Osteosarcopenia as a predictor of inferior patient-reported outcomes following total hip arthroplasty in older adults: a propensity score-matched analysis

Osteosarcopenia as a predictor of inferior patient-reported outcomes following total hip arthroplasty in older adults: a propensity score-matched analysis | 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 Research Article Osteosarcopenia as a predictor of inferior patient-reported outcomes following total hip arthroplasty in older adults: a propensity score-matched analysis Yoshinori Okamoto, Hitoshi Wakama, Takafumi Saika, Kengo Tani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6532044/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Total hip arthroplasty (THA) is an effective surgical option for older adults (aged ≥65 years) with advanced hip osteoarthritis. However, functional recovery and patient satisfaction remain variable despite technical success. Osteosarcopenia—the coexistence of osteoporosis and sarcopenia—reportedly contributes to suboptimal postoperative outcomes due to its association with frailty, falls, and impaired physical function. Aims: To investigate whether osteosarcopenia independently predicts poorer patient-reported outcomes in older adults undergoing elective THA. Methods: We retrospectively analysed 214 patients (mean age: 73.8 ± 6.8 years) who underwent unilateral primary THA, with a mean follow-up of 42 (range 24–66) months. Osteoporosis was defined by lumbar spine T-score <−2.5. Sarcopenia was assessed using psoas muscle index (PMI), a validated measure correlating with EWGSOP2 criteria. Patients were categorised into four groups: osteosarcopenia (13%), sarcopenia-only (32%), osteoporosis-only (22%), and normal (33%). The primary outcome was achieving the minimum clinically important difference (MCID), defined as the smallest change in score that patients perceive as beneficial, using the Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR). Propensity score matching compared osteosarcopenia (n = 25) and control (n = 50) groups, adjusting for age, sex, body mass index, and comorbidities. Results: Osteoporosis and sarcopenia reduced likelihood of achieving MCID (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.60–0.83 and OR 0.79, 95%CI 0.64–0.97, respectively; both P < 0.05). Patients with osteosarcopenia had significantly lower HOOS-JR ( P < 0.001), EuroQol-5D ( P = 0.029) and satisfaction levels ( P < 0.001) than controls. Preoperative PMI and nutritional status were correlated with final outcomes. Conclusions: Osteosarcopenia independently predicts inferior functional outcomes after THA in older adults. Preoperative screening for this geriatric syndrome should be incorporated into assessment protocols, as it may help guide personalised perioperative interventions, including nutritional support and adapted rehabilitation, thus enhancing recovery. osteoporosis osteosarcopenia patient-reported outcomes sarcopenia total hip arthroplasty Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Total hip arthroplasty (THA), which is now widely recognised as a standard and highly effective treatment for older adults (aged 65 years and above) with advanced hip osteoarthritis, offers substantial pain relief and improved mobility [ 1 – 10 ]. Despite its technical success and increasing utilisation—particularly among aging populations with multiple comorbidities—postoperative functional recovery and patient-perceived benefits remain inconsistent, with up to 15% of patients reporting dissatisfaction with the outcomes [ 6 , 11 , 12 ]. This variability underscores the need to investigate not only surgical variables, but also the biological and functional status of patients at the time of surgery, especially age-related conditions that may impair recovery and rehabilitation [ 2 ]. Identifying relevant preoperative predictors is therefore essential for effective risk stratification and personalised perioperative management in geriatric populations. Among the emerging risk factors, osteosarcopenia—the coexistence of osteoporosis and sarcopenia—has gained increasing attention in geriatric and musculoskeletal research. This geriatric syndrome affects approximately 5–10% of community-dwelling older adults and up to 40% of institutionalised elderly [ 13 – 17 ]. As a composite syndrome, it is associated with frailty, falls, disability, and increased mortality in older adults [ 15 – 17 ]. Moreover, it has been postulated to negatively affect recovery after major orthopaedic procedures by compromising both skeletal integrity and muscular support, which are particularly crucial for weight-bearing joints, such as the hip. Although several studies have independently examined osteoporosis or sarcopenia in relation to THA outcomes, the combined effect of osteosarcopenia has received limited attention [ 5 , 8 , 17 ]. In particular, its role in achieving clinically meaningful improvements in functional recovery from a geriatric perspective remains unclear and warrants further investigation. Given the dual burden this syndrome places on skeletal fragility and muscular decline, exploring osteosarcopenia as a composite condition may offer novel insights for enhancing perioperative care strategies in aging populations. Recognising the paucity of data, we aimed to determine whether osteosarcopenia predicts poorer functional recovery following elective THA in older adults. Using validated imaging-based criteria, we hypothesised that individuals with osteosarcopenia would be less likely to achieve satisfactory postoperative recovery compared to those without this condition, thereby contributing to the evidence base for risk stratification in geriatric orthopaedic care. Materials and Methods Statement of Ethics The study design was approved by our institutional ethics review board. All patients provided informed consent for the use of their clinical data for research purposes. Study Design and Population This retrospective cohort study, conducted at a single centre, analysed the outcomes of patients aged ≥ 65 years who underwent elective unilateral primary THA between August 2018 and February 2023. To minimise the confounding effects of ethnic variation, only patients of Asian ethnicity were included. Among 272 consecutive patients, 12 hips were excluded due to insufficient follow-up (< 24 months), leaving 326 hips eligible for further assessment. Of these, 112 hips were excluded based on predefined criteria: staged bilateral procedures, age < 65 years, prior spine or hip surgeries, postoperative complications, THA first with subsequent spine fusion, or trauma-related indications. The final analysis included 214 unilateral THAs in patients aged ≥ 65 years (Fig. 1 ). The mean age was 73.8 ± 6.8 years, and the mean follow-up period was 42 months (range, 24–66). While age varied significantly between included and excluded patients ( P 0.05). Surgical Procedure and Postoperative Protocol Surgical Procedure and Postoperative Protocol Four experienced arthroplasty surgeons performed all the procedures using a direct lateral approach with the patient in the lateral decubitus position. The surgeries utilised cemented prostheses in line with previously established techniques [ 6 , 8 , 18 ]. The implants included ultra-high molecular weight cross-linked polyethylene acetabular components (K-MAX CLPE cup for 176 hips or EXL GP Socket for 32 hips, both from Kyocera Medical Corporation, Osaka, Japan), or dual mobility systems (Avantage acetabular system for 6 hips; Zimmer-Biomet, Warsaw, IN). Femoral components comprised cobalt-chromium heads and stems, such as the K-MAX SC hip system (191 hips; Kyocera Medical Corporation), Exeter Universal femoral stems (20 hips; Stryker Orthopaedics, Mahwah, NJ), and CPT 12/14 hip stems (3 hips; Zimmer Biomet, Warsaw, IN). Assessment Methods The primary endpoints of this study included the European Quality of Life 5-Dimension 3-Level (EQ-5D) and visual analogue scale (VAS) for hip and low back pain [ 4 , 19 , 20 ]. Pain severity was rated on a 100-mm VAS, where 0 indicated no pain and 100 indicated the worst imaginable pain. Assessments were conducted at baseline, 2 weeks postoperatively, 6–12 months postoperatively, and annually thereafter. The EQ-5D, a validated instrument for measuring health-related quality of life, covers five dimensions: mobility, pain/discomfort, anxiety/depression, self-care, and daily activities [ 4 ]. To assess hip-specific function, we used the Hip Disability and Osteoarthritis Outcome Score–Joint Replacement (HOOS-JR), a validated, joint-specific patient-reported outcome measure developed for individuals undergoing hip replacement surgery [ 21 ]. The HOOS-JR consists of six items selected from the original HOOS questionnaire, covering domains of pain, stiffness, and physical function in daily living. Each item is scored on a five-point Likert scale (0 = no problems, 4 = extreme problems). The total raw score was transformed to a 0–100 interval scale, where higher scores indicated better hip function and fewer symptoms. This instrument was widely validated and suitable for aging populations undergoing hip arthroplasty. To interpret clinical effectiveness, we employed the minimum clinically important difference (MCID), which represents the smallest score improvement that patients perceive as beneficial [ 19 – 21 ]. This threshold is particularly informative in geriatric populations, where comorbidities and baseline functional limitations can make absolute scores less reflective of meaningful recovery. For the HOOS-JR, an 18-point cutoff was adopted based on prior validation in patients undergoing THA [ 4 , 21 ]. The use of MCID allows for the interpretation of outcomes in a way that emphasizes individual-level improvement, making it a relevant and patient-centered metric in the context of aging-related musculoskeletal care. To assess patient satisfaction with THA, we employed a custom-designed questionnaire covering various domains, including pain relief, ability to perform household or recreational activities, and overall satisfaction with the surgery [ 12 ]. Responses were rated on a five-point scale, ranging from 'very dissatisfied to 'very satisfied'. An overall satisfaction score was calculated by weighting all the responses equally. This was assessed using a validated measure, which has demonstrated high internal consistency and feasibility [ 12 ]. This tool has been shown to reliably capture the impact of various surgical techniques, implant choices, and perioperative strategies on patient-reported satisfaction [ 6 , 8 ]. Bone and Muscle Quality Assessment Osteosarcopenia was defined as the coexistence of low bone mineral density and low skeletal muscle mass, using criteria validated in orthopaedic and geriatric populations [ 13 – 17 ]. Osteoporosis was defined as a lumbar spine T-score < − 2.5, based on the World Health Organisation criteria and assessed using dual-energy X-ray absorptiometry. Sarcopenia was assessed using the psoas muscle index (PMI), calculated by dividing the cross-sectional area of the bilateral psoas muscles at the L4 vertebral level by height squared. The cutoff values were < 7.5 cm²/m² for men and < 5.2 cm²/m² for women, based on normative data from healthy adults aged 18 to 39 years. These thresholds correspond to two standard deviations below the sex-specific mean and are consistent with the recommendations from the European Working Group on Sarcopenia in Older People [ 5 , 22 , 23 ]. These definitions served as the basis for patient classification and subsequent analyses. This dual-criterion approach reflected the integrated nature of osteosarcopenia as a musculoskeletal syndrome, encompassing both bone fragility and reduced muscle reserves. Preoperative imaging assessments were performed using dual-energy X-ray absorptiometry and computed tomography (CT). Bone mineral density of the lumbar spine was measured using a Hologic Horizon Wi scanner (Hologic, Marlborough, MA, USA). Scans were obtained at L1–L4 with patients in the supine position and a calf support to reduce lumbar lordosis. The intercrestal line was used to approximate the L4/L5 level. T-scores at the L1 vertebra were recorded [ 5 ]. Skeletal muscle mass was assessed by measuring the cross-sectional area of the psoas muscle on axial CT images at the L4 vertebral level (Fig. 2 ). CT scans were performed with standard parameters (120 kV, 375 mA, 1.0-mm slice thickness) using a 64-slice scanner (Aquilion Prime SP; Canon Medical Systems, Otawara, Japan) and analysed via Picture Archiving and Communication Systems (IMPAX; Agfa Healthcare, Mortsel, Belgium). The L4 level was identified as the slice immediately below the anterior-superior edge of the L4 vertebral endplate, confirmed using sagittal multiplanar reconstruction. This level was chosen due to its well-documented prognostic value and established normative reference ranges [ 16 , 22 ]. To account for differences in the body size, the cross-sectional area of the psoas muscle was normalised by height squared, yielding the PMI [ 8 ]. The mean interval between preoperative imaging and surgery was 44 days (range: 1–51 days). To assess reliability, 15 hips and participants were randomly selected for PMI by two orthopaedic surgeons. The average interval between measurements was 4.2 weeks, with results rounded to one decimal place. The intra- and interclass correlation coefficients were 0.816 and 0.835, respectively. The intra‐ and interrater agreements with a discrepancy of < 0.2 cm²/m² were 92% and 85%, respectively. Statistical analysis Patients were classified according to whether they achieved the MCID for the HOOS-JR (≥ 18 points) at the final follow-up, as defined by Lyman et al [ 21 ]. Group comparisons were performed using the Mann–Whitney U tests for continuous variables and either the Pearson Chi-square test or Fisher’s exact tests for categorical variables, based on suitability determined by data distribution. The Shapiro–Wilk test was applied to assess normality. Logistic regression was employed to evaluate the differences in achieving MCID for the HOOS-JR across the groups, with adjustments made for the following confounding factors: age, sex, body mass index, prevalent vertebral fractures defined as Genant grade ≥ 2, Onodera’s Prognostic Nutritional Index (O-PNI), osteoporosis, and sarcopenia [ 5 , 8 , 24 , 25 ]. Multicollinearity was assessed using the variance inflation factor, with values exceeding 10 considered problematic. All the variance inflation factor values were maintained below this threshold to ensure robust results. A significance level of P -value < 0.05 was adopted for all the analyses. Patients were subdivided into four groups: (1) low bone density and PMI, representing osteosarcopenia, (2) low PMI with normal bone density, (3) low bone density with normal PMI, and (4) normal bone density and PMI [ 5 , 8 , 16 ]. Baseline characteristics and outcomes among these groups were compared using analysis of variance. Tukey's Honestly Significant Difference post-hoc test was applied to adjust for multiple comparisons. Using the propensity score, we generated a 1:2 matched cohort to facilitate comparison between patients who had and did not have osteosarcopenia. Propensity-score matching used covariates such as age, sex, body mass index, and Charlson Comorbidity Index, with a calliper width of 0.20. All the standardised mean differences were below 0.10, indicating that the matching process successfully minimised selection bias and enabled a balanced comparison between the groups. To assess the robustness of our findings, we conducted sensitivity analyses using the full unmatched cohort and an alternative calliper width of 0.10, which yielded comparable results. Linear regression was applied to evaluate the relationship between nutrition status, PMI, and patient-reported outcomes, with Pearson’s correlation coefficient [ 8 , 18 , 21 , 24 ]. All the statistical analyses were conducted using JMP 17 software (SAS Institute). Results Predictive Factors Influencing the Achievement of MCID for HOOS-JR Osteoporosis ( P = 0.032) and sarcopenia ( P = 0.041) were identified as independent variables of the MCID threshold for HOOS-JR (Table 1 ). Patients were distributed across four groups: osteosarcopenia was observed in 28 patients (13%), low PMI alone in 68 patients (32%), low bone density alone in 47 patients (22%), and normal bone and muscle status in 71 patients (33%) (Table 2 ). Although no significant differences in the preoperative HOOS-JR were observed among the four groups ( P = 0.783), the postoperative outcomes for the osteosarcopenia group differed from those of the other three groups (Fig. 3 ). In MCID achievement, the osteosarcopenia group demonstrated significantly lower HOOS-JR rates ( P < 0.001) and low back pain ( P = 0.024) improvements compared to the normal group. Table 1 Comparison of the demographic variables and multivariate logistic regression analyses between patients who did and did not achieve the MCID for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement Achieved MCID Did not achieve MCID B SE Wald Chi-square Exp(B) 95% CI p value Number of hips (%) 154 (72) 60 (28) Age, years 74 (5, 65–93) 74 (4, 65–90) 0.068 0.129 0.276 1.07 0.83–1.38 0.296 Men, n (%) 26 (17) 10 (17) -0.051 0.321 0.026 0.95 0.51–1.78 0.371 BMI, kg/m 2 23 (3, 18–31) 25 (3, 18–35) 0.030 0.271 0.011 1.03 0.61–1.75 0.678 Vertebral fractures, n (%) 17 (11) 11 (18) -0.151 0.088 2.924 0.86 0.72–1.02 0.168 Sarcopenia, n (%) 49 (32) 47 (78) -0.236 0.105 5.050 0.79 0.64–0.97 0.041 Osteoporosis, n (%) 34 (22) 41 (68) -0.342 0.818 17.530 0.71 0.60– 0.83 0.032 Data are expressed as mean (standard deviation, range) or number of hip involvements (%), as appropriate for the data type P < 0.05, bold indicates significant between-group differences of variables in the logistic regression BMI body mass index, CI confidence interval, MCID minimum clinically important difference, SE standard error Table 2 Baseline characteristics and outcomes stratified by the bone density and muscle status Osteosarcopenia Sarcopenia alone Osteoporosis alone Normal p value Number of hips, n (%) 28 (13) 68 (32) 47 (22) 71 (33) Age, year 76 (5, 65–90) c 74 (6, 65–85) 75 (5, 65–87) 72 (7, 65–88) 0.513 Men, n (%) 6 (21) 8 (12) 9 (19) 13 (18) 0.580 BMI, kg/m 2 23 (3, 18–27) 24 (3, 18–30) 23 (4, 19–29) 24 (4, 18–35) 0.843 CCI > 2, n (%) 7 (25) c 6 (9) 6 (13) 4 (6) 0.040 Vertebral fractures, n (%) 9 (32) c 6 (9) 8 (17) 5 (7) 0.005 O-PNI ≤ 40, n (%) 7 (25 ) c 5 (7) 5 (11) 3 (4) 0.013 Follow-up duration, months 41 (5, 24–63) 43 (5, 24–64) 42 (5, 24–65) 42 (5, 24–66) 0.387 EQ-5D a 0.42 (0.10, 0.57) 0.44 (0.11, 0.64) 0.45 (0.18, 0.61) 0.42 (0.10, 0.58) 0.984 0.72 (0.49, 0.87) c, d 0.72 (0.38, 0.88) c, d 0.71 (0.59, 0.87) c, d 0.85 (0.51, 0.91) d 0.038 HOOS-JR a 51 (45, 56) 51 (44, 57) 50 (49, 51) 49 (46, 53) 0.783 63 (59, 69) c 85 (81, 89) d 81 (75, 87) d 85 (80, 91) d 0.044 VAS-hip pain a 75 (7, 42–100) 76 (7, 55–100) 73 (8, 51–100) 71 (7, 45–100) 0.742 20 (5, 0–65) d 21 (5, 0–54) d 22 (5, 0–35) d 16 (5, 0–40) d 0.581 VAS-low back pain a 58 (10, 45–80) 43 (8, 33–82) 41 (8, 25–80) 38 (7, 20–75) 0.592 46 (8, 15–65) c 12 (7, 0–52) d 12 (6, 0–38) d 11 (5, 0–26) d 0.002 Achieved MCID, n (%) EQ-5D > 0.27 13 (46) c 43 (63) 27 (57) 49 (70) 0.008 HOOS-JR > 18 11 (39) c 54 (79) 31 (66) 58 (82) 18.6 mm 26 (92) 62 (91) 45 (95) 69 (97) 0.447 VAS-low back pain > 20 mm 15 (54) c 51 (75) 36 (77) 59 (83) 0.024 Patient satisfaction, n (%) b 15 (54) c 56 (82) 37 (79) 63 (89) 0.001 Data are expressed as mean (standard deviation, range) for normally distributed variables and the median value (interquartile range) for non-normally distributed variables or the number of hip involvements (%), as appropriate for the data type P < 0.05, bold indicates significant between-group differences CCI Charlson Comorbidity Index, EQ-5D EuroQol 5-Dimension 3-Level scale, HOOS-JR Hip Disability and Osteoarthritis Outcome Score Joint Replacement, MCID minimum clinically important difference, O-PNI Onodera’s prognostic nutritional index = 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/mm 3 ), VAS visual analogue scale a Between-group comparisons of outcomes pre-operatively (upper row) and at the last follow-up (lower row) b Count (%) of patients who answered satisfied or very satisfied, graded on a 5-point scale c P < 0.05 versus the normal group with respect to the corresponding variable d P < 0.05 versus a pre-operative variable in the corresponding group Propensity Score-Matched Comparison and Relationship Between the Baseline Variables and Outcomes After successfully matching patients who did (n = 25) and did not (n = 50) have osteosarcopenia, the standardised differences were < 0.10 for all the covariates. Significant differences were observed in the O-PNI ( P = 0.008), MCID ( P = 0.029 for EQ-5D, P < 0.001 for HOOS-JR, and P < 0.001 for low back pain), and patient satisfaction ( P < 0.001, Table 3 ). In both cohorts, preoperative PMI and nutritional status demonstrated a positive correlation with the HOOS-JR at the final follow-up ( P < 0.05). These two baseline variables exhibited an inverse relationship with the VAS-low back pain ( P < 0.05, Fig. 4 ). Table 3 Propensity score-matched comparison of variables between individuals who did and did not have osteosarcopenia Propensity Score-Matched p value Osteosarcopenia Non-osteosarcopenia Number of hips (%) 25 (33) 50 (67) Age, years 74 (5, 65–90) 74 (6, 65–88) 0.829 a Men, n (%) 5 (20) 9 (18) 0.834 a BMI, kg/m 2 23 (3, 18–27) 23 (3, 20–30) 0.983 a CCI > 2, n (%) 6 (24) 