Relationship between degenerative changes in the lumbar spine and sacroiliac joint in patients with total hip arthroplasty: Possibility of Hip-Sacroiliac Joint-Spine syndrome

Relationship between degenerative changes in the lumbar spine and sacroiliac joint in patients with total hip arthroplasty: Possibility of Hip-Sacroiliac Joint-Spine syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Relationship between degenerative changes in the lumbar spine and sacroiliac joint in patients with total hip arthroplasty: Possibility of Hip-Sacroiliac Joint-Spine syndrome Ayumi Kaneuji, Makoto Fukui, Eiji Takahashi, Yusuke Sanji, Hiroaki Hirata, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3333581/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Feb, 2024 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract This study is designed to compare the extent of sacroiliac joint (SIJ) degeneration at total hip arthroplasty (THA) for two pathologies: osteoarthritis of the hip (OA) and osteonecrosis of the femoral head (ON). We also assessed the prevalence of SIJ degeneration in patients with lumbar spondylolisthesis or degenerative scoliosis. A total of 138 hips from 138 patients (69 OA and 69 ON) were assessed in this study, including 66 hips affected by OA secondary to developmental dysplasia of the hip. The degenerative changes in the SIJ and lumbar spine were evaluated prior to THA using radiographs and computed tomography (CT) scans, showing 9 instances of spondylolisthesis and 38 of degenerative scoliosis. The OA group exhibited longer duration from onset to surgery than the ON group. The OA group also included more cases with significant pelvic obliquity (3 degrees or more) and with significant increases in SIJ sclerosis and irregularities. Patients with lumbar spondylolisthesis or degenerative scoliosis were significantly more likely to have SIJ irregularities. The prevalence of SIJ degeneration was higher in cases of THA for OA than for ON. This study also suggests the possibility of Hip-SIJ-Spine syndrome in THA patients with OA. Health sciences/Diseases Health sciences/Medical research Figures Figure 1 Figure 2 Introduction Hip-spine syndrome was first described by Offierski and Macnab in 1983 [ 1 ]. It is classified into four types: simple, complex, mixed, and misdiagnosed. The simple type involves degenerative changes in either the hip joint or the spine, with that degeneration being the primary cause of the condition. The complex type involves degenerative changes in both the hip joint and the spine, with both contributing to the pathology. The mixed type refers to the interaction between hip and spinal pathologies, so that the conditions of the hip joint and the spine mutually affect each other. The misdiagnosed type occurs when incorrect treatment is provided due to a lack of awareness of the involvement of both hip and spine pathologies. An anatomical study also has detailed the mutual influence of degenerative changes in the spine and the hip joint [ 2 ]. In recent years, researchers have suggested that lumbosacral fusion and long fusion of the lumbar spine can lead to progressive hip osteoarthritis (hip OA) [ 3 , 4 ]. Additionally, sacroiliac joint (SIJ) fixation has been linked to a two-fold increase in the risk of dislocation after total hip arthroplasty [ 5 ], suggesting a mechanical influence on the SIJ between the lumbar spine and the hip joint. Credible reports indicate that 14–30% of low back pain originates from the SIJ [ 7 – 9 ], and extensive study of the nerve supply to the SIJ suggests that not only the SIJ capsule but also the surrounding tissues such as ligaments can manifest pain [ 10 – 18 ]. However, the origin of SIJ pain remains unclear [ 6 , 16 , 17 ]. While excessive motion is restricted by ligaments, the SIJ joint has some limited mobility [ 6 ], and increased instability or stress on the posterior ligaments of the SIJ may cause pain and dysfunction. In fact, symptomatic relief has been reported from immobilization by external fixation of the pelvis or injections into the posterior ligaments [ 19 , 20 ]. There have been reports of increased stress on the SIJ due to lumbosacral fusion [ 21 , 22 ], as well as reports of increased degeneration of the SIJ [ 23 ], strongly indicating an interrelationship between the lumbar spine and the SIJ, and a link between hip OA and SIJ dysfunction has been suggested [ 24 , 25 ]. Asada et al. analyzed preoperative CT scans of patients with hip OA who underwent total hip arthroplasty (THA) and noted a significantly higher incidence of narrowed joint space, osteophyte formation, and vacuum phenomena in the SIJ compared with a control group [ 25 ]. Elucidating the relationship between the hip, spine, and SIJ disorders is thus of considerable clinical importance. In this study, we formulated two hypotheses: first, that long-term degeneration of the hip joint has a major impact on the SIJ, making it more susceptible to Hip-SIJ syndrome, and second, that patients with the condition termed “Hip-Spine syndrome” show a higher prevalence of SIJ degeneration, suggesting the existence of what we have designated as “Hip-SIJ-Spine syndrome”. We then conducted a comparative study of patients undergoing THA for hip OA and for idiopathic osteonecrosis of the femoral head (ON). THA for OA is often performed after a long duration of illness, while ON frequently requires THA within a short timeframe. This is the reason for selecting these two conditions for comparison. Furthermore, in our facility, a significant proportion of OA cases are associated with developmental dysplasia of the hip (DDH), and ON often occurs in the unaffected hip joint, making it easier to compare and study in the context of this research. Methods The subjects of this study were patients who underwent THA for the treatment of OA or ON. A total of 93 patients (100 hips) who received THA for OA between June 2016 and December 2016 were enrolled. Since there was a possibility of changes in findings after unilateral surgery, seven cases of bilateral procedures were included only for analysis of the first operated side. An additional 24 patients (24 hips) were excluded because of inadequate CT confirmation of SIJ, so that 69 patients (69 hips) were included in analysis for the OA group. Because the annual number of cases of ON is relatively small, the treatment period for ON was extended from January 2010 to October 2022, and 83 patients (109 hips) were enrolled. Of those, 26 bilateral cases were counted on one side only. Seven patients (7 hips) were excluded because the patient had already undergone THA on one side, and an additional seven patients (7 hips) were excluded because of inadequate confirmation of the SIJ by CT or because of significant collapse of the necrotic area from advanced OA. This resulted in 69 cases (69 hips) that were included in analysis for the ON group. Patient demographics are shown in