1

Lifestyle and health-related quality of life in Asian patients with total hip

arthroplasties

Running title: Asian lifestyle and quality of life

Kimie Fujita, MSN, PhD1, Xia Zhenlan, MSN2, Liu Xueqin, BS2, Masaaki

Mawatari, MD, PhD3, and Kiyoko Makimoto, MPH, PhD4

1Department of Nursing, Saga University, Japan; 2 Department of nursing,

Zhujiang Hospital, Southern Medical University, China; 3 Department of

orthopedic surgery, Saga University Hospital, Japan; 4 Department of

nursing, Graduate School of Medicine, Osaka University, Japan

Corresponding author: Professor Liu Xueqin

Address for correspondence: Teaching & research section of clinical nursing,

Zhujiang Hospital, Southern Medical University, 253 Gongye Road M.,

Guangzhou 510282 China

Tel: 86-20-61643173

Fax: 86-20-61643173

E-mail: liuxueqin_1@126.com

2

Total hip arthroplasty reduces pain and restores physical function in patients

with hip joint problems. This study examined lifestyle and health-related

quality of life before and after total hip arthroplasty in Japanese and Chinese

patients. Two hospitals in China recruited 120 patients and 120 Japanese

patients matched by age and operative status who were drawn from a

prospective cohort database. Oxford Hip Score, EuroQol, and characteristics

of Asian lifestyle and attitudes toward the operation were assessed. There

were no differences between patients from the two countries in quality-of-life

scale scores: postoperative patients had significantly better quality-of-life

scores than preoperative patients in both countries. In China, patients who

reported that living at home was inconvenient had significantly worse Oxford

Hip Scores than those who did not. Mean scores for anxiety items concerning

possible dislocation and durability of the implant were significantly higher in

Japanese than in Chinese subjects. Our findings suggest that providing

information about housing conditions and lifestyles would result in improved

quality of life and reduced anxiety in patients with implanted joints.

Key words: anxiety, Asia, lifestyle, patient education, quality of life, total hip

arthroplasty

3

INTRODUCTION

In parallel with the increasing number of elderly people in East Asian

countries, the proportion of individuals with osteoarthritis is increasing

(Fransen et al., 2011). Advanced osteoarthritis causes pain and disability,

posing a heavy burden on the patient. Total hip arthroplasty (THA) is a

treatment option for severe hip joint disease in patients in Western Europe,

North America, and some Asian countries (Merx et al., 2003). THA, which

was developed in the United Kingdom, is tailored to the lifestyle of patients in

Western countries, and most research on health-related quality of life

(HRQOL) of THA patients is from Western countries.

Quantification of the impact of THA from the patient’s perspective by

developing tools for measuring HRQOL drew considerable attention in the

late 20th century. Two types of HRQOL scales have been used in THA

patients: non-disease-specific scales such as the Medical Outcome Study

Short Form 36 (SF-36) (Ethgen et al., 2004) and disease-specific scales such

as the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis

Index (Ethgen et al., 2004). A systematic review of 74 prospective studies of

THA and total knee arthroplasty patients reported a marked reduction in

pain and improved physical function as measured by these scales (Ethgen et

al., 2004). Although there are few studies of HRQOL in Asian THA patients,

4

improvements in HRQOL as measured by the SF-36 have been reported in

Japan and China (Chiu et al., 2001; Uesugi et al., 2009).

It is expected that THAs will be increasingly performed in those Asian

countries in which Western and Asian lifestyles now coexist. The traditional

Asian lifestyle generally requires deep flexion of the hip joint (Mulholland &

Wyss, 2001; Hemmerich et al., 2006), common postures including floor-sitting,

squatting, and kneeling (Muraki et al., 2009). Because these postures

increase the risk of dislocation, Asian THA patients may have more problems

with postoperative adjustment than their Western counterparts.

To investigate the impact of the Asian lifestyle on Japanese patients before

and after THA, in 2003 we began a prospective study of HRQOL in patients

waiting to undergo THA in Saga University Hospital, Japan, using the

WOMAC Index and EuroQol for evaluation (Fujita et al., 2009). In addition,

we added three Japanese lifestyle-related items to the standard

questionnaire, our aim being to evaluate the impact of postures characteristic

of the traditional Japanese lifestyle and requiring deep flexion of the hip joint,

such as the use of the Asian-style toilets (squat toilets) and seiza (sitting on

one’s legs on the floor). This study showed that pain and physical function

related to the hip joint improved markedly by 6 months after THA. In

5

contrast, three other Japanese lifestyle-related items showed much less

improvement.

