Aims

Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain.

Purpose

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice.

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first.

Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining.

Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ²=44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ²=6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy.

With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making.