Table I. There were no significant differences in age, height, weight and BMI between the groups. However, due to a higher prevalence of OA resulting from developmental dysplasia of the hip (DDH), female patients made up a significantly higher portion of the OA group (87%) than of the ON group (55%). In the OA group, only 3 hips were classified as primary OA, while 66 hips (96%) were classified as secondary OA from DDH. Crowe classification Group I accounted for 61 hips (92%), indicating a relatively low degree of hip dislocation in this group. In the ON group, 38 hips (55%) were classified as Group 4, indicating narrowing of the joint space but not reaching terminal OA. Preoperative leg length discrepancy was measured by assessing the difference in Spina Malleolar Distance between the left and right sides before surgery, and was classified as an absolute value of ≤ 5 mm or ≥ 6 mm. A difference of ≥ 6 mm was defined as leg length discrepancy. Table I. Demographic data for all patients OA ON p-value Cases 69 69 NS Hips 69 69 NS Female : Male 60 : 9 38 : 31 < 0.01 Right : Left 38 : 31 39 : 30 NS Age (years)* 62.0 (44–87) 59.4 (33–81) NS Height (cm)* 156.3 (142.6–181.0) 160.2 (140.0-178.6) NS Weight (kg)* 58.5 (36.8–98.8) 61.5 (40.8–99.0) NS BMI (kg/m 2 )* 23.9 (15.6–40.7) 23.9 (14.6–36.8) NS Tönnis grade (0 : 1 : 2 : 3) 0 : 0 : 7 : 62 NA Crowe classification [34] (group I : II : III : IV) 61 : 5 : 0 : 0 NA Stage classification [35] for ON (1: 2 : 3 : 4) NA 0 : 6 : 25 : 38 OA: Osteoarthritis of the hip joint, ON: Osteonecrosis of the femoral head, BMI: Body mass index * Values are mean and range, NA: not applicable, NS: not significant Radiographic and CT analysis The following items were investigated using imaging: I. Preoperative anteroposterior pelvic radiographs Pelvic tilt angle: Confirmation of the presence of lateral tilt of the iliac wings, with a tilt of 3 degrees or more in either direction classified as tilt present. Discrepancy in the obturator foramen: Confirmation of any obvious left-right asymmetry in the shape of the obturator foramen. II. Preoperative frontal and lateral lumbar spine images Lumbar scoliosis: Confirmation of the presence of lumbar scoliosis and measurement of the Cobb angle. A Cobb angle of 5 degrees or more was classified as scoliosis present. Lumbar degenerative spondylolisthesis: Presence of more than 25% slip of a lumbar vertebra was classified as spondylolisthesis present. III. Preoperative CT images SIJ degenerative changes [ 26 , 27 ]: CT cross-sectional images with a slice interval of 1 mm were examined for the following: Sclerosis: Presence of sclerosis adjacent to either the sacral or iliac side of the SIJ was classified as sclerosis present. Vacuum phenomenon: Presence of CT attenuation similar to air in the joint space of the SIJ was classified as vacuum phenomenon present. Discrepancy in joint space width: Confirmation of asymmetry in the width of the SIJ space was classified as discrepancy in joint space width. Irregularities: Slight narrowing of the SIJ space, non-parallel joint surfaces of the sacral or iliac side, or erosive changes in a portion of the joint surface were classified as irregularities present. Discrepancy in iliac wing opening angle: Measurement of the angle formed by drawing a perpendicular line from the midline sacral ridge to the vertebral body at the second sacrum level and drawing a line from the midpoint of the width of the most anterior part of the iliac wing visible on the CT slice to the sacral ridge. A difference in absolute values of 3 degrees or more between the left and right sides was classified as iliac wing opening angle discrepancy present. Statistical analysis Statistical analysis was performed using the chi-square test or Fisher's exact test by Microsoft Excel. A p-value of 0.05 or less was considered statistically significant. All methods in this study were performed in accordance with the relevant guidelines and regulations, and approval was granted by the Ethics Committee of Kanazawa Medical University. Results The OA group differed significantly from the ON group in several parameters. Significantly more prevalent in the OA group were duration of illness, angle of pelvic outward tilt, instances of pelvic outward tilt of 3 degrees or more, and sclerotic and irregular images in the SIJ (Table II). No significant intergroup differences were noted in the frequency of lumbar spondylolisthesis and scoliosis. However, the presence of lumbar spondylolisthesis and of 5 degrees or more of scoliosis were significantly associated with a higher prevalence of irregular SIJ images (P = 0.027) and (P = 0.00373), respectively (Table III). Further analysis revealed that the presence of SIJ irregularities was significantly associated with asymmetry in the SIJ joint space in the entire group (P < 0.0001). No significant differences were observed in other parameters. Table II. Comparison of OA and ON groups OA ON p-value Duration from onset to surgery (years) # 5.0 (0.25-20) 0.75 (0.1–24) = 6mm (yes : no) 44: 25 26: 43 0.07 Lateral inclination angle of pelvis (°)* 1.6 (0–9) 0.7 (0–11) = 3 °(yes : no) 25 : 44 6 : 63 = 5 °(yes : no) 20 : 49 18 : 51 0.751 Sclerotic change of SIJ (yes : no) 30 : 39 14: 55 < 0.01 Vacuum phenomenon of SIJ (yes : no) 32 : 37 17 : 52 0.828 Asymmetry of SIJ space (yes : no) 20 : 49 7 : 62 0.464 Irregularity of SIJ (yes : no) 38 : 31 9 : 60 < 0.01 Angle of right iliac wing (°)* 44.7 (34–58) 45.8 (36–58) 0.464 Angle of left iliac wing (°)* 44.9 (33–59) 45.5 (34–58) 0.134 Difference in bilateral iliac wing angle (°)* 4.5 (0–25) 3.5 (0–15) 0.598 SIJ: Sacro-iliac joint, OA: Osteoarthritis of the hip joint, ON: Osteonecrosis of the femoral head # Values are median and range. * Values are mean and range. Statistical analysis for continuous values was performed using a t-test. A chi-square test was conducted for the other variables. Table III. Relationship between lumbar spine degeneration and SIJ degeneration Spondylolisthesis Cobb angle > = 5 ° Yes (cases) No (cases) p-value Yes (cases) No (cases) p-value Irregularity of SIJ yes 7 40 0.027 15 32 0.0037 no 2 89 23 68 Sclerotic change in SIJ yes 5 47 0.35 13 39 0.5733 no 4 82 25 61 Asymmetry of SIJ space yes 5 22 0.518 7 20 0.0861 no 4 107 31 80 Asymmetry of obturator foramen yes 3 21 0.482 7 17 0.2877 no 6 108 31 83 Vacuum phenomenon in SIJ yes 5 45 0.485 12 38 0.6745 no 4 84 26 62 Lateral inclination of pelvis>= 3 ° yes 5 78 0.122 22 61 0.2769 no 4 51 16 39 SIJ: Sacro-iliac joint, Fisher's exact test was conducted for all analyses. Case Study 1 (Fig. 1 a,b and c): A 58-year-old female presented with bilateral hip OA. She had been experiencing bilateral hip pain for the past 10 years. The pain gradually worsened, leading to limited range of motion, and she underwent left THA. Subsequently, a right THA was also performed. Case Study 2 (Fig. 2 a,b and c): A 51-year-old male presented with left hip pain