Even though Japanese patients with THAs are quite satisfied with their

dramatic improvements in pain, they reportedly experience anxiety about

possible dislocation and durability of their prostheses (Fujita, et al., 2006).

These attitudes are not covered by the HRQOL scales.

In terms of activities requiring deep flexion of the hip joint, the Chinese

lifestyle is considered closer to a Western one than is the Japanese lifestyle.

Although the number of THAs in China is expected to outnumber that of any

nation in coming years, there is little research from this country regarding

the impact of non-Western lifestyles on THA patients.

STUDY AIM

The purposes of this study were 1) to explore the impact of non-Western

lifestyles on HRQOL in pre- and post-THA patients and 2) to examine the

association between HRQOL and attitudes toward THA in Japan and China.

METHODS

Study design

In China, a cross-sectional survey of pre-THA patients and those who had

6

undergone THA 1 or 3 years prior to the study was conducted. In Japan,

patients were retrospectively selected from a patient research database that

had been established between 2008 and 2011 by the Department of

Orthopedic Surgery of Saga University Hospital. Based on previous studies

(Fujita et al., 2009), a sample size of 120 per country was set to obtain

statistically significant differences in HRQOL scores between pre- and

post-THA patients. One-third of the study group comprised pre-THA patients,

one-third 1-year post-THA patients, and the remaining one-third 3-year

post-THA patients. The postoperative period of 3 years was chosen because

the Chinese hospitals participating in the study had few patients who were

more than 3 years post-THA.

Study subjects

Eligibility criteria in both countries were 1) community-dwelling patients

who were scheduled to undergo THA or who had undergone THA 1 or 3 years

prior to the survey and 2) patients who could comprehend the questionnaire.

The exclusion criterion was a comorbidity or disability that affected

ambulation, such as stroke. Japanese patients had been recruited from the

university hospital in the Kyushu region in Japan between December 2008

and July 2011. Chinese patients were recruited from two hospitals in

7

Guangzhou, China between March and June 2011.

Measures

Both generic and disease-specific HRQOL scales were used. The EuroQol, a

generic instrument used to assess quality of life, comprises five questions

about mobility, self-care, usual activity, pain/discomfort, and

anxiety/depression (Wolfe & Hawley, 1997). There are three possible response

levels for each item. A single weighted utility score, the EuroQol utility, is

calculated from the scores on each of these five categories. The utility score

for perfect health is 1 and for death 0; states worse than death (<0) can also

be rated. Higher scores for the EuroQol index items indicate worse outcomes

whereas higher EuroQol utility scores indicate better health outcomes.

The Oxford hip score was chosen to assess disease-specific HRQOL because

it has been shown to be more sensitive than the WOMAC Index regarding

THA outcomes (Garbuz et al., 2006). The Oxford hip score comprises 12 items

addressing physical function and pain; the total score is in the range of 12–48.

The higher the score, the lower is the HRQOL. The Japanese version of the

Oxford hip score was validated in 2009 (Uesugi et al., 2009) and the Chinese

version in 2011 (Xia et al., 2012).

The Japanese lifestyle questions that had been added address three

8

postures requiring deep flexion of the hip joint, namely 1) performing seiza, 2)

getting in/out of the bathtub, and 3) using an Asian-style toilet. The responses

are on a five-point Likert scale with a range of “not difficult” to “very

difficult.” After discussing these items with the Chinese research team, the

first two questions were deleted from the Chinese questionnaire because

seiza is not performed in China and people in the study area do not use

bathtubs; they only take showers.

In addition, two items related to problems in patients’ living environments

had been added to the Japanese questionnaire. One was “there are steps in

the home” and the responses were on a five-point Likert scale with a range of

“strongly agree” to “strongly disagree”. After discussing this item with the

Chinese research team, it was changed to “there are barriers (e.g., a step or

steps) in the home” because there are few steps in a typical Chinese home.

