.7) before surgery to 52.3 (47.8, 55.9) and the SF-12 physical component score (PCS) increased from 36.8 (28.3, 43.4) before surgery to 52.0 (46.7, 54.5) (all P < 0.001). Evaluation of the hip satisfaction at the last follow-up showed that 58.8% (200 hips) were very satisfied, 35.3% (120 hips) were satisfied, 4.1% (14 hips) were less satisfied, 1.8% (6 hips) were very unsatisfactory, and the overall satisfaction rate was 94.1%. The postoperative systemic complications included pulmonary infection in 6 hips (1.8%), urinary tract infection in 10 hips (2.9%), cholecystitis in one hip (0.3%), intracranial infection in one hip (0.3%), cerebral infarction in 2 hips (0.6%), pulmonary embolism in 2 hips (0.6%), and atrial fibrillation in 2 hips (0.6%). Consequently, all hips were divided into those with systemic complications (25 hips) and those without systemic complications (315 hips). The results of intergroup comparisons showed significant differences in preoperative SF-12 PCS (P=0.031), postoperative SF-12 PCS (P=0.007), and postoperative HHS (P=0.005). The postoperative orthopedic complications included delayed wound healing in 28 hips (8.2%), joint noise in 11 hips (3.2%), periprosthetic infection in 3 hips (0.9%), dislocation in 3 hips (0.9%), and periprosthetic fracture in 2 hips (0.6%). All hips were divided into the delayed wound healing group (28 hips) and the normal wound healing group (312 hips). The results of intergroup comparisons revealed significant differences in preoperative SF-12 PCS (P=0.009), postoperative SF-12 MCS (P=0.025), and the proportion of THA using ceramic-on-polyethylene bearing (P=0.009) between the two groups. Multivariate logistic regression analysis indicated that preoperative SF-12 PCS (P=0.014, OR=0.94) and the use of ceramic-on-polyethylene bearing surface (P=0.014, OR=2.90) were associated factors for delayed wound healing after THA. Conclusion: The clinical results of THA reconstruction for the treatment of ONFH in SLE patients were reliable with high level of clinical scores and patient satisfaction. Unfortunately, a relatively high rate of systemic and orthopedic complications, including urinary tract infection and delayed healing of incision, deserved attention. Therefore, the perioperative management regimen should be emphasized in order to minimize the risk of postoperative complications.

Key words: Systemic lupus erythematosus, Femur head necrosis, Total hip arthroplasty, Postoperative complications, Patient satisfaction

CLC Number: 

  • R687.42

Table 1

Intergroup comparisons between the systemic complications group and no systemic complications group"

