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Failure of Pelvic Fixation after Long Construct Fusions in Adult Deformity Patients; Clinical and Radiographic Risk Factors Woojin Cho, MD, PhD; Jonathan.

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Presentation on theme: "Failure of Pelvic Fixation after Long Construct Fusions in Adult Deformity Patients; Clinical and Radiographic Risk Factors Woojin Cho, MD, PhD; Jonathan."— Presentation transcript:

1 Failure of Pelvic Fixation after Long Construct Fusions in Adult Deformity Patients; Clinical and Radiographic Risk Factors Woojin Cho, MD, PhD; Jonathan R. Mason, MD; Adam S. Wilson, MD; Christopher I. Shaffrey, MD; Francis H. Shen, MD; Adam L. Shimer, MD; Wendy M. Novicoff, PhD; Kai-Ming Fu, MD, PhD; Joshua Heller, MD; Vincent Arlet, MD

2  Rigid internal fixation → higher fusion rates  Lumbosacral fusion : L5-S1 fixation alone :Pelvic fixation Introduction long constructs, high grade spondylolithesis unstable sacral fractures, sacral tumors -

3  Various Pelvic Fixation Methods : Galveston technique, S2 screws, four rod technique, S2 alar iliac screws, and S1-Iliac screws  S1-Iliac Screw Constructs : long term study with minimum 5 year follow up 5 nonunions out of 67 cases 23 removal of iliac screws spondylolisthesis + long constructs No reports of the risk factors for failure (Tsuchiya K, Bridwell KH, Kuklo TR, et al. Spine 2006) Introduction

4 To report the failure rate and risk factors for failure of pelvic fixation with S1-Iliac screws used at the base of long constructs in adult deformity patients Purpose

5  190 adult deformity patients : Retrospective review  Long construct instrumentation : > 6 levels with iliac screws  Clinical and Radiographic data Methods 1

6  Failure (F) and Non-Failure (N-F) Major F: rod breakage between L4 and S1, failure of S1 screws (breakage, halo formation, or pullout), and prominent iliac screws requiring removal Minor F: rod breakage between S1 and iliac screws and failure of iliac screws (not require revision surgery) Methods 2

7  Major Failure (Major F) Vs. Non-Failure (N-F) Clinical data: age, body mass index (BMI), number of comorbities, and previous revision surgery Radiographic data (Preop, Postop, Change): pelvic incidence, pelvic tilt, sacral slope, sagittal balance, coronal balance, lordosis, and Fusion status (L4-S1) Methods 3

8  Combined anterior and posterior fusion grading (L4- S1) (A modified Lenke’s fusion grading system) Posterior Fusion (PF) : Grade A, B, C Anterior Fusions (AF) : a sentinel sign at both L4-5 and L5-S1 Combined Fusions : PF or AF Methods 4

9  Failure rate : Major F & minor F  Risk factors for failure of pelvic fixation : Major F Vs. N-F Methods 5

10  190 patients → 67 patients  Overall Failure (F) rate: 34.3% Major F: 8 Pts (11.9%) rod breakage between L4 and S1, failure of S1 screws (breakage, halo formation, or pullout), and prominent iliac screws requiring removal Minor F: 15 Pts (22.4%) rod breakage between S1 and iliac screws and failure of iliac screws. (not require revision surgery) Result 1

11 Results 2 (Major F Vs. N-F)

12  Anterior Column Support (ALIF or TLIF) Major F group % of patients Non Failure (N-F) % Result 3

13 Major F

14 Bilateral rods breakage at L5-S1 level which is considered Major failure because it needed a revision surgery due to psuedarthrosis.

15 Minor F

16 Unilateral rod breakage below the S1 level which is a Minor failure because it doesn’t need a revision surgery as it can occur due to continuous motion at the SI joint after solid fusion at L5-S1.

17  The incidence of overall failure after pelvic fixation in adult deformity surgery : 34.3% Major failure : 11.9% Minor failure : 22.4%  Risk factors for Major failures : larger Pelvic Incidence, Revision Surgery, failure to restore Lumbar Lordosis failure to restore Sagittal Balance Conclusion

18  Proper sagittal alignment  ↑pelvic incidence → ↑ postoperative lumbar lordosis  ↓lumbar lordosis → ↓ optimal sagittal alignment → may predispose for more biomechanical stress on pelvic fixation → ↑ failure rate  Therefore, adult deformity surgeons who use pelvic fixation for long construct fusions should pay special attention to restoring optimal sagittal alignment to prevent pelvic fixation failure. Discussion

19 1.. Boos N, Webb JK. Pedicle screw fixation in spinal disorders: a European view. Eur Spine J. 1997;6(1): Kebaish KM. Sacropelvic fixation: techniques and complications. Spine. 2010;35(25): Allen BL Jr, Ferguson RL. The Galveston experience with L-rod instrumentation for adolescent idiopathic scoliosis. Clin Orthop Relat Res 1988;229:59– Mirkovic S, Abitbol JJ, Steinman J, Edwards CC, Schaffler M, Massie J, Garfin SR. Anatomic consideration for sacral screw placement. Spine. 1991;16(6 Suppl):S Shen FH, Harper M, Foster WC, Marks I, Arlet V. A novel "four-rod technique" for lumbo-pelvic reconstruction: theory and technical considerations. Spine. 2006;31(12): Matteini LE, Kebaish KM, Volk WR, Bergin PF, Yu WD, O'Brien JR. An S-2 alar iliac pelvic fixation. Technical note. Neurosurg Focus Mar;28(3):E Bridwell KH, Kuklo T, Edwards CC II, et al. Sacropelvic Fixation. Memphis, TN: Medtronic Sofamor Danek; Kuklo TR, Bridwell KH, Lewis SJ, Baldus C, Blanke K, Iffrig TM, Lenke LG. Minimum 2-year analysis of sacropelvic fixation and L5–S1 fusion using S1 and iliac screws. Spine 2001;26:1976– Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5–S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 2006;31:303– Lenke LG, Bridwell KH. Adult spondylolisthesis with lysis, Chapter 72. In: Bridwell KH, DeWald RL, eds. The Textbook of Spinal Surgery, 2nd ed. Philadelphia: Lippincott-Raven, 1997:1269 – Cunningham BW, Lewis SJ, Long J, Dmitriev AE, Linville DA, Bridwell KH. Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis: an in vitro porcine model. Spine (Phila Pa 1976) Nov 1;27(21): Lebwohl NH, Cunningham BW, Dmitriev A, Shimamoto N, Gooch L, Devlin V, Boachie-Adjei O, Wagner TA. Biomechanical comparison of lumbosacral fixation techniques in a calf spine model. Spine (Phila Pa 1976) Nov 1;27(21): O’Shaughnessy B, Lenke LG, Bridwell KH, Cho W, Chang MS, Auerbach JD, Crawford CH, Koester LA. Should Symptomatic Iliac Screws be Electively Removed in Postoperative Adult Spinal Deformity Patients Fused to the Sacrum? Presented at: the Scoliosis Research Socieuty Annual Meeting; September 23-26, 2008; San Antonio, TX. 14. Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976) Aug 1;34(17): Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G. An analysis of sagittal spinal alignment following long adult lumbar instrumentation and fusion to L5 or S1: can we predict ideal lumbar lordosis? Spine (Phila Pa 1976) Sep 15;31(20): References


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