The Journal of Arthroplasty 33 (2018) 297e300

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Review

Prior Lumbar Spinal Fusion is Associated With an Increased Risk of

Dislocation and Revision in Total Hip Arthroplasty: A Meta-Analysis
Vincent V.G. An, BSc (Adv) a, *, Kevin Phan, BSc (Adv), MPhil b, c,
Brahman S. Sivakumar, BSc (Med), MBBS, MS d,
Ralph J. Mobbs, BSc (Med), MBBS, FRACS (Neuro) b, c,
Warwick J. Bruce, MBBS, FRACS (Orth), FAOrthA a, e
a
Faculty of Medicine, University of Sydney, Sydney, Australia
b
NeuroSpine Surgery Research Group (NSURG), Sydney, Australia
c
Faculty of Medicine, University of New South Wales, Sydney, Australia
d
Department of Orthopaedics, Nepean Hospital, Sydney, Australia
e
Sydney Olympic Park Hip and Knee Clinic, Sydney, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: The biomechanical relationship between the lumbar spine and the hip is well-documented.
Received 25 July 2017 It follows that fusing the lumbar spine would have implications on the outcomes of total hip arthroplasty
Received in revised form (THA). This study aimed to determine the effect of preexisting lumbar spinal fusion surgery on the
21 August 2017
outcomes of THA by synthesizing the available evidence via systematic review and meta-analysis.
Accepted 29 August 2017
Available online 9 September 2017
Methods: A systematic review with meta-analysis was performed in accordance to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic searches were per-
formed in 6 different databases for studies comparing outcomes in patients after THA with or without a
Keywords:
hip
history of lumbar fusion. Studies were required to report at least one outcome out of dislocation, revision
total hip arthroplasty due to hip instability or patient-reported outcomes.
spine Results: Patients with a history of lumbar spinal fusion are at a significantly increased risk of dislocation
lumbar fusion (relative risk 2.03, P < .00001) and revision (relative risk 3.36, P ¼ .006) after THA. Patient-reported
meta-analysis outcomes were also poorer in patients with prior lumbar fusion compared with those without,
although meta-analysis could not be performed due to heterogeneity in the outcome measure used
between studies.
Conclusion: Previous lumbar spinal fusion increases risk of dislocation and revision, and may negatively
impacts patient-reported outcomes after THA. Orthopaedic surgeons should pay particular attention to
these patients and could use patient-specific planning, instrumentation, and targeted counselling to
optimize clinical and subjective outcomes. Future studies could clarify the impact of prior fusion on
patient-reported outcomes after THA.
© 2017 Elsevier Inc. All rights reserved.

The relationship between hip osteoarthritis and lower back
pathology is well-documented. Concomitant lower back pain has
been in up to 49.4% of patients undergoing total hip arthroplasty
(THA) for end-stage osteoarthritis [1]. A subset of these patients
with concomitant pathology have undergone spinal surgery before
No author associated with this paper has disclosed any potential or pertinent
conflicts which may be perceived to have impending conflict with this work. For
full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.08.040.
* Reprint requests: Vincent V. G. An, BSc (Adv), 93 Arthur St, Strathfield, NSW
2135, Australia.
THAdregistry data demonstrates 3.5% of those undergoing hip
arthroplasty have had prior spinal surgery [2].
The consequences of prior lumbar surgery on the outcomes of
THA have been demonstrated in recent studies. Registry data from
Singapore and the United States have demonstrated an increased
rate of dislocation and revision due to instability post-THA in
patients with previous lumbar fusion [3,4]. Preexisting lumbar
disease alone as well as lumbar surgery has been associated with
poorer patient-reported outcome measures (PROMs) post-THA [2],
underlining the importance of recognizing the importance of the
complex hip-spine relationship. This is due to acetabular orienta-
tion and therefore hip biomechanics are influenced by the arc of

http://dx.doi.org/10.1016/j.arth.2017.08.040
0883-5403/© 2017 Elsevier Inc. All rights reserved.
298 V.V.G. An et al. / The Journal of Arthroplasty 33 (2018) 297e300