The second item was “I feel that living at home is,” and the responses were on

a five-point Likert scale with a range of “not inconvenient” to “very

inconvenient.”

Based on a qualitative study of THA patients, the following four items

related to post-THA experience were also added (Fujita, et al., 2006). All were

on a 6-point Likert scale.

1. I am satisfied that I can take a long walk (extremely dissatisfied to

9

extremely satisfied).

2. My anxiety level concerning possible dislocation is (extremely anxious to

not at all anxious).

3. My anxiety level concerning durability of artificial joints is (extremely

anxious to not at all anxious).

4. The operated hip feels strange (extremely agree to extremely disagree).

Procedure

In China, pre-THA patients were asked to fill out the questionnaire when

they visited the outpatient clinic. If the patient could not read it, a family

member filled it out based on the patient’s spoken responses. A researcher

administered the questionnaire by telephone to post-THA patients.

In Japan, patients were retrospectively selected from a patient research

database that had been established between 2008 and 2011 by the

Department of Orthopedic Surgery of Saga University Hospital, which had

started a prospective study of HRQOL in patients waiting to undergo THA in

2003. Patients had been asked to fill out the questionnaire upon admission,

and the same questionnaire had been mailed to them 1, 3, and 5 years

post-THA. This 2-year interval was chosen to facilitate comparison with

previous studies (Ethgen 2004, Ahmad 2011). A cross-sectional Japanese

sample was not selected because it would have been difficult to obtain a

10

sample comparable to the Chinese one in terms of operative status and age

within a short period of time. Japanese patients from the database were

matched with the Chinese patients by age (± 5 years) and pre- and post-THA

status.

In both countries, the same sets of questionnaires related to HRQOL and

patient lifestyle were used (apart from the deletion of some questions from

the Chinese one, as described above) and data on the surgical procedure,

diagnosis, and comorbidities requiring treatment were obtained from the

medical records.

Statistical analysis

The Student’s t-test was used to evaluate differences in HRQOL scale items

between pre- and post-THA patients in each country and the Χ2 test for

categorical variables, such as type of lifestyle. All hypotheses were two sided,

and a P value of 0.05 was used as the cut-off point for statistical significance.

Ethical considerations

The Japanese study was approved by the Ethics Committee of Saga

University School of Medicine and the Chinese study was approved by that of

Zhujiang Hospital, Southern Medical University. Patients were informed that

11

1) study participation was voluntary, 2) study participation would not affect

treatment, 3) they could withdraw from the study at any point, and 4) only

aggregated data would be presented. Written informed consent was obtained

from patients who self-administered the questionnaire and oral consent from

the Chinese telephone survey participants.

RESULTS

Patient characteristics and lifestyle

In China, 120 patients completed the questionnaire, and in Japan, 120

matched patients were selected from a database as described above. All but

six patients were matched by age and operative status. The Chinese sample

included six patients aged <30 years; however, the Japanese database

included only one such patient. Thus, five Japanese controls were selected

from the 30- to 35-year-old age group. Relevant patient characteristics are

displayed in Table 1. The mean age was 56.9 (± 13.0) years, and the

proportion of post-THA patients was 66.7%. The distributions of sex and

major diagnosis differed significantly between the two countries, the

proportion of women being significantly higher in Japan than in China (Table

1). In terms of indications for THA, osteoarthritis accounted for >80% of the

patients in Japan and avascular necrosis for >80% of the patients in China

12

(Table 1). No post-operative complications had occurred in the Japanese

sample, whereas a small percentage of the Chinese sample experienced deep

venous thrombosis, surgical site infection, or dislocations (Table 1).

Over 50% of the patients in both countries reported that there were many

steps in their homes and that their activities of daily living were affected to

some extent (Table 1). Asian-style toilets were used in both countries;

however, Chinese patients reported a higher rate of Asian-style toilet use

than did Japanese patients (Table 1).

HRQOL

Because THA status was a confounder, HRQOL scores were stratified by pre-

and post-THA status. In both countries, post-THA patients had significantly

higher EuroQol utility, and index item scores than did pre-THA patients

(Table 2). In addition, in both countries mean EuroQol utility scores for

post-THA patients exceeded 0.800, indicating a health condition that is close

to perfect.

