Strategic Surgical Intervention in a Rare Presentation of Hip-Spine Syndrome With Lumbosacral Malunion: A Case Report.

The hip and lumbar spine are closely related and can create similar patterns of pain and dysfunction. Furthermore, diagnosing and treating hip and spine conditions can be challenging due to the overlap of symptoms. This report describes the successful treatment of a 54-year-old male with hip-spine syndrome following multiple surgeries for spondylolytic spondylolisthesis. The patient presented with low back pain (LBP) and bilateral hip pain, with radiological findings indicating spinal deformity and hip joint synovitis. Two years after two-stage corrective surgery, including pedicle subtraction osteotomy (PSO), the hip synovitis resolved and the symptoms improved. This case emphasizes the need to consider hip-spine syndrome as a possible complication of lumbosacral spine fusion surgery and demonstrates the efficacy of two-stage corrective surgery with pedicle subtraction osteotomy in treating this condition.

Previous lumbar spine fusion increases the risk of dislocation following total hip arthroplasty in patients with hip-spine syndrome: a systematic review and meta-analysis.

BACKGROUND: With life expectancy on the rise, there has been an increase in patients with concomitant degenerative hip and spine pathology, defined as hip-spine syndrome (HSS). Patients affected by HSS may require both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), although there is a paucity of data regarding how the sequential timing of these procedures may influence clinical outcomes. This study aims to compare complications and spinopelvic parameters in patients with HSS who underwent either LSF first or THA first. METHODS: A systematic search of PubMed and Scopus was conducted for randomized and nonrandomized studies investigating complications and spinopelvic parameters in patients with HSS who had undergone THA and LSF. The Methodological Index for Non-Randomized Studies (MINORS) tool was utilized to assess the risk of bias in included studies. Relevant outcomes were pooled for meta-analysis. RESULTS: Eleven articles were included in this study. There was a significantly higher THA dislocation rate in patients who had undergone LSF first compared to those who had THA first (OR: 3.17, 95% CI 1.23-8.15, P = 0.02). No significant difference was found in terms of THA aseptic loosening (OR: 0.86; 95% CI 0.32-2.32, p = 0.77) and revision rate (OR: 1.18, 95% CI: 0.53-2.62) between these two groups. Individuals who received THA only showed a significantly lower risk of hip dislocation (OR: 0.14, 95% CI: 0.08-0.25, P < 0.00001) and THA revision (OR: 0.22, 95% CI: 0.14-0.36, P < 0.00001) compared to patients with a previous LSF. CONCLUSIONS: In HSS patients who underwent both LSF and THA, those who received LSF first displayed an increased risk of hip dislocation after subsequent THA. Additionally, the relative risks of dislocation and revision rate appeared significantly lower in patients who had undergone THA only when compared to THA patients with a history of previous LSF. Due to the impact of LSF on spinopelvic biomechanics, caution must be exercised when performing THA in individuals with instrumented spines. PROSPERO ID: CRD42023412447. LEVEL OF EVIDENCE: LL.

Hip-Spine and Knee-Spine Syndrome: Is Low Back Pain Improved After Total Hip and Knee Arthroplasty?

INTRODUCTION: Hip and knee osteoarthritis (OA) and low back pain (LBP) are prevalent diseases that can negatively impact daily activities. The concurrent existence of lumbar spine disorders with hip or knee issues forms two syndromes: hip-spine syndrome (HSS) and knee-spine syndrome (KSS). The primary objective of this study is to evaluate the relationship between hip and knee OA and LBP, as well as the changes to LBP after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The secondary objective is to identify the cause of LBP among patients with hip and knee OA. MATERIAL AND METHODS: The group of hip OA patients treated with THA consisted of 34 individuals, and the group of knee OA patients treated with TKA consisted of 45 individuals. In these two groups of patients, the LBP was assessed using the visual analog scale score preoperatively and four and 12 months postoperatively. To determine the cause of LBP, we compared preoperative and postoperative (12-month) pelvic obliquity and hip or knee pain in patients with and without preoperative LBP. RESULTS: For hip OA-THA, more than half (55.88%) of patients suffering from hip OA also experienced moderate to severe LBP. Improvement in LBP was noticed in 79% of these patients at both four and 12 months post-THA, with levels dropping from 6.84 to 2.58 and then 2.53, respectively. Moreover, improvements in hip pain and pelvic obliquity were observed in patient groups both with and without preoperative LBP following THA. This suggests that there's no obvious correlation between LBP and these parameters. For knee OA-TKA, most (62.22%) patients with knee OA experienced moderate to very severe LBP. In 50% of these patients, LBP showed improvement at four and 12 months post-TKA (6.39 → 4.79 → 4.04). Additionally, in both groups with and without preoperative LBP, knee pain and pelvic obliquity were improved after TKA, suggesting no clear association between LBP and these parameters. CONCLUSIONS: HSS and KSS were frequently observed in patients. A significant improvement in LBP was seen after THA or TKA, suggesting that total arthroplasty should be prioritized before spinal surgery. Furthermore, there is not a definitive link between LBP, joint pain, and pelvic obliquity.