4 (8) 0.055 a Vertebral fractures, n (%) 8 (32) 4 (8) 0.008 O-PNI ≤ 40, n (%) 6 (24) 2 (4) 0.008 Achieved MCID, n (%) EQ-5D > 0.27 11 (44) 35 (70) 0.029 HOOS-JR > 18 10 (40) 41 (82) 18.6 mm 24 (96) 47 (94) 0.716 VAS-low back pain > 20 mm 13 (52) 45 (90) < 0.001 Patient satisfaction, n (%) b 14 (56) 45 (90) < 0.001 Data are expressed as mean (standard deviation, range) or number of hip involvements (%), as appropriate for the data type P < 0.05, bold indicates significant between-group differences BMI body mass index, CCI Charlson Comorbidity Index, EQ-5D EuroQol 5-Dimension 3-Level scale, HOOS-JR Hip Disability and Osteoarthritis Outcome Score Joint Replacement, MCID minimum clinically important difference, O-PNI Onodera’s prognostic nutritional index = 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/mm 3 ), VAS visual analogue scale a denotes a standard mean difference < 0.10 b count (%) of patients who answered satisfied or very satisfied, graded on a 5-point scale Discussion This study provides important insights into the prognostic role of osteosarcopenia in patients undergoing THA. By employing validated imaging-based criteria, we established reproducible thresholds for diagnosing sarcopenia and osteoporosis, facilitating a comprehensive understanding of how combined bone and muscle deficiencies affect postoperative recovery [ 14 , 15 ]. To our knowledge, this is among the first studies to evaluate the impact of osteosarcopenia on clinically meaningful improvements in THA outcomes using a matched geriatric cohort. This study builds upon prior work by integrating validated geriatric metrics and employing propensity score matching to isolate the effect of osteosarcopenia [ 13 – 17 ]. Subgroup analysis excluding patients with major complications, such as fractures, dislocations, and infections, confirmed that osteosarcopenia remained significantly associated with inferior postoperative outcomes (Table 2 ). This suggests that its prognostic value extends beyond complications typically linked to frailty. Although prior research has emphasised the increased risk of falls and fractures in individuals with osteosarcopenia, our results indicate that the condition independently contributes to suboptimal functional recovery—even in the absence of such events [ 15 ]. These findings underscore the importance of early detection and proactive intervention targeting both bone and muscle health [ 17 ]. A notable strength of our study is the application of propensity score matching, which helped mitigate selection bias inherent to retrospective designs (Table 3 ). Furthermore, we observed a significant correlation between the PMI and the nutritional status, indicating that O-PNI could serve as a practical surrogate marker for sarcopenia, especially in clinical settings where CT-based muscle assessment is not feasible [ 8 , 24 ]. The high inter- and intra-observer reliability of PMI measurements further reinforces the robustness of this imaging biomarker in orthopaedic practice. Our 4-group stratification allowed us to distinguish isolated sarcopenia/osteoporosis from combined burden, enhancing clinical relevance. Although PMI and O-PNI correlated with outcomes, causality cannot be inferred from observational data. Despite its strengths, this study has several limitations. First, the sample size was relatively small and limited to Asian patients, which may affect the generalizability of findings to other populations [ 8 ]. Second, the retrospective single-center design introduces the potential for selection bias and unmeasured confounders, such as physical activity or social determinants of health [ 14 ]. While we adopted imaging-based definitions of osteosarcopenia using validated thresholds, we were unable to incorporate muscle strength or physical performance measures recommended by European Working Group on Sarcopenia in Older People criteria. This limits the diagnostic comprehensiveness, and future prospective studies should adopt the full criteria to improve diagnostic precision. Third, patients with periprosthetic complications (e.g., fracture, dislocation, infection) were excluded; thus, the relationship between osteosarcopenia and these outcomes remains unexamined (Fig. 1 ). Fourth, our assessment of muscle quality was limited to static cross-sectional imaging. We did not evaluate functional dynamics such as posture-related changes or spinal canal stenosis, which may influence low back pain and mobility, especially in osteoporotic individuals [ 10 , 18 ]. Fifth, although we adjusted the psoas muscle area for height, other body composition metrics such as body mass index and adipose tissue infiltration were not analyzed. These could further clarify the clinical implications of muscle quality. Finally, while we applied propensity score matching and confirmed the consistency of results through sensitivity analyses, residual confounding cannot be entirely excluded due to the retrospective nature of the study. From a clinical and geriatric care perspective, our findings highlight the need for early identification and risk stratification of osteosarcopenia in older adults undergoing THA. Laboratory-based indices such as the O-PNI may offer a pragmatic, cost-effective adjunct to sarcopenia screening, particularly where advanced imaging is not feasible. While our findings support its potential as a surrogate marker due to its correlation with PMI, O-PNI reflects systemic nutritional and inflammatory status rather than musculoskeletal anatomy. Thus, its interpretive limitations must be acknowledged. Ultrasonography has also gained attention as a scalable, non-invasive alternative to CT-based assessments for estimating muscle quantity and quality [ 8 , 26 ]. Its portability, repeatability, and low burden on patients make it especially valuable in frail or community-dwelling populations. Incorporating such screening tools—whether laboratory- or imaging-based—into preoperative assessments may enhance personalized perioperative planning and improve surgical outcomes. These strategies align with geriatric care priorities focused on promoting mobility, independence, and functional recovery in aging surgical patients. Further research is warranted to validate these approaches across care settings and integrate them into standardized protocols for osteosarcopenia risk assessment. As the global burden of musculoskeletal aging rises, such integrative risk models incorporating sarcopenia, osteoporosis, and nutrition status may serve as critical components of precision geriatric surgery. These findings may inform future screening protocols and perioperative risk stratification guidelines for aging populations undergoing joint replacement. Conclusions This study highlights the significant impact of osteosarcopenia on THA outcomes, emphasising the importance of comprehensive preoperative assessment and tailored management strategies. By integrating validated imaging metrics and alternative tools such as O-PNI into clinical practice, clinicians can enhance preoperative risk stratification and optimise perioperative care. These efforts are particularly crucial in managing aging populations with increasing prevalence of osteosarcopenia to improve surgical outcomes, recovery, and patient satisfaction. Declarations Funding This study was supported by the Hip Joint Foundation of Japan and the Grants-in-Aid for Scientific Research of Japan Society KAKENHI for the Promotion of Science, Grant Number 21K09239. Competing Interests The authors declare no competing interests. Ethics approval Human Ethics and Consent to Participate declarations: The methods used in this study were approved by our institutional ethics review board (No. 2020-098-2). Consent All patients provided informed consent for the use of their clinical data for research purposes. Data and/or Materials availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Code availability Not applicable. Authors’ contribution YO: Conceptualization, Data curation, Funding acquisition, Writing – original draft, Writing – review & editing. HW: Data curation, Investigation. TS: Conceptualization, Data curation, Investigation. KT: Formal Analysis, Methodology, Investigation. SO: Validation, Supervision References Ferguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S (2018) Hip replacement. 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Aging Clin Exp Res 34:535–543. https://doi.org/10.1007/s40520-021-01968-y Chen S, Xu X, Gong H et al (2024) Global epidemiological features and impact of osteosarcopenia: A comprehensive meta-analysis and systematic review. J Cachexia Sarcopenia Muscle 15:8–20. https://doi.org/10.1002/jcsm.13392 Nguyen BTT, Lin AP, Yang WW et al (2024) Impacts of osteosarcopenia on musculoskeletal health, risks of falls and fractures, and activities of daily living among population aged 50 and above: an age- and sex-matched cross-sectional analysis. Aging Clin Exp Res 37:8. https://doi.org/10.1007/s40520-024-02902-8 Solla-Suarez P, Arif SG, Ahmad F et al (2024) Osteosarcopenia and Mortality in Older Adults Undergoing Transcatheter Aortic Valve Replacement. JAMA Cardiol 9:611–618. https://doi.org/10.1001/jamacardio.2024.0911 Veronese N, Ragusa FS, Sabico S et al (2024) Osteosarcopenia increases the risk of mortality: a systematic review and meta-analysis of prospective observational studies. Aging Clin Exp Res 36:132. https://doi.org/10.1007/s40520-024-02785-9 Okamoto Y, Wakama H, Matsuyama J et al (2023) Clinical significance of relative pelvic version measurement as a predictor of low back pain after total hip arthroplasty. Eur Spine J 32:4452–4463. https://doi.org/10.1007/s00586-023-07956-2 Ostelo RW, de Vet HC (2005) Clinically important outcomes in low back pain. Best Pract Res Clin Rheumatol 19:593–607. https://doi.org/10.1016/j.berh.2005.03.003 Danoff JR, Goel R, Sutton R, Maltenfort MG, Austin MS (2018) How Much Pain Is Significant? Defining the Minimal Clinically Important Difference for the Visual Analog Scale for Pain After Total Joint Arthroplasty. J Arthroplasty 33:S71–S. 75.e2 Lyman S, Lee YY, McLawhorn AS, Islam W, MacLean CH (2018) What Are the Minimal and Substantial Improvements in the HOOS and KOOS and JR Versions After Total Joint Replacement? Clin Orthop Relat Res 476:2432–2441. https://doi.org/10.1097/corr.0000000000000456 Derstine BA, Holcombe SA, Goulson RL et al (2017) Quantifying Sarcopenia Reference Values Using Lumbar and Thoracic Muscle Areas in a Healthy Population. J Nutr Health Aging 21:180–185. https://doi.org/10.1007/s12603-017-0983-3 De Marco D, Mamane S, Choo W et al (2022) Muscle Area and Density Assessed by Abdominal Computed Tomography in Healthy Adults: Effect of Normal Aging and Derivation of Reference Values. J Nutr Health Aging 26:243–246. https://doi.org/10.1007/s12603-022-1746-3 Onodera T, Goseki N, Kosaki G (1984) Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients [article in Japanese]. Nihon Geka Gakkai Zasshi 85:1001–1005 Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Min Res 8:1137–1148. https://doi.org/10.1002/jbmr.5650080915 Kremer WM, Labenz C, Kuchen R et al (2022) Sonographic assessment of low muscle quantity identifies mortality risk during COVID-19: a prospective single-centre study. J Cachexia Sarcopenia Muscle 13:169–179. https://doi.org/10.1002/jcsm.12862 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. 