Pre-THA patients had significantly worse Oxford hip scores than did

post-THA patients in both countries. The largest difference between mean

scores of pre- and post-THA patients was that for usual pain (Table 2). Oxford

hip scores for any other individual item did not differ significantly between

13

patients in the two countries.

Relationships between HRQOL and Asian lifestyle

Differences between Asian and non-Asian lifestyles in HRQOL scores were

assessed by country and operative status. However, the Japanese sample was

drawn retrospectively from a prospective study in which some questions had

not been asked in every phase of the survey to reduce the length of the

questionnaire for these mostly elderly patients. For example, whether living

at home was convenient or inconvenient was not asked in the pre-THA period

because it was expected that the overwhelming majority would respond

‘inconvenient’. The item concerning barriers in the home was asked at

pre-THA and 1 year after THA but not 3 years after THA.

As a consequence, the proportion of missing responses for the question

regarding living at home was 38% and only 1.4% responded with

“inconvenient”. The proportion of missing responses for the question

regarding barriers in the home was 60% and 13% responded “yes”. Because of

the substantial proportion of missing answers and the small number of

patients with Asian lifestyles in the Japanese sample, the relationship

between HRQOL scores and lifestyle was examined only in the Chinese

sample.

14

Contrary to our expectations, regardless of THA status patients with

Asian-style toilets did not have worse HRQOL scores than those with

non-Asian-style toilets according to EuroQol and Oxford hip scores (data not

shown). The same was found for the item concerning barriers in the home

(data not shown). In contrast, those who reported that living at home was

inconvenient had worse Oxford hip scores in both the pre-THA (P = 0.034)

and post-THA periods than did patients who reported that living at home was

convenient (P < 0.001) (Fig. 1).

Satisfaction and anxiety

Chinese participants had significantly higher mean scores for dissatisfaction

with long walks than did Japanese subjects and the trend was the same for

the implant feeling strange (Table 3). Conversely, Japanese subjects had

significantly higher anxiety mean scores about dislocation and durability of

their THAs than did their Chinese counterparts (Table 3).

In terms of correlations between these attitude variables and HRQOL

scores, dissatisfaction with long walks was moderately correlated with two

HRQOL scale scores in both the Chinese and Japanese samples, whereas two

anxiety items were not correlated with these two HRQOL scale scores (Table

4). The implant feeling strange was weakly associated with Oxford hip scores

15

in both samples.

DISCUSSION

This is the first published cross-cultural study of HRQOL and attitudes of

pre- and post-THA patients toward THA from non-Western countries. Our

most significant finding is that lifestyle and HRQOL are associated in pre-

and post-THA patients.

There were differences between Japan and China in the indications for THA.

Nearly half the Chinese patients had avascular necrosis, whereas this

condition accounted for <10% of the Japanese patients. In a systematic

review of HRQOL in THA patients, most studies included only patients with

osteoarthritis and in the remaining studies more than two-thirds of the

patients had osteoarthritis (Ethgen et al., 2004).

The low prevalence of osteoarthritis in the Chinese sample may reflect

differences between the two countries in health insurance policies. In Japan,

THA is a standard treatment option for advanced osteoarthritis, whereas this

is not so for Chinese patients with osteoarthritis. Published reports suggest

that the rate of THA is lower in most Asian than in Western countries, the

difference being attributable to financial considerations (Lau et al., 1996).

Despite the discrepancy in the distributions of the major diagnoses between

16

the two countries, HRQOL outcomes did not differ. Thus, THA seems to be

beneficial for patients with avascular necrosis according to postoperative

EuroQol and Oxford hip scores.

The traditional Asian lifestyle often requires squatting and kneeling

(Thumboo et al., 2001); however, the Oxford hip score does not take these

postures into account. In Korea, because kneeling is a component of daily

activities, low satisfaction is reportedly associated with the limited flexion

imposed by total knee arthroplasty (Kim et al., 2010). In our study, there was

no correlation between use of Asian-style toilets and Oxford hip scores in the

Chinese subjects. On discussing this unexpected finding with the Chinese

researchers, we discovered that not all Asian-style toilets require squatting.

Further research is needed to clarify which specific types of toilets require

squatting.