movement undertaken by the lumbar spine [5]. Therefore, modi-

fication to the lumbar spine, as in lumbar spinal fusion, could
modify spinopelvic biomechanics, therefore altering the stability of
the hip.
This study aimed to clarify the implications of preexisting
lumbar spinal fusion surgery on the outcomes of THA by synthe-
sizing the available evidence via systematic review and meta-
analysis. The authors hypothesized that prior spinal surgery
would confer an increased rate of revision and dislocation after
THA, as well as poorer patient-reported outcomes.

Materials and Methods

Search Strategy

A systematic review of the literature with meta-analysis was

conducted in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses guidelines [6,7]. Searches
were performed in Ovid MEDLINE, PubMed, Cochrane Central
Register of Controlled Trials, Cochrane Database of Systematic
Reviews, ACP Journal Club, and Database of Abstracts of Review of
Effectiveness during June 2017. The search terms “lumbar spine OR
lumbar spine fusion OR lumbar spinal fusion OR lumbar spine
arthrodesis OR lumbar spinal arthrodesis,” “hip,” and “arthroplasty Fig. 1. Results of the search performed in this meta-analysis.
OR replacement” were combined to identify relevant articles.

methodological reasons for this were explored qualitatively. In the

Inclusion and/or Exclusion Criteria
present meta-analysis, the results using the random-effects model
were presented to take into account the possible clinical diversity
This article included original data studies published at any time
and methodological variation between studies. Specific analyses
in English which compared the outcomes of THA in patients who
considering confounding factors were not possible because raw
had previously received lumbar spinal fusion and those who had
data were not available. All P values were 2-sided.
not. Whenever propensity score matched or matched data were
available, this was included in the analysis. Included studies were
required to report at least one outcome out of dislocation, revision Results
due to hip instability or patient-reported outcomes post-THA.
Single-arm studies were excluded. Case reports and conference Search Results
abstracts were not included.
The search returned 1147 nonduplicate citations. After title and
Quality Appraisal abstract screening, 14 articles were retrieved for full-text screening.
Seven articles were then further excluded based on exclusion
As the scoring of studies is controversial, 2 authors individually criteriad2 were review articles and 5 discussed the impact of
reviewed each article and resolved any disagreements on the lumbar disease without fusion on THA outcomes. During data
inclusion or exclusion of any article. Ongoing disagreements on extraction, a further article was excluded as it reported coexisting
whether to include or exclude studies were resolved by an expert lumbar fusion both before and after THA [8], leaving 6 articles to be
orthopedic surgeon. The Strengthening the Reporting of Observa- included in this review (Fig. 1) [2e4,9e11]. Of these studies, 4 were
tional Studies in Epidemiology checklist was used to appraise the matched-pair analyses and 2 were registry analyses. There were
structure and comprehensiveness of each included study. 4 level III studies and 2 level IV studies as per the Journal of Bone
and Joint Surgery levels of evidence [12].
Data Extraction and Analysis
Table 1
Data were extracted from the text, figures, tables, and supple- Summary of the Studies Included in This Meta-Analysis.
mentary material of the included studies. Relative risk (RR) was Author Year LoE Design n F/U n
used as a summary statistic. Collected data were stored in a single
Previous THA Only
spreadsheet on Microsoft Excel (Microsoft, Redmond, WA). In the LSF
present study, both fixed-effect and random-effect models were
Sing 2016 IV Registry 598,995 24 mo 9695 589,300
tested. In the fixed-effects model, it was assumed that treatment Perfetti 2017 III Matched 1968 12 mo 934 934
effect in each study was the same, whereas in a random-effects pair
model, it was assumed that there were variations between Loh 2016 III Matched 164 24 mo 82 82
studies. c2 tests were used to study heterogeneity between trials. I2 pair
Buckland 2017 IV Registry 853,672 12 mo 14,668 839,004