continuing for the past 3 months and was diagnosed with stage 3 ON on the left side. Due to severe pain, he underwent left THA. Discussion The results of this study suggested that THA was associated with significantly more degenerative change in the SIJ of the OA group than the ON group. In addition, the presence of irregularities in the SIJ was significantly associated with greater asymmetry in the SIJ space, indicating that excessive load on the SIJ due to hip OA may have led to degenerative changes [ 24 , 25 ]. This study showed little correlation with leg length discrepancy, suggesting that SIJ degeneration may progress even in the absence of conditions such as DDH-related leg shortening. However, it is also possible that DDH itself increases stress on the SIJ. Toyohara et al. analyzed SIJ stress using finite element models based on CT images before and after periacetabular osteotomy in four DDH patients [ 28 ]. They reported that stress on the SIJ and the posterior sacroiliac ligament, which is commonly observed in preoperative dysplastic hips, often decreased after surgery, indicating that excessive load on the SIJ was reduced after formation of a near-normal acetabulum. This suggests that the morphology of DDH itself may increase the load on the SIJ. A significant association was noted between SIJ joint irregularities and the presence of more than 25% of lumbar spondylolisthesis or scoliosis of 5° or more, indicating a higher prevalence of SIJ degeneration in the patient group that underwent THA and had degenerative spinal diseases. Kwon et al. reported a higher prevalence of SIJ degeneration in patients with spinopelvic imbalance compared to those with lumbar spinal canal stenosis (LSCS) [ 29 ], and Chen has stated that SIJ degeneration was more common in patients with spondylolisthesis [ 30 ]. Although a systematic review has shown no consensus regarding SIJ degeneration after lumbar spinal fixation [ 31 ], there has been some suggestion that the SIJ degeneration described in the previous reports [ 24 , 25 , 30 ] might have been caused by spinal disease or hip OA. However, our study showed SIJ degeneration in some cases of Hip-Spine syndrome, in which spinal degeneration is associated with hip OA. Although further investigation is needed in a larger number of clinical cases, of course, with careful consideration of clinical symptoms, the new concept of “ Hip-SIJ-Spine syndrome ” should be focused on patients with Hip-Spine syndrome. This study did not make use of the SIJ degeneration score developed by Backlund et al. or Eno's classification [ 32 , 33 ]. This was because previous reports on the relationship between hip OA and SIJ degeneration [ 25 ] showed no significant difference in scores between the OA and control groups, and data on osteophyte levels were contradictory. In the present study, SIJ joint irregularities, which were not included in the SIJ degeneration score, were found to be associated with hip OA. SIJ joint irregularities are often observed on CT scans as early changes and may be interpreted as the first imaging of SIJ degeneration [ 27 ]. Considering that SIJ instability can induce symptoms [ 19 ], these changes may also represent the first imaging of instability. Further investigation is needed in the future. This study had several limitations. First, observations were limited to cases that underwent THA, and it is unclear whether similar occurrences of Hip-SIJ-Spine syndrome are more likely in cases of DDH or femoroacetabular impingement. Second, no data is currently available on whether SIJ degeneration is similarly likely to occur in simple Hip-Spine syndrome where pathology extends from the lumbar spine to the hip. Third, clinical symptoms were not confirmed, so it is unclear whether the concept of Hip-SIJ-Spine syndrome is clinically relevant or clearly expressed. Fourth, cases of DDH-related hip OA predominated in this study, and we do not know whether the same pathology would occur in cases of primary hip OA. Fifth, the sample size was small. Diagnosing SIJ dysfunction was not easy in the past, but it has been facilitated by the SIJ scoring system developed by Kurosawa et al. and based on physical examination and pain region [ 18 ]. The SIJ score has a total of 9 possible points, including 2 points for groin pain. In this context, for physicians working with OA patients who require THA, our findings may be useful clinically as a warning that groin pain should be differentiated from SIJ if the spine also has degenerative disease. Further research is warranted. Declarations Acknowledgments: Medical editor Lee Seaman (Seaman Medical Inc., Bellingham WA) provided professional English-language editing of this article. Funding information: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Conflict of interest: The authors declare that they have no conflict of interest. Authors’ contributions: Conceptualization: AK; Data curation: MF, YS, HH; Formal analysis: AK, ET; Investigation: AK, MF, YS, HH; Methodology: AK; Resources: AK, ET; Supervision: NK; Validation: AK, ET, NK; Writing – original draft: AK; Writing – review & editing: AK, NK Data availability statement The datasets analyzed during this given study are available from the corresponding author on reasonable request. Ethical approval: Approval was granted by the Ethics Committee of Kanazawa Medical University Consent to participate: Written informed consent was obtained from the all patients. References Offierski CM, MacNab I. Hip-spine syndrome. Spine 8 :316-321 (1983). Weinberg DS, Gebhart JJ, Liu RW. Hip-spine syndrome: A cadaveric analysis between osteoarthritis of the lumbar spine and hip joints. Orthop Traumatol Surg Res 103 :651-656 (2017). Kozaki T et al. Adjacent segment disease on hip joint as a complication of spinal fusion surgery including sacroiliac joint fixation. 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Cite Share Download PDF Status: Published Journal Publication published 15 Feb, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 05 Dec, 2023 Reviews received at journal 11 Nov, 2023 Reviews received at journal 06 Nov, 2023 Reviewers agreed at journal 06 Nov, 2023 Reviewers agreed at journal 02 Nov, 2023 Reviewers invited by journal 17 Oct, 2023 Editor assigned by journal 17 Oct, 2023 Editor invited by journal 14 Sep, 2023 Submission checks completed at journal 14 Sep, 2023 First submitted to journal 07 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3333581","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":233199069,"identity":"4390e3e0-05b6-4c2e-85d6-5d5a3dbec2c7","order_by":0,"name":"Ayumi