Surgical Management of Hip-Spine Syndrome: A Systematic Review of the Literature.

BACKGROUND: Hip-spine syndrome (HSS) was first described in 1983 to describe the symptomatology resulting from concomitant lumbar degenerative stenosis and hip osteoarthritis. Numerous studies have sought to understand the underlying pathology and appropriate management of this syndrome. The purpose of this article is to review the literature for the specific imaging characteristics and the optimal surgical treatment of HSS. METHODS: A systematic review was conducted via an electronic database search through PubMed to identify all publications related to HSS. All publications that contained data on patients who underwent surgical treatment for HSS and reported patient-reported outcome measures or radiographic data were included. Exclusion criteria consisted of publications in a language other than English, review articles, and technique articles. RESULTS: Fifteen articles that focused on the surgical management of HSS were identified. Of these 15 articles, 8 reported radiographic outcomes, with most reporting no significant change in spinopelvic parameters before and after surgery. Thirteen articles reported clinical outcomes, with 8 of those 13 articles identifying patient-reported outcome measures to be significantly improved following surgery. CONCLUSIONS: The data on the surgical management of HSS remains sparse. While there is some evidence that total hip arthroplasty in patients who previously underwent spinal fusion may have higher complication rates, there remains debate regarding which surgical problem to address first, the hip or the spine.

Prevalence of total joint arthroplasty in the adult spine deformity population.

PURPOSE: The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution. METHODS: Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed. RESULTS: 572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%). CONCLUSIONS: This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.

Association between cup orientation and low back pain after total hip arthroplasty in patients with osteonecrosis of the femoral head.

BACKGROUND: Postoperative low back pain (LBP) following total hip arthroplasty (THA) is classified as secondary hip-spine syndrome. The purpose of this study was to explore the correlations between cup orientation of THA and postoperative LBP in patients with osteonecrosis of the femoral head (ONFH). METHODS: A retrospective cohort study included 364 ONFH patients who underwent bilateral THA between January 2011 and December 2020. Among them, 53 patients (14.6%) experienced postoperative LBP at the end of follow-up and were designated as pain group (PG). A control group (CG) consisting of 106 patients with similar age, sex, and body mass index (BMI) to those in the PG was selected. Postoperative LBP in the PG was assessed using the visual analogue scale (VAS). Demographic data, clinical information, and radiographic criteria were evaluated as potential predictors of LBP. RESULTS: Patients in PG (mean age, 47.3 years [range, 27 to 75 years]; 42 [79%] male) had a mean VAS score of 4.6 (range, 1 to 9) compared with 0 for the patients in CG (mean age, 47.6 years [range, 19 to 77 years]; 84 [79%] male). There were no significant differences in clinical data between the two groups (p > 0.05). Preoperative radiographic variables also showed no significant differences between the PG and CG (p > 0.05). However, the postoperative inclination, anteversion, and standing ante-inclination (AI) were significantly lower in the PG compared to the CG, whereas the sitting and standing sacral slope (SS) were significantly higher (p < 0.05). Moreover, the variations in standing AI, standing and sitting pelvic tilt (PT) were significantly lower in the PG compared to the CG, while the variations in standing and sitting SS and lumbar lordosis (LL) were significantly higher (p < 0.05). The variation in standing AI in the PG showed a significantly correlation with the variation of standing SS, standing PT, and LL (p < 0.05). CONCLUSION: Postoperative LBP in ONFH patients after bilateral THA is significantly associated with the intraoperative cup orientation. The variation in standing AI is correlated with the variations in standing SS, standing PT, and LL, potentially contributing to the development of postoperative LBP.

Spinal fusion and total hip arthroplasty: why timing is important.

