Surgical Treatment of Patients With Dual Hip and Spinal Degenerative Disease

Abstract

Study Design. Retrospective study. Objective. To determine how lumbar spinal fusion-total hip arthroplasty (LSF-THA) operative sequence would affect THA outcomes. Summary of Background Data. Outcomes following THA in patients with a history of lumbar spinal degenerative disease and fusion are incompletely understood. Methods. The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary THA. Patients were divided into four cohorts: 1) Primary THA without spine pathology, 2) remote LSF prior to hip pathology and THA, and patients with concurrent hip and spinal pathology that had 3) THA following LSF, and 4) THA prior to LSF. Postoperative complications and opioid use were assessed with multivariable logistic regression to determine the effect of spinal degenerative disease and operative sequence. Results. Between 2007 and 2017, 85,595 patients underwent primary THA, of whom 93.6% had THA without lumbar spine degenerative disease, 0.7% had a history of remote LSF, and those with concurrent hip and spine pathology, 1.6% had THA prior to LSF, and 2.4% had THA following LSF. Patients with hip and lumbar spine pathology who underwent THA prior to LSF had significantly higher rates of dislocation (aOR = 2.46, P < 0.0001), infection (aOR = 2.65, P < 0.0001), revision surgery (aOR = 1.91, P < 0.0001), and postoperative opioid use at 1 month (aOR: 1.63, P < 0.001), 3 months (aOR = 1.80, P < 0.001), 6 months (aOR: 2.69, P < 0.001), and 12 months (aOR = 3.28, P < 0.001) compared with those treated with THA following LSF. Conclusion. Patients with degenerative hip and lumbar spine pathology who undergo THA prior to LSF have a significantly increased risk of postoperative dislocation, infection, revision surgery, and prolonged opioid use compared with THA after LSF. Surgeons should consider the surgical sequence of THA and LSF on outcomes for patients with this dual pathology. Shared decision making between patients, spine surgeons, and arthroplasty surgeons is necessary to optimize outcomes in patients with concomitant hip and spine pathology. Level of Evidence: 3

Stability in Direct Lateral vs Direct Anterior Total Hip Arthroplasty in the Context of Lumbar Spinal Fusion

“…The group evaluated 23,584 patients (13,102 THA after LSF; 10,482 THA before LSF) and found that patients who received the THA after LSF demonstrated a greater rate of prosthetic dislocations at 90 days (2.8% versus 0.2%) and 2 years (4.6% versus 1.7). 40 By contrast, Yang et al 41 retrospectively reviewed a national database (PearlDiver Patient Records Database) and compared perioperative outcomes in a group of 3,372 patients (2,016 THA after LSF; 1,356 THA before LSF) and uncovered a greater odds of sustaining a post-THA dislocation in patients who received the THA before the LSF (odds ratio = 2.46 [1.90 to 3.12] versus 1.29 [0.99 to 1.65]). The aforementioned set of conflicting studies demonstrate the lack of clear understanding surrounding the topic of surgical timing and post-THA dislocations in patients who require surgical intervention to address simultaneous hip and lumbar spine pathology; thus, additional analysis is warranted.…”

The Hip-Spine Challenge

“…These patients also have decreased satisfaction, less improvement with respect to overall pain, and worse quality-of-life measures than those without previous LSF 43,44 . While multiple authors have demonstrated that LSF is a significant risk factor for postoperative dislocation, recent literature has shown that patients with a history of LSF >2 years before the THA had no increase in dislocations or 30-day complications, but there was a significant increase in the THA revision rate 5,6,[45][46][47] . Therefore, a discussion with the patient regarding expectations, increased risk of complications, timing of surgery, and pain management strategies should occur preoperatively.…”

“…Patients with a history of LSF after THA have been shown to have less improvement in back pain and increased rates of postoperative complications, but no significant alteration in patient-related outcome measures (PROMs), satisfaction, or disability index compared with those without THA 67,68 . These patients also have increased rates of periprosthetic joint infection, revision, and opiate use 45 . This may argue for spinal intervention prior to THA.…”

What’s New in Hip Replacement

“…Lumbar Spinal Fusion or THA First Yang et al screened 85,595 patients who underwent THA and identified 1,356 patients who underwent THA before lumbar spinal fusion and 2,016 patients who underwent THA after spinal fusion 31 . The authors found that the patients who underwent THA first had an increased dislocation risk, higher rate of periprosthetic joint infection, surgical site complications, revision, and postoperative opioid use compared with those who underwent THA after lumbar spinal fusion.…”