Variable Total (n=340) Without systemic complication (n=315) With systemic complication (n=25) Statistic P
BMI/(kg/m2) 22.3 (19.9, 25.3) 22.3 (20.0, 25.4) 23.4 (19.7, 24.2) Z=-0.10 0.922
Gender χ2=0.09 0.763
    Male 54 (15.9) 49 (15.6) 5 (20.0)
    Female 286 (84.1) 266 (84.4) 20 (80.0)
Age at surgery/years 35.0 (27.0, 47.0) 35.0 (27.0, 46.0) 36.0 (28.0, 51.0) Z=-0.88 0.380
Age at SLE onset/years 28.0 (22.0, 38.0) 28.0 (22.0, 37.0) 32.0 (25.0, 40.0) Z=-1.43 0.152
Treatment interval/years 6.0 (4.0, 11.0) 6.0 (4.0, 11.0) 4.0 (3.0, 7.0) Z=-1.21 0.225
Preoperative steroid dose/mg 5.0 (2.5, 10.0) 5.0 (2.5, 10.0) 5.00 (5.0, 10.0) Z=-1.48 0.139
Immunosuppressant use 277.0 (81.5) 256.0 (81.3) 21.0 (84.0) χ2=0.01 0.944
Biologic agent use 16.0 (4.7) 16.0 (5.1) 0 (0.0) χ2=0.44 0.507
Combined APS 17.0 (5.0) 16.0 (5.1) 1.0 (4.0) χ2=0.00 >0.999
Laboratory tests
    WBC/(×109/L) 5.7 (4.6, 7.0) 5.9 (4.6, 7.0) 5.6 (4.9, 6.2) Z=-0.74 0.460
    HGB/(g/L) 125.0 (116.8, 136.0) 125.0 (117.0, 136.0) 124.0 (116.0, 137.0) Z=-0.20 0.843
    ESR/(mm/h) 19.0 (11.0, 36.0) 19.0 (11.0, 36.0) 19.0 (13.0, 34.0) Z=-0.10 0.918
    CRP/(mg/L) 5.4 (3.0, 9.7) 5.4 (3.0, 9.7) 6.0 (3.7, 9.7) Z=-0.14 0.885
    C3/(g/L) 0.8 (0. 6, 1.0) 0.8 (0.6, 1.0) 0.7 (0.6, 1.0) Z=-0.58 0.565
    C4/(g/L) 0.2 (0.2, 0.3) 0.2 (0.2, 0.3) 0.2 (0.2, 0.3) Z=-0.45 0.650
    ALB/(g/L) 42.2 (39.7, 44.9) 42.2 (39.7, 44.8) 42.1 (39.8, 45.7) Z=-0.42 0.671
    BUN/(mmol/L) 5.1 (4.0, 6.2) 5.2 (4.0, 6.4) 4.5 (4.0, 5.6) Z=-1.34 0.181
    Cr/(μmol/L) 56.0 (47.0, 67.0) 56.0 (47.0, 67.0) 53.0 (48.0, 62.0) Z=-0.39 0.699
    Anti-dsDNA positive 78.0 (22.9) 74.0 (23.5) 4.0 (16.0) χ2=0.74 0.391
    Urine protein positive 137.0 (40.29) 125.0 (39.68) 12.0 (48.0) χ2=0.67 0.414
Surgery side χ2=1.22 0.270
    Left 185.0 (54.6) 174.0 (55.4) 11.0 (44.0)
    Right 154.0 (45.4) 140.0 (44.6) 14.0 (56.0)
Surgical approach χ2=0.05 0.830
    Posterolateral 316.0 (92.9) 292.0 (92.7) 24.0 (96.0)
    DAA 24.0 (7.1) 23.0 (7.3) 1.0 (4.0)
Bearing surface χ2=0.26 0.612
    Ceramic-on-ceramic 233.0 (68.5) 217.0 (68.9) 16.0 (64.0)
    Ceramic-on-polyethylene 107.0 (31.5) 98.0 (31.1) 9.0 (36.0)
Disease-related score
    SLEDAI 4.00 (1.0, 5.0) 4.00 (1.0, 5.0) 4.0 (1.0, 5.0) Z=-0.32 0.749
    Preoperative HHS 32.0 (23.8, 39.3) 32.0 (23.5, 38.5) 34.0 (26.0, 41.0) Z=-0.49 0.624
    Preoperative SF-12 PCS 36.8 (28.3, 43.4) 36.8 (29.5, 43.5) 32.2 (25.1, 39.1) Z=-2.16 0.031
    Preoperative SF-12 MCS 42.3 (35.7, 48.7) 42.3 (35.8, 48.7) 42.5 (35.5, 48.5) Z=-0.38 0.704
    Postoperative HHS 88.0 (84.0, 91.0) 88.0 (85.0, 91.0) 85.0 (82.0, 88.0) Z=-2.79 0.005
    Postoperative SF-12 PCS 52.0 (46.7, 54.5) 52.0 (47.8, 54.5) 46.7 (37.8, 52.9) Z=-2.72 0.007
    Postoperative SF-12 MCS 52.3 (47.8, 55.9) 52.3 (48.0, 55.9) 50.2 (45.6, 55.6) Z=-0.98 0.329

Table 2

Intergroup comparisons between the delayed wound healing group and the normal wound healing group"