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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-6532044","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454524952,"identity":"e537c435-ce6f-44dc-9669-abdc874f0238","order_by":0,"name":"Yoshinori Okamoto","email":"data:image/png;base64,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","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":true,"prefix":"","firstName":"Yoshinori","middleName":"","lastName":"Okamoto","suffix":""},{"id":454524953,"identity":"365ccfda-35d6-4ada-9b9d-ea3afd58cf20","order_by":1,"name":"Hitoshi Wakama","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Hitoshi","middleName":"","lastName":"Wakama","suffix":""},{"id":454524954,"identity":"863686e1-49f9-4733-a3f6-67c291fdc653","order_by":2,"name":"Takafumi Saika","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Takafumi","middleName":"","lastName":"Saika","suffix":""},{"id":454524955,"identity":"d893c80e-f449-489a-8f07-193fe693fd2f","order_by":3,"name":"Kengo Tani","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Kengo","middleName":"","lastName":"Tani","suffix":""},{"id":454524956,"identity":"e6721526-b65f-4b9e-8096-711f8ace3622","order_by":4,"name":"Shuhei Otsuki","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Shuhei","middleName":"","lastName":"Otsuki","suffix":""}],"badges":[],"createdAt":"2025-04-26 01:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6532044/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6532044/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82605087,"identity":"5f6c4e25-a846-4445-b5f8-eabdd5f2d9c5","added_by":"auto","created_at":"2025-05-13 10:00:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30587,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection and classification.\u003c/p\u003e\n\u003cp\u003ePatients aged ≥65 years who underwent elective unilateral total hip arthroplasty (THA) were screened based on predefined inclusion and exclusion criteria. After classification into four groups according to the presence of sarcopenia and/or osteoporosis, multivariate analyses were performed. A subset of patients with osteosarcopenia was matched to a control group without the condition using propensity score matching to compare postoperative outcomes, including HOOS-JR, EQ-5D, and patient satisfaction.\u003c/p\u003e\n\u003cp\u003e* Sarcopenia was defined as a cross-sectional psoas muscle area on axial computed tomography at the L4 vertebral level of \u0026lt;7.5 cm²/m² for men and \u0026lt;5.2 cm²/m² for women.\u003c/p\u003e\n\u003cp\u003e†Osteoporosis was defined as a lumbar spine T-score \u0026lt; −2.5.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHOOS-JR\u003c/em\u003e Hip Disability and Osteoarthritis Outcome Score Joint Replacement, \u003cem\u003eMCID\u003c/em\u003e minimum clinically important difference, \u003cem\u003eTHA\u003c/em\u003etotal hip arthroplasty\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6532044/v1/6eb5b88cb4850c74dfce45a2.png"},{"id":82606440,"identity":"0e63fcd6-dbd4-425e-b1aa-f7713170cbda","added_by":"auto","created_at":"2025-05-13 10:08:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":242263,"visible":true,"origin":"","legend":"\u003cp\u003eThe cross-sectional area of the right (*R) and left psoas major (*L) at the mid-level of the L4 vertebral body, determined by manual tracing of preoperative computed tomography images. The sum of the two sides was determined as the psoas muscle area, which positively correlated with the total volume of the skeletal muscle, providing a useful index for diagnosing sarcopenia. This creates a normalised measure for between-subject evaluation of the relative health and function of the psoas, facilitating clinical interpretation and decision-making. The image was taken 44 days preoperatively from a 77-year-old woman with left-sided hip osteoarthritis, demonstrating an ipsilateral iliopsoas muscle of 513 mm² compared with 626 mm² on the contralateral side.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6532044/v1/5af01bd8adf660f6b1bef99f.png"},{"id":82607442,"identity":"778ba136-2290-4a18-826d-503694df79bd","added_by":"auto","created_at":"2025-05-13 10:16:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":17151,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the HOOS-JR stratified by bone density and muscle status. Box plots depict the HOOS-JR at the preoperative (\u003cem\u003ewhite\u003c/em\u003e) and final follow-up (\u003cem\u003egrey\u003c/em\u003e) assessments. The median (horizontal line), interquartile range (box), and data range (whiskers) are shown. Outliers are represented as individual points. The figure highlights both group differences and changes within each category. A two-way repeated-measures analysis of variance reveals significant effects of the disease type (F (3, 210) = 4.52, \u003cem\u003eP \u003c/em\u003e\u0026lt; 0.001) and time (F (1, 210) = 50.27, \u003cem\u003eP \u003c/em\u003e\u0026lt; 0.001) on the outcome.\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003eP \u003c/em\u003e\u0026lt; 0.05 indicates a significant difference between the baseline and final follow-up in the corresponding group, or with respect to the corresponding time point.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHOOS-JR\u003c/em\u003e Hip Disability and Osteoarthritis Outcome Score Joint Replacement\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6532044/v1/bbd0cca3e389ef56a5e72d9f.png"},{"id":82605091,"identity":"6f9b278b-0e47-45ac-876a-9d36b9b54e17","added_by":"auto","created_at":"2025-05-13 10:00:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":66294,"visible":true,"origin":"","legend":"\u003cp\u003eScatter plots showing the relationship between the preoperative status (A, psoas muscle index; and B, Onodera's prognostic nutritional index) and HOOS-JR at the final follow-up, and between the preoperative status (C, psoas muscle index; and D, Onodera's prognostic nutritional index) and VAS-low back pain at the final follow-up.\u003c/p\u003e\n\u003cp\u003ePearson's correlation coefficients and linear regression lines are presented, with solid lines for the normal group (\u003cem\u003eclosed circles\u003c/em\u003e) and dashed lines for the osteosarcopenia group (\u003cem\u003eopen circles\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003e* \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCI\u003c/em\u003econfidence interval, \u003cem\u003eHOOS-JR\u003c/em\u003e Hip Disability and Osteoarthritis Outcome Score Joint Replacement, \u003cem\u003eVAS\u003c/em\u003e visual analogue scale\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6532044/v1/454d3a5b90f3c33251fa684f.png"},{"id":83763964,"identity":"2278e02f-8b72-428b-bf9b-5ff9fd2ddb2a","added_by":"auto","created_at":"2025-06-02 10:23:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1439740,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6532044/v1/a266703b-60f1-414b-b358-7df0fa818c66.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Osteosarcopenia as a predictor of inferior patient-reported outcomes following total hip arthroplasty in older adults: a propensity score-matched analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal hip arthroplasty (THA), which is now widely recognised as a standard and highly effective treatment for older adults (aged 65 years and above) with advanced hip osteoarthritis, offers substantial pain relief and improved mobility [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite its technical success and increasing utilisation\u0026mdash;particularly among aging populations with multiple comorbidities\u0026mdash;postoperative functional recovery and patient-perceived benefits remain inconsistent, with up to 15% of patients reporting dissatisfaction with the outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This variability underscores the need to investigate not only surgical variables, but also the biological and functional status of patients at the time of surgery, especially age-related conditions that may impair recovery and rehabilitation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Identifying relevant preoperative predictors is therefore essential for effective risk stratification and personalised perioperative management in geriatric populations.\u003c/p\u003e \u003cp\u003eAmong the emerging risk factors, osteosarcopenia\u0026mdash;the coexistence of osteoporosis and sarcopenia\u0026mdash;has gained increasing attention in geriatric and musculoskeletal research. This geriatric syndrome affects approximately 5\u0026ndash;10% of community-dwelling older adults and up to 40% of institutionalised elderly [\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As a composite syndrome, it is associated with frailty, falls, disability, and increased mortality in older adults [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, it has been postulated to negatively affect recovery after major orthopaedic procedures by compromising both skeletal integrity and muscular support, which are particularly crucial for weight-bearing joints, such as the hip. Although several studies have independently examined osteoporosis or sarcopenia in relation to THA outcomes, the combined effect of osteosarcopenia has received limited attention [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In particular, its role in achieving clinically meaningful improvements in functional recovery from a geriatric perspective remains unclear and warrants further investigation. Given the dual burden this syndrome places on skeletal fragility and muscular decline, exploring osteosarcopenia as a composite condition may offer novel insights for enhancing perioperative care strategies in aging populations.\u003c/p\u003e \u003cp\u003eRecognising the paucity of data, we aimed to determine whether osteosarcopenia predicts poorer functional recovery following elective THA in older adults. Using validated imaging-based criteria, we hypothesised that individuals with osteosarcopenia would be less likely to achieve satisfactory postoperative recovery compared to those without this condition, thereby contributing to the evidence base for risk stratification in geriatric orthopaedic care.