Comparative effectiveness of bone grafting vs. total hip arthroplasty in non-traumatic osteonecrosis of femoral head: a 5-year follow-up study with patient-reported outcomes

To compare mid-term survival and health-related quality of life differences between bone grafting (BG) and total hip arthroplasty (THA) in non-traumatic osteonecrosis of the femoral head (NTONFH) patients under 50 years of age. This single-center retrospective study analyzed 165 consecutive NTONFH patients (2015–2020) undergoing BG (n = 55) or THA (n = 110). Primary outcomes were 5-year survival (revision endpoint), with secondary outcomes including Harris Hip Score, complications, and patient-reported measures (SF-36, JHEQ, UCLA). Survival analysis employed log-rank tests and Cox proportional hazards model. The THA group exhibited significantly higher 5-year survival rates than the BG group (95.5% vs. 81.8%, p = 0.003). The THA group demonstrated superior postoperative HHS total scores (91.3 ± 3.2 vs. 82.1 ± 6.7, p < 0.001), pain scores (42.8 ± 1.6 vs. 40.1 ± 3.2, p < 0.001), and physical activity levels (UCLA: 7.2 ± 1.5 vs. 6.5 ± 1.8, p = 0.018). However, the BG group outperformed in mental health domains: SF-36 mental component score (65.8 ± 13.2 vs. 58.4 ± 14.7, p = 0.021) and JHEQ mental score (24.3 ± 4.9 vs. 20.7 ± 5.6, p = 0.004). Subgroup analysis revealed comparable survival rates between BG and THA in ARCO IIIA-stage patients (87.2% vs. 94.6%, p = 0.672), while BG failure rates reached 44.4% in JIC C2-type patients. THA offers advantages in functional recovery and survival rates, but rigorously selected ARCO IIIA-stage patients undergoing BG achieve comparable survival outcomes to THA while exhibiting superior mental health benefits. BG is recommended for ARCO II-IIIA/JIC A-C1-type patients to preserve joint function and enhance psychosocial adaptation, whereas THA remains the optimal choice for advanced-stage (IIIB/IV) or JIC C2-type patients to ensure rapid functional restoration. This study provides evidence for personalized treatment strategies based on disease staging, anatomical severity, and patient psychological needs.