Which Should Be Operated on First—The Spine or the Hip? A Survey-Based Study on Treatment Order in Patients with Concurrent Degenerative Disorders of the Hip and Spine
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Published:
Jun 27, 2025
Keywords:
Spine, hip, survey
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Abstract
Introduction: In patients presenting with both hip osteoarthritis (OA) and spinal pathology, and where symptoms from both conditions are severe enough to warrant surgical intervention, determining the optimal order of treatment can be challenging.
Objective: To identify surgeons’ preferences and the rationale behind the treatment order in patients with hip OA and five different lumbar spine disorders.
Materials and Methods: A survey-based study was conducted among hip and spine specialists.Respondents were asked which condition they would operate on first in five clinical scenarios involving hip OA combined with: 1) lumbar spinal stenosis with neurogenic claudication, 2) low-grade lumbar spondylolisthesis with radicular pain, 3) lumbar disc herniation with muscle weakness, 4) degenerative lumbar scoliosis with sagittal imbalance, and 5) thoracolumbar disc herniation with myelopathy.
Results: The percentage of hip specialists who recommended addressing the hip first was: 45% for scenario 1, 61% for scenario 2, 20% for scenario 3, 71% for scenario 4, and 26% for scenario 5. Among spine specialists, those percentages were: 56%, 69%, 9%, 77%, and 16%, respectively. There was no consistent agreement between specialists from different fields—or even within the same specialty—as indicated by a low kappa concordance index across all scenarios.
Conclusions: Given the low level of agreement among both hip and spine surgeons, interdisciplinary discussions are essential when managing complex cases. An individualized treatment plan should be developed for each patient, particularly when the spinal pathology ismore complex.
Objective: To identify surgeons’ preferences and the rationale behind the treatment order in patients with hip OA and five different lumbar spine disorders.
Materials and Methods: A survey-based study was conducted among hip and spine specialists.Respondents were asked which condition they would operate on first in five clinical scenarios involving hip OA combined with: 1) lumbar spinal stenosis with neurogenic claudication, 2) low-grade lumbar spondylolisthesis with radicular pain, 3) lumbar disc herniation with muscle weakness, 4) degenerative lumbar scoliosis with sagittal imbalance, and 5) thoracolumbar disc herniation with myelopathy.
Results: The percentage of hip specialists who recommended addressing the hip first was: 45% for scenario 1, 61% for scenario 2, 20% for scenario 3, 71% for scenario 4, and 26% for scenario 5. Among spine specialists, those percentages were: 56%, 69%, 9%, 77%, and 16%, respectively. There was no consistent agreement between specialists from different fields—or even within the same specialty—as indicated by a low kappa concordance index across all scenarios.
Conclusions: Given the low level of agreement among both hip and spine surgeons, interdisciplinary discussions are essential when managing complex cases. An individualized treatment plan should be developed for each patient, particularly when the spinal pathology ismore complex.
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How to Cite
López, P. D., Iglesias, S. L., Nally, F. J., & Allende, B. L. (2025). Which Should Be Operated on First—The Spine or the Hip? A Survey-Based Study on Treatment Order in Patients with Concurrent Degenerative Disorders of the Hip and Spine. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(3), 253-262. https://doi.org/10.15417/issn.1852-7434.2025.90.3.2028
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Clinical Research
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References
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3. Grammatopoulos G, Dhaliwal K, Pradhan R, Parker SJM, Lynch K, Marshall R, et al. Does lumbar arthrodesis compromise outcome of total hip arthroplasty? Hip Int 2019;29(5):496-503.
https://doi.org/10.1177/1120700018793373
4. Parvizi J, Pour AE, Hillibrand A, Goldberg G, Sharkey PF, Rothman RH. Back pain and total hip arthroplasty: a prospective natural history study. Clin Orthop Relat Res 2010;468:1325-30.
https://doi.org/10.1007/s11999-010-1236-5
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6. Stefl M, Lundergan W, Heckmann N, McKnight B, Ike H, Murgai R, et al. Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint J 2017;99-B(1 Suppl A):37-45.
https://doi.org/10.1302/0301-620X.99B1.BJJ-2016-0415.R1
7. Bala A, Chona DV, Amanatullah DF, Hu SS, Wood KB, Alamin TF, et al. Timing of lumbar spinal fusión affects total hip arthroplasty outcomes. J Am Acad Orthop Surg Glob Res Rev 2019;3(11): e00133. https://doi.org/10.5435/JAAOSGlobal-D-19-00133
8. Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, et al. Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion. Bone Joint J 2017;99-B(5):585. https://doi.org/10.1302/0301-620X.99B5.BJJ-2016-0657.R1
9. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25):2940-52.
