Shifting surgical strategies for osteonecrosis of the femoral head: evidence from a nationwide Japanese database.

introductionOsteonecrosis of the femoral head (ONFH) is a progressive condition that often requires surgical intervention. Although treatment strategies have traditionally emphasized joint-preserving procedures in younger patients, advances in implant technology and perioperative management may have altered contemporary surgical decision-making. However, large-scale evidence describing temporal changes in surgical treatment patterns for ONFH is limited. MATERIALS AND

methodsUsing the Japanese Diagnosis Procedure Combination (DPC) database, we conducted a nationwide retrospective cohort study of patients who underwent surgical treatment for ONFH between December 2012 and March 2023. Surgical procedures were categorized as total hip arthroplasty (THA), bipolar hemiarthroplasty (BHA), proximal femoral osteotomy, pelvic osteotomy, or hip arthroscopy. Temporal trends in procedure selection were evaluated overall and by age group. Postoperative complications, including infection, deep vein thrombosis (DVT), pulmonary embolism, periprosthetic fracture, and in-hospital mortality, were compared between THA and BHA using univariate and multivariable logistic regression analyses.

resultsA total of 36,109 patients were included. THA was the most frequently performed procedure throughout the study period, with its proportion increasing from 72.6% in 2012 to 90.6% in 2022, while the use of BHA and joint-preserving osteotomy steadily declined. Among patients aged ≤ 20 years, proximal femoral osteotomy predominated until 2020; thereafter, arthroplasty procedures accounted for more than half of all surgeries in this age group. Similar shifts toward THA were observed in patients aged 21-40 years. In adjusted analyses, BHA was associated with a higher risk of postoperative infection and DVT, whereas THA was associated with a higher risk of periprosthetic fracture and in-hospital mortality. No significant differences were observed in dislocation or pulmonary embolism rates.

conclusionsNationwide data demonstrate a substantial shift in surgical management of ONFH in Japan, with increasing use of THA and declining reliance on joint-preserving procedures, even among younger patients. While arthroplasty has become the dominant treatment modality, careful consideration of long-term outcomes, complication profiles, and patient age remains essential. Integration of large-scale administrative data with detailed clinical and imaging information may further refine optimal treatment strategies for ONFH.