BACKGROUND: There is increasing debate among orthopaedic surgeons over the temporal relationship between lumbar spinal fusion (LSF) and total hip arthroplasty (THA) for patients with hip-spine syndrome. Few large studies have directly compared the results of patients who undergo LSF prior to THA (LSF-THA) to those who undergo LSF after THA (THA-LSF). The current study matched THA patients with a prior LSF to patients who underwent LSF after THA to assess: 90-day and 1-year (1) medical/surgical complications; and (2) revisions. METHODS: We queried a national, all-payer database to identify all patients undergoing THA between 2010 and 2018 (n = 716,084). The LSF-THA patients and THA-LSF patients were then matched 1:1 on age, sex, Charleson Comorbidity Index, and obesity. Medical/surgical complications and revisions at 90 days and 1 year were recorded. Categorical and continuous variables were analysed utilising t-tests and chi-square, respectively. RESULTS: LSF-THA patients experienced significantly more postoperative dislocations at 90 days and 1 year compared to THA-LSF patients (p = 0.048 and p < 0.001). There were a similar number of revisions performed for LSF-THA and THA-LSF patients at both 90 days and 1 year (p = 0.183 and p = 0.426). Furthermore, at 1 year, LSF-THA patients experienced more pneumonia (p = 0.005) and joint infection (p = 0.020). CONCLUSIONS: Prior LSF has been demonstrated to increase the risk of postoperative dislocation in patients undergoing THA. The results of the present study demonstrate increased dislocations with LSF-THA compared to THA-LSF. For "hip spine syndrome" patients requiring both LSF and THA, it may be more beneficial to undergo THA prior to LSF. Arthroplasty surgeons may wish to collaborate with spinal surgeons to ensure optimal outcomes for this group of patients.

How the hip-spine relationship influences total hip arthroplasty.

INTRODUCTION: Motion in the spine, pelvis and hips which make up the spinopelvic femoral complex (SPFC) implies mechanical relationships that help maintain trunk balance and optimize hip functionThe aim of this study was to understand the physiology of the SPFC and evaluate the dysfunctions of the SPFC and their implications for total hip arthroplasty considering the hip-spine relationship. METHODS: A review of relevant and comprehensive studies on this subject is reported in order to highlight a pathophysiology that integrates the description of the evaluations of the spine-pelvic and hip parameters and recommendations for the kinematic planning of the THA procedure. The primary objective was to determine which type of hip-spine relationship has the highest risk for THA complications and to become proficient in selecting the priority surgical intervention when both the hip and spine are affected. Finally, this review attempted to assist hip surgeons with surgical technique, tools, implant selection, and goals of planning a THA that requires personalized kinematic alignment. Determine the influence of THA on these kinematics and the effect of stiffness of the lumbopelvic complex on the risk of THA failure. RESULTS: When a person sits, the pelvis goes into retroversion and the acetabulum opens forward. This frees the femoral head and neck to allow hip flexion. The opposite - pelvic anteversion - occurs when a person stands. When pelvic mobility is limited, the hip must increase its range of motion to accommodate these posture changes. Disturbances in spinal and pelvic kinematics lead to abnormal hip function, which may contribute to complications following total hip arthroplasty (THA). CONCLUSION: A precise evaluation of the parameters governing the SPFC must be taken into account in order to best optimize the placement and choice of THA implants. LEVEL OF EVIDENCE: IV.

What patient parameters influence lumbar stiffness in patients with hip pathology?

Lumbar stiffness leads to greater hip dependence to achieve sagittal motion and increases instability after total hip arthroplasty (THA). We aimed to determine parameters that influence lumbar stiffness among patients with hip pathology. We hypothesized that modifiable (degenerative changes, spinal canal stenosis, facet orientation) and nonmodifiable factors (muscle condition) would be associated with lumbar spine stiffness. In this retrospective case-cohort study from a tertiary referral center, consecutive patients presenting at a hip specialist clinic underwent standing and deep-seated radiographic assessment to measure lumbar lordosis (∆LL) (stiffness: ∆LL < 20°), hip flexion (∆PFA: pelvic femoral angle), and degree of degenerative-disc-disease (DDD) (facet osteoarthritis, disc height, endplate proliferative changes). Of these, 65 patients were selected with previous lumbar spine magnetic resonance imaging, allowing to determine lumbar facet orientation, spinal canal stenosis (Schizas classification), and flexor- and extensor-muscle atrophy (Goutallier classification). Mean ∆LL was 45° (range: 11°-72°) and four patients (6%) exhibited spine stiffness. Patients with multilevel DDD (n = 22) had less ∆LL than those with no/single level (n = 43) DDD (34° [range: 11°-53°] vs. 51° [21°-72°]; p < 0.001). Number of DDD levels correlated strongly with ∆LL (ρ = -0.642; p < 0.001). Spinal stiffness was only seen in patients with ≥4 DDD levels. There was no correlation between ∆LL and facet orientation (p > 0.05). ∆LL correlated strongly with extensor atrophy at L3-L4 (ρ = -0.473), L4-L5 (ρ = -0.520), and L5-S1 (ρ = -0.473) and poorly with flexors at L4-L5 (ρ = -0.134) and L5-S1 (ρ = -0.227). Lumbar stiffness is dependent on modifiable (muscle atrophy) and nonmodifiable (extend of DDD) factors. This can guide nonoperative management of hip pathology, emphasizing the relevance of core muscle rehabilitation to improve posture and stiffness. Identification ≥4 DDD levels should alert surgeons of increased THA instability risk. Level of evidence: level IV, cohort series.