Kaneuji","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYBACCTDJIyEngSHK2IBfizGpWhgYEmdgE8UKJNvPHnzMI2ORPhPI+Pij5rA8g9jhgzcYauwYmGdjt0aaJy/ZmIdHInc2kCEhceywYYN0WrIFw7FkBsY5B7BqkWPIMZMGaZnHkGMgYcB2m3H/7RwzCQa2AwyMMxKwa+F/Y/4bqCUdyDD+kfDvtn2DdP43CYZ/uLVIS+SYMQO1JIAYEgfbbic2SOewSTC24dYiOeONseQcHgnDmTPemFk29v1PBvrF2CKxL5kHl18kzucYfnjbUycPZBjf/PEtzbZBOvnhjQ/f7OQMcYQYGDD2oIsAncRjOAOLUjj4gU1QHm+EjoJRMApGwQgCABi/Vf8j1C7zAAAAAElFTkSuQmCC","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ayumi","middleName":"","lastName":"Kaneuji","suffix":""},{"id":233199070,"identity":"5d56e012-bb3c-417e-b9dc-9f13380bef0a","order_by":1,"name":"Makoto Fukui","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Makoto","middleName":"","lastName":"Fukui","suffix":""},{"id":233199072,"identity":"9f6afb9e-bebd-4059-80cd-7a7652710c2a","order_by":2,"name":"Eiji Takahashi","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eiji","middleName":"","lastName":"Takahashi","suffix":""},{"id":233199073,"identity":"0fee49b3-e4d6-48a4-8bbb-cae82729925e","order_by":3,"name":"Yusuke Sanji","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Sanji","suffix":""},{"id":233199074,"identity":"87c83365-6c24-441c-86c1-a5818dbccde9","order_by":4,"name":"Hiroaki Hirata","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Hirata","suffix":""},{"id":233199077,"identity":"2297bdcb-015d-454d-ba2d-014491c90bb2","order_by":5,"name":"Norio Kawahara","email":"","orcid":"","institution":"Kanazawa Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Norio","middleName":"","lastName":"Kawahara","suffix":""}],"badges":[],"createdAt":"2023-09-07 08:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3333581/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3333581/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-54472-4","type":"published","date":"2024-02-15T15:01:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":43379063,"identity":"f1170c10-1240-44af-8248-70dd1e092a49","added_by":"auto","created_at":"2023-09-19 16:41:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":317045,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHip OA secondary to DDH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Pre-operative x-ray. The patient had bilateral terminal-stage OA of the hip joint. The SIJ space differed visibly between right and left sides.\u003c/p\u003e\n\u003cp\u003eb. Prior to left-side surgery, the patient was diagnosed with a 25% slip of the fourth lumbar vertebra indicative of spondylolisthesis. Scoliosis with a Cobb angle of 7 degrees was also observed.\u003c/p\u003e\n\u003cp\u003ec. CT imaging showed SIJ irregularities and the presence of vacuum phenomena (yellow arrows).\u003c/p\u003e\n\u003cp\u003eOA: osteoarthritis, DDH: developmental dysplasia of the hip, SIJ: sacroiliac joint, CT: computed tomography\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3333581/v1/85690928b0fc24cafa51a9c8.png"},{"id":43377765,"identity":"e1ca8c0b-30c5-4eb1-873a-7df5356d4bfa","added_by":"auto","created_at":"2023-09-19 16:33:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":428639,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAlcohol-induced ON\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. The sclerotic boundary was visible (white triangles), with bone collapse on the left femoral head (yellow arrows).\u003c/p\u003e\n\u003cp\u003eb. X-ray images showed no lumbar spondylolisthesis except for slight scoliosis.\u003c/p\u003e\n\u003cp\u003ec. CT images showed no abnormalities, including SIJ irregularities.\u003c/p\u003e\n\u003cp\u003eON: osteonecrosis of the femoral head, SIJ: sacroiliac joint, CT: computed tomography\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3333581/v1/bf62c33315f541da814bb98a.png"},{"id":51323017,"identity":"32e89581-d7e2-46dd-89a6-537d29427e4e","added_by":"auto","created_at":"2024-02-19 15:14:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1319177,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3333581/v1/b1d5686f-55a4-4b85-989d-5c94e52d0d01.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship between degenerative changes in the lumbar spine and sacroiliac joint in patients with total hip arthroplasty: Possibility of Hip-Sacroiliac Joint-Spine syndrome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHip-spine syndrome was first described by Offierski and Macnab in 1983 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is classified into four types: simple, complex, mixed, and misdiagnosed. The simple type involves degenerative changes in either the hip joint or the spine, with that degeneration being the primary cause of the condition. The complex type involves degenerative changes in both the hip joint and the spine, with both contributing to the pathology. The mixed type refers to the interaction between hip and spinal pathologies, so that the conditions of the hip joint and the spine mutually affect each other. The misdiagnosed type occurs when incorrect treatment is provided due to a lack of awareness of the involvement of both hip and spine pathologies. An anatomical study also has detailed the mutual influence of degenerative changes in the spine and the hip joint [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, researchers have suggested that lumbosacral fusion and long fusion of the lumbar spine can lead to progressive hip osteoarthritis (hip OA) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, sacroiliac joint (SIJ) fixation has been linked to a two-fold increase in the risk of dislocation after total hip arthroplasty [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], suggesting a mechanical influence on the SIJ between the lumbar spine and the hip joint. Credible reports indicate that 14\u0026ndash;30% of low back pain originates from the SIJ [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and extensive study of the nerve supply to the SIJ suggests that not only the SIJ capsule but also the surrounding tissues such as ligaments can manifest pain [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the origin of SIJ pain remains unclear [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While excessive motion is restricted by ligaments, the SIJ joint has some limited mobility [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and increased instability or stress on the posterior ligaments of the SIJ may cause pain and dysfunction. In fact, symptomatic relief has been reported from immobilization by external fixation of the pelvis or injections into the posterior ligaments [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere have been reports of increased stress on the SIJ due to lumbosacral fusion [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], as well as reports of increased degeneration of the SIJ [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], strongly indicating an interrelationship between the lumbar spine and the SIJ, and a link between hip OA and SIJ dysfunction has been suggested [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Asada et al. analyzed preoperative CT scans of patients with hip OA who underwent total hip arthroplasty (THA) and noted a significantly higher incidence of narrowed joint space, osteophyte formation, and vacuum phenomena in the SIJ compared with a control group [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Elucidating the relationship between the hip, spine, and SIJ disorders is thus of considerable clinical importance.