There was also no correlation between barriers in the home and HRQOL

scores in Chinese participants. However, patients who reported that it was

inconvenient to live in the home had worse Oxford hip scores than did those

who did not report that this was inconvenient. In future studies, items

concerning barriers in the home need to be more specifically worded and the

types of conditions that patients feel are inconvenient should be identified.

Previously unexplored aspects of THA patients’ experience differed

17

markedly between Japan and China. Higher scores for anxiety about possible

dislocation and durability of THAs in Japanese than in Chinese patients may

reflect differences in patient education between the two countries. Because

the Japanese lifestyle increases the risk of dislocation (Satoh et al., 2009),

healthcare professionals tend to focus on how to avoid dislocation when they

prepare patients for discharge. Further comparative studies examining the

relationship between patient education and post-THA anxiety should assess

the specific content of patient education.

In contrast to anxiety levels, Chinese participants reported greater

dissatisfaction with long walks and that their implants felt strange more

frequently than their Japanese counterparts; both these variables were

correlated with HRQOL scores. The Chinese sample included a much higher

proportion of avascular necrosis than the Japanese sample; patients’

expectations of THA may differ depending on duration of pain and disability.

Further, types of surgical approach and prosthesis may impact on patients’

experiences of walking and strange sensations. These factors need to be

examined in future studies.

Implications for practice

Evidence for poor HRQOL outcomes in THA patients with non-Western

18

lifestyles has been accumulating (Fujita et al., 2009; Kim et al., 2010).

Although there were no significant findings related to deep flexion of the

implanted hip in the Chinese sample, those who agreed that living at home is

inconvenient had worse HRQOL scores than those who did not. Factors

associated with ‘inconvenient to live at home’ in Chinese patients must be

explored preoperatively to facilitate formulation of appropriate discharge and

rehabilitation plans.

Dislocation and loosening are major possible complications of THA (Lucas,

2004). In the Japanese lifestyle, postures requiring hip joint flexion of >90°

are commonly associated with eating, toileting, bathing, and sleeping (Satoh

et al., 2009). In addition to being discouraged from using Asian-style toilets,

Japanese THA patients are discouraged from using chairs that are low to the

ground and deep bathtubs and from sleeping on futons laid on the floor. Home

visits are ideal for surveying the conditions in the home and lifestyle and

facilitating the giving of specific advice for reducing the risk of dislocation.

However, such visits are not covered by health insurance in Japan. The use of

information technology to support post-THA patients during the early

discharge period is currently being pilot tested (Satoh, 2010).

The Japanese lifestyle may also increase the risk of revision surgery.

According to a case-control study of revision surgery conducted in Osaka,

19

Japan, risk factors for revision were dislocation after primary THA and

insufficient advance preparation of aids to daily living and discouragement of

dangerous toileting postures (Satoh et al., 2009). This study suggests that

reducing the risk of dislocation would reduce the rate of revision. Patient

education is a key to minimizing the rate of revision surgery.

In the Chinese sample, the prevalence of dislocation was low. However, a

much larger follow-up study is necessary to identify risk factors for

dislocation and revision that are likely to be related to poor HRQOL. China is

geographically and culturally diverse and has many ethnic minorities with

lifestyles that differ from mainstream Chinese culture. Patients’ living

conditions and activities related to deep flexion of the implanted joint need to

be assessed pre-operatively as a component of discharge planning.

To improve HRQOL in THA patients, healthcare professionals in Asian

countries must assess the living conditions of their patients and educate them

on how to cope with barriers in the home and deal with requirements for

kneeling and squatting postures.

Limitations

Because the Chinese part of this study had a cross-sectional design, the better

HRQOL scores in the post- than the pre-THA group may not reflect actual

20

improvement in HRQOL. Nevertheless, our findings are in agreement with

previous prospective studies in Taiwan, Korea, and Japan that showed

significant improvement in HRQOL according to the WOMAC Index or

Oxford hip scores post-THA (Shi et al., 2009; Fujita et al., 2009; Lee et al.,

2012).

The Japanese sample was taken from a prospective study cohort database

and some lifestyle questions had not been asked in every phase of that study.

In addition, because only a small proportion of the Japanese sample had an

Asian lifestyle, it was not possible to compare the Japanese with the Chinese

sample.

