The Optimal Full-body Alignment for Adult Spinal Deformity after Surgical Treatment--A clinical and radiographic analysis

The Optimal Full-body Alignment for Adult Spinal Deformity after Surgical Treatment--A clinical and radiographic analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Optimal Full-body Alignment for Adult Spinal Deformity after Surgical Treatment--A clinical and radiographic analysis Han Yu, Tianhao Wang, Juncheng Li, Chao Xue, Guoquan Zheng, Yaqing Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9388030/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aimed to investigate the optimal full-body alignment (FBA) for adult spinal deformity (ASD) underwent deformity surgical procedures. Methods Patients with ASD who underwent long-segment fusion involving the thoracolumbar spine were retrospectively reviewed. The FBA was converted to numeric value by the formula: N-FBA = WHD/WSD. HRQoL was evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) at baseline and final follow-up. All patients were assigned into the group A, B, and C by the optimal N-FBA. A Kaplan-Meier curve and log-rank test was used to analyze the differences in PJF-free survival time among groups. Results A total of 106 patients were included. According to the excellent improvement in Oswestry disability index (E-ODI≥50%) peri-operatively, ROC analysis determined the optimal value of 0.65 for N-FBA (sensitivity = 73.8%, specificity = 71.4%, AUC = 0.732, P < 0.001). Because the W-line were expressed as positive (+) or negative (-) values, the optimal threshold of N-FBA was recorded as ± 0.65. There were 34, 49, and 23 patients in the group A (N-FBA≥0.65), B (-0.65 < N-FBA < 0.65), and C (N-FBA≤-0.65) respectively. Patients in the group A showed the highest incidence of PJF (12/22 vs. 3/46 vs. 1/22, P < 0.001), and the shortest PJF-free survival time (P = 0.011, log-rank test). Conclusion The mild inclining posture forwardly, W-line going through hip joints peripherally, may be the optimal full-body alignment for ASD patients who have undergone long-fusion surgical procedures. Adult spinal deformity Oswestry disability index Full-body alignment Proximal junctional failure W-line. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction With increasing life expectancy, the prevalence of adult spinal deformity (ASD) has become common among individuals aged over 65 years, affecting approximately 68% of this population.[ 1 , 2 ] Previous studies have demonstrated that patients with ASD undergoing surgical intervention show statistically significant improvements in all health-related quality of life (HRQoL) measures compared with those receiving non-surgical treatment.[ 3 , 4 ] Long-segment fusion (≥5 vertebrae) with instrumentation has been shown to be an effective treatment for ASD.[ 5 , 6 ] However, these complex procedures are often associated with various complications,[ 7 , 8 ] among which proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) account for a substantial proportion.[ 9 ] Recent studies have reported that full-spinal realignment,[ 9 , 10 ] sagittal vertical axis, and global sagittal alignment (GSA; thoracic kyphosis + lumbar lordosis + pelvic incidence > 45°[ 11 ]) are significantly correlated with HRQoL and the occurrence of PJK/PJF in patients with ASD who have undergone long-fusion surgery. In ASD, sagittal balance describes the optimal spinopelvic alignment in the sagittal plane, resulting from the interaction between the spine and lower limbs via the pelvis.[ 12 – 14 ] The center-of-gravity line ( W-line in this study), which passes vertically through the ear canal,[ 15 – 17 ] is influenced by full-body alignment (FBA) and may play an important role in both HRQoL and overall balance. However, few studies have investigated the optimal FBA in patients with ASD who have undergone surgical correction. Therefore, the purpose of this study was to determine the optimal postoperative FBA based on perioperative HRQoL improvement in patients with ASD who underwent long-fusion surgery with instrumentation. Materials and Methods Prior to the study, approval was obtained from the Clinical Research Ethics Committee of our hospital. We retrospectively reviewed data from patients with ASD treated at our institution between March 2014 and April 2019, with a minimum follow-up of 24 months. All patients underwent long-segment fusion (≥ 5 vertebrae) with titanium alloy screws and two-rod constructs via a posterior-only approach. Inclusion criteria were: ASD patients with 1) age ≥ 45 years; 2) complete clinical and radiographic data; and 3) follow-up duration ≥ 24 months. Exclusion criteria included: prior spine surgery, spinal neoplasms, spinal tuberculosis, spinal or pelvic trauma, non-structural curvature, prior lower joints surgery, or leg length discrepancy ≥ 2 cm. The W-line was defined as the plumb line passing through the ear canal. The horizontal distance between the W-line and the center of the femoral head was defined as the WHD, which was recorded as negative (-) when the W-line was posterior to the femoral head and positive (+) when anterior. The horizontal distance between the W-line and the posterosuperior corner of S1 was defined as WSD, recorded similarly. The numeric W-line, representing full-body alignment (N-FBA), was calculated using the equation N-FBA = WHD/WSD. Details are shown in Fig. 1 . To minimize misclassification of PJK, only PJF was recorded, defined as a fracture of the upper instrumented vertebra (UIV) or UIV + 1, or evidence of pedicle screw loosening, dislodgment, or pullout at the UIV.[ 18 ] Demographic data (age, sex, body mass index (BMI), comorbidities, operative details (duration, blood loss, UIV, lower instrumented vertebra [LIV], the number of fused vertebrae) were recorded in detail. Postoperatively, follow-up time, PJF-free survival time, and complications during follow-up were documented. HRQoL questionnaires and radiographs were collected preoperatively, 3 months postoperatively, and at the final follow-up. HRQoL evaluation HRQoL was assessed using the visual analog scale (VAS) and Oswestry Disability Index (ODI). The ODI consists of 10 sections: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex, social life, and traveling. When all 10 sections were completed, the score was calculated as follows: total score out of total possible scores × 100%. If some sections were missing (or not applicable), the score was calculated as follows: [total score/(5 × number of questions answered)] × 100. The improvement in ODI (I-ODI) perioperatively was calculated between the preoperative and final postoperative follow-ups as follows: I-ODI = [(Post-ODI – Pre-ODI) / (50 - Pre-ODI)] × 100%. An I-ODI ≥ of 50% was defined as excellent improvement. Radiographic evaluation Radiographic data were obtained from full-length coronal and sagittal radiographs taken in a free-standing posture, with the upper limbs supported, shoulders forward flexed at 30°, and elbows slightly flexed.[ 19 ] Measurements were performed using Surgimap Software (version: 2.3.2.1; Spine Software, New York, NY, USA). Measured parameters are shown in Fig. 2 , including cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), and T1 pelvic angle (TPA). Kyphosis was recorded as positive (+) and lordosis as negative (-). PI-LL was calculated as PI minus LL. All measurements were performed by an independent radiographic team. Statistical Analysis Continuous variables with normal distribution were expressed as mean ± standard deviation (SD), and non-normally distributed data as medians. Categorical variables were expressed as counts or percentages. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal N-FBA threshold for predicting excellent I-ODI (≥ 50%), and the area under the curve (AUC) with 95% confidence intervals (CI) was calculated. Patients were categorized into Groups A, B, and C according to the optimal N-FBA value. Kaplan-Meier analysis and log-rank tests were used to compare PJF-free survival among groups. Chi-square or Fisher’s exact tests were used for categorical variables, and one-way ANOVA for continuous variables. Statistical analyses were performed using IBM SPSS (Mac version 26.0, IBM Corp., Armonk, NY, USA). A two-sided P < 0.05 was considered statistically significant. Results A total of 190 patients with ASD underwent long-fusion surgery at our hospital between March 2014 and April 2019. However, 84 patients were excluded, including 38 who underwent prior surgeries in the spine or hip joints and 46 with a follow-up period of less than 18 months. Ultimately, 106 patients (male: 21, female: 85) were included, with a mean age of 64.48 years (SD 8.88; range,45‒89 years) and a median follow-up of 51.68 months (SD 15.6, 24–87 months). Overall, 48 patients showed excellent improvement in ODI (I-ODI ≥50%) from preoperative to final postoperative follow-up; the remaining 58 patients showed moderate improvement (≥25% to < 50%). Sixteen patients developed PJF (15.09%; three patients with pedicle screw dislodgment, pullout of instrumentation at the UIV, and 13 patients with fracture at the UIV and/or UIV + 1) during follow-up. Fourteen patients (87.5%) developed PJF within 24 months after surgery, while two developed at 36 and 43 months, respectively, during follow-up. According to the I-ODI 50% criterion, ROC analysis determined an optimal threshold value of 0.65 for N-FBA at the 3rd month postoperatively (sensitivity, 73.8%; specificity, 71.4%; area under the curve, 0.732; 95% CI 0.618‒0.917; P < 0.001) (Fig. 3 ). Because the positions of the W-line relative to the S1 or hip joints were expressed as positive (+) or negative (-) values for N-FBA, the optimal threshold of N-FBA was recorded as ± 0.65. All patients were assigned to groups A (N-FBA≥0.65), B (-0.65 < N-FBA < 0.65), and C (N-FBA≤-0.65) (Fig. 4 ). There were 34, 49, and 23 patients in Groups A, B, and C, respectively. Postoperatively, 4, 31, and 13 patients showed excellent improvement in ODI ( P < 0.001), and 12, 3, and 1 patients developed PJF in Groups A, B, and C, respectively. There were no significant differences among the three groups in terms of age, BMI, sex, comorbidities, or follow-up duration (Table 1 ). Radiographic data obtained preoperatively, at the 3rd month, and at the final postoperative follow-up are listed in Table 2 . Patients in group A had the smallest PI ( P = 0.029), TPA ( P = 0.008), PI-LL ( P = 0.017), and SVA ( P < 0.001) preoperatively. Although there were no perioperative differences in the correction of spinopelvic parameters (Table 3 ), patients in the three groups had significantly different spinopelvic parameters, including PT ( P = 0.004), SVA ( P < 0.001), TPA( P < 0.001), and PI-LL ( P < 0.001) at the 3rd month postoperatively. At the final follow-up, spinopelvic parameters, including TK ( P = 0.014), LL ( P = 0.023), PT ( P < 0.001), PI-LL ( P < 0.001), and SVA ( P < 0.001), were significantly different among the three groups. The Kaplan-Meier curve and log-rank test revealed significant differences in PJF-free survival time among the three groups ( P = 0.011, log-rank test), as shown in Fig. 5 . ODI[ 20 ] and VAS[ 20 ] scores in all patients improved significantly after surgery ( P < 0.001); however, group B demonstrated the best outcomes at the final follow-up. Details are presented in Table 4 . Table 1 Comparisons of demographic data in the group A, B, and C. Variable Group A (n = 34) Group B (n = 49) Group C (n = 23) Statistical Values p-value Female, n(%) 26(76.5%) 41(83.7%) 18(78.3%) 0.724* 0.696 Mean age, years 63.79±9.73 64.4±8.23 65.91±6.45 0.444† 0.643 Mean BMI, kg/m2 24.58±10.30 24.17±10.59 25.13±7.27 0.568† 0.618 Comorbidity, n(%) 23(71.9%) 38(77.6%) 13(55.6%) 3.396* 0.183 Follow-up, month 52.29±16.76 51.26±14.79 50.04±16.21 0.140† 0.870 Mean values are presented as the mean±SD. * Chi-squared values. † f-values. Table 2 Comparisons of the radiographic data among the group A, B, and C. Parameters Group A (n = 34) Group B (n = 49) Group C (n = 23) f-value p-value Preop-CL (°) -13.25 ± 17.78 -19.88 ± 19.33 -17.85 ± 16.21 0.740 0.482 Postop-CL (°) -7.52 ± 16.68 -10.45 ± 13.94 -7.97 ± 17.65 0.189 0.829 F/U-CL (°) -10.56 ± 13.88 -16.8 ± 11.20 -13.77 ± 15.77 2.162 0.109 Preop-TK (°) 19.85 ± 13.84 15.26 ± 13.19 15.58 ± 9.51 1.374 0.258 Postop-TK (°) 23.18 ± 10.07 20.92 ± 11.40 23.54 ± 7.67 0.511 0.601 F/U-TK (°) 29.87 ± 10.30 24.41 ± 11.33 31.89 ± 9.04 4.356 0.014‡ Preop-LL (°) -27.37 ± 20.69 -17.63 ± 21.16 -25.71 ± 16.62 2.474 0.09 Postop-LL (°) -41.83 ± 11.59 -35.63 ± 12.51 -38.08 ± 10.88 2.542 0.084 F/U-LL (°) -44.60 ± 12.87 -32.08 ± 13.42 -42.80 ± 11.82 4.122 0.023‡ Preop-SS (°) 20.66 ± 13.44 20.14 ± 13.74 27.03 ± 10.00 2.281 0.108 Postop-SS (°) 29.20 ± 10.78 29.55 ± 10.82 29.39 ± 9.60 0.010 0.99 F/U-SS (°) 31.32 ± 9.44 28.43 ± 10.39 30.36 ± 8.19 0.626 0.419 Preop-PT (°) 21.80 ± 11.75 26.53 ± 12.25 23.15 ± 9.7 1.651 0.197 Postop-PT (°) 12.46 ± 8.35 18.24 ± 9.60 19.98 ± 8.67 5.834 0.004‡ F/U-PT (°) 12.84 ± 9.84 23.14 ± 10.74 22.98 ± 10.67 9.268 < 0.001‡ Preop-PI (°) 42.46 ± 9.61 46.68 ± 11.54 50.64 ± 12.66 3.676 0.029‡ Postop-PI (°) 41.93 ± 9.00 47.79 ± 11.88 49.36 ± 12.22 3.810 0.026‡ Preop- PI-LL (°) 14.45 ± 21.62 28.15 ± 19.72 27.92 ± 15.38 4.298 0.017‡ Postop- PI-LL (°) 0.09 ± 10.39 12.16 ± 12.30 11.27 ± 9.84 12.220 < 0.001‡ F/U- PI-LL (°) 0.11 ± 9.96 11.92 ± 11.22 13.06 ± 9.77 13.012 < 0.001‡ Preop-TPA (°) 18.24 ± 11.40 27.42 ± 13.99 22.41 ± 10.49 5.055 0.008‡ Postop-TPA (°) 8.99 ± 5.99 17.81 ± 9.56 15.82 ± 7.47 11.648 < 0.001‡ F/U-TPA (°) 16.78 ± 10.21 21.86 ± 10.88 22.83 ± 11.73 2.482 0.106 Preop-SVA (mm) 23.08 ± 36.40 76.49 ± 60.57 47.34 ± 43.22 10.933 < 0.001‡ Postop-SVA (mm) -7.72 ± 42.45 32.24 ± 24.50 14.76 ± 14.16 16.166 < 0.001‡ F/U-SVA (mm) 17.97 ± 30.21 43.67 ± 23.45 35.6 ± 19.65 7.124 < 0.001‡ Mean values are presented as the mean ± SD. Preop- and postop- indicate pre-operation and post- operation; CL, cervical lordosis; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; LL, lumbar lordosis; SS, sacral slope; PT, pelvic tilt; PI, pelvic incidence; PI-LL, mismatch of pelvic incidence minus lumbar lordosis; TPA, T1 pelvic angle; SVA, sagittal vertical axis; F/U, final follow-up. ‡ statistical differences. Table 3 Comparisons of the correction in radiographic data perioperatively and the surgical data among the group A, B, and C. Variable Group A (n = 34) Group B (n = 49) Group C (n = 23) Statistical Values p-value Mean d-TK(°) 2.85 ± 9.74 5.67 ± 9.89 7.8 ± 11.41 1.633† 0.201 Mean d-LL(°) 14.82 ± 14.67 17.99 ± 17.75 12.04 ± 14.77 1.029† 0.361 Mean d-SVA(mm) -31.47 ± 53.34 -44.09 ± 53.04 -31.92 ± 44.10 0.693† 0.503 Mean d-TPA(°) -9.32 ± 8.88 -9.39 ± 9.33 -6.68 ± 6.30 0.828† 0.440 Mean Timing (min) 276.25 ± 58.99 289.55 ± 45.32 267.57 ± 64.31 1.220† 0.300 Mean Blood loss(ml) 495.48 ± 167.84 527.75 ± 174.72 484.76 ± 149.25 0.596† 0.568 Mean Segments 7.94 ± 1.90 8.69 ± 2.36 7.96 ± 2.55 1.304† 0.276 UIV(T10 or above), n(%) 25 (73.5%) 32 (65.3%) 15 (65.2%) 0.722* 0.697 LIV(S1/S2/ilium), n(%) 14 (41.2%) 28 (57.1%) 13 (56.5%) 2.302* 0.316 E-ODI, n(%) 4 (11.8%) 31 (63.3%) 13 (56.5%) 22.984* < 0.001‡ PJF, n(%) 12 (35.3%) 3 (7.1%) 1 (4.3%) 15.975* < 0.001‡ Mean values are presented as the mean ± SD. d-, indicates the correction of those radiographic data; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; LL, lumbar lordosis; SVA, sagittal vertical axis; TPA, T1 pelvic angle; UIV, upper instrumented vertebra; LIV, lower instrumented vertebra; E-ODI, excellent improvement in Oswestry disability index; PJF, proximal junctional failure. * Chi-squared values. † f-values. ‡ statistical differences. Table 4 Comparisons of clinical outcomes among three groups at pre-, post-operation and the final follow-up. VAS ODI Pre-op Post-op F/U f-value p-value Pre-op Post-op F/U f-value p-value A 6.9 3.2 5.1 6.992 < 0.001‡ 68.9 42.9 58.8 6.383 < 0.001‡ B 7.2 3.5 2.2 10.018 < 0.001‡ 71.6 30.6 12.6 23.014 < 0.001‡ C 6.7 2.9 3.8 7.125 < 0.001‡ 69.2 31.2 21.2 18.072 < 0.001‡ f-value 0.532 0.785 4.176 - 0.503 3.012 16.225 p-value 0.85 0.68 0.018‡ - - 0.87 0.102 < 0.001‡ - Note: ‡ indicates statistical differences. Abbreviations: VAS, visual analogue scale; ODI, Oswestry disability index; Pre-op, pre-operation; Post-op, post- operation; F/U, final follow-up. ‡ statistical differences. A series of full-spine radiographs of a representative patient is shown in Fig. 6 . Discussion The current literature evaluating sagittal spinal alignment in the management of ASD has been primarily based on the Schwab criteria and related modifiers.[ 21 ] These spinal curvatures interact to maintain the virtual center of gravity (VCG) within the normal range in standing posture.