\u003c/p\u003e \u003cp\u003eIn this study, we formulated two hypotheses: first, that long-term degeneration of the hip joint has a major impact on the SIJ, making it more susceptible to Hip-SIJ syndrome, and second, that patients with the condition termed \u0026ldquo;Hip-Spine syndrome\u0026rdquo; show a higher prevalence of SIJ degeneration, suggesting the existence of what we have designated as \u0026ldquo;Hip-SIJ-Spine syndrome\u0026rdquo;. We then conducted a comparative study of patients undergoing THA for hip OA and for idiopathic osteonecrosis of the femoral head (ON).\u003c/p\u003e \u003cp\u003eTHA for OA is often performed after a long duration of illness, while ON frequently requires THA within a short timeframe. This is the reason for selecting these two conditions for comparison. Furthermore, in our facility, a significant proportion of OA cases are associated with developmental dysplasia of the hip (DDH), and ON often occurs in the unaffected hip joint, making it easier to compare and study in the context of this research.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe subjects of this study were patients who underwent THA for the treatment of OA or ON. A total of 93 patients (100 hips) who received THA for OA between June 2016 and December 2016 were enrolled. Since there was a possibility of changes in findings after unilateral surgery, seven cases of bilateral procedures were included only for analysis of the first operated side. An additional 24 patients (24 hips) were excluded because of inadequate CT confirmation of SIJ, so that 69 patients (69 hips) were included in analysis for the OA group. Because the annual number of cases of ON is relatively small, the treatment period for ON was extended from January 2010 to October 2022, and 83 patients (109 hips) were enrolled. Of those, 26 bilateral cases were counted on one side only. Seven patients (7 hips) were excluded because the patient had already undergone THA on one side, and an additional seven patients (7 hips) were excluded because of inadequate confirmation of the SIJ by CT or because of significant collapse of the necrotic area from advanced OA. This resulted in 69 cases (69 hips) that were included in analysis for the ON group.\u003c/p\u003e \u003cp\u003ePatient demographics are shown in Table I. There were no significant differences in age, height, weight and BMI between the groups. However, due to a higher prevalence of OA resulting from developmental dysplasia of the hip (DDH), female patients made up a significantly higher portion of the OA group (87%) than of the ON group (55%). In the OA group, only 3 hips were classified as primary OA, while 66 hips (96%) were classified as secondary OA from DDH. Crowe classification Group I accounted for 61 hips (92%), indicating a relatively low degree of hip dislocation in this group. In the ON group, 38 hips (55%) were classified as Group 4, indicating narrowing of the joint space but not reaching terminal OA.\u003c/p\u003e \u003cp\u003ePreoperative leg length discrepancy was measured by assessing the difference in Spina Malleolar Distance between the left and right sides before surgery, and was classified as an absolute value of \u0026le;\u0026thinsp;5 mm or \u0026ge;\u0026thinsp;6 mm. A difference of \u0026ge;\u0026thinsp;6 mm was defined as leg length discrepancy.\u003c/p\u003e \u003cp\u003e\u003cb\u003eTable I. Demographic data for all patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eON\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale : Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 : 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 : 31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight : Left\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 : 31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 : 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.0 (44\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.4 (33\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156.3 (142.6\u0026ndash;181.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160.2 (140.0-178.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.5 (36.8\u0026ndash;98.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.5 (40.8\u0026ndash;99.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.9 (15.6\u0026ndash;40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.9 (14.6\u0026ndash;36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT\u0026ouml;nnis grade (0 : 1 : 2 : 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 : 0 : 7 : 62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrowe classification\u003csup\u003e[34]\u003c/sup\u003e (group I : II : III : IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 : 5 : 0 : 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage classification\u003csup\u003e[35]\u003c/sup\u003e for ON (1: 2 : 3 : 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 : 6 : 25 : 38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOA: Osteoarthritis of the hip joint, ON: Osteonecrosis of the femoral head, BMI: Body mass index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Values are mean and range, NA: not applicable, NS: not significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRadiographic and CT analysis\u003c/h2\u003e \u003cp\u003eThe following items were investigated using imaging:\u003c/p\u003e \u003cp\u003eI. Preoperative anteroposterior pelvic radiographs\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePelvic tilt angle: Confirmation of the presence of lateral tilt of the iliac wings, with a tilt of 3 degrees or more in either direction classified as tilt present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiscrepancy in the obturator foramen: Confirmation of any obvious left-right asymmetry in the shape of the obturator foramen.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eII. Preoperative frontal and lateral lumbar spine images\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLumbar scoliosis: Confirmation of the presence of lumbar scoliosis and measurement of the Cobb angle. A Cobb angle of 5 degrees or more was classified as scoliosis present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLumbar degenerative spondylolisthesis: Presence of more than 25% slip of a lumbar vertebra was classified as spondylolisthesis present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIII. Preoperative CT images\u003c/p\u003e \u003cp\u003eSIJ degenerative changes [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]: CT cross-sectional images with a slice interval of 1 mm were examined for the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSclerosis: Presence of sclerosis adjacent to either the sacral or iliac side of the SIJ was classified as sclerosis present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eVacuum phenomenon: Presence of CT attenuation similar to air in the joint space of the SIJ was classified as vacuum phenomenon present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiscrepancy in joint space width: Confirmation of asymmetry in the width of the SIJ space was classified as discrepancy in joint space width.