How Do Spinal Parameters Change in Patients Who Have Improvement of Low Back Pain After Total Hip Arthroplasty? A Propensity Score-Matched Cohort Study.

BACKGROUND: Many studies have demonstrated that low back pain (LBP) improves after total hip arthroplasty (THA). However, the mechanism underlying this improvement remains unclear. We aimed to investigate changes in the spinal parameters of patients who had LBP improvement after THA to elucidate the mechanism of LBP improvement. METHODS: We included 261 patients who underwent primary THA between December 2015 and June 2021 and had a preoperative visual analog scale score of ≥ 2 for LBP. The patients were classified into the LBP-improved or LBP-continued groups based on the visual analog scale for LBP at 1 year after THA. Preoperative and postoperative changes in the coronal and sagittal spinal parameters were compared between the 2 groups after propensity score matching for age, sex, body mass index, and preoperative spinal parameters. RESULTS: A total of 161 patients (61.7%) were classified into the LBP-improved group. After 85 patients in both groups were matched, the LBP-improved group showed significant differences in spinal parameter changes, which were a higher lumbar lordosis (LL) (P = .04) and lower sagittal vertical axis (SVA) (P = .02) and pelvic incidence (PI) minus LL (PI-LL) (P = .01) postoperatively, whereas the LBP-continued group showed worsened changes in LL and SVA and PI-LL mismatch. CONCLUSION: Patients who had LBP improvement after THA had significant differences in spinal parameter changes in LL, SVA, and PI-LL. These spinal parameters may be the key factors in the mechanism of LBP improvement after THA.

Outcomes and complications of Total Hip Arthroplasty in patients with a pre-existing pathologic spine-hip relation. A systematic review of the literature.

BACKGROUND: There has been a growing interest in pathologic spine-hip relations (PSHR) in current literature, with the aim of reducing the risk of prosthetic impingement, dislocation, and edge loading in total hip arthroplasty (THA). The primary objective of this review is to determine the effect of different PSHR on primary THA outcomes and complication profile. The secondary objective is to stratify the risk of different subgroups of PSHR patients. METHODS: A systematic review of the literature was performed in accordance with PRISMA guidelines. Randomised controlled trials, comparative cohort studies and case-control studies comparing outcomes and complication rates of primary THA in patients with and without a PSHR (spinal fusion; degenerative spinal conditions determining stiff spine and/or spinal misalignment) were included. The quality of the included studies and the risk of bias were assessed. The revision rate, complications, and clinical and radiological data were analysed. Complications included: aseptic loosening (AL), periprosthetic joint infections (PJI), hip dislocations and periprosthetic fractures (PF). RESULTS: Fifteen articles were included with 3.306.342 THAs. The mean follow-up (FU) was 31.4 ± 21.7 months. The population was divided into three subgroups: spinal fusion patients (48.315 THAs); non-fused patients with spinal stiffness (106.110 THAs); non-fused patients with normal spines (3.151.917 THAs). A statistically significant risk stratification was observed about dislocation rate (5.98 ± 6.9% SF, 3.0 ± 1.9% non-SF Stiff and 2.26 ± 1.4% non-SF; p = 0.028). Similarly, about THA revision rate, a statistically significant risk stratification was also observed (7.3 ± 6.8% SF, 6.4 ± 3.1% non-SF Stiff and 2.7 ± 1.7% non-SF; p = 0.020). No statistically significant difference was observed when analysing AL, PJI and PF. CONCLUSION: A statistically significant risk stratification of dislocation and revision rate was observed in the different PHSR, as theorised by the Bordeaux classification. Fused patients present a higher risk, degenerated and/or stiff spine an intermediate risk and mobile spines a lower risk profile. A standardised approach to THA candidate patients must consider the possible PSHR to improve clinical outcomes and reduce adverse events of THA.

