Surgical Treatment of Patients With Dual Hip and Spinal Degenerative Disease: Effect of Surgical Sequence of Spinal Fusion and Total Hip Arthroplasty on Postoperative Complications

Hip Osteoarthritis in Patients Undergoing Surgery for Severe Adult Spinal Deformity: Prevalence and Impact on Spine Surgery Outcomes

BACKGROUND

Hip osteoarthritis (OA) is common in patients with adult spinal deformity (ASD). Limited data exist on the prevalence of hip OA in patients with ASD, or on its impact on baseline and postoperative alignment and patient-reported outcome measures (PROMs). Therefore, this paper will assess the prevalence and impact of hip OA on alignment and PROMs.

METHODS

Patients with ASD who underwent L1-pelvis or longer fusions were included. Two independent reviewers graded hip OA with the Kellgren-Lawrence (KL) classification and stratified it by severity into non-severe (KL grade 1 or 2) and severe (KL grade 3 or 4). Radiographic parameters and PROMs were compared among 3 patient groups: Hip-Spine (hip KL grade 3 or 4 bilaterally), Unilateral (UL)-Hip (hip KL grade 3 or 4 unilaterally), or Spine (hip KL grade 1 or 2 bilaterally).

RESULTS

Of 520 patients with ASD who met inclusion criteria for an OA prevalence analysis, 34% (177 of 520) had severe bilateral hip OA and unilateral or bilateral hip arthroplasty had been performed in 8.7% (45 of 520). A subset of 165 patients had all data components and were examined: 68 Hip-Spine, 32 UL-Hip, and 65 Spine. Hip-Spine patients were older (67.9 ± 9.5 years, versus 59.6 ± 10.1 years for Spine and 65.8 ± 7.5 years for UL-Hip; p < 0.001) and had a higher frailty index (4.3 ± 2.6, versus 2.7 ± 2.0 for UL-Hip and 2.9 ± 2.0 for Spine; p < 0.001). At 1 year, the groups had similar lumbar lordosis, yet the Hip-Spine patients had a worse sagittal vertebral axis (SVA) measurement (45.9 ± 45.5 mm, versus 25.1 ± 37.1 mm for UL-Hip and 19.0 ± 39.3 mm for Spine; p = 0.001). Hip-Spine patients also had worse Veterans RAND-12 Physical Component Summary scores at baseline (25.7 ± 9.3, versus 28.7 ± 9.8 for UL-Hip and 31.3 ± 10.5 for Spine; p = 0.005) and 1 year postoperatively (34.5 ± 11.4, versus 40.3 ± 10.4 for UL-Hip and 40.1 ± 10.9 for Spine; p = 0.006).

CONCLUSIONS

This study of operatively treated ASD revealed that 1 in 3 patients had severe hip OA bilaterally. Such patients with severe bilateral hip OA had worse baseline SVA and PROMs that persisted 1 year following ASD surgery, despite correction of lordosis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD).

BACKGROUND

Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD.

PATIENTS AND METHODS

In total, 527 preoperative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full-body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation.

RESULTS

The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, and 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment ( P <0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt ( P =0.001) and sacrofemoral angle ( P <0.001), but increased knee flexion ( P =0.012). Regression analysis revealed that with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis ( r2 =0.812). Hip osteoarthritis decreased compensation through sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100).

CONCLUSIONS

For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.

Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study

BACKGROUND

While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF.

METHODS

A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences.

RESULTS

Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031).

CONCLUSIONS

Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.

Superior outcomes of total hip arthroplasty without prior lumbar arthrodesis: a systematic review and meta-analysis

PURPOSE

The number of patients undergoing total hip arthroplasty (THA) surgery after previous lumbar arthrodesis (LA) is rising. Literature suggests that LA may significantly impact pelvic biomechanics and potentially compromise the success of prosthetic hip replacement. This study aims to evaluate complication rates, dislocation rates, and revision rates in patients with prior LA undergoing THA surgery compared to those undergoing THA surgery without prior LA.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A PICOS template was developed to ensure a structured approach. The search for relevant studies was performed across five databases, including Pubmed, Scopus, Embase, Medline, and Cochrane. The selected articles were evaluated based on the Levels of Evidence (LoE) criteria. The Coleman Methodology Score (mCMS) was employed to analyze the retrospective studies. This systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews (PROSPERO). For the outcomes that allowed for a meta-analysis performed using R software, a p < 0.05 was considered statistically significant.