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIrregularities: Slight narrowing of the SIJ space, non-parallel joint surfaces of the sacral or iliac side, or erosive changes in a portion of the joint surface were classified as irregularities present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiscrepancy in iliac wing opening angle: Measurement of the angle formed by drawing a perpendicular line from the midline sacral ridge to the vertebral body at the second sacrum level and drawing a line from the midpoint of the width of the most anterior part of the iliac wing visible on the CT slice to the sacral ridge. A difference in absolute values of 3 degrees or more between the left and right sides was classified as iliac wing opening angle discrepancy present.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using the chi-square test or Fisher's exact test by Microsoft Excel. A p-value of 0.05 or less was considered statistically significant.\u003c/p\u003e \u003cp\u003e All methods in this study were performed in accordance with the relevant guidelines and regulations, and approval was granted by the Ethics Committee of Kanazawa Medical University.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe OA group differed significantly from the ON group in several parameters. Significantly more prevalent in the OA group were duration of illness, angle of pelvic outward tilt, instances of pelvic outward tilt of 3 degrees or more, and sclerotic and irregular images in the SIJ (Table II). No significant intergroup differences were noted in the frequency of lumbar spondylolisthesis and scoliosis. However, the presence of lumbar spondylolisthesis and of 5 degrees or more of scoliosis were significantly associated with a higher prevalence of irregular SIJ images (P\u0026thinsp;=\u0026thinsp;0.027) and (P\u0026thinsp;=\u0026thinsp;0.00373), respectively (Table III). Further analysis revealed that the presence of SIJ irregularities was significantly associated with asymmetry in the SIJ joint space in the entire group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). No significant differences were observed in other parameters.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II. Comparison of OA and ON groups\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eON\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration from onset to surgery (years)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 (0.25-20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.75 (0.1\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg length discrepancy (LLD) at surgery (mm)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 (0\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.7 (0\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLD \u0026gt;= 6mm (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44: 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26: 43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral inclination angle of pelvis (\u0026deg;)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 (0\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7 (0\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral inclination angle of pelvis \u0026gt;= 3 \u0026deg;(yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 : 44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 : 63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymmetry of obturator foramen (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 : 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 : 62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpondylolisthesis (cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 : 61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 : 68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCobb angle at lumbar spine (\u0026deg;)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 (0\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9 (0\u0026ndash;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCobb angle\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;5 \u0026deg;(yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 : 49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 : 51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSclerotic change of SIJ (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 : 39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14: 55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVacuum phenomenon of SIJ (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 : 37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 : 52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymmetry of SIJ space (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 : 49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 : 62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregularity of SIJ (yes : no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 : 31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 : 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngle of right iliac wing (\u0026deg;)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.7 (34\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.8 (36\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngle of left iliac wing (\u0026deg;)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.9 (33\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.5 (34\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference in bilateral iliac wing angle (\u0026deg;)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5 (0\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (0\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSIJ: Sacro-iliac joint, OA: Osteoarthritis of the hip joint, ON: Osteonecrosis of the femoral head\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e# Values are median and range. * Values are mean and range.\u003c/p\u003e \u003cp\u003eStatistical analysis for continuous values was performed using a t-test. A chi-square test was conducted for the other variables.