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatement of Ethics\u003c/h2\u003e \u003cp\u003e The study design was approved by our institutional ethics review board. All patients provided informed consent for the use of their clinical data for research purposes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design and Population\u003c/h3\u003e\n\u003cp\u003eThis retrospective cohort study, conducted at a single centre, analysed the outcomes of patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years who underwent elective unilateral primary THA between August 2018 and February 2023. To minimise the confounding effects of ethnic variation, only patients of Asian ethnicity were included. Among 272 consecutive patients, 12 hips were excluded due to insufficient follow-up (\u0026lt;\u0026thinsp;24 months), leaving 326 hips eligible for further assessment. Of these, 112 hips were excluded based on predefined criteria: staged bilateral procedures, age\u0026thinsp;\u0026lt;\u0026thinsp;65 years, prior spine or hip surgeries, postoperative complications, THA first with subsequent spine fusion, or trauma-related indications. The final analysis included 214 unilateral THAs in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age was 73.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8 years, and the mean follow-up period was 42 months (range, 24\u0026ndash;66). While age varied significantly between included and excluded patients (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), no significant differences were observed in other patient-related variables (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003ch3\u003eSurgical Procedure and Postoperative Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eSurgical Procedure and Postoperative Protocol\u003c/div\u003e \u003cp\u003eFour experienced arthroplasty surgeons performed all the procedures using a direct lateral approach with the patient in the lateral decubitus position. The surgeries utilised cemented prostheses in line with previously established techniques [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The implants included ultra-high molecular weight cross-linked polyethylene acetabular components (K-MAX CLPE cup for 176 hips or EXL GP Socket for 32 hips, both from Kyocera Medical Corporation, Osaka, Japan), or dual mobility systems (Avantage acetabular system for 6 hips; Zimmer-Biomet, Warsaw, IN). Femoral components comprised cobalt-chromium heads and stems, such as the K-MAX SC hip system (191 hips; Kyocera Medical Corporation), Exeter Universal femoral stems (20 hips; Stryker Orthopaedics, Mahwah, NJ), and CPT 12/14 hip stems (3 hips; Zimmer Biomet, Warsaw, IN).\u003c/p\u003e\n\u003ch3\u003eAssessment Methods\u003c/h3\u003e\n\u003cp\u003eThe primary endpoints of this study included the European Quality of Life 5-Dimension 3-Level (EQ-5D) and visual analogue scale (VAS) for hip and low back pain [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Pain severity was rated on a 100-mm VAS, where 0 indicated no pain and 100 indicated the worst imaginable pain. Assessments were conducted at baseline, 2 weeks postoperatively, 6\u0026ndash;12 months postoperatively, and annually thereafter. The EQ-5D, a validated instrument for measuring health-related quality of life, covers five dimensions: mobility, pain/discomfort, anxiety/depression, self-care, and daily activities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To assess hip-specific function, we used the Hip Disability and Osteoarthritis Outcome Score\u0026ndash;Joint Replacement (HOOS-JR), a validated, joint-specific patient-reported outcome measure developed for individuals undergoing hip replacement surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The HOOS-JR consists of six items selected from the original HOOS questionnaire, covering domains of pain, stiffness, and physical function in daily living. Each item is scored on a five-point Likert scale (0\u0026thinsp;=\u0026thinsp;no problems, 4\u0026thinsp;=\u0026thinsp;extreme problems). The total raw score was transformed to a 0\u0026ndash;100 interval scale, where higher scores indicated better hip function and fewer symptoms. This instrument was widely validated and suitable for aging populations undergoing hip arthroplasty. To interpret clinical effectiveness, we employed the minimum clinically important difference (MCID), which represents the smallest score improvement that patients perceive as beneficial [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This threshold is particularly informative in geriatric populations, where comorbidities and baseline functional limitations can make absolute scores less reflective of meaningful recovery. For the HOOS-JR, an 18-point cutoff was adopted based on prior validation in patients undergoing THA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The use of MCID allows for the interpretation of outcomes in a way that emphasizes individual-level improvement, making it a relevant and patient-centered metric in the context of aging-related musculoskeletal care.\u003c/p\u003e \u003cp\u003eTo assess patient satisfaction with THA, we employed a custom-designed questionnaire covering various domains, including pain relief, ability to perform household or recreational activities, and overall satisfaction with the surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Responses were rated on a five-point scale, ranging from 'very dissatisfied to 'very satisfied'. An overall satisfaction score was calculated by weighting all the responses equally. This was assessed using a validated measure, which has demonstrated high internal consistency and feasibility [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This tool has been shown to reliably capture the impact of various surgical techniques, implant choices, and perioperative strategies on patient-reported satisfaction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eBone and Muscle Quality Assessment\u003c/h3\u003e\n\u003cp\u003eOsteosarcopenia was defined as the coexistence of low bone mineral density and low skeletal muscle mass, using criteria validated in orthopaedic and geriatric populations [\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Osteoporosis was defined as a lumbar spine T-score\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;2.5, based on the World Health Organisation criteria and assessed using dual-energy X-ray absorptiometry. Sarcopenia was assessed using the psoas muscle index (PMI), calculated by dividing the cross-sectional area of the bilateral psoas muscles at the L4 vertebral level by height squared. The cutoff values were \u0026lt;\u0026thinsp;7.5 cm\u0026sup2;/m\u0026sup2; for men and \u0026lt;\u0026thinsp;5.2 cm\u0026sup2;/m\u0026sup2; for women, based on normative data from healthy adults aged 18 to 39 years. These thresholds correspond to two standard deviations below the sex-specific mean and are consistent with the recommendations from the European Working Group on Sarcopenia in Older People [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These definitions served as the basis for patient classification and subsequent analyses. This dual-criterion approach reflected the integrated nature of osteosarcopenia as a musculoskeletal syndrome, encompassing both bone fragility and reduced muscle reserves.\u003c/p\u003e \u003cp\u003ePreoperative imaging assessments were performed using dual-energy X-ray absorptiometry and computed tomography (CT). Bone mineral density of the lumbar spine was measured using a Hologic Horizon Wi scanner (Hologic, Marlborough, MA, USA). Scans were obtained at L1\u0026ndash;L4 with patients in the supine position and a calf support to reduce lumbar lordosis. The intercrestal line was used to approximate the L4/L5 level. T-scores at the L1 vertebra were recorded [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Skeletal muscle mass was assessed by measuring the cross-sectional area of the psoas muscle on axial CT images at the L4 vertebral level (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). CT scans were performed with standard parameters (120 kV, 375 mA, 1.0-mm slice thickness) using a 64-slice scanner (Aquilion Prime SP; Canon Medical Systems, Otawara, Japan) and analysed via Picture Archiving and Communication Systems (IMPAX; Agfa Healthcare, Mortsel, Belgium). The L4 level was identified as the slice immediately below the anterior-superior edge of the L4 vertebral endplate, confirmed using sagittal multiplanar reconstruction. This level was chosen due to its well-documented prognostic value and established normative reference ranges [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. To account for differences in the body size, the cross-sectional area of the psoas muscle was normalised by height squared, yielding the PMI [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The mean interval between preoperative imaging and surgery was 44 days (range: 1\u0026ndash;51 days).\u003c/p\u003e \u003cp\u003eTo assess reliability, 15 hips and participants were randomly selected for PMI by two orthopaedic surgeons. The average interval between measurements was 4.2 weeks, with results rounded to one decimal place. The intra- and interclass correlation coefficients were 0.816 and 0.835, respectively. The intra‐ and interrater agreements with a discrepancy of \u0026lt;\u0026thinsp;0.2 cm\u0026sup2;/m\u0026sup2; were 92% and 85%, respectively.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003ePatients were classified according to whether they achieved the MCID for the HOOS-JR (\u0026ge;\u0026thinsp;18 points) at the final follow-up, as defined by Lyman et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Group comparisons were performed using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e tests for continuous variables and either the Pearson Chi-square test or Fisher\u0026rsquo;s exact tests for categorical variables, based on suitability determined by data distribution. The Shapiro\u0026ndash;Wilk test was applied to assess normality. Logistic regression was employed to evaluate the differences in achieving MCID for the HOOS-JR across the groups, with adjustments made for the following confounding factors: age, sex, body mass index, prevalent vertebral fractures defined as Genant grade\u0026thinsp;\u0026ge;\u0026thinsp;2, Onodera\u0026rsquo;s Prognostic Nutritional Index (O-PNI), osteoporosis, and sarcopenia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Multicollinearity was assessed using the variance inflation factor, with values exceeding 10 considered problematic. All the variance inflation factor values were maintained below this threshold to ensure robust results. A significance level of \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was adopted for all the analyses. Patients were subdivided into four groups: (1) low bone density and PMI, representing osteosarcopenia, (2) low PMI with normal bone density, (3) low bone density with normal PMI, and (4) normal bone density and PMI [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Baseline characteristics and outcomes among these groups were compared using analysis of variance. Tukey's Honestly Significant Difference post-hoc test was applied to adjust for multiple comparisons.