RESULTS

The final analysis included seventeen studies comprising a total of 3,139,164 cases of THA. Among these cases, 3,081,137 underwent THA surgery alone, while 58,027 patients underwent THA with a previous LA. The study investigated various factors, including dislocation rates, revision rates, and complication, as well as the surgical approach and type of implant used, for both the THA-only group and the group of patients who underwent THA with prior LA. The analysis revealed a statistically significant difference (p < 0.05) for all variables studied, favoring the group of patients who underwent THA alone without prior LA.

CONCLUSIONS

This systematic review and meta-analysis demonstrated a statistically significant superiority in all analyzed outcomes for patients who underwent THA-only without prior LA. Specifically, patients with isolated THA implants experienced significantly lower incidences of THA dislocation, wound complications, periprosthetic joint infection, revision, and mechanical complications.

LEVEL OF EVIDENCE

Level IV.

Change of Symptoms after Total Hip Arthroplasty in Patients with Hip-Spine Syndrome

Purpose

Elderly patients with degenerative diseases undergo treatment for the hip and spine; these patients present with various symptoms. This study focused on patients with residual symptoms, predominantly pain, even after receiving treatment for their spinal lesions.

Materials and Methods

Patients who underwent total hip arthroplasty (THA) between 2016 and 2022 at a single tertiary hospital were included in the study. Of the 417 patients who underwent primary THA, a retrospective review of 40 patients with previous lesions of the spine was conducted. Patients were stratified to two cohorts: Patients with symptoms related to the spine (Group A), and those with hip-related symptoms (Group B). Pre- and postoperative comparisons of groups A and B were performed.

Results

Improvements in patients' symptoms were observed in groups A and B after THA. In Group A, the mean preoperative visual analog scale (VAS) score was 5.10±0.876, which showed a postoperative decrease to 2.70±1.767. In Group B, the mean preoperative VAS score was 5.10±1.539, which showed a postoperative decrease to 2.67±1.493.

Conclusion

According to the findings, promising results were achieved with THA in treatment of debilitating diseases of the hip for both the prognosis of the disease, as well as the patients' symptoms. In addition, in some cases elderly patients with dual pathologies underwent treatment for spinal lesions without performance of any evaluation related to the hip. Thus, evaluation of a patient's hip must be performed and performance of THA in patients with symptoms even after treatment of spinal lesions is recommended.

Direct anterior approach associated with lower dislocation risk after primary total hip arthroplasty in patients with prior lumbar spine fusion

BACKGROUND

While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population.

METHODS

A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis.

RESULTS

In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach (n = 76), and 34.3% underwent a posterior approach (n = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3-30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p = 0.036) and posterior groups (6.9%, p = 0.026).

CONCLUSIONS

The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF.

Patients Who Have Had Three or More Levels Fused During Lumbar Spinal Fusion Have Worse Functional Outcomes After Total Hip Arthroplasty

BACKGROUND

Lumbar spinal fusion (LSF) and total hip arthroplasty (THA) are commonly performed in patients who have concomitant spine and hip pathology. While patients who have three or more levels fused during LSF have increased postoperative opioid consumption after undergoing THA, it is unknown whether the number of levels fused during LSF affects THA functional outcomes.

METHODS

A retrospective study was conducted at a tertiary academic center for patients who underwent LSF first and then had a primary THA performed with a minimum of one-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR). Operative notes were reviewed to determine the number of levels fused during LSF. There were 105 patients who underwent one-level LSF, 55 patients underwent two-level LSF, and 48 patients underwent three-or-more-level LSF. No significant differences existed in age, race, body mass index, and comorbidities between the cohorts.

RESULTS

While preoperative HOOS-JR was similar among the three cohorts, patients who had three-or-more-level LSF had significantly lower HOOS-JR scores than patients who had two-level or one-level LSF (71.4 versus 82.4 versus 78.2; P = .010) and a lower delta HOOS-JR (27.2 versus 39.4 versus 35.9; P = .014). Patients who had three-or-more-level LSF had a significantly lower rate of achieving minimal clinically important difference (61.7% versus 87.2% versus 78.7%; P = .011) and the patient acceptable symptom state (37.5% versus 69.1% versus 59.0%; P = .004) for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively.