[ 22 , 23 ] Accordingly, patients with ASD whose VCG is restored after surgery often show significant improvement in HRQoL and reduced risk of biomechanical complications such as PJK or PJF. However, few studies have investigated optimal FBA in patients with ASD following deformity correction surgery. In this study, after defining the ear-canal plumb line ( W-line) as the FBA,[ 15 ] 106 patients with ASD were subdivided into three groups: N-FBA ≥ 0.65 (W-line located completely behind the sacrum or deviating from the hip joints), -0.65 < N-FBA < 0.65 (W-line passing through the hip joints), and N-FBA ≤ -0.65 (W-line positioned within the posterior pelvis). Comparisons among the three groups revealed significant differences in HRQoL scores and radiographic parameters both pre- and postoperatively. More patients in groups B and C showed excellent improvement in HRQoL scores. Although preoperative HRQoL scores were similar among the three groups, both VAS and ODI scores were significantly better in groups B and C at the final follow-up. Spinopelvic parameters, including PT, SVA, TPA, and PI-LL, are strongly associated with HRQoL in patients with ASD.[ 24 – 27 ] Patients with ASD with low PT (< 20°) postoperatively may have poorer HRQoL,[ 25 ] while those with postoperative TPA ≤ 20° tend to have better spinopelvic alignment and improved ODI.[ 26 ] Additionally, in patients with ASD undergoing long-fusion surgery, the optimal mismatch (PI-LL) was 10°‒20°.[ 28 , 29 ] In this study, patients in group B and C had larger PT (18.24° ± 9.6°), SVA (32.24 mm ± 24.5 mm), TPA (17.81° ± 9.56°), and PI-LL (12.16° ± 12.3°) at the 3rd month postoperatively, consistent with previous findings. Furthermore, patients in groups B and C demonstrated greater postoperative improvements in HRQOL and maintained better outcomes at the final follow-up. PJF significantly worsens HRQoL in patients with ASD.[ 9 ] Previous studies demonstrated that spinopelvic risk factors for PJK/PJF included larger TK, SVA, global sagittal alignment (GSA, PI + TK+LL > 45°) and PI.[ 9 , 11 , 30 , 31 ] In the present study, although perioperative correction of spinopelvic parameters was similar among the three groups, patients in the group A‒those with the W-line located completely behind the sacrum (22 cases) or deviating forward from the hip joints (1 case)‒had the smallest PI, SVA, TPA, and PI-LL at the 3rd month postoperatively. Moreover, group A showed the highest incidence of PJF (12/22 vs. 3/46 vs. 1/22, P < 0.001), and the shortest PJF-free survival time ( P = 0.011, log-rank test). Carender et al. [ 30 ] reported that a lower PI is significantly correlated with PJF, and based on our findings, this may be due to suboptimal W-line positioning after surgery. With aging, the human torso naturally inclines forward, leading to gradual increases in SVA, PI-LL, and TPA.[ 32 , 33 ] Recent evidence suggests that corrections in radiographic parameters should consider both patient age and PI in ASD surgery.[ 34 ] The mean age in our study was approximately 65 years (45‒79 years). Spinopelvic alignment in group A may have been inconsistent with age-related biomechanical adaptation, as 35.3% (12/34) of these patients developed PJF within 24 months postoperatively. Conversely, patients in groups B and C‒with mildly inclined posture and W-line passing through the hip joints‒had a much lower incidence of PJF and better ODI and VAS outcomes. Therefore, maintaining the W-line around the hip joints postoperatively may represent the most physiologically balanced spine-pelvis-hip alignment in ASD correction. This study had some limitations. The sample size and retrospective design may limit the generalizability of our findings. Although significant postoperative changes in full-body alignment were observed, surgical strategies were not analyzed, which was beyond the study’s scope. Future prospective studies with larger cohorts and long-term follow-up are needed to confirm the optimal full-body alignment in ASD correction. In conclusion, for patients with ASD, maintaining the W-line around the hip joints may provide optimal full-body alignment after long-segment fusion surgery. Conversely, a postoperative W-line located entirely within the pelvis or deviating forward from the hip joints may increase the risk of HRQoL deterioration and PJF development during follow-up. Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Ethics Committee of Chinese PLA General Hosptial with the approval number S2024-556-01 and was also registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2400090679). Written informed consent was obtained from all participants for publication of identifiable images in this study. Consent for publication Written informed consent was obtained from the patient for publication of this research and anyaccompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests Each author certifies that neither he, nor any member of his immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Funding This study was sponsored by the postdoctoral foundation of affiliated hospital of Jining medical university (321210), the National Key Research and Development Program Fund of China (2020YFC1107404), the Youth Science Fund of National Natural Science Foundation of China (82102184), and Fund projects in the field of Foundation Strengthening Program (2020-JCJQ-JJ-356). Author Contribution All authors contributed to the study conception and design. ZFZ contributed to the study design. GQZ, YQZ, ZFZ performed the surgery. HY and THW were responsible for the collection and analysis of the data, as well as writing and revising the manuscript for important intellectual content. JCL and CX were contributed to the critical revision of the article. All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors read and approved the final manuscript. Acknowledgement We thank the participants who generously agreed to be interviewed for this current study. Z. F. Zhang appreciate the instructions given by the professor Y. Wang, working in the Chinese PLA general hospital, during his PhD. Data Availability The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. References Schwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082–5. /10.1097/01.brs.0000160842.43482.cd . Qiu GX. Scoliosis in China: History and Present Status. Chin Med J (Engl). 2017;130(21):2521–3. /10.4103/0366-6999.217081 . Adogwa O, Karikari IO, Elsamadicy AA, Sergesketter AR, Galan D, Bridwell KH. Correlation of 2-year SRS-22r and ODI patient-reported outcomes with 5-year patient-reported outcomes after complex spinal fusion: a 5-year single-institution study of 118 patients. J Neurosurg Spine. 2018;29(4):422–8. /10.3171/2018.2.SPINE171142 . Teles AR, Mattei TA, Righesso O, Falavigna A. Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature. Global Spine J. 2017;7(2):170–8. /10.1177/2192568217699182 . Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V. Adult spinal deformity. Lancet. 2019;394(10193):160–72. /10.1016/s0140-6736(19)31125-0 . Zhang HC, Yu HL, Yang HF, Sun PF, Wu HT, Zhan Y, Wang Z, Xiang LB. Short-segment decompression/fusion versus long-segment decompression/fusion and osteotomy for Lenke-Silva type VI adult degenerative scoliosis. Chin Med J (Engl). 2019;132(21):2543–9. /10.1097/CM9.0000000000000474 . Sugawara R, Takeshita K, Takahashi J, Arai Y, Watanabe K, Yamato Y, Oba H, Matsumoto M. The complication trends of adult spinal deformity surgery in Japan - The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017. J Orthop Sci;S. 2020;0949–2658(20):30145–7. /10.1016/j.jos.2020.05.006 . Charosky S, Guigui P, Blamoutier A, Roussouly P, Chopin D, Study Group on S. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976). 2012;37(8):693–700. /10.1097/BRS.0b013e31822ff5c1 . Hyun SJ, Lee BH, Park JH, Kim KJ, Jahng TA, Kim HJ. Proximal Junctional Kyphosis and Proximal Junctional Failure Following Adult Spinal Deformity Surgery. Korean J Spine. 2017;14(4):126–32. /10.14245/kjs.2017.14.4.126 . Lafage R, Schwab F, Glassman S, Bess S, Harris B, Sheer J, Hart R, Line B, Henry J, Burton D, Kim H, Klineberg E, Ames C, Lafage V, International Spine Study G. Age-Adjusted Alignment Goals Have the Potential to Reduce PJK. Spine (Phila Pa 1976). 2017;42(17):1275–82. /10.1097/BRS.0000000000002146 . Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36(1):E60–8. /10.1097/BRS.0b013e3181eeaee2 . Savarese LG, Menezes-Reis R, Bonugli GP, Herrero C, Defino HLA, Nogueira-Barbosa MH. Spinopelvic sagittal balance: what does the radiologist need to know? Radiol Bras. 2020;53(3):175–84. /10.1590/0100-3984.2019.0048 . Nishida N, Izumiyama T, Asahi R, Iwanaga H, Yamagata H, Mihara A, Nakashima D, Imajo Y, Suzuki H, Funaba M, Sugimoto S, Fukushima M, Sakai T. Changes in the global spine alignment in the sitting position in an automobile. Spine J. 2020;20(4):614–20. /10.1016/j.spinee.2019.11.016 . Liu CJ, Zhu ZQ, Wang KF, Duan S, Xu S, Liu HY. Radiological Analysis of Thoracolumbar Junctional Degenerative Kyphosis in Patients with Lumbar Degenerative Kyphosis. Chin Med J (Engl). 2017;130(21):2535–40. /10.4103/0366-6999.217090 . Le Huec JC, Saddiki R, Franke J, Rigal J, Aunoble S. Equilibrium of the human body and the gravity line: the basics. Eur Spine J. 2011;20(Suppl 5):558–63. /10.1007/s00586-011-1939-7 . Kuntz Ct, Levin LS, Ondra SL, Shaffrey CI, Morgan CJ. Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J Neurosurg Spine. 2007;6(2):104–12. /10.3171/spi.2007.6.2.104 . Kuntz Ct, Shaffrey CI, Ondra SL, Durrani AA, Mummaneni PV, Levin LS, Pettigrew DB. (2008) Spinal deformity: a new classification derived from neutral upright spinal alignment measurements in asymptomatic juvenile, adolescent, adult, and geriatric individuals. Neurosurgery;63(3 Suppl):25–39. /10.1227/01.NEU.0000313120.81565.D7 Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2. nd.(2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976);30(14):1643-9. /10.1097/01.brs.0000169451.76359.49 Marks M, Stanford C, Newton P. Which lateral radiographic positioning technique provides the most reliable and functional representation of a patient's sagittal balance? Spine (Phila Pa 1976). 2009;34(9):949–54. /10.1097/BRS.0b013e318199650a . Yu H, Wang Q, Fan Y, Qi D, Wang T, Li B, Huang Y, Wang Z, Xue C, Zheng G. Vertebral Column Decancellation for Correcting Cervicothoracic Kyphotic Deformity in Patients With Ankylosing Spondylitis. Orthop Surg. 2024. /10.1111/os.14306 . Schwab F, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D, DeWald C, Mehdian H, Shaffrey C, Tribus C, Lafage V. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37(12):1077–82. /10.1097/BRS.0b013e31823e15e2 . Duval-Beaupere G, Schmidt C, Cosson P. A Barycentremetric study of the sagittal shape of spine and pelvis: the conditions required for an economic standing position. Ann Biomed Eng. 1992;20(4):451–62. /10.1007/BF02368136 . Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346–53. /10.1097/01.brs.0000152379.54463.65 . Protopsaltis TS, Lafage R, Smith JS, Passias PG, Shaffrey CI, Kim HJ, Mundis GM, Ames CP, Burton DC, Bess S, Klineberg E, Hart RA, Schwab FJ, Lafage V, International Spine Study G.. (2018) The Lumbar Pelvic Angle, the Lumbar Component of the T1 Pelvic Angle, Correlates With HRQOL, PI-LL Mismatch, and it Predicts Global Alignment. Spine (Phila Pa 1976);43(10):681-7. /10.1097/BRS.0000000000002346 Takemoto M, Boissiere L, Vital JM, Pellise F, Perez-Grueso FJS, Kleinstuck F, Acaroglu ER, Alanay A, Obeid I. Are sagittal spinopelvic radiographic parameters significantly associated with quality of life of adult spinal deformity patients? Multivariate linear regression analyses for pre-operative and short-term post-operative health-related quality of life. Eur Spine J. 2017;26(8):2176–86. /10.1007/s00586-016-4872-y . Banno T, Hasegawa T, Yamato Y, Kobayashi S, Togawa D, Oe S, Mihara Y, Matsuyama Y. (2016) T1 Pelvic Angle Is a Useful Parameter for Postoperative Evaluation in Adult Spinal Deformity Patients. Spine (Phila Pa 1976);41(21):1641-8. /10.1097/BRS.0000000000001608 Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599–606. /10.1097/BRS.0b013e3181aad219 . Bai H, Li Y, Liu C, Zhao Y, Zhao X, Lei W, Feng Y, Wu Z. (2020) Surgical Management of Degenerative Lumbar Scoliosis Associated With Spinal Stenosis: Does the PI-LL Matter? Spine (Phila Pa 1976);45(15):1047–54. /10.1097/BRS.0000000000003465 Zhang HC, Zhang ZF, Wang ZH, Cheng JY, Wu YC, Fan YM, Wang TH, Wang Z. Optimal Pelvic Incidence Minus Lumbar Lordosis Mismatch after Long Posterior Instrumentation and Fusion for Adult Degenerative Scoliosis. Orthop Surg. 2017;9(3):304–10. /10.1111/os.12343 . Carender CN, Morris WZ, Poe-Kochert C, Thompson GH, Son-Hing JP, Liu RW. (2016) Low Pelvic Incidence Is Associated With Proximal Junctional Kyphosis in Patients Treated With Growing Rods. Spine (Phila Pa 1976);41(9):792-7. /10.1097/BRS.0000000000001352 Zhang ZF, Qi DB, Wang TH, Wang Z, Zheng GQ, Wang Y. Correlation of Acetabular Anteversion and Thoracic Kyphosis Postoperatively with Proximal Junctional Failure in Adult Spinal Deformity Fused to Pelvis. Orthop Surg. 2021. /10.1111/os.13159 . Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J. (2006) The vertical projection of the sum of the ground reactive forces of a standing patient is not the same as the C7 plumb line: a radiographic study of the sagittal alignment of 153 asymptomatic volunteers. Spine (Phila Pa 1976);31(11):E320-5. /10.1097/01.brs.0000218263.58642.ff Iyer S, Lenke LG, Nemani VM, Albert TJ, Sides BA, Metz LN, Cunningham ME, Kim HJ. (2016) Variations in Sagittal Alignment Parameters Based on Age: A Prospective Study of Asymptomatic Volunteers Using Full-Body Radiographs. Spine (Phila Pa 1976);41(23):1826-36. /10.1097/BRS.0000000000001642 Protopsaltis TS, Soroceanu A, Tishelman JC, Buckland AJ, Mundis GM Jr., Smith JS, Daniels A, Lenke LG, Kim HJ, Klineberg EO, Ames CP, Hart RA, Bess S, Shaffrey CI, Schwab FJ, Lafage V, International Spine Study G. (2020) Should Sagittal Spinal Alignment Targets for Adult Spinal Deformity Correction Depend on Pelvic Incidence and Age? Spine (Phila Pa 1976);45(4):250-7. /10.1097/BRS.0000000000003237 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9388030","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633351887,"identity":"7ce44af1-ee8b-4cd4-8d58-0c3f12a2c349","order_by":0,"name":"Han Yu","email":"","orcid":"","institution":"Medical School Of Chinese People’s Liberation Army","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"","lastName":"Yu","suffix":""},{"id":633351888,"identity":"eec0c189-5204-4d6e-a319-3f0b14d5e11b","order_by":1,"name":"Tianhao Wang","email":"","orcid":"","institution":"Senior Department of Orthopedics, Chinese PLA Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tianhao","middleName":"","lastName":"Wang","suffix":""},{"id":633351889,"identity":"e1b8e419-0315-4561-a46f-a1c272f6e3d9","order_by":2,"name":"Juncheng Li","email":"","orcid":"","institution":"Xinhua Hospital Affiliated To Shanghai jiaotong University School Of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Juncheng","middleName":"","lastName":"Li","suffix":""},{"id":633351890,"identity":"e7b5911a-73b4-41e8-a159-d2244f5e072c","order_by":3,"name":"Chao Xue","email":"","orcid":"","institution":"Senior Department of Orthopedics, Chinese PLA Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Xue","suffix":""},{"id":633351891,"identity":"f43e420d-f52d-43fc-8f26-b53197779245","order_by":4,"name":"Guoquan Zheng","email":"","orcid":"","institution":"Senior Department of Orthopedics, Chinese PLA Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guoquan","middleName":"","lastName":"Zheng","suffix":""},{"id":633351892,"identity":"e87b4fd5-5a3c-4fc2-8c62-d0cc633bf5e7","order_by":5,"name":"Yaqing Zhang","email":"","orcid":"","institution":"Xinhua Hospital Affiliated To Shanghai jiaotong University School Of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yaqing","middleName":"","lastName":"Zhang","suffix":""},{"id":633351893,"identity":"bc011437-81b4-4bfd-9663-b1fd62c87c52","order_by":6,"name":"Zifang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie3RP0vDQBjH8QuB65LY9RdSmrdwJVAdHHwpjwjekoKTZCoW4bL4AgIVX0bnhILTDY4BHeKiawaRDAU928EpaUfB+w7PLfeB+8OYzfYXw24OzXBqEqdjPsiKg0hww5grmvQyPvI0HULYD+FBrtfnDzgTvSJa3r69fmxOMFxmT6GvXKnAiLXpqpM494/H8cgD8KKvYl/xmQoXhXOnnzuJC5qGBsxZldCFr7yZGhXkOqqbcMjPEAKIDFn7CpKDRC/xkEyDhgBRyXKRa0F7CZBch6wAJlXisialiTKPXPbdJcrlKmg3c4wr+d6S+IqiLCvrNu0m2yfwdmf8/Y6id7/JabfLoN630Waz2f5p3+yvVYbxP0CKAAAAAElFTkSuQmCC","orcid":"","institution":"Xinhua Hospital Affiliated To Shanghai jiaotong University School Of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Zifang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-04-11 12:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9388030/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9388030/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108631089,"identity":"bfcd7297-40f8-4875-bf52-4d30bc4be808","added_by":"auto","created_at":"2026-05-06 16:40:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1586998,"visible":true,"origin":"","legend":"\u003cp\u003eW-line represents the vertical line passing through the ear canal. WSD indicates the horizontal distance from the posterosuperior corner of S1 to the W-line. WHD is the horizontal distance from the center of the femoral heads to the W-line.