\u003c/p\u003e \u003cp\u003eUsing the propensity score, we generated a 1:2 matched cohort to facilitate comparison between patients who had and did not have osteosarcopenia. Propensity-score matching used covariates such as age, sex, body mass index, and Charlson Comorbidity Index, with a calliper width of 0.20. All the standardised mean differences were below 0.10, indicating that the matching process successfully minimised selection bias and enabled a balanced comparison between the groups. To assess the robustness of our findings, we conducted sensitivity analyses using the full unmatched cohort and an alternative calliper width of 0.10, which yielded comparable results. Linear regression was applied to evaluate the relationship between nutrition status, PMI, and patient-reported outcomes, with Pearson\u0026rsquo;s correlation coefficient [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. All the statistical analyses were conducted using JMP 17 software (SAS Institute).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePredictive Factors Influencing the Achievement of MCID for HOOS-JR\u003c/h2\u003e \u003cp\u003eOsteoporosis (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032) and sarcopenia (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.041) were identified as independent variables of the MCID threshold for HOOS-JR (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were distributed across four groups: osteosarcopenia was observed in 28 patients (13%), low PMI alone in 68 patients (32%), low bone density alone in 47 patients (22%), and normal bone and muscle status in 71 patients (33%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Although no significant differences in the preoperative HOOS-JR were observed among the four groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.783), the postoperative outcomes for the osteosarcopenia group differed from those of the other three groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In MCID achievement, the osteosarcopenia group demonstrated significantly lower HOOS-JR rates (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and low back pain (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024) improvements compared to the normal group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the demographic variables and multivariate logistic regression analyses between patients who did and did not achieve the MCID for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\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\u003eAchieved MCID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDid not achieve MCID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWald Chi-square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hips (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 \u003cem\u003e(72)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 \u003cem\u003e(28)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003e74 (5, 65\u0026ndash;93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (4, 65\u0026ndash;90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.83\u0026ndash;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 \u003cem\u003e(17)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 \u003cem\u003e(17)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.51\u0026ndash;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.371\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 (3, 18\u0026ndash;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (3, 18\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.61\u0026ndash;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.678\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral fractures, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 \u003cem\u003e(11)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 \u003cem\u003e(18)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.72\u0026ndash;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSarcopenia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 \u003cem\u003e(32)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 \u003cem\u003e(78)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.64\u0026ndash;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteoporosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 \u003cem\u003e(22)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 \u003cem\u003e(68)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17.530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.60\u0026ndash; 0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eData are expressed as mean (standard deviation, range) or number of hip involvements (%), as appropriate for the data type\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, bold indicates significant between-group differences of variables in the logistic regression\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eCI\u003c/em\u003e confidence interval, \u003cem\u003eMCID\u003c/em\u003e minimum clinically important difference, \u003cem\u003eSE\u003c/em\u003e standard error\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and outcomes stratified by the bone density and muscle status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\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\u003eOsteosarcopenia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSarcopenia alone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoporosis alone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hips, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 \u003cem\u003e(13)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 \u003cem\u003e(32)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 \u003cem\u003e(22)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71 \u003cem\u003e(33)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (5, 65\u0026ndash;90) \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (6, 65\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (5, 65\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72 (7, 65\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 \u003cem\u003e(21)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 \u003cem\u003e(12)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 \u003cem\u003e(19)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 \u003cem\u003e(18)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.580\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 (3, 18\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (3, 18\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (4, 19\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (4, 18\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI\u0026thinsp;\u0026gt;\u0026thinsp;2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 \u003cem\u003e(25)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 \u003cem\u003e(9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 \u003cem\u003e(13)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 \u003cem\u003e(6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral fractures, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 \u003cem\u003e(32)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 \u003cem\u003e(9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 \u003cem\u003e(17)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 \u003cem\u003e(7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-PNI\u0026thinsp;\u0026le;\u0026thinsp;40, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 \u003cem\u003e(25\u003c/em\u003e) \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 \u003cem\u003e(7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 \u003cem\u003e(11)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 \u003cem\u003e(4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up duration, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (5, 24\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (5, 24\u0026ndash;64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (5, 24\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (5, 24\u0026ndash;66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.42 (0.10, 0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.44 (0.11, 0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45 (0.18, 0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42 (0.10, 0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.984\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.49, 0.87) \u003csup\u003ec, d\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72 (0.38, 0.88) \u003csup\u003ec, d\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71 (0.59, 0.87) \u003csup\u003ec, d\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85 (0.51, 0.91) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHOOS-JR \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (45, 56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (44, 57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (49, 51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (46, 53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.783\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (59, 69) \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (81, 89) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81 (75, 87) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85 (80, 91) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-hip pain \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (7, 42\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (7, 55\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73 (8, 51\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71 (7, 45\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (5, 0\u0026ndash;65) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (5, 0\u0026ndash;54) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (5, 0\u0026ndash;35) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (5, 0\u0026ndash;40) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.581\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-low back pain \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (10, 45\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (8, 33\u0026ndash;82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (8, 25\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (7, 