CONCLUSIONS

Surgeons should counsel patients who have had three-or-more-level LSF that they may have a lower rate of hip function improvement and symptom acceptability after THA, compared to patients who have had a less number of levels fused during LSF.

Spine or Hip First? Outcomes in Patients Undergoing Sequential Lumbar Spine or Hip surgery

INTRODUCTION

Lumbar spine pathology frequently coexists in patients who have hip arthrosis. There is controversy on whether lumbar or hip pathology should be first addressed. The purpose of this study was to evaluate the outcomes of sequential lumbar spine (LSP) or hip arthroplasty (THA).

METHODS

Using a large national database from 2010 to 2020, we reviewed the records of 241,279 patients who had concurrent hip arthritis and lumbar spine disease defined as spinal stenosis, lumbar radiculopathy, or degenerative disc disease. During the study period, 6,458 (2.7%) patients with concurrent hip/spine disease underwent sequential operative treatment of either the hip joint or lumbar spine within 2 years. The rates of subsequent surgery in either the hip or spine, opioid requirements, and rates of hip dislocation were determined and analyzed using compared Chi-squared analyses.

RESULTS

Patients undergoing THA first had lower risk of subsequent spinal procedure compared to patients who had spinal procedures first (5.7 vs. 23.7 %, P < 0.001). This disparity was maintained up to 5 years (P<0.001). Opioid requirements at 1 year were highest in patients who underwent spinal procedures only (836 pills/patient) compared to any other group (THA only (566 pills/patient), LSP and then THA (564 pills/patient), THA and LSP (586 pills/patient). Also, THA following LSP was associated with significantly higher rates of dislocation compared to patients undergoing THA first (3.2 versus 1.9%, P<0.001).

SUMMARY

Total hip arthroplasty first in patients who have concurrent spine disease was associated with lower risk of subsequent surgery, opioid requirement, and risk of postoperative instability compared to patients having lumbar procedure first.

Risk of Dislocation and Revision Following Primary Total Hip Arthroplasty in Patients With Prior Lumbar Fusion With Spinopelvic Fixation

BACKGROUND

The effect of spinopelvic fixation in addition to lumbar spinal fusion (LSF) on dislocation/instability and revision in patients undergoing primary total hip arthroplasty (THA) has not been reported previously.

METHODS

The PearlDiver Research Program was used to identify patients aged 30 and above undergoing primary THA who received (1) THA only, (2) THA with prior single-level LSF, (3) THA with prior 2-5 level LSF, or (4) THA with prior LSF with spinopelvic fixation. The incidence of THA revision and dislocation/instability was compared through logistic regression and Chi-squared analysis. All regressions were controlled for age, gender, and Elixhauser Comorbidity Index (ECI).

RESULTS

Between 2010 and 2018, 465,558 patients without history of LSF undergoing THA were examined and compared to 180 THA patients with prior spinopelvic fixation, 5,299 with prior single-level LSF, and 1,465 with prior 2-5 level LSF. At 2 years, 7.8% of THA patients with prior spinopelvic fixation, 4.7% of THA patients with prior 2-5 level LSF, 4.2% of THA patients with prior single-level LSF, and 2.2% of THA patients undergoing only THA had a dislocation event or instability (P < .0001). After controlling for length of fusion, pelvic fixation itself was associated with higher independent risk of revision (at 2 years: 2-5 level LSF + spinopelvic fixation: aHR = 3.15, 95% CI 1.77-5.61, P < .0001 vs 2-5 level LSF with no spinopelvic fixation: aOR = 1.39, 95% CI 1.10-1.76, P < .0001).

CONCLUSION

At 2 years, spinopelvic fixation in THA patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without LSF, and an over 2-fold increase in THA revision risk compared to those with LSF without spinopelvic fixation.

LEVEL OF EVIDENCE

III.

Does fusion length matter? Total hip arthroplasty dislocation after extension of lumbosacral fusion: a case report

CASE

Hip-spine syndrome is a complex challenge for orthopedic surgeons. We present a 60-year-old female with a history of spinal fusion and total hip arthroplasty. The patient underwent extension of the previous fusion with sacropelvic fixation, and 5 months later she presented with left posterior prosthetic hip dislocation which required sedation and closed reduction.

CONCLUSION

Even with no change in lumbar lordosis or pelvic tilt and adequate acetabular cup position, extension of the fusion construct may predispose patients to dislocation. This may be the result of an increased lever arm acting at the hip joint, thereby leading to instability.