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/ec57398dd91e698e15e21785.png"},{"id":108631090,"identity":"95ea13c1-4483-48dc-9b01-b9bd239fb6cf","added_by":"auto","created_at":"2026-05-06 16:40:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":473503,"visible":true,"origin":"","legend":"\u003cp\u003eRadiographic sagittal spinopelvic parameters include: cervical lordosis (CL), the angle between the lower endplate of C2 and C7; thoracic kyphosis (TK), the angle between the upper endplate of T4 and the lower endplate of T12; lumbar lordosis (LL), the angle between the upper endplate of L1 and S1; sacral slope (SS), the angle between the sacral endplate and the horizontal line; pelvic tilt (PT), the angle between the line from the middle of the sacral plate to the hip axis and the vertical line; pelvic incidence (PI), the angle between the line perpendicular to the midpoint of the sacral plate and the line connecting this to the midpoint of the hip axis; sagittal vertical axis (SVA), the horizontal offset between the center of C7 and the plumb line drawn from the posterosuperior corner of S1, and T1 pelvic angle (TPA), the angle between the line from the axis of the femoral head to the center of T1 and the line from the axis of the femoral head to the midpoint of S1 endplate.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/c31e5138221a72a2f6ba7bc4.png"},{"id":108631095,"identity":"bbb09068-35fd-41a5-ba64-ad482e634136","added_by":"auto","created_at":"2026-05-06 16:40:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":412964,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) curve for predicting excellent improvement in ODI based on N-FBA values representing W-line positions.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/53414c5c2d3ca08768fca312.png"},{"id":108631092,"identity":"df38824d-d427-4097-840c-1848cba971b3","added_by":"auto","created_at":"2026-05-06 16:40:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1863970,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of W-line positions among patients in group A (N-FBA ³ 0.65), Group B (-0.65 \u0026lt; N-FBA \u0026lt; 0.65), and Group C (N-FBA £-0.65).\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/717176593867d22cb94c819a.png"},{"id":108631091,"identity":"52d004d8-4fa5-45b7-bd20-5ae30d6c6875","added_by":"auto","created_at":"2026-05-06 16:40:40","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":374364,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves showing PJF-free survival among Groups A, B, and C (1 = Group A; 2= Group B; 3= Group C).\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/78a404311aab85f5268f754b.png"},{"id":108631093,"identity":"37facbfc-a886-4b95-bb17-0620592411bb","added_by":"auto","created_at":"2026-05-06 16:40:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":4770089,"visible":true,"origin":"","legend":"\u003cp\u003eA 68 year-old female patient with adult spinal deformity (a) underwent long-fusion surgery with instrumentation (T10‒L5). The patient demonstrated a well-erect posture immediately postoperatively (b) but developed proximal junctional failure at the 4th month follow-up (c). After comprehensive evaluation, revision surgery (T5‒L5) was performed, resulting in mild forward trunk inclination (d) and W-line passing through the periphery of the hip joints. The patient showed excellent ODI improvement post-revision and maintained it at 3-year follow-up (e).\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/da54d45ec0fec1a48d918fdf.png"},{"id":108986880,"identity":"782b32e3-7e2a-4931-9b81-71011c842d1e","added_by":"auto","created_at":"2026-05-11 12:56:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9397223,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9388030/v1/6df3f392-e406-44e2-854b-58d4674d7d4a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Optimal Full-body Alignment for Adult Spinal Deformity after Surgical Treatment--A clinical and radiographic analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith increasing life expectancy, the prevalence of adult spinal deformity (ASD) has become common among individuals aged over 65 years, affecting approximately 68% of this population.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Previous studies have demonstrated that patients with ASD undergoing surgical intervention show statistically significant improvements in all health-related quality of life (HRQoL) measures compared with those receiving non-surgical treatment.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Long-segment fusion (\u0026ge;5 vertebrae) with instrumentation has been shown to be an effective treatment for ASD.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] However, these complex procedures are often associated with various complications,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] among which proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) account for a substantial proportion.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Recent studies have reported that full-spinal realignment,[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] sagittal vertical axis, and global sagittal alignment (GSA; thoracic kyphosis\u0026thinsp;+\u0026thinsp;lumbar lordosis\u0026thinsp;+\u0026thinsp;pelvic incidence\u0026thinsp;\u0026gt;\u0026thinsp;45\u0026deg;[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]) are significantly correlated with HRQoL and the occurrence of PJK/PJF in patients with ASD who have undergone long-fusion surgery.\u003c/p\u003e \u003cp\u003eIn ASD, sagittal balance describes the optimal spinopelvic alignment in the sagittal plane, resulting from the interaction between the spine and lower limbs via the pelvis.[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The center-of-gravity line ( W-line in this study), which passes vertically through the ear canal,[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] is influenced by full-body alignment (FBA) and may play an important role in both HRQoL and overall balance. However, few studies have investigated the optimal FBA in patients with ASD who have undergone surgical correction. Therefore, the purpose of this study was to determine the optimal postoperative FBA based on perioperative HRQoL improvement in patients with ASD who underwent long-fusion surgery with instrumentation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e Prior to the study, approval was obtained from the Clinical Research Ethics Committee of our hospital. We retrospectively reviewed data from patients with ASD treated at our institution between March 2014 and April 2019, with a minimum follow-up of 24 months. All patients underwent long-segment fusion (\u0026ge;\u0026thinsp;5 vertebrae) with titanium alloy screws and two-rod constructs via a posterior-only approach.\u003c/p\u003e \u003cp\u003eInclusion criteria were: ASD patients with 1) age\u0026thinsp;\u0026ge;\u0026thinsp;45 years; 2) complete clinical and radiographic data; and 3) follow-up duration\u0026thinsp;\u0026ge;\u0026thinsp;24 months.\u003c/p\u003e \u003cp\u003eExclusion criteria included: prior spine surgery, spinal neoplasms, spinal tuberculosis, spinal or pelvic trauma, non-structural curvature, prior lower joints surgery, or leg length discrepancy\u0026thinsp;\u0026ge;\u0026thinsp;2 cm.\u003c/p\u003e \u003cp\u003eThe W-line was defined as the plumb line passing through the ear canal. The horizontal distance between the W-line and the center of the femoral head was defined as the WHD, which was recorded as negative (-) when the W-line was posterior to the femoral head and positive (+) when anterior. The horizontal distance between the W-line and the posterosuperior corner of S1 was defined as WSD, recorded similarly. The numeric W-line, representing full-body alignment (N-FBA), was calculated using the equation N-FBA\u0026thinsp;=\u0026thinsp;WHD/WSD. Details are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo minimize misclassification of PJK, only PJF was recorded, defined as a fracture of the upper instrumented vertebra (UIV) or UIV\u0026thinsp;+\u0026thinsp;1, or evidence of pedicle screw loosening, dislodgment, or pullout at the UIV.