Hip joint stress distribution changes depending on three-dimensional pelvic orientation: Finite-element analysis.

BACKGROUND: Pelvis experiences changes in its orientation due to the alignment of the hip joint and spine, and its orientation might affect both joints. Pelvic tilt on the sagittal plane has been widely discussed; however, the pelvis is oriented also on the coronal and horizontal planes. This study aimed to examine how stress distribution on intact hip joint changes under the three-dimensional pelvic orientation. METHODS: Computed tomography data of five patients with unilateral pelvic girdle were analyzed. Thirteen models were evaluated by the MECHANICAL FINDER: neutral position at 0°; 10° and 20° anterior and posterior pelvic tilt; 10° and 20° pelvic hike and drop; 10° and 20° pelvic forward and backward rotation. Stress assessment was performed in four parts of the acetabulum: anterosuperior, posterosuperior, posteroinferior, and central parts. RESULTS: Compared with the neutral position, the mean value of the equivalent stress and maximum principal stress in the anterosuperior part significantly increased by 1.51 times and 1.57 times at 20° posterior tilt, respectively. The maximum principal stress in the anterosuperior part significantly increased by 1.44 times at 20° hike. A significant increase of 1.45 times was found in the maximum principal stress in the anterosuperior part at 20° forward rotation. CONCLUSIONS: Local stress accumulated in the anterosuperior acetabulum at the posterior pelvic tilt, pelvic hike, and pelvic forward rotation, which might lead to hip overload. The effect of posterior pelvic tilt appears to be greater for the hip joint than at the pelvic hike or forward rotation.

Current Concepts in Diagnosis and Management of Patients Undergoing Total Hip Replacement with Concurrent Disorders of Spinopelvic Anatomy: A Narrative Review.

Despite the high success rate of primary total hip replacement (THR), a significant early revision rate remains, which is largely attributed to instability and dislocations. Despite the implants being placed according to the safe zone philosophy of Lewinnek, occurrence of THR dislocation is not an uncommon complication. Large diagnostic and computational model studies have shown variability in patients' mobility based on the individual anatomic and functional relationship of the hip-pelvis-spine complex. The absolute and relative position of hip replacement components changes throughout motion of the patient's body. In the case of spinopelvic pathology such as spine stiffness, the system reaches abnormal positional states, as shown with computerized models. The clinical result of such pathologic hip positioning is edge loading, implant impingement, or even joint dislocation. To prevent such complications, surgeons must change the dogma of single correct implant positioning and take into account patients' individualized anatomy and function. It is essential to broaden the standard diagnostics and their anatomical interpretation, and correct the pre-operative surgical planning. The need for correct and personalized implant placement pushes forward the development and adaptation of novel technologies in THR, such as robotics. In this current concepts narrative review, we simplify the spinopelvic biomechanics and pathoanatomy, the relevant anatomical terminology, and the diagnosis and management algorithms most commonly used today.

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up.

BACKGROUND: The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion. PURPOSE: To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA). RESULTS: A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up. CONCLUSION: After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification.

Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.

Bilateral psoas release for long standing hip-spine syndrome: surgical technique and case report.

Background: Severe positive sagittal malalignment can potentially lead to shortening and contracture of the psoas and joint capsule in a flexed spinopelvic position. The utilization of bilateral psoas release to supplement sagittal spinal deformity correction in the same hospitalization was not reported in the literature. Case presentation: A 66-year-old patient presented with a 5-year history of severe global spinal deformity (sagittal vertical axis 220 mm, 60° spinopelvic mismatch) that did not improve on supine radiographs, and a modified Thomas test with more than 30° flexion contracture of bilateral hips. A 3-stage operation utilizing posterior spinal column osteotomies, anterior lumbar interbody fusion, and bilateral psoas releases was performed. Outcome: Her postoperative alignment significantly improved and she was pleased with her new posture and the ability to stand up straight. Conclusions: This report is the first to demonstrate safe and substantial correction of severe spinal deformities associated with bilateral hip flexion contracture in 1 hospitalization.

Validity and application of Doiguchi's pelvic tilt measurement method.