Lumbar spinal fusion does not increase early dislocation risk in primary total hip arthroplasty through the direct anterior approach

INTRODUCTION

Patients with total hip arthroplasty (THA) and a concomitant lumbar spinal fusion (LSF) might have an increased incidence of revision surgery and postoperative complications such as early THA dislocation. The direct anterior approach (DAA) has gained popularity in THA due to its soft tissue-preserving nature and the relatively low dislocation risk. The purpose of the present study was to examine whether LSF patients undergoing minimally invasive THA through the DAA might have an increased risk of prosthetic-related complications compared to matched-control patients without a LSF.

MATERIALS AND METHODS

Patients who underwent THA through the DAA in our institution from January 2014 to December 2018 were identified. A total of 30 primary THA also underwent LSF within 3 months from the initial operation. These patients were randomly matched (1:3) for sex, age, and body mass index with patients who underwent primary THA in our institution without a history of LSF (control group). Peri and postoperative complications, revisions, radiographic and clinical outcomes were assessed retrospectively.

RESULTS

LSF patients who underwent THA through the DAA did not have an increased risk of prosthetic-related complications compared to matched-control subjects without a LSF (6.6% versus 4.4%, P < 0.05). The functional and radiological outcomes were similar between groups.

CONCLUSION

LSF patients undergoing THA could benefit from the DAA similarly to patients without LSF and without increased rate of early THA dislocation. Although the complex interplay between the lumbar spine and hip in THA patients warrants further investigation, the outcomes of THA through the DAA in LSF patients appear promising.

LEVEL OF EVIDENCE

Retrospective case-control study, III.

Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis

Background

Ankylosing spondylitis (AS) and spinal fusion (SF) classified as stiff spines have been associated with the increased rate of complications following total hip arthroplasty (THA). However, the differences between the two cohorts have inconsistent evidence.

Methods

We searched for studies comparing complications among stiff spine patients, including SF and AS, who underwent THA in PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus until March 2021. Studies detailing rates of mechanical complications, aseptic loosening, dislocation, infection, and revisions were included. We performed network meta-analyses using frequentist random-effects models to compare differences between cohorts. We used P-score to rank the better exposure with the lowest complications.

Results

Fourteen studies were included in the final analysis. A total of 740,042 patients were included in the systematic review and network meta-analysis. Mechanical complications were highest among SF patients (OR 2.33, 95% CI 1.86, 2.92, p < 0.05), followed by AS patients (OR 1.18, 95% CI 0.87, 1.61, p = 0.82) compared to controls. Long Spinal Fusions had the highest aseptic loosening (OR 2.33, 95% CI 1.83, 2.95, p < 0.05), dislocations (OR 3.25, 95% CI 2.58, 4.10, p < 0.05), infections (OR 2.14, 95% CI 1.73, 2.65, p < 0.05), and revisions (OR 5.25, 95% CI 2.23, 12.32, p < 0.05) compared to AS and controls. Our results suggested that SF with longer constructs may be associated with higher complications in THA patients.

Conclusions

THAs following SFs have higher mechanical complications, aseptic loosening, dislocations, and infections, especially with longer constructs. AS patients may have fewer complications compared to this cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03237-8.

The effect of lumbar spinal fusion on native acetabular anteinclination in standing position

PURPOSE

The complex and dynamic spinopelvic interplay is not well understood. The aims of the present study were to investigate the following: (1) whether native acetabular anteinclination (AI) in standing position changes following lumbar spinal fusion (LSF); (2) potential correlations between AI change (ΔAI) and several spinopelvic parameters such as the change in lumbar lordosis (ΔLL), pelvic tilt (ΔPT), and anterior pelvic plane angle (ΔaPP).

METHODS

A total of 485 patients (Males: 262, Females: 223) with an average age of 64 ± 13 years who underwent a primary LSF were identified from our institutional database. The difference (Δ) between pre-and postoperative acetabular anteinclination (AI), lumbar lordosis (LL), anterior pelvic plane angle (aPP), sacral slope (SS), and pelvic tilt (PT) were measured on a standing lateral radiograph (EOS®) and compared to find the effect of LSF on the lumbopelvic geometry.