20\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (8, 15\u0026ndash;65) \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (7, 0\u0026ndash;52) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (6, 0\u0026ndash;38) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (5, 0\u0026ndash;26) \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchieved MCID, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D\u0026thinsp;\u0026gt;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 \u003cem\u003e(46)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 \u003cem\u003e(63)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 \u003cem\u003e(57)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 \u003cem\u003e(70)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHOOS-JR\u0026thinsp;\u0026gt;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 \u003cem\u003e(39)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 \u003cem\u003e(79)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 \u003cem\u003e(66)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 \u003cem\u003e(82)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-hip pain\u0026thinsp;\u0026gt;\u0026thinsp;18.6 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 \u003cem\u003e(92)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 \u003cem\u003e(91)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 \u003cem\u003e(95)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69 \u003cem\u003e(97)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-low back pain\u0026thinsp;\u0026gt;\u0026thinsp;20 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 \u003cem\u003e(54)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 \u003cem\u003e(75)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 \u003cem\u003e(77)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59 \u003cem\u003e(83)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient satisfaction, n (%) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 \u003cem\u003e(54)\u003c/em\u003e \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 \u003cem\u003e(82)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 \u003cem\u003e(79)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63 \u003cem\u003e(89)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eData are expressed as mean (standard deviation, range) for normally distributed variables and the median value (interquartile range) for non-normally distributed variables or the number of hip involvements (%), as appropriate for the data type\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, bold indicates significant between-group differences\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eCCI\u003c/em\u003e Charlson Comorbidity Index, \u003cem\u003eEQ-5D\u003c/em\u003e EuroQol 5-Dimension 3-Level scale, \u003cem\u003eHOOS-JR\u003c/em\u003e Hip Disability and Osteoarthritis Outcome Score Joint Replacement, \u003cem\u003eMCID\u003c/em\u003e minimum clinically important difference, \u003cem\u003eO-PNI\u003c/em\u003e Onodera\u0026rsquo;s prognostic nutritional index\u0026thinsp;=\u0026thinsp;10 \u0026times; serum albumin (g/dL)\u0026thinsp;+\u0026thinsp;0.005 \u0026times; total lymphocyte count (/mm\u003csup\u003e3\u003c/sup\u003e), \u003cem\u003eVAS\u003c/em\u003e visual analogue scale\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Between-group comparisons of outcomes pre-operatively (upper row) and at the last follow-up (lower row)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Count (%) of patients who answered satisfied or very satisfied, graded on a 5-point scale\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 versus the normal group with respect to the corresponding variable\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ed\u003c/sup\u003e \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 versus a pre-operative variable in the corresponding group\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePropensity Score-Matched Comparison and Relationship Between the Baseline Variables and Outcomes\u003c/h2\u003e \u003cp\u003eAfter successfully matching patients who did (n\u0026thinsp;=\u0026thinsp;25) and did not (n\u0026thinsp;=\u0026thinsp;50) have osteosarcopenia, the standardised differences were \u0026lt;\u0026thinsp;0.10 for all the covariates. Significant differences were observed in the O-PNI (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008), MCID (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029 for EQ-5D, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for HOOS-JR, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for low back pain), and patient satisfaction (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In both cohorts, preoperative PMI and nutritional status demonstrated a positive correlation with the HOOS-JR at the final follow-up (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These two baseline variables exhibited an inverse relationship with the VAS-low back pain (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePropensity score-matched comparison of variables between individuals who did and did not have osteosarcopenia\u003c/p\u003e \u003c/div\u003e \u003c/caption\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\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePropensity Score-Matched\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOsteosarcopenia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-osteosarcopenia\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hips (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 \u003cem\u003e(33)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 \u003cem\u003e(67)\u003c/em\u003e\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\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (5, 65\u0026ndash;90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (6, 65\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.829 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 \u003cem\u003e(20)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 \u003cem\u003e(18)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.834 \u003csup\u003ea\u003c/sup\u003e\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 (3, 18\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (3, 20\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.983 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI\u0026thinsp;\u0026gt;\u0026thinsp;2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 \u003cem\u003e(24)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 \u003cem\u003e(8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral fractures, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 \u003cem\u003e(32)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 \u003cem\u003e(8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-PNI\u0026thinsp;\u0026le;\u0026thinsp;40, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 \u003cem\u003e(24)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 \u003cem\u003e(4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchieved MCID, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\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\u003eEQ-5D\u0026thinsp;\u0026gt;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 \u003cem\u003e(44)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 \u003cem\u003e(70)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHOOS-JR\u0026thinsp;\u0026gt;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 \u003cem\u003e(40)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 \u003cem\u003e(82)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-hip pain\u0026thinsp;\u0026gt;\u0026thinsp;18.6 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 \u003cem\u003e(96)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 \u003cem\u003e(94)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS-low back pain\u0026thinsp;\u0026gt;\u0026thinsp;20 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 \u003cem\u003e(52)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 \u003cem\u003e(90)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient satisfaction, n (%) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 \u003cem\u003e(56)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 \u003cem\u003e(90)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are expressed as mean (standard deviation, range) or number of hip involvements (%), as appropriate for the data type\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, bold indicates significant between-group differences\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eCCI\u003c/em\u003e Charlson Comorbidity Index, \u003cem\u003eEQ-5D\u003c/em\u003e EuroQol 5-Dimension 3-Level scale, \u003cem\u003eHOOS-JR\u003c/em\u003e Hip Disability and Osteoarthritis Outcome Score Joint Replacement, \u003cem\u003eMCID\u003c/em\u003e minimum clinically important difference, \u003cem\u003eO-PNI\u003c/em\u003e Onodera\u0026rsquo;s prognostic nutritional index\u0026thinsp;=\u0026thinsp;10 \u0026times; serum albumin (g/dL)\u0026thinsp;+\u0026thinsp;0.005 \u0026times; total lymphocyte count (/mm\u003csup\u003e3\u003c/sup\u003e), \u003cem\u003eVAS\u003c/em\u003e visual analogue scale\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e denotes a standard mean difference\u0026thinsp;\u0026lt;\u0026thinsp;0.10\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e count (%) of patients who answered satisfied or very satisfied, graded on a 5-point scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides important insights into the prognostic role of osteosarcopenia in patients undergoing THA. By employing validated imaging-based criteria, we established reproducible thresholds for diagnosing sarcopenia and osteoporosis, facilitating a comprehensive understanding of how combined bone and muscle deficiencies affect postoperative recovery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. To our knowledge, this is among the first studies to evaluate the impact of osteosarcopenia on clinically meaningful improvements in THA outcomes using a matched geriatric cohort. This study builds upon prior work by integrating validated geriatric metrics and employing propensity score matching to isolate the effect of osteosarcopenia [\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSubgroup analysis excluding patients with major complications, such as fractures, dislocations, and infections, confirmed that osteosarcopenia remained significantly associated with inferior postoperative outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This suggests that its prognostic value extends beyond complications typically linked to frailty. Although prior research has emphasised the increased risk of falls and fractures in individuals with osteosarcopenia, our results indicate that the condition independently contributes to suboptimal functional recovery\u0026mdash;even in the absence of such events [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These findings underscore the importance of early detection and proactive intervention targeting both bone and muscle health [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA notable strength of our study is the application of propensity score matching, which helped mitigate selection bias inherent to retrospective designs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Furthermore, we observed a significant correlation between the PMI and the nutritional status, indicating that O-PNI could serve as a practical surrogate marker for sarcopenia, especially in clinical settings where CT-based muscle assessment is not feasible [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The high inter- and intra-observer reliability of PMI measurements further reinforces the robustness of this imaging biomarker in orthopaedic practice. Our 4-group stratification allowed us to distinguish isolated sarcopenia/osteoporosis from combined burden, enhancing clinical relevance. Although PMI and O-PNI correlated with outcomes, causality cannot be inferred from observational data.