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Demographic data (age, sex, body mass index (BMI), comorbidities, operative details (duration, blood loss, UIV, lower instrumented vertebra [LIV], the number of fused vertebrae) were recorded in detail. Postoperatively, follow-up time, PJF-free survival time, and complications during follow-up were documented. HRQoL questionnaires and radiographs were collected preoperatively, 3 months postoperatively, and at the final follow-up.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHRQoL evaluation\u003c/h2\u003e \u003cp\u003eHRQoL was assessed using the visual analog scale (VAS) and Oswestry Disability Index (ODI). The ODI consists of 10 sections: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex, social life, and traveling. When all 10 sections were completed, the score was calculated as follows: total score out of total possible scores \u0026times; 100%. If some sections were missing (or not applicable), the score was calculated as follows: [total score/(5 \u0026times; number of questions answered)] \u0026times; 100. The improvement in ODI (I-ODI) perioperatively was calculated between the preoperative and final postoperative follow-ups as follows: I-ODI = [(Post-ODI \u0026ndash; Pre-ODI) / (50 - Pre-ODI)] \u0026times; 100%. An I-ODI \u0026ge; of 50% was defined as excellent improvement.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRadiographic evaluation\u003c/h3\u003e\n\u003cp\u003eRadiographic data were obtained from full-length coronal and sagittal radiographs taken in a free-standing posture, with the upper limbs supported, shoulders forward flexed at 30\u0026deg;, and elbows slightly flexed.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Measurements were performed using Surgimap Software (version: 2.3.2.1; Spine Software, New York, NY, USA).\u003c/p\u003e \u003cp\u003eMeasured parameters are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, including cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), and T1 pelvic angle (TPA). Kyphosis was recorded as positive (+) and lordosis as negative (-). PI-LL was calculated as PI minus LL. All measurements were performed by an independent radiographic team.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables with normal distribution were expressed as mean \u0026plusmn; standard deviation (SD), and non-normally distributed data as medians. Categorical variables were expressed as counts or percentages. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal N-FBA threshold for predicting excellent I-ODI (\u0026ge;\u0026thinsp;50%), and the area under the curve (AUC) with 95% confidence intervals (CI) was calculated. Patients were categorized into Groups A, B, and C according to the optimal N-FBA value. Kaplan-Meier analysis and log-rank tests were used to compare PJF-free survival among groups. Chi-square or Fisher\u0026rsquo;s exact tests were used for categorical variables, and one-way ANOVA for continuous variables. Statistical analyses were performed using IBM SPSS (Mac version 26.0, IBM Corp., Armonk, NY, USA). A two-sided \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 190 patients with ASD underwent long-fusion surgery at our hospital between March 2014 and April 2019. However, 84 patients were excluded, including 38 who underwent prior surgeries in the spine or hip joints and 46 with a follow-up period of less than 18 months. Ultimately, 106 patients (male: 21, female: 85) were included, with a mean age of 64.48 years (SD 8.88; range,45‒89 years) and a median follow-up of 51.68 months (SD 15.6, 24\u0026ndash;87 months). Overall, 48 patients showed excellent improvement in ODI (I-ODI \u0026ge;50%) from preoperative to final postoperative follow-up; the remaining 58 patients showed moderate improvement (\u0026ge;25% to \u0026lt;\u0026thinsp;50%). Sixteen patients developed PJF (15.09%; three patients with pedicle screw dislodgment, pullout of instrumentation at the UIV, and 13 patients with fracture at the UIV and/or UIV\u0026thinsp;+\u0026thinsp;1) during follow-up. Fourteen patients (87.5%) developed PJF within 24 months after surgery, while two developed at 36 and 43 months, respectively, during follow-up.\u003c/p\u003e \u003cp\u003eAccording to the I-ODI 50% criterion, ROC analysis determined an optimal threshold value of 0.65 for N-FBA at the 3rd month postoperatively (sensitivity, 73.8%; specificity, 71.4%; area under the curve, 0.732; 95% CI 0.618‒0.917; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Because the positions of the W-line relative to the S1 or hip joints were expressed as positive (+) or negative (-) values for N-FBA, the optimal threshold of N-FBA was recorded as \u0026plusmn; 0.65. All patients were assigned to groups A (N-FBA\u0026ge;0.65), B (-0.65\u0026thinsp;\u0026lt;\u0026thinsp;N-FBA\u0026thinsp;\u0026lt;\u0026thinsp;0.65), and C (N-FBA\u0026le;-0.65) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). There were 34, 49, and 23 patients in Groups A, B, and C, respectively. Postoperatively, 4, 31, and 13 patients showed excellent improvement in ODI (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and 12, 3, and 1 patients developed PJF in Groups A, B, and C, respectively. There were no significant differences among the three groups in terms of age, BMI, sex, comorbidities, or follow-up duration (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Radiographic data obtained preoperatively, at the 3rd month, and at the final postoperative follow-up are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Patients in group A had the smallest PI (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029), TPA (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008), PI-LL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017), and SVA (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) preoperatively. Although there were no perioperative differences in the correction of spinopelvic parameters (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), patients in the three groups had significantly different spinopelvic parameters, including PT (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), SVA (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), TPA(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PI-LL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) at the 3rd month postoperatively. At the final follow-up, spinopelvic parameters, including TK (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014), LL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023), PT (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), PI-LL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and SVA (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), were significantly different among the three groups. The Kaplan-Meier curve and log-rank test revealed significant differences in PJF-free survival time among the three groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011, log-rank test), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. ODI[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and VAS[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] scores in all patients improved significantly after surgery (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); however, group B demonstrated the best outcomes at the final follow-up. Details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of demographic data in the group A, B, and C.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistical\u003c/p\u003e \u003cp\u003eValues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(76.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(83.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18(78.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.724*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.79\u0026plusmn;9.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.4\u0026plusmn;8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.91\u0026plusmn;6.