RESULTS

Following LSF, the average absolute ΔAI was 5.4 ± 4 (0 to 26)°, ΔLL: 5.5 ± 4 (0 to 27)°, ΔaPP: 5.4 ± 4 (0 to 38)°, ΔPT: 7 ± 5 (0 to 33)° and ΔSS: 5.3 ± 4 (0 to 33)°. No significant differences were observed between LSF levels. A ΔAI ≥ 10° was observed in 66 (13.6%) and ΔAI ≥ 20° in 5 (1%) patients. The Pearson correlation demonstrated a strong negative correlation of ΔAI with ΔLL (r = 0.72, p < .001).

CONCLUSION

Clinical decision-making should consider the relationship between native anteinclination and lumbar lordosis to reduce the risk of functional acetabular component malalignment in patients with concomitant hip and spine pathology.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

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

INTRODUCTION

Lumbar spinal fusion (LSF) may increase the risk of dislocation in patients who have undergone total hip arthroplasty (THA), especially when the LSF was done before the THA. Most publications evaluated patients who had undergone THA using a posterior approach to the hip, yet there are little data on the influence of other surgical approaches. The goal of this study was to evaluate the risk of THA dislocation with anterior supine-based surgical approaches to the hip in patients who have undergone surgical management of concurrent hip and spine pathology.

METHODS

Patients older than 18 years who underwent an LSF and THA using a supine approach-either direct anterior (DA) or direct lateral (DL)-between 2000 and 2018 were identified. Only standard bearings (28-32-36-40 mm) were used. The dislocation rate was determined in this cohort. A subsequent analysis was conducted, stratifying patients based on the order in which they received the LSF or THA.

RESULTS

A total of 582 surgical hip-spine patients were retrospectively identified and included in the cohort. Of total, 332 patients (57.0%) received an LSF before the THA; 250 (43.0%) had the fusion after a primary hip replacement. There were 143 patients (24.6%) in the DA group and 439 (75.4%) in the DL group. Overall, there were five dislocations (0.9%) in the entire cohort.

CONCLUSIONS

In patients with simultaneous degenerative hip and lumbar spine pathology, anterior supine-based approaches demonstrate a low (<1%) risk of instability. Given the small number of total dislocation events (n = 5), additional analysis is warranted to assess the effect of different anterior approaches (DA versus DL) or timing of lumbar spinal surgery (before or after THA).

LEVEL OF EVIDENCE

Level III.

Lower Extremity Osteoarthritis: A Risk Factor for Mental Health Disorders, Prolonged Opioid Use, and Increased Resource Utilization After Single-Level Lumbar Spinal Fusion

INTRODUCTION

Few studies have examined the effect of hip or knee osteoarthritis, together described as lower extremity osteoarthritis (LEOA) on patient outcomes after lumbar fusion. The purpose of this study was to evaluate the effect of LEOA on postoperative outcomes and resource utilization in patients undergoing single-level lumbar fusion.

METHODS

Using a national deidentified database, TriNetX, a retrospective observational study of 17,289 patients undergoing single-level lumbar fusion with or without a history of LEOA before September 1, 2019, was conducted. The no-LEOA and LEOA groups were propensity score matched, and 2-year outcomes were compared using univariate statistical analysis.

RESULTS

After propensity score matching, 2289 patients with no differences in demographics or comorbidities remained in each group. No differences in the rate of repeat lumbar surgery were observed between groups (all P > 0.30). In comparison with patients with no LEOA, patients with LEOA experienced higher rates of overall and new onset depression or anxiety, prolonged opioid use, hospitalizations, emergency department visits, and ambulatory visits over the 2-year postoperative period (all P < 0.02).

CONCLUSION

Patients with LEOA undergoing single-level lumbar fusion surgery are at higher risk for suboptimal outcomes and increased resource utilization postoperatively. This complex population may benefit from additional individualized education and multidisciplinary management.

Timing of Total Hip Arthroplasty Affects Lumbar Spinal Fusion Outcomes

STUDY DESIGN

This is a retrospective cohort study of consecutive patients undergoing lumbar spinal fusion (LSF) within the PearlDiver Humana research database from 2010 to 2018.

OBJECTIVE

The aim of this study was to determine if timing of total hip arthroplasty (THA) affects LSF outcomes.

SUMMARY OF BACKGROUND DATA

In patients with both spine and hip pathology, outcomes of THA have been shown to be affected by the timing of THA relative to LSF. However, few studies have assessed postoperative outcomes following LSF in this clinical scenario.