In terms of data collection, all Japanese patients self-administered the

questionnaire, whereas telephone surveys were used for the Chinese THA

patients because of difficulty in accessing community-dwelling post-THA

patients. These patients were not accustomed to postal surveys and some

were illiterate. Despite the differences between the two countries in data

collection methods, HRQOL in the post-THA patients between the two

countries did not differ significantly.

Because this was not a multicenter study, our patient samples may not

have been representative of each country in terms of lifestyle and HRQOL. A

multicenter prospective study is necessary to explore the impact of the Asian

21

lifestyle on HRQOL of THA patients and to examine regional variations

within each country.

CONCLUSION

This cross-sectional survey was conducted to examine the relationship

between Asian lifestyle and HRQOL in pre- and post-THA patients in Japan

and China. Post-THA patients had significantly higher EuroQol, and Oxford

hip scores than did pre-THA patients in both countries. In the Chinese

sample, those who reported that living at home was inconvenient had

significantly worse Oxford hip scores than did patients who did not report

this. This finding suggests the importance of assessing THA patients’ living

conditions and lifestyles to improve HRQOL. Future research needs to

explore factors associated with satisfaction and anxiety.

Acknowledgments

The authors would like to express deep appreciation for Ms. Li Li, and Ms.Xie

Xiaoyan(Director of Nursing) from Zhujiang Hospital and chief research

assistant Ms. Liao Xiaoyan, Southern Medical University for their full

cooperation with completing this comparative study. The authors also thank

the staff of Saga University Hospital for their cooperation during this study

22

and are especially grateful to the orthopedic department, Zhujiang Hospital,

Southern Medical University for their full collaboration. This work was

supported in part by a Grant-in-Aid for Scientific Research (Grant-in-Aid C,

no. 21592897, 2008–2011) from the Japanese Ministry of Education, Culture,

Sports, Science and Technology.

Contributions

Study design: K.F., M.M., and K.M.

Data collection and analysis: Z.X., K.F.,X.L., and K.M.

Manuscript writing: K.F., X.L.,Z.X., and K.M.

23

References

Ahmad MA, Xypnitos FN, Giannoudis PV. Measuring hip outcomes: common

scales and checklists. Injury 2011; 42: 259-264.

Chiu HC, Mau LW, Hsu YC, Chang JK. Postoperative 6-month and 1-year

evaluation of health-related quality of life in total hip replacement patients. J.

Formos. Med. Assoc. 2001; 100: 461-465.

Ethgen O, Bruyère O, Richy F, Dardennes C, Reginster JY. Health-related

quality of life in total hip and total knee arthroplasty. A qualitative and

systematic review of the literature. J. Bone Joint Surg. Am. 2004; 86:

963-974.

Fransen M, Bridgett L, March L, Hoy D, Penserga E, Brooks P. The

epidemiology of osteoarthritis in Asia. Int. J. Rheum. Dis. 2011; 14: 113-121.

Fujita K, Makimoto K, Hotokebuchi T. Qualitative study of osteoarthritis

patients’ experience before and after total hip arthroplasty in Japan. Nursing

and Health Sciences 2006; 8:81-87.

Fujita K, Makimoto K, Higo T, Shigematsu M, Hotokebuchi T. Changes in the

WOMAC, EuroHRQOL and Japanese lifestyle measurements among patients

24

undergoing total hip arthroplasty. Osteoarthritis Cartilage 2009; 17: 848-855.

Garbuz DS, Xu M, Sayre EC. Patients’ outcome after total hip arthroplasty: a

comparison between the Western Ontario and McMaster Universities index

and the Oxford 12-item hip score. J. Arthroplasty 2006; 21: 998-1004.

Hemmerich A, Brown H, Smith S, Marthandam SS, Wyss UP. Hip, knee, and

ankle kinematics of high range of motion activities of daily living. J. Orthop.

Res. 2006; 24: 770-781.

Jones CA, Beaupre LA, Johnston DW, Suarez-Almazor ME. Total joint

arthroplasties: current concepts of patient outcomes after surgery. Clin.

Geriatr. Med. 2005; 21: 527-541.

Kim TK, Kwon SK, Kang YG, Chang CB, Seong SC. Functional disabilities

and satisfaction after total knee arthroplasty in female Asian patients. J.

Arthroplasty 2010; 25: 458-464.