https://doi.org/10.1097/00007632-200011150-00017
10. Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel S, et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine (Phila Pa 1976) 2007;32:2099-2102. https://doi.org/10.1097/BRS.0b013e318145a3c5
11. Liu N, Goodman SB, Lachiewicz PF, Wood KB. Hip or spine surgery first?: a survey of treatment order for patients with concurrent degenerative hip and spinal disorders. Bone Joint J 2019;101-B(6_Suppl_B):37,2019. https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1073.R1
12. López PD, Orosco Falcone LDE, Iglesias SL, Pioli IJ, Gómez JM, Allende BL. Influencia de la fusión espinal en la orientación del implante acetabular. Rev Asoc Argent Ortop Traumatol 2021;86(4):463-74. https://doi.org/10.15417/issn.1852-7434.2021.86.4.1302
13. Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty
patient: A simplified approach to a complex problem. J Arthroplasty 2019;34(7S):S57.
https://doi.org/10.1016/j.arth.2019.01.012
14. Heckmann N, McKnight B, Stefl M, Trasolini NA, Ike H, Dorr LD. Late dislocation following total
hip arthroplasty: Spinopelvic imbalance as a causative factor. J Bone Joint Surg Am 2018;100(21):1845. https://doi.org/10.2106/JBJS.18.00078
15. Nessler JM, Malkani AL, Sachdeva S, Nessler JP, Westrich G, Harwin SF, et al. Use of dual mobility cups in patients undergoing primary total hip arthroplasty with prior lumbar spine fusion. Int Orthop 2020;44(5):857-62. https://doi.org/10.1007/s00264-020-04507-y
2012;20:434-42. https://doi.org/10.5435/JAAOS-20-07-434
2. Malkani AL, Garber AT, Ong KL, Dimar JR, Baykal D, Glassman SD, et al. Total hip arthroplasty in patients with previous lumbar fusion surgery: are there more dislocations and revisions? J Arthroplasty 2018;33:1189-93. https://doi.org/10.1016/j.arth.2017.10.041
3. Grammatopoulos G, Dhaliwal K, Pradhan R, Parker SJM, Lynch K, Marshall R, et al. Does lumbar arthrodesis compromise outcome of total hip arthroplasty? Hip Int 2019;29(5):496-503.
https://doi.org/10.1177/1120700018793373
4. Parvizi J, Pour AE, Hillibrand A, Goldberg G, Sharkey PF, Rothman RH. Back pain and total hip arthroplasty: a prospective natural history study. Clin Orthop Relat Res 2010;468:1325-30.
https://doi.org/10.1007/s11999-010-1236-5
5. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet
2007;370(9597):1508-19. https://doi.org/10.1016/S0140-6736(07)60457-7
6. Stefl M, Lundergan W, Heckmann N, McKnight B, Ike H, Murgai R, et al. Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint J 2017;99-B(1 Suppl A):37-45.
https://doi.org/10.1302/0301-620X.99B1.BJJ-2016-0415.R1
7. Bala A, Chona DV, Amanatullah DF, Hu SS, Wood KB, Alamin TF, et al. Timing of lumbar spinal fusión affects total hip arthroplasty outcomes. J Am Acad Orthop Surg Glob Res Rev 2019;3(11): e00133. https://doi.org/10.5435/JAAOSGlobal-D-19-00133
8. Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, et al. Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion. Bone Joint J 2017;99-B(5):585. https://doi.org/10.1302/0301-620X.99B5.BJJ-2016-0657.R1
9. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25):2940-52.
https://doi.org/10.1097/00007632-200011150-00017
10. Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel S, et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine (Phila Pa 1976) 2007;32:2099-2102. https://doi.org/10.1097/BRS.0b013e318145a3c5
11. Liu N, Goodman SB, Lachiewicz PF, Wood KB. Hip or spine surgery first?: a survey of treatment order for patients with concurrent degenerative hip and spinal disorders. Bone Joint J 2019;101-B(6_Suppl_B):37,2019. https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1073.R1
12. López PD, Orosco Falcone LDE, Iglesias SL, Pioli IJ, Gómez JM, Allende BL. Influencia de la fusión espinal en la orientación del implante acetabular. Rev Asoc Argent Ortop Traumatol 2021;86(4):463-74. https://doi.org/10.15417/issn.1852-7434.2021.86.4.1302
13. Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty
patient: A simplified approach to a complex problem. J Arthroplasty 2019;34(7S):S57.
https://doi.org/10.1016/j.arth.2019.01.012
14. Heckmann N, McKnight B, Stefl M, Trasolini NA, Ike H, Dorr LD. Late dislocation following total
hip arthroplasty: Spinopelvic imbalance as a causative factor. J Bone Joint Surg Am 2018;100(21):1845. https://doi.org/10.2106/JBJS.18.00078
15. Nessler JM, Malkani AL, Sachdeva S, Nessler JP, Westrich G, Harwin SF, et al. Use of dual mobility cups in patients undergoing primary total hip arthroplasty with prior lumbar spine fusion. Int Orthop 2020;44(5):857-62. https://doi.org/10.1007/s00264-020-04507-y