MATERIALS AND METHODS

A national database was queried for patients undergoing lumbar fusion and divided into 4 groups: (1) those who underwent LSF without THA (No THA); (2) those who underwent THA at least 2 years before LSF (>2 Prior THA); (3) those who underwent THA in the 2 years before LSF (0-2 Prior THA); and (4) those who underwent THA after LSF (THA After). We assessed lumbar-specific outcomes, including pseudarthrosis, revision, mechanical failure, and adjacent segment disease (ASD); as well as systemic complications. Controlling for age, sex, and Charlson comorbidity index, complication rates between all groups were assessed using univariate and multivariate logistic regression analysis. Post hoc comparisons were performed using the Fisher exact test with Bonferroni correction to account for multiple pairwise comparisons, resulting in an adjusted threshold for statistical significance of P<0.007.

RESULTS

When compared with the no THA group, those in the THA After group had a higher rate of ASD on multivariate analysis [adjusted odds ratio: 1.53, 95% confidence interval: 1.20-1.94, P<0.001]. When compared with all patients who underwent THA before LSF, patients who underwent THA after LSF had an increased risk of ASD (adjusted odds ratio: 3.80, 95% confidence interval: 2.21-6.98, P<0.001).

CONCLUSIONS

Patients who undergo THA after LSF have an increased rate of lumbar-related complications both when compared with patients who do not undergo THA and when compared with patients who undergo THA before LSF.

Does Prior Lumbar Fusion Influence Dislocation Risk in Hip Arthroplasty Performed for Femoral Neck Fracture?

BACKGROUND

Immobility of the lumbar spine predicts instability following elective total hip arthroplasty (THA). The purpose of this study is to determine how prior lumbar fusion (LF) influenced dislocation rates and revision rates for patients undergoing THA or hemiarthroplasty (HA) for femoral neck fracture (FNF).

METHODS

A retrospective cohort analysis was conducted utilizing the PearlDiver database from 2010 to 2018. Patients who underwent arthroplasty for FNF were identified based on history of LF and whether they underwent THA or HA. Univariate and multivariate analyses were performed.

RESULTS

A total of 328 patients with prior LF and FNF who underwent THA were at increased risk for 1-year dislocation (odds ratio [OR] 2.19, P < .001) and 2-year revision (OR 2.22, P < .001) compared to 14,217 patients without LF. The 461 patients with prior LF and FNF who underwent HA were at increased risk for dislocation (OR 2.22, P < .001) compared to 42,327 patients without LF. Patients with prior LF and FNF who underwent THA had higher rates of revision than patients with prior LF who underwent HA for FNF (OR 2.11, P < .001). In patients with prior LF and FNF, THA was associated with significantly increased risk for dislocation (OR 3.07, P < .001) and revision (OR 2.53, P < .001) compared to THA performed for osteoarthritis.

CONCLUSION

Patients with prior LF who sustained an FNF and underwent THA or HA were at increased risk for early dislocation and revision compared to those without prior LF. This risk of dislocation and revision is even greater than that observed in patients with prior LF who underwent THA for osteoarthritis.

LEVEL OF EVIDENCE

Level III.

Preoperative Factors Associated With Low Back Pain Improvement After Total Hip Arthroplasty in a Japanese Population

BACKGROUND

Spinal disorders and low back pain (LBP) have been associated with worse clinical outcomes of total hip arthroplasty (THA). It is essential to identify spinal factors associated with post-THA LBP improvement. Therefore, we aimed to determine the proportion of patients with improved LBP after THA and to identify the preoperative spinal factors associated with LBP improvement.

METHODS

We included 151 patients who underwent primary THA between December 2015 and December 2019 and had a preoperative visual analog scale score for LBP of ≥2. The patients were classified into the LBP improved or LBP continued group based on a visual analog scale score for LBP at 1 year after THA. Preoperative spinal parameters were compared between the 2 groups.

RESULTS

Ninety-five patients (62.9%) were classified into the LBP improved group. Among the coronal spinal parameters, the Cobb angle was significantly lower in the LBP improved group. Among the sagittal spinal parameters, the LBP continued group showed a significantly more posteriorly titled pelvis, lower lumbar lordosis, greater sagittal vertical axis, and greater pelvic incidence minus lumbar lordosis mismatch, indicating a sagittal spinal imbalance. Logistic regression analysis found that preoperative factors associated with LBP improvement after THA had a low Cobb angle and high anterior pelvic plane angle (anteriorly tilted pelvis).