Variable Normal wound healing (n=312) Delayed wound healing (n=28) Statistic P
BMI/(kg/m2) 22.3 (20.0, 25.3) 19.8 (18.4, 24.7) Z=-1.35 0.176
Gender χ2=0.00 0.977
    Male 49 (15.7) 5 (17.9)
    Female 263 (84.3) 23 (82.1)
Age at surgery/years 35.0 (26.8, 46.3) 34.5 (29.0, 55.0) Z=-1.15 0.251
Age at SLE onset/years 28.0 (22.0, 37.0) 30.0 (24.5, 38.0) Z=-0.97 0.332
Treatment interval/years 6.0 (3.8, 11.0) 6.0 (4.0, 12.0) Z=-0.59 0.555
Preoperative steroid dose/mg 5.0 (2.5, 10.0) 5.0 (5.0, 10.0) Z=-1.10 0.272
Immunosuppressant use 254 (81.4) 23 (82.1) χ2=0.01 0.924
Biologic agent use 13 (4.2) 3 (10.7) χ2=1.21 0.271
Combined APS 16 (5.1) 1 (3.6) χ2=0.00 >0.999
Laboratory tests
    WBC/(×109/L) 5.8 (4.6, 6.9) 5.54 (4.8, 7.3) Z=-0.04 0.970
    HGB/(g/L) 124.5 (117.0, 136.0) 128.5 (114.5, 136.3) Z=-0.24 0.807
    ESR/(mm/h) 20.0 (11.8, 36.0) 17.0 (7.6, 22.8) Z=-1.58 0.114
    CRP/(mg/L) 5.3 (3.0, 9.5) 6.7 (3.4, 14.0) Z=-1.32 0.186
    C3/(g/L) 0.8 (0.6, 1.0) 0.8 (0.6, 1.0) Z=-0.23 0.816
    C4/(g/L) 0.2 (0.2, 0.3) 0.2 (0.2, 0.3) Z=-0.71 0.475
    ALB/(g/L) 42.2 (39.7, 44.9) 41.7 (40.5, 44.9) Z=-0.15 0.881
    BUN/(mmol/L) 5.1 (4.0, 6.1) 5.6 (4.3, 6.8) Z=-1.44 0.149
    Cr/(μmol/L) 56.0 (47.0, 66.0) 57.5 (50.0, 74.8) Z=-0.94 0.348
    Anti-dsDNA positive 75 (24.0) 3 (10.7) χ2=2.58 0.108
    Urine protein positive 126 (40.4) 11 (39.3) χ2=0.01 0.910
Surgery side χ2=0.26 0.612
    Left 171 (55.0) 14 (50.0)
    Right 140 (45.0) 14 (50.0)
Surgical approach χ2=0.13 0.714
    Posterolateral 289 (92.6) 27 (96.4)
    DAA 23 (7.4) 1 (3.6)
Bearing surface χ2=6.91 0.009
    Ceramic-on-ceramic 220(70.5) 13(46.4)
    Ceramic-on-polyethylene 92 (29.5) 15 (53.6)
Disease-related score
    SLEDAI 4.0 (1.0, 5.0) 4.0 (1.5, 5.0) Z=-0.51 0.611
    Preoperative HHS 32.0 (23.8, 40.0) 30.5 (24.8, 37.3) Z=-0.63 0.530
    Preoperative SF-12 PCS 36.8 (29.9, 43.4) 31.9 (22.1, 37.9) Z=-2.62 0.009
    Preoperative SF-12 MCS 42.4 (35.7, 48.8) 41.6 (38.9, 46.7) Z=-0.09 0.930
    Postoperative HHS 88.0 (84.0, 91.0) 87.5 (84.8, 91.0) Z=-0.06 0.949
    Postoperative SF-12 PCS 51.7 (46.7, 54.5) 53.4 (48.9, 56.0) Z=-1.79 0.073
    Postoperative SF-12 MCS 52.4 (47.8, 56.4) 50.9 (45.7, 52.7) Z=-2.25 0.025

Table 3

Multivariate Logistic regression analysis for delayed wound healing"

Variety β SE Z P OR (95%CI)
Female -0.40 0.55 -0.73 0.468 0.67 (0.23-1.98)
Age at surgery 0.01 0.02 0.46 0.646 1.01 (0.98-1.04)
Ceramic-on-polyethylene bearing surface 1.07 0.43 2.47 0.014 2.90 (1.25-6.76)
BMI -0.06 0.06 -1.06 0.290 0.94 (0.84-1.05)
Preoperative SF-12 PCS -0.06 0.02 -2.47 0.014 0.94 (0.90-0.99)
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