Lau EM, Symmons DP, Croft P. The epidemiology of hip osteoarthritis and

rheumatoid arthritis in the Orient. Clin. Orthop. Relat. Res. 1996; 323: 81-90.

Lee YK, Chung CY, Park MS, et al. Transcultural adaptation and testing of

psychometric properties of the Korean version of the Oxford hip score. J.

25

Orthop. Sci. 2012; 17: 377-381.

Lucas B. Nursing management issues in hip and knee replacement surgery.

Br. J. Nurs. 2004; 13: 782-787.

Matsumoto T, Kaneuji A, Hiejima Y, et al. Japanese Orthopaedic Association

Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation

tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the

Clinical Outcome Committee of the Japanese Orthopaedic Association. J.

Orthop. Sci. 2012; 17: 25-38.

Merx H, Dreinhöfer K, Schräder P, et al. International variation in hip

replacement rates. Ann. Rheum. Dis. 2003; 62: 222-226.

Mulholland SJ, Wyss UP. Activities of daily living in non-Western cultures:

range of motion requirements for hip and knee joint implants. Int. J. Rehabil.

Res. 2001; 24: 191-198.

Muraki S, Akune T, Oka H, et al. Association of occupational activity with

radiographic knee osteoarthritis and lumbar spondylosis in elderly patients of

population-based cohorts: a large-scale population-based study. Arthritis

Rheum. 2009; 61: 779-786.

26

Satoh M, Kawaguchi T, Masuhara K. Risk factors for revision total hip

arthroplasty: emphasis on the characteristics of Japanese lifestyle. Arch.

Orthop. Trauma Surg. 2009; 129: 1707-1713.

Satoh M. A telenursing system based on prehospital assessment for patients

undergoing total hip arthroplasty. Japanese Journal of Telemedicine and

Telecare (in Japanese). 2012; 8: 170-172.

Shi HY, Khan M, Culbertson R, Chang JK, Wang JW, Chiu HC.

Health-related quality of life after total hip replacement: a Taiwan study. Int.

Orthop. 2009; 33: 1217-1222.

Thumboo J, Chew LH, Soh CH. Validation of the Western Ontario and

McMaster University osteoarthritis index in Asians with osteoarthritis in

Singapore. Osteoarthritis Cartilage 2001; 9: 440-446.

Uesugi Y, Makimoto K, Fujita K, Nishii T, Sakai T, Sugano N. Validity and

responsiveness of the Oxford hip score in a prospective study with Japanese

total hip arthroplasty patients. J. Orthop. Sci. 2009; 14: 35-39.

Wolfe F, Hawley DJ. Measurement of the quality of life in rheumatic

disorders using the EuroQol. Br. J. Rheumatol. 1997; 36: 786-793.

27

Xia ZL, He B, Fan MX, Liu XQ. Reliability and validity of Chinese version of

Oxford Hip Score. Journal of Nursing (in Chinese). 2012; 19: 23-25.

28

p<0.001

p=0.034

Figure 1. Oxford hip scores (OHS) according to THA status and “inconvenient

to live at home” response status in the Chinese sample.

Note 1: The higher the score, the worse is the quality of life.

Note 2: The Student’s t-test was used to test differences in mean scores

between the two lifestyles.

29

Table 1 Characteristics of patients in Japan and China

Japan China P values

Number of patients n = 120 n = 120

Age (years), mean ± SD 56.6 ±

12.2

57.1 ±

14.0

n.s

Gender (% female) 78.3 52.5 P < 0.001

Living with family member (%) 87.5 91.7 n.s

Diagnosis (%) Osteoarthritis 84.9 6.7 P < 0.001

Avascular

necrosis

7.5 82.5

Other 7.6 10.8

Postoperative years, mean ± SD 2.2 ± 1.3 2.2 ± 1.1 n.s

Comorbidity (%) Yes 45.8 53.3 n.s

Hypertension 18.2 46.9

Heart disease 3.6 4.7

Hepatic disease 9.1 1.6

Post-THA

complications

(n=80)

Surgical site

infection

0 1.3

DVT* 0 2.5

Dislocation 0 2.5

Toilet Asian style 3.5 33.3 P < 0.001

Western style 96.5 66.7

Steps inside the home

Many 41.7 58.3 P = 0.025

Few 58.3 41.7

Living at home is

Inconvenient 12.2 55.9 P < 0.001

Not

inconvenient

87.8 44.1

Note: Differences between Japan and China were examined by the Student’s

t-test or the Χ2 test.