CONCLUSION

Among patients with LBP before THA, 62.9% had improved LBP. Sagittal spinal imbalance and high Cobb angle were the key spinal factors associated with persistent LBP. Our findings suggest that hip surgeons should evaluate spinal alignment before THA in patients with LBP.

The Hip-Spine Challenge

➤

The proper diagnosis and treatment of patients with concurrent hip and spine pathological processes can be challenging because of the substantial overlap in symptomatology.

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There is no consensus on which pathological condition should be addressed first.

➤

Factors such as advanced spinal degeneration, deformity, and prior fusion alter the biomechanics of the spinopelvic unit. Attention should be paid to recognizing these issues during the work-up for a total hip arthroplasty as they can result in an increased risk of dislocation.

➤

In patients with concurrent spine and hip degeneration, the surgeon must pay close attention to appropriate implant positioning and have consideration for implants with enhanced stability to minimize the risk of dislocation.

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A proper understanding of sagittal balance and restoration of this balance is integral to improving patient outcomes following spinal surgery.

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The advent of new imaging modalities, increased awareness of spinopelvic mobility, as well as a better understanding of sagittal alignment will hopefully improve our treatment of patients with hip-spine syndrome.

Does total hip arthroplasty have a higher risk of failure in patients who undergo lumbar spinal fusion?

AIMS

Total hip arthroplasty (THA) patients undergoing or having a prior lumbar spine fusion (LSF) have an increased risk of mechanical complications. The aim of this registry-based, retrospective comparative cohort study is to assess the longer term survival of THA in patients who have undergone a LSF during a 17-year period (2000 to 2017).

METHODS

A registry-based population study was conducted on 679 patients who underwent both THA and LSF surgeries. Patients were identified from the regional arthroplasty data base and cross linked to patients with LSF from the regional hospital discharge database between 2000 and 2017. Demographic data, diagnosis leading to primary THA, primary implant survival, perioperative complications, number and causes of failure, and patients requiring revision arthroplasty were collated and compared. For comparison, data from 67,919 primary THAs performed during the same time time period were also retrieved and analyzed.

RESULTS

Patients undergoing THA and LSF showed homogeneous demographic data compared to those undergoing THA alone, but a significantly lower eight-year THA implant survival (96.7 vs 96.0, p = 0.024) was observed. Moreover, THA plus LSF patients showed increased incidence of mechanical complications in the first two years after THA surgery compared to THA alone patients.

CONCLUSION

This registry-based population study shows that approximately 679 (1%) THA patients were subjected to LSF. Patients undergoing THA and LSF have an increased risk of mechanical complications with their THA and a slightly increased risk of revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(3):486-491.

Comparable dislocation and revision rates for patients undergoing total hip arthroplasty with subsequent or prior lumbar spinal fusion: a meta-analysis and systematic review

BACKGROUND

There is a known correlation between the procedures of lumbar spinal fusion (LSF), total hip arthroplasty (THA) and the complication of hip dislocation and revision occurring in patients. However there is no consensus as to whether the risk of this complication is higher if THA is performed before or after LSF. This meta-analysis aims to determine the influence of surgical sequence of lumbar spinal fusion and total hip arthroplasty on the rates of hip dislocation and revisions.

METHODS

A meta-analysis was conducted with a multi-database search (PubMed, OVID, EMBASE, Medline) according to PRISMA guidelines on 27th May 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.

FINDINGS

A total of 25,558 subsequent LSF and 43,880 prior LSF THA patients were included in this study. There was no statistically significant difference in all-cause revisions (OR = 0.86, 95%CI: 0.48-1.54, p = 0.61), dislocation (OR = 0.82, 95%CI: 0.25-2.72, p = 0.75) or aseptic loosening (OR = 1.14, 95%CI: 0.94-1.38, p = 0.17) when comparing patients receiving LSF subsequent versus prior to THA.

CONCLUSION

Lumbar spinal fusion remains a risk factor for dislocation and revision of total hip arthroplasties regardless of whether it is performed prior to or after THA. Further preoperative assessment and altered surgical technique may be required in patients having THA who have previously undergone or are likely to undergo LSF in the future.

EVIDENCE LEVEL

Level II, Meta-analysis of homogeneous studies.

Postoperative complication rates and hazards-model survival analysis of revision surgery following occipitocervical and atlanto-axial fusion

Background

Methods

Results

Conclusions