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable III. Relationship between lumbar spine degeneration and SIJ degeneration\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eSpondylolisthesis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eCobb angle\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;5 \u0026deg;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes (cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo (cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIrregularity of SIJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSclerotic change in SIJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.5733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAsymmetry of SIJ space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAsymmetry of obturator foramen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.2877\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVacuum phenomenon in SIJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.6745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLateral inclination of pelvis\u0026gt;= 3 \u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.2769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSIJ: Sacro-iliac joint, Fisher's exact test was conducted for all analyses.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase Study 1\u003c/b\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003ea,b and c): A 58-year-old female presented with bilateral hip OA. She had been experiencing bilateral hip pain for the past 10 years. The pain gradually worsened, leading to limited range of motion, and she underwent left THA. Subsequently, a right THA was also performed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase Study 2\u003c/b\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003ea,b and c): A 51-year-old male presented with left hip pain continuing for the past 3 months and was diagnosed with stage 3 ON on the left side. Due to severe pain, he underwent left THA.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study suggested that THA was associated with significantly more degenerative change in the SIJ of the OA group than the ON group. In addition, the presence of irregularities in the SIJ was significantly associated with greater asymmetry in the SIJ space, indicating that excessive load on the SIJ due to hip OA may have led to degenerative changes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This study showed little correlation with leg length discrepancy, suggesting that SIJ degeneration may progress even in the absence of conditions such as DDH-related leg shortening. However, it is also possible that DDH itself increases stress on the SIJ. Toyohara et al. analyzed SIJ stress using finite element models based on CT images before and after periacetabular osteotomy in four DDH patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. They reported that stress on the SIJ and the posterior sacroiliac ligament, which is commonly observed in preoperative dysplastic hips, often decreased after surgery, indicating that excessive load on the SIJ was reduced after formation of a near-normal acetabulum. This suggests that the morphology of DDH itself may increase the load on the SIJ.\u003c/p\u003e \u003cp\u003eA significant association was noted between SIJ joint irregularities and the presence of more than 25% of lumbar spondylolisthesis or scoliosis of 5\u0026deg; or more, indicating a higher prevalence of SIJ degeneration in the patient group that underwent THA and had degenerative spinal diseases. Kwon et al. reported a higher prevalence of SIJ degeneration in patients with spinopelvic imbalance compared to those with lumbar spinal canal stenosis (LSCS) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and Chen has stated that SIJ degeneration was more common in patients with spondylolisthesis [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although a systematic review has shown no consensus regarding SIJ degeneration after lumbar spinal fixation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], there has been some suggestion that the SIJ degeneration described in the previous reports [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] might have been caused by spinal disease or hip OA. However, our study showed SIJ degeneration in some cases of Hip-Spine syndrome, in which spinal degeneration is associated with hip OA. Although further investigation is needed in a larger number of clinical cases, of course, with careful consideration of clinical symptoms, the new concept of \u0026ldquo;\u003cem\u003eHip-SIJ-Spine syndrome\u003c/em\u003e\u0026rdquo; should be focused on patients with Hip-Spine syndrome.\u003c/p\u003e \u003cp\u003eThis study did not make use of the SIJ degeneration score developed by Backlund et al. or Eno's classification [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This was because previous reports on the relationship between hip OA and SIJ degeneration [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] showed no significant difference in scores between the OA and control groups, and data on osteophyte levels were contradictory. In the present study, SIJ joint irregularities, which were not included in the SIJ degeneration score, were found to be associated with hip OA. SIJ joint irregularities are often observed on CT scans as early changes and may be interpreted as the first imaging of SIJ degeneration [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Considering that SIJ instability can induce symptoms [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], these changes may also represent the first imaging of instability. Further investigation is needed in the future.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, observations were limited to cases that underwent THA, and it is unclear whether similar occurrences of Hip-SIJ-Spine syndrome are more likely in cases of DDH or femoroacetabular impingement. Second, no data is currently available on whether SIJ degeneration is similarly likely to occur in simple Hip-Spine syndrome where pathology extends from the lumbar spine to the hip. Third, clinical symptoms were not confirmed, so it is unclear whether the concept of Hip-SIJ-Spine syndrome is clinically relevant or clearly expressed. Fourth, cases of DDH-related hip OA predominated in this study, and we do not know whether the same pathology would occur in cases of primary hip OA. Fifth, the sample size was small.