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.

Purpose

Blood transfusions cause morbidity and complications in hip fracture patients. This includes increased risk of bacterial infection, potentially increased mortality, and higher hospital costs. Factors such as delay from admission to surgery, fracture pattern, method of fixation, operating time, age, and gender, may affect transfusion requirements. The purpose of this study was to evaluate the effect of patient and operative factors on blood loss and transfusion requirements.

We present our experience with the use of the Anterior Tension Band plate (ATB) following ALIF, which utilises the existing surgical approach obviating the need for posterior fixation. The ATB is a small, smooth, low profile plate. It can be placed through the existing approach (anterolateral retroperitoneal or anterior transperitoneal) across the reconstructed level to prevent extension of the graft space and anterior migration of the spacer. The primary objective of this study is to measure radiographic fusion success in patients with lumbar degenerative disc disease using the ATB system. The secondary objective is to accurately define the clinical benefits to the patient.

This is a prospective multi-center outcome study. Each patient was treated with an ATB plate at one or two levels between L2 & S1 and 1 ALIF or FRA allograft spacer per level. Patient data (VAS Pain, SF-12 and Oswestry) was collected preoperatively, and at six, twelve and twenty-four month post-operative intervals. Fusion was evaluated upon demonstration of bridging trabecular bone through or external to the femoral ring. Secondary endpoint success includes demonstration of 15% improvement over baseline on the VAS, Oswestry and SF-12 patient questionnaires.

To date one hundred and thirty-one patients have undergone surgery. There were ninety-two (70%) single-level ALIF procedures and thirty-nine (30%) two-level ALIF procedures. Patients that have returned for twelve month follow-up (n=41) have had a fusion success rate of 81%. The fusion rate among one-level patients is 89% (n=25) and 67% (n=15) among two-level patients. Four of five of the un-fused two-level patients had one level fused but not the other. At twelve months, Oswestry scores improved by an average of 40% with thirty-one of forty-seven (66%) patients achieving success and VAS scores improved by 42% with thirty-five of forty-seven (75%) being successful.

Preliminary analysis of current data shows positive outcomes using the ATB plating system in ALIF procedures. Primary and secondary outcomes are compatible with current standards of care, and device related complications are minimal. Further analysis of outcome data including will be reported upon the completion of the study.