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.444\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean BMI, kg/m2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.58\u0026plusmn;10.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.17\u0026plusmn;10.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.13\u0026plusmn;7.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.568\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(71.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(77.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.396*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up, month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.29\u0026plusmn;16.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.26\u0026plusmn;14.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.04\u0026plusmn;16.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.140\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eMean values are presented as the mean\u0026plusmn;SD. * Chi-squared values. \u0026dagger; f-values.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of the radiographic data among the group A, B, and C.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ef-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-CL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-13.25 \u0026plusmn; 17.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-19.88 \u0026plusmn; 19.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-17.85 \u0026plusmn; 16.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-CL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-7.52 \u0026plusmn; 16.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-10.45 \u0026plusmn; 13.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.97 \u0026plusmn; 17.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-CL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-10.56 \u0026plusmn; 13.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-16.8 \u0026plusmn; 11.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-13.77 \u0026plusmn; 15.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-TK (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.85 \u0026plusmn; 13.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.26 \u0026plusmn; 13.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.58 \u0026plusmn; 9.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-TK (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.18 \u0026plusmn; 10.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.92 \u0026plusmn; 11.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.54 \u0026plusmn; 7.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-TK (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.87 \u0026plusmn; 10.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.41 \u0026plusmn; 11.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.89 \u0026plusmn; 9.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-27.37 \u0026plusmn; 20.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-17.63 \u0026plusmn; 21.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-25.71 \u0026plusmn; 16.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-41.83 \u0026plusmn; 11.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-35.63 \u0026plusmn; 12.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-38.08 \u0026plusmn; 10.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-44.60 \u0026plusmn; 12.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-32.08 \u0026plusmn; 13.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-42.80 \u0026plusmn; 11.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.023\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-SS (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.66 \u0026plusmn; 13.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.14 \u0026plusmn; 13.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.03 \u0026plusmn; 10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-SS (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.20 \u0026plusmn; 10.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.55 \u0026plusmn; 10.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.39 \u0026plusmn; 9.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-SS (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.32 \u0026plusmn; 9.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.43 \u0026plusmn; 10.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.36 \u0026plusmn; 8.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-PT (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.80 \u0026plusmn; 11.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.53 \u0026plusmn; 12.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.15 \u0026plusmn; 9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-PT (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.46 \u0026plusmn; 8.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.24 \u0026plusmn; 9.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.98 \u0026plusmn; 8.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.004\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-PT (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.84 \u0026plusmn; 9.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.14 \u0026plusmn; 10.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.98 \u0026plusmn; 10.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-PI (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.46 \u0026plusmn; 9.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.68 \u0026plusmn; 11.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.64 \u0026plusmn; 12.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.029\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-PI (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.93 \u0026plusmn; 9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.79 \u0026plusmn; 11.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.36 \u0026plusmn; 12.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.026\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop- PI-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.45 \u0026plusmn; 21.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.15 \u0026plusmn; 19.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.92 \u0026plusmn; 15.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.017\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop- PI-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.09 \u0026plusmn; 10.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.16 \u0026plusmn; 12.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.27 \u0026plusmn; 9.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U- PI-LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.11 \u0026plusmn; 9.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.92 \u0026plusmn; 11.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.06 \u0026plusmn; 9.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-TPA (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.24 \u0026plusmn; 11.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.42 \u0026plusmn; 13.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.41 \u0026plusmn; 10.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.008\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-TPA (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.99 \u0026plusmn; 5.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.81 \u0026plusmn; 9.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.82 \u0026plusmn; 7.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-TPA (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.78 \u0026plusmn; 10.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.86 \u0026plusmn; 10.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.83 \u0026plusmn; 11.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-SVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.08 \u0026plusmn; 36.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.49 \u0026plusmn; 60.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.34 \u0026plusmn; 43.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-SVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-7.72 \u0026plusmn; 42.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.24 \u0026plusmn; 24.