statistic was used to estimate the percentage of total variation
Barry 2017 III Matched 105 90 d 35 70
across studies, owing to heterogeneity rather than chance, with pair
values >50% considered as substantial heterogeneity. I2 can be Eneqvist 2017 III Matched 1994 12 mo 997 997
calculated as: I2 ¼ 100%  (Q  df)/Q, with Q defined as Cochrane pair
heterogeneity statistics and df defined as degrees of freedom. If F/U, follow up; LoE, level of evidence; LSF, lumbar spinal fusion; THA, total hip
there was substantial heterogeneity, the possible clinical and arthroplasty.
 V.V.G. An et al. / The Journal of Arthroplasty 33 (2018) 297e300
Fig. 2. Comparison of rates of dislocation after total hip arthroplasty (THA) between patients with prior lumbar fusion and those without. CI, confidence interval.
The 6 included studies investigated a total of 1,456,898 patients.
Of these, 26,411 were THA patients with previous lumbar spinal
fusion, and 1,430,387 were THA patients with no history of lumbar
spinal fusion. Follow-up period ranged from 90 days to 24 months
(Table 1).
Stability Outcomes
Patients with prior lumbar fusion had significantly higher rates
of dislocation after THA compared with patients without (RR 2.03,
95% confidence interval 1.52-2.72, P < .00001), with significant
heterogeneity detected (I2 ¼ 83%, P < .0001) (Fig. 2). Patients with
prior lumbar fusion also had significantly higher rates of revision
after THA compared with patients without (RR 3.36, 95% confi-
dence interval 1.41-7.99, P ¼ .006), with significant heterogeneity
detected (I2 ¼ 98%, P < .00001) (Fig. 3).
Patient-Reported Outcomes
Two of the included studies also compared PROMs between THA
patients with or without prior lumbar fusion. However, the het-
erogeneity in PROMs used in both studies precluded formal meta-
analysis. Despite this, all studies demonstrated poorer PROMs in
patients with prior lumbar fusion (Table 2).
Discussion
The negative impact of previous lumbar fusion on the outcomes
of patients undergoing THA has been previously demonstrated by
individual studies [2e4,9e11]. This meta-analysis confirms this
relationship, demonstrating that patients who have had prior
lumbar fusion had a significantly higher complication rate after hip
arthroplasty. In particular, these patients had a 2-fold higher risk of
dislocation, and a 3-fold greater risk of needing subsequent revi-
sion arthroplasty surgery. Prior lumbar fusion is also associated
with poorer PROMs after THA.
Fig. 3. Comparison of rates of revision after THA between patients with prior lumbar fusion and those without.
299
The etiology of increased instability in patients undergoing THA
post lumbar fusion is still being elucidated, and is likely due to the
complex biomechanical interplay between the hip joint and lumbar
spinal mechanics. Traditionally, the Lewinnek plane (15 ± 10 of
anteversion and 40 ± 10 of inclination) has been used as a “safe
zone” target in THA to optimize stability [13]. However, recent
in vivo studies using computed tomographical data demonstrate
that the Lewinnek plane varies with pelvic tilt and variations in
posture [5,14]. Specifically, a posteriorly tilted position in the
standing position (relative hypolordosis) is associated with a more
flexed orientation of the acetabulum, leading to posterior
impingement as well as theoretically an increased risk of anterior
dislocation [15,16]. Posterior pelvic tilt has also been associated
with an increased risk of superior edge loading and wear, which
may also impact implant survival, although this relationship needs
to be clarified clinically in long-term studies [17]. Although the
disease-free spine is generally able to compensate for this with
normal lumbar arc of movement, the fused spine has considerably
reduced range of motion at the index levels, therefore explaining
the increased risk of instability as demonstrated in our analysis.
One strategy to negate this in future cases is by customizing
acetabular targets to specific patients to optimize the biomechanics
of the hip joint with consideration to patients' lumbar spine status.
Novel planning tools have been developed, with accompanying
patient-specific instrumentation providing a means of accurately
delivering the patient-specific plan [18,19]. Advances in positional
preoperative imaging (such as standing, sitting, and squatting) also
