The Effect of Changes in Defecation Posture on Health-Related Quality of Life Among Elderly Habitual Squat-Toilet Users After Total Hip Arthroplasty for Femoral Neck Fracture

Background: Elderly patients undergoing total hip arthroplasty (THA) for femoral neck fractures are commonly restricted from squatting postoperatively. In regions where squat toilets are widely used, older adults who are accustomed to squatting may be forced to transition to a sitting defecation posture, which can affect daily functioning and health-related quality of life (HRQoL), yet this culturally specific clinical issue remains insufficiently studied. Methods: A total of 152 elderly patients with displaced intracapsular femoral neck fractures underwent primary cementless THA between January 2023 and July 2024. Defecation posture was evaluated using the 10-item Toilet Posture Score (TPS) preoperatively and at 1, 3, and 6 months after surgery. HRQoL was assessed with the EQ-5D-5L and EQ-VAS. Changes in TPS were examined across time points using repeated-measures ANOVA. Multivariable linear regression models were constructed to determine whether 6-month TPS improvement predicted 6-month HRQoL gains after adjustment for age, sex, body mass index, and Charlson Comorbidity Index. Results: The mean age was 77.82 ± 7.11 years, and 72.4% were women. TPS decreased from 16.02 ± 2.37 preoperatively to 15.38 ± 2.61 at 1 month (P = 0.004), and further improved to 12.68 ± 2.49 and 11.22 ± 2.70 at 3 and 6 months (both P < 0.001). EQ-5D-5L increased from 0.61 ± 0.15 preoperatively to 0.82 ± 0.13 at 6 months (P < 0.001), and EQ-VAS increased from 55.10 ± 11.90 to 78.38 ± 12.31 (P < 0.001). Greater improvement in defecation posture independently predicted larger improvements in both EQ-5D-5L (B = -0.037; 95% CI -0.043 to -0.032; P < 0.001) and EQ-VAS (B = -1.319; 95% CI -1.386 to -1.252; P < 0.001) change scores at 6 months. Constipation requiring medical advice occurred in 36 patients (23.7%). Conclusion: Elderly patients who are accustomed to squatting experience considerable restrictions in defecation posture after THA. The degree of postural improvement independently predicts HRQoL gains assessed by both EQ-5D-5L and EQ-VAS. Post-THA rehabilitation should include targeted toileting education and gradual posture retraining to facilitate a safe transition from squat toilets to sitting toilets while maintaining hip precautions.