BACKGROUND: The validity of Doiguchi's pelvic tilt measurement method has not been proven. The objective in our study was to validate the method. METHODS: Our investigation included 73 total hip arthroplasties (THAs) performed using our cup placement procedure from July 2020 to November 2021. Pelvic tilt formed by the pubic symphysis and sacral promontory (PTPS) in supine and lateral positions was calculated by two methods (the Doiguchi method and the digital reconstructed radiograph (DRR) method using a 3D computer templating system) based on the transverse and longitudinal diameters of the pelvic ring measured immediately before THA. RESULTS: There was a strong/moderate correlation in the values of PTPS between the Doiguchi and DRR methods. However, the value of PTPS calculated by the Doiguchi method was significantly lower than that calculated by DRR, and there was a partially direct match. On the other hand, there was no significant difference in the value of PT change from supine to lateral position between the Doiguchi and DRR methods. The PT changes based on both methods were strongly correlated, and the PT change calculated by the Doiguchi method was almost identical to that calculated by the DRR method. CONCLUSIONS: Doiguchi's pelvic tilt measurement method was validated for the first time. These results demonstrated that the ratio of the transverse and longitudinal diameters of the pelvic ring was an important factor defining the change in pelvic tilt. The slope in the linear function of the Doiguchi method was found to be almost the correct value, although the intercept of the linear function exhibited individual differences.

Does Order of Operation Matter in Patients Who Have Concomitant Hip and Spine Pathology?

BACKGROUND: In patients, who have coexisting lumbar spine and degenerative hip disease, there remains uncertainty regarding whether hip or spine surgery should be performed first. We hypothesized that undergoing total hip arthroplasty (THA) would protect against subsequent lumbar spine surgery (LSS) in patients who have 'hip-spine syndrome.' METHODS: A retrospective cohort study was performed from 2013 to 2021 on patients who had radiographically-confirmed hip osteoarthritis and degenerative lumbar spine pathology, evaluated separately in spine and arthroplasty clinics prior to surgical intervention. Included patients ultimately underwent THA and/or LSS. The primary outcome was survivorship free of LSS or THA after the other was initially performed. RESULTS: Of 256 patients, 206 (80.5%) underwent THA first. Only 14 of 206 (6.8%) who underwent THA required subsequent LSS, while 31 of 50 (62%) who underwent LSS required subsequent THA, (P < .001). At 5 years, there was 93.9% survivorship-free of LSS in the THA first group, compared to 44.7% survivorship-free of subsequent THA in the LSS group. Multivariate analyses showed that patients who had THA first had lower odds of undergoing subsequent surgery (odds ratio [OR]: 0.61, CI: 0.52-0.70, P < .001) compared to those who underwent LSS first. Additionally, those who have higher initial Kellgren-Lawrence grade hip osteoarthritis had lower odds (OR: 0.94, CI: 0.89-0.99, P = .04), and those who have progressive neurologic deficits (OR: 2.64, CI: 1.89-3.7, P < .001) and neurogenic claudication (OR: 1.15, CI: 1.06-1.24, P = .001) had increased odds of undergoing subsequent LSS. CONCLUSION: Patients with 'hip-spine syndrome' may receive more initial benefit from undergoing THA, potentially reducing the subsequent need for LSS. The exceptions were those patients who had lower-severity hip osteoarthritis and symptoms of major spinal stenosis.

Spine or Hip First? Outcomes in Patients Undergoing Sequential Lumbar Spine or Hip Surgery.

BACKGROUND: 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 the 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 versus 23.7%, P < .001). This disparity was maintained up to 5 years (P < .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 < .001). CONCLUSION: 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.

Hip-Spine Syndrome: A Focus on the Pelvic Incidence in Hip Disorders.

Since Offierski and MacNab reported a close association between the hip and spine as hip-spine syndrome in 1983, many studies on spinal alignment in hip disorders have been conducted. Notably, the pelvic incidence angle (PI) is the most important parameter and is determined by the anatomical variations in the sacroiliac joint and hip. Studies on the association of the PI with hip disorders can help in understanding the pathophysiology of hip-spine syndrome. A PI increase has been observed during the evolution of bipedal locomotion in humans and in the acquisition of gait during child development. Although the PI is a fixed parameter that is stable and unaffected by posture from adulthood onwards, it has become clear that it increases in the standing position in older people. While it may be associated with a greater risk of developing or progressing to spinal disorders, the association between the PI and hip disorders remains controversial because of the multifactorial nature of hip osteoarthritis (HOA) and the wide range of PIs in HOA (18-96°), making the interpretation of results difficult. However, several hip disorders (i.e., femoroacetabular impingement and rapid destructive coxarthrosis) have been shown to be associated with the PI. Further investigation on this topic is, therefore, warranted.