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Hip And Knee Implants In BulgariaWe read with interest the paper by Natalia Wilson and colleagues (Nov/Dec 08) about ongoing policy considerations for hip and knee implants. Summarizing recent evidence on hip-spine syndrome (HSS) management, we contribute recent results from a university hospital in Plovdiv, Bulgaria. HSS is chronically progressing and, if untreated appropriately, leads to deterioration of functional fitness and quality of life. In prior research, surgery (laminectomy) had multiple advantages over nonsurgical therapy in lumbar spinal stenosis (LSS) at the third month in prospective cohorts. A 7.8-point difference from baseline in bodily pain (according to the SF-36) also was evidence of its effectiveness.1 Supporting these findings, we found that total hip replacement, alone or after laminectomy, was highly effective in aged patients with both lumbar and hip pain. Combined findings from our unique observational prospective data indicated very high efficacy levels of THR (in fifty-eight HSS patients).2 In particular, twenty-nine patients with hip osteoarthritis underwent THR; hip pain disappeared in 68.97 percent of them. Lumbar pain remained in eight who also had LSS. Seventeen out of another twenty-five patients with LSS underwent laminectomy. Lumbar pain decreased, but hip pain persisted. Thirteen patients had hip osteoarthritis (bilateral in six of them). Our most important advantage was targeted, patient-level decision making by a panel of highly-specialized experts (neurologist, neurosurgeon, orthopedic surgeon, roentgenologist) acting together to choose the best surgical intervention in each case. Assessing their own quality-of-life improvement, many patients reported relief from pain. Undoubtedly, our individualized surgery showed very high effectiveness as both clinical effects and patient-reported outcomes, especially in LSS combined with hip osteoarthritis. Interestingly, similar improvements in both patient-reported outcomes and clinical measures were reported in comparable prospective cohort of forty-two Japanese patients with LSS.3
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