\u003c/p\u003e \u003cp\u003eDespite its strengths, this study has several limitations. First, the sample size was relatively small and limited to Asian patients, which may affect the generalizability of findings to other populations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Second, the retrospective single-center design introduces the potential for selection bias and unmeasured confounders, such as physical activity or social determinants of health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. While we adopted imaging-based definitions of osteosarcopenia using validated thresholds, we were unable to incorporate muscle strength or physical performance measures recommended by European Working Group on Sarcopenia in Older People criteria. This limits the diagnostic comprehensiveness, and future prospective studies should adopt the full criteria to improve diagnostic precision. Third, patients with periprosthetic complications (e.g., fracture, dislocation, infection) were excluded; thus, the relationship between osteosarcopenia and these outcomes remains unexamined (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Fourth, our assessment of muscle quality was limited to static cross-sectional imaging. We did not evaluate functional dynamics such as posture-related changes or spinal canal stenosis, which may influence low back pain and mobility, especially in osteoporotic individuals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Fifth, although we adjusted the psoas muscle area for height, other body composition metrics such as body mass index and adipose tissue infiltration were not analyzed. These could further clarify the clinical implications of muscle quality. Finally, while we applied propensity score matching and confirmed the consistency of results through sensitivity analyses, residual confounding cannot be entirely excluded due to the retrospective nature of the study.\u003c/p\u003e \u003cp\u003eFrom a clinical and geriatric care perspective, our findings highlight the need for early identification and risk stratification of osteosarcopenia in older adults undergoing THA. Laboratory-based indices such as the O-PNI may offer a pragmatic, cost-effective adjunct to sarcopenia screening, particularly where advanced imaging is not feasible. While our findings support its potential as a surrogate marker due to its correlation with PMI, O-PNI reflects systemic nutritional and inflammatory status rather than musculoskeletal anatomy. Thus, its interpretive limitations must be acknowledged. Ultrasonography has also gained attention as a scalable, non-invasive alternative to CT-based assessments for estimating muscle quantity and quality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Its portability, repeatability, and low burden on patients make it especially valuable in frail or community-dwelling populations. Incorporating such screening tools\u0026mdash;whether laboratory- or imaging-based\u0026mdash;into preoperative assessments may enhance personalized perioperative planning and improve surgical outcomes. These strategies align with geriatric care priorities focused on promoting mobility, independence, and functional recovery in aging surgical patients. Further research is warranted to validate these approaches across care settings and integrate them into standardized protocols for osteosarcopenia risk assessment. As the global burden of musculoskeletal aging rises, such integrative risk models incorporating sarcopenia, osteoporosis, and nutrition status may serve as critical components of precision geriatric surgery. These findings may inform future screening protocols and perioperative risk stratification guidelines for aging populations undergoing joint replacement.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the significant impact of osteosarcopenia on THA outcomes, emphasising the importance of comprehensive preoperative assessment and tailored management strategies. By integrating validated imaging metrics and alternative tools such as O-PNI into clinical practice, clinicians can enhance preoperative risk stratification and optimise perioperative care. These efforts are particularly crucial in managing aging populations with increasing prevalence of osteosarcopenia to improve surgical outcomes, recovery, and patient satisfaction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Hip Joint Foundation of Japan and the Grants-in-Aid for Scientific Research of Japan Society KAKENHI for the Promotion of Science, Grant Number 21K09239.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate declarations: The methods used in this study were approved by our institutional ethics review board (No. 2020-098-2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided informed consent for the use of their clinical data for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and/or Materials availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYO: Conceptualization, Data curation, Funding acquisition, Writing – original draft, Writing – review \u0026amp; editing. HW: Data curation, Investigation. TS: Conceptualization, Data curation, Investigation. KT: Formal Analysis, Methodology, Investigation. SO: Validation, Supervision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S (2018) Hip replacement. Lancet 392:1662\u0026ndash;1671. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0140-6736(18)31777-x\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(18)31777-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLalani A, Lee YY, Pitta M, Westrich GH, Lyman S (2019) Age-Related Decline in Patient-Reported Outcomes 2 and 5 Years Following Total Hip Arthroplasty. 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J Cachexia Sarcopenia Muscle 13:169\u0026ndash;179. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jcsm.12862\u003c/span\u003e\u003cspan address=\"10.1002/jcsm.12862\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"osteoporosis, osteosarcopenia, patient-reported outcomes, sarcopenia, total hip arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-6532044/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6532044/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground: \u003c/strong\u003e\u003c/em\u003eTotal hip arthroplasty (THA) is an effective surgical option for older adults (aged ≥65 years) with advanced hip osteoarthritis. However, functional recovery and patient satisfaction remain variable despite technical success. Osteosarcopenia—the coexistence of osteoporosis and sarcopenia—reportedly contributes to suboptimal postoperative outcomes due to its association with frailty, falls, and impaired physical function.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAims:\u003c/strong\u003e\u003c/em\u003eTo investigate whether osteosarcopenia independently predicts poorer patient-reported outcomes in older adults undergoing elective THA.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eWe retrospectively analysed 214 patients (mean age: 73.8 ± 6.8 years) who underwent unilateral primary THA, with a mean follow-up of 42 (range 24–66) months. Osteoporosis was defined by lumbar spine T-score \u0026lt;−2.5. Sarcopenia was assessed using psoas muscle index (PMI), a validated measure correlating with EWGSOP2 criteria. Patients were categorised into four groups: osteosarcopenia (13%), sarcopenia-only (32%), osteoporosis-only (22%), and normal (33%). The primary outcome was achieving the minimum clinically important difference (MCID), defined as the smallest change in score that patients perceive as beneficial, using the Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR). Propensity score matching compared osteosarcopenia (n = 25) and control (n = 50) groups, adjusting for age, sex, body mass index, and comorbidities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/em\u003eOsteoporosis and sarcopenia reduced likelihood of achieving MCID (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.60–0.83 and OR 0.79, 95%CI 0.64–0.97, respectively; both \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). Patients with osteosarcopenia had significantly lower HOOS-JR (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), EuroQol-5D (\u003cem\u003eP\u003c/em\u003e = 0.029) and satisfaction levels (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) than controls. Preoperative PMI and nutritional status were correlated with final outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003e\u003c/em\u003eOsteosarcopenia independently predicts inferior functional outcomes after THA in older adults. Preoperative screening for this geriatric syndrome should be incorporated into assessment protocols, as it may help guide personalised perioperative interventions, including nutritional support and adapted rehabilitation, thus enhancing recovery.\u003c/p\u003e","manuscriptTitle":"Osteosarcopenia as a predictor of inferior patient-reported outcomes following total hip arthroplasty in older adults: a propensity score-matched analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 10:00:01","doi":"10.21203/rs.3.rs-6532044/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"abb0eb1b-6023-48e8-9dce-1cb06313ee72","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T10:23:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 10:00:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6532044","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6532044","identity":"rs-6532044","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}