*Deep venous thrombosis

30

Table 2. Mean scores and standard deviations of EuroQol and Oxford hip

scores by pre- and post-THA periods

Japan

(n=120)

China (n=120)

Pre-THA

(n=40)

Post-THA

(n=80)

P-va

lues

Pre-THA

(n=40)

Post-THA

(n=80)

P-va

lues

EuroQol, utility score

0-1

0.60±0.12 0.86±0.18 ** 0.43±0.33 0.80±0.19 **

EuroQol, index items 1-3

Mobility 1.8±0.4 1.3±0.4 ** 2.1±0.5 1.6±0.5 **

Activity 1.5±0.5 1.1±0.3 ** 1.7±0.6 1.3±0.5 **

Self care 1.9±0.4 1.2±0.4 ** 2.1±0.5 1.5±0.5 **

Pain/Discomfort 2.1±0.5 1.3±0.5 ** 2.1±0.3 1.3±0.5 **

Depression 1.5±0.6 1.2±0.4 * 1.7±0.6 1.2±0.4 **

Oxford hip score (0-48) 21.1±9.1 4.1±5.2 ** 24.8±9.2 5.1±5.7 **

Oxford hip score items (0-4)

Usual pain 2.8±0.8 0.5±0.8 ** 2.7±0.8 0.4±0.6 **

Washing oneself 1.3±1.0 0.3±0.6 ** 1.0±1.3 0.2±0.6 **

Getting in/out of a car 1.7±1.0 0.4±0.8 ** 1.9±1.2 0.4±0.7 **

Putting on socks 2.0±1.2 0.8±1.0 ** 1.6±1.4 0.6±0.9 **

While shopping 1.6±1.5 0.4±1.0 ** 1.9±1.5 0.3±0.8 **

Pain while walking 1.7±1.0 0.3±0.7 ** 2.1±1.3 0.4±0.8 **

Ascending stairs 2.0±1.1 0.5±0.8 ** 1.9±1.3 0.7±0.7 **

Pain while standing 1.7±0.9 0.2±0.4 ** 1.9±1.1 0.3±0.5 **

Limp 1.7±1.1 0.3±0.6 ** 3.4±1.0 1.0±1.4 **

Sudden pain 1.6±1.2 0.2±0.6 ** 1.7±1.1 0.1±0.5 **

Pain interfering with

work

1.7±1.0 0.3±0.6 ** 2.2±1.3 0.4±0.8 **

Pain at night 1.6±1.2 0.1±0.4 ** 2.7±1.1 0.2±0.6 **

Note: For Oxford Hip Score and EuroQol index items, higher scores indicate

worse health, whereas for EuroQol utility scores, higher scores indicate better

health. Differences between pre- and post-THA findings were examined by

the Student’s t-test. *P < 0.05, **P < 0.001

31

Table 3 Satisfaction and anxiety in post-THA patients in Japan and China

Japan

(n=80)

China

(n=80)

P-values

Dissatisfaction with long walk 3.0±3.2 5.2±2.3 p<0.001

Anxiety about dislocation

5.0±2.8

3.4±1.7

p<0.001

Anxiety about implant

durability

5.3±2.8

3.3±1.6

p<0.001

Strange sensation of the

implant

3.5±2.4

4.9±2.5

p<0.001

Note: Differences between Japan and China were examined by the Student’s

t-test.

32

Table 4 Spearman correlation coefficients between satisfaction/anxiety items

and quality-of-life scale scores in THA patients by country

Japan

(n=80)

China

(n=80)

EuroQol,

utility

scores

OH S# EuroQol,

utility

scores

OH S

Dissatisfaction with long

walk

-0.55 ** 0.54 *

*

-0.65 ** -0.64 **

Anxiety about dislocation -0.11 0.20 -0.08 0.15

Anxiety about implant

durability

-0.14 0.16 -0.06 0.18

Strange sensation of the

implant

-0.34 ** 0.39 *

*

-0.20 0.33 **

#OHS: Oxford Hip Score

** P < 0.01