help identify high-risk situations and alterations accordingly. In
addition, spinal surgeons are placing increasing emphasis on the
importance of spinal sagittal alignment when performing lumbar
fusions, although the specific targets for sagittal balance remain
unclear [20]. One may foresee increasing collaboration between hip
and spine surgeons to account for modified targets tailored toward
optimizing spinopelvic alignment.
Although meta-analysis was not able to be performed on PROMs
after THA, the included studies demonstrated an association with
poorer outcomes with patients who had previously received lumbar
300 V.V.G. An et al. / The Journal of Arthroplasty 33 (2018) 297e300
Table 2
Summary of Patient-Reported Outcome Measures in Included Studies.
Author Year Outcome Measure Previous Lumbar THA Only
Fusion
Loh 2016 WOMAC 213.5 267.41
Oxford 86.08 78.25
SF-36 69.21 79.71
Eneqvist 2017 Pain VAS 20.4 (22.0) 16.1 (18.7)
EQ-5D Index 0.66 (0.24) 0.75 (0.24)
EQ-VAS 66.3 (22.8) 73.1 (20.2)
Satisfaction VAS 22.7 (24.9) 16.7 (20.2)
EQ-5D, EuroQol 5 dimensions; EQ-VAS, EuroQol visual analog scale; SF-36, Short
Form-36; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Uni-
versities Osteoarthritis Index.
spinal fusion. There may be several reasons behind this. Poorer
patient-reported measures may result from the relatively decreased
range of motion in the lumbar spinal population, which may limit
function and therefore, patient-reported satisfaction [21]. Low back
pain and pathology has also been associated with poorer patient
satisfaction, which may influence patient satisfaction after their
index THA [22]. Patients with fused lumbar vertebrae over a pro-
longed period are at higher risk of adjacent segment disease, which
would further reduce lumbar spine range of motion and exacerbate
poor patient satisfaction indexes. However, as demonstrated in this
meta-analysis, further high-quality research is required to quantify
and clarify the impact of previous lumbar spinal fusion on THA
outcomes. Nonetheless, hip surgeons should bring concurrent or
previous lumbar spinal pathology into consideration when coun-
selling patients pre-THA, and should manage patient expectations
adequately to optimize patient satisfaction.
Limitations
However, this study was not without its own limitations. The
inclusion of two major registry studies contributed to a degree of
heterogeneity for both dislocation and revision outcomes, meaning
that there was a significant variation between the individual results
of included studies. Nonetheless, inspection of the forest plots
unanimously demonstrates that spinal fusion indeed increases the
risk of instability after THA. Furthermore, the included studies
analyzed patients with a history of lumbar spinal fusion irre-
spective of when this was performed. The effect of time between
the prior fusion and THA is unclear, and should be considered in
future investigations. We speculate that patients with a prolonged
history of lumbar fusion, because of the development of adjacent
vertebral segment disease, would have even poorer satisfaction
results after THA [23]. In addition, the longer amount of time spent
with altered hip biomechanics after lumbar fusion could further
contribute to poorer outcomes. As mentioned previously, although
clinical outcomes were assessed, patient-reported outcome and
satisfaction could not be formally analyzed, and therefore remains
unclear. Future research should investigate the influence of lumbar
spinal fusion on PROMs and satisfaction using matched-pair ana-
lyses or registry data to elucidate the nature of this interaction, to
inform orthopedic surgeons of how to adequately counsel and
intervene in this particular subset of patients.
Conclusion
Patients receiving THA with a history of lumbar spinal fusion are
at an increased risk of dislocation and revision compared with
patients without. Prior lumbar fusion is also associated with poorer
patient-reported outcomes, although this needs to be further
clarified in future studies. Orthopaedic surgeons should pay
P Value particular attention to these patients and could use patient-specific
planning, instrumentation and targeted counselling to optimize
.05 clinical and subjective outcomes.
.08
.04
<.001
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