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

Abstract

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).

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

“…The surgical approach may affect the results of THA among previous SF patients. Goyal et al demonstrated that anterior supine-based approaches including direct anterior and direct lateral for THA had a low risk of instability (< 1%) from a total of 582 previous SF patients [ 38 ]. This network meta-analysis demonstrates that the subset cohort of long spinal fusion construct patients present with the greatest risk of postoperative complications following THA.…”

Challenges in Total Hip Arthroplasty with Prior Spinal Arthrodesis: A Comprehensive Review of Biomechanics, Complications, and Surgical Strategies

“…Inoue et al propose a study using the CT/X-rays matching technique of the pelvis [ 18 ]. Other authors, however, such as Goyal et al and Furuhashi et al, proposed a standing and seated radiographic study of the pelvis and spine together in AP and lateral-lateral X-rays to examine postural changes where there is likely to be the most significant risk of dislocation [ 11 , 19 ]. Behery et al and Schmidth Braekling et al propose the use of combined AP and lateral-lateral X-rays of the pelvis and spine in other positions in addition to standing and sitting, such as maximum trunk flexion position while seated or single-leg standing visualization, which emphasizes the compensatory mechanisms of patients and may provide information on patients at high risk of dislocation in THA.…”

“…The choice of the surgical approach is a crucial factor that can significantly impact the outcomes of THA for patients with prior LA [ 18 , 19 , 20 ].…”

“…The anterior approach, which involves accessing the hip joint from the front, offers a direct view of the acetabulum and femur, enabling precise component placement. This approach is particularly advantageous in patients with lumbar fusion, as it allows for intraoperative adjustments to accommodate the fixed spinal-pelvic alignment, therefore reducing the risk of impingement and dislocation [ 18 , 19 ].…”

“…In some cases, the direct lateral approach may be considered. It offers a balance between anterior and posterior techniques, with a reduced risk of dislocation and good access to the hip joint [ 19 ].…”