\u003c/p\u003e \u003cp\u003eDiagnosing SIJ dysfunction was not easy in the past, but it has been facilitated by the SIJ scoring system developed by Kurosawa et al. and based on physical examination and pain region [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The SIJ score has a total of 9 possible points, including 2 points for groin pain. In this context, for physicians working with OA patients who require THA, our findings may be useful clinically as a warning that groin pain should be differentiated from SIJ if the spine also has degenerative disease. Further research is warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e Medical editor Lee Seaman (Seaman Medical Inc., Bellingham WA) provided professional English-language editing of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u0026nbsp;\u003c/strong\u003eAK; \u003cstrong\u003eData curation:\u003c/strong\u003e MF, YS, HH; \u003cstrong\u003eFormal analysis:\u003c/strong\u003e AK, ET; \u003cstrong\u003eInvestigation:\u0026nbsp;\u003c/strong\u003eAK, MF, YS, HH; \u003cstrong\u003eMethodology:\u0026nbsp;\u003c/strong\u003eAK; \u003cstrong\u003eResources:\u0026nbsp;\u003c/strong\u003eAK, ET; \u003cstrong\u003eSupervision:\u003c/strong\u003e NK; \u003cstrong\u003eValidation:\u003c/strong\u003e AK, ET, NK; \u003cstrong\u003eWriting – original draft:\u003c/strong\u003e AK; \u003cstrong\u003eWriting – review \u0026amp; editing:\u003c/strong\u003e AK, NK\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during this given study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e Approval was granted by the Ethics Committee of\u0026nbsp;Kanazawa Medical University\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the all patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOffierski CM, MacNab I. Hip-spine syndrome. \u003cem\u003eSpine\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e:316-321 (1983).\u003c/li\u003e\n\u003cli\u003eWeinberg DS, Gebhart JJ, Liu RW. Hip-spine syndrome: A cadaveric analysis between osteoarthritis of the lumbar spine and hip joints. \u003cem\u003eOrthop Traumatol Surg Res\u003c/em\u003e \u003cstrong\u003e103\u003c/strong\u003e:651-656 (2017).\u003c/li\u003e\n\u003cli\u003eKozaki T et al. Adjacent segment disease on hip joint as a complication of spinal fusion surgery including sacroiliac joint fixation. \u003cem\u003eEur Spine J\u003c/em\u003e\u003cstrong\u003e30\u003c/strong\u003e:1314-1319 (2021).\u003c/li\u003e\n\u003cli\u003eKawai T et al. Number of Levels of Spinal Fusion Associated with the Rate of Joint-Space Narrowing in the Hip. \u003cem\u003eJ Bone Joint Surg Am \u003c/em\u003e\u003cstrong\u003e103\u003c/strong\u003e:953-960 (2021).\u003c/li\u003e\n\u003cli\u003eRamamurti P et al. 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Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. \u003cem\u003eSpine\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e:1889\u0026ndash;1892 (1996). \u003c/li\u003e\n\u003cli\u003eSembrano JN, Polly DW Jr . How often is low back pain not coming from the back? \u003cem\u003eSpine\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e: E27\u0026ndash;E32 (2009). \u003c/li\u003e\n\u003cli\u003eSolonen KA. The sacroiliac joint in the light of anatomical, roentgenological and clinical studies. \u003cem\u003eActa Orthop Scand Suppl \u003c/em\u003e\u003cstrong\u003e27\u003c/strong\u003e:1\u0026ndash;127 (1957). \u003c/li\u003e\n\u003cli\u003eNakagawa T. Study on the distribution of nerve filaments over the iliosacral joint and its adjacent region in the Japanese. \u003cem\u003eNihon Seikeigeka Gakkai zasshi\u003c/em\u003e.\u003cstrong\u003e40\u003c/strong\u003e:419\u0026ndash;30. 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The prevalence of sacroiliac joint degeneration in asymptomatic adults. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e \u003cstrong\u003e97\u003c/strong\u003e:932-936 (2015). \u003c/li\u003e\n\u003cli\u003eCrowe JF, Mani VJ, Ranawat CS Total hip replacement in congenital dislocation and dysplasia of the hip.\u003cem\u003e J Bone Joint Surg Am\u003c/em\u003e \u003cstrong\u003e61\u003c/strong\u003e:15-23 (1979).\u003c/li\u003e\n\u003cli\u003eSugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K. The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. \u003cem\u003eJ Orthop Sci\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e:601-605 (2002). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3333581/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3333581/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study is designed to compare the extent of sacroiliac joint (SIJ) degeneration at total hip arthroplasty (THA) for two pathologies: osteoarthritis of the hip (OA) and osteonecrosis of the femoral head (ON). We also assessed the prevalence of SIJ degeneration in patients with lumbar spondylolisthesis or degenerative scoliosis.\u003c/p\u003e \u003cp\u003eA total of 138 hips from 138 patients (69 OA and 69 ON) were assessed in this study, including 66 hips affected by OA secondary to developmental dysplasia of the hip. The degenerative changes in the SIJ and lumbar spine were evaluated prior to THA using radiographs and computed tomography (CT) scans, showing 9 instances of spondylolisthesis and 38 of degenerative scoliosis.\u003c/p\u003e \u003cp\u003eThe OA group exhibited longer duration from onset to surgery than the ON group. The OA group also included more cases with significant pelvic obliquity (3 degrees or more) and with significant increases in SIJ sclerosis and irregularities. Patients with lumbar spondylolisthesis or degenerative scoliosis were significantly more likely to have SIJ irregularities.\u003c/p\u003e \u003cp\u003eThe prevalence of SIJ degeneration was higher in cases of THA for OA than for ON. This study also suggests the possibility of Hip-SIJ-Spine syndrome in THA patients with OA.\u003c/p\u003e","manuscriptTitle":"Relationship between degenerative changes in the lumbar spine and sacroiliac joint in patients with total hip arthroplasty: Possibility of Hip-Sacroiliac Joint-Spine syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-19 16:33:38","doi":"10.21203/rs.3.rs-3333581/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-12-05T05:06:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-12T01:43:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-06T06:06:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3c6292d0-a2f5-4df5-adf5-d9dcbcaac17e","date":"2023-11-06T05:58:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3b5423ce-c977-4f32-867f-d423ed7a1404_SNPRID","date":"2023-11-02T21:51:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-17T19:13:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-17T19:12:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-09-14T10:27:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-09-14T08:34:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2023-09-07T08:16:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"437ed41d-f3cc-4c9b-b4c1-72d23f6b3327","owner":[],"postedDate":"September 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":24657205,"name":"Health sciences/Diseases"},{"id":24657206,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2024-02-19T15:07:58+00:00","versionOfRecord":{"articleIdentity":"rs-3333581","link":"https://doi.org/10.1038/s41598-024-54472-4","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-02-15 15:01:34","publishedOnDateReadable":"February 15th, 2024"},"versionCreatedAt":"2023-09-19 16:33:38","video":"","vorDoi":"10.1038/s41598-024-54472-4","vorDoiUrl":"https://doi.org/10.1038/s41598-024-54472-4","workflowStages":[]},"version":"v1","identity":"rs-3333581","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3333581","identity":"rs-3333581","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}