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.76 \u0026plusmn; 14.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF/U-SVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.97 \u0026plusmn; 30.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.67 \u0026plusmn; 23.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.6 \u0026plusmn; 19.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eMean values are presented as the mean \u0026plusmn; SD. Preop- and postop- indicate pre-operation and post- operation; CL, cervical lordosis; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; LL, lumbar lordosis; SS, sacral slope; PT, pelvic tilt; PI, pelvic incidence; PI-LL, mismatch of pelvic incidence minus lumbar lordosis; TPA, T1 pelvic angle; SVA, sagittal vertical axis; F/U, final follow-up. \u0026Dagger; statistical differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of the correction in radiographic data perioperatively and the surgical data among the group A, B, and C.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistical\u003c/p\u003e \u003cp\u003eValues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean d-TK(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.85 \u0026plusmn; 9.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.67 \u0026plusmn; 9.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8 \u0026plusmn; 11.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.633\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean d-LL(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.82 \u0026plusmn; 14.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.99 \u0026plusmn; 17.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.04 \u0026plusmn; 14.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.029\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean d-SVA(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-31.47 \u0026plusmn; 53.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-44.09 \u0026plusmn; 53.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-31.92 \u0026plusmn; 44.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.693\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean d-TPA(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-9.32 \u0026plusmn; 8.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9.39 \u0026plusmn; 9.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.68 \u0026plusmn; 6.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.828\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.440\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Timing (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e276.25 \u0026plusmn; 58.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e289.55 \u0026plusmn; 45.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267.57 \u0026plusmn; 64.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.220\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Blood loss(ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e495.48 \u0026plusmn; 167.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e527.75 \u0026plusmn; 174.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e484.76 \u0026plusmn; 149.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.596\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Segments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.94 \u0026plusmn; 1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.69 \u0026plusmn; 2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.96 \u0026plusmn; 2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.304\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUIV(T10 or above), n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (73.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (65.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.722*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLIV(S1/S2/ilium), n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.302*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.316\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE-ODI, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.984*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePJF, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.975*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eMean values are presented as the mean \u0026plusmn; SD. d-, indicates the correction of those radiographic data; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; LL, lumbar lordosis; SVA, sagittal vertical axis; TPA, T1 pelvic angle; UIV, upper instrumented vertebra; LIV, lower instrumented vertebra; E-ODI, excellent improvement in Oswestry disability index; PJF, proximal junctional failure. * Chi-squared values. \u0026dagger; f-values. \u0026Dagger; statistical differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of clinical outcomes among three groups at pre-, post-operation and the final follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eODI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF/U\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ef-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost-op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eF/U\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ef-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e58.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e23.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e18.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ef-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.018\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003eNote: \u0026Dagger; indicates statistical differences.\u003c/p\u003e \u003cp\u003eAbbreviations: VAS, visual analogue scale; ODI, Oswestry disability index; Pre-op, pre-operation; Post-op, post- operation; F/U, final follow-up. \u0026Dagger; statistical differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA series of full-spine radiographs of a representative patient is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current literature evaluating sagittal spinal alignment in the management of ASD has been primarily based on the Schwab criteria and related modifiers.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] These spinal curvatures interact to maintain the virtual center of gravity (VCG) within the normal range in standing posture.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Accordingly, patients with ASD whose VCG is restored after surgery often show significant improvement in HRQoL and reduced risk of biomechanical complications such as PJK or PJF. However, few studies have investigated optimal FBA in patients with ASD following deformity correction surgery.\u003c/p\u003e \u003cp\u003eIn this study, after defining the ear-canal plumb line ( W-line) as the FBA,[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] 106 patients with ASD were subdivided into three groups: N-FBA \u0026ge; 0.65 (W-line located completely behind the sacrum or deviating from the hip joints), -0.65\u0026thinsp;\u0026lt;\u0026thinsp;N-FBA\u0026thinsp;\u0026lt;\u0026thinsp;0.65 (W-line passing through the hip joints), and N-FBA \u0026le; -0.65 (W-line positioned within the posterior pelvis). Comparisons among the three groups revealed significant differences in HRQoL scores and radiographic parameters both pre- and postoperatively. More patients in groups B and C showed excellent improvement in HRQoL scores. Although preoperative HRQoL scores were similar among the three groups, both VAS and ODI scores were significantly better in groups B and C at the final follow-up.\u003c/p\u003e \u003cp\u003eSpinopelvic parameters, including PT, SVA, TPA, and PI-LL, are strongly associated with HRQoL in patients with ASD.[\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Patients with ASD with low PT (\u0026lt;\u0026thinsp;20\u0026deg;) postoperatively may have poorer HRQoL,[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] while those with postoperative TPA \u0026le; 20\u0026deg; tend to have better spinopelvic alignment and improved ODI.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Additionally, in patients with ASD undergoing long-fusion surgery, the optimal mismatch (PI-LL) was 10\u0026deg;‒20\u0026deg;.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] In this study, patients in group B and C had larger PT (18.24\u0026deg; \u0026plusmn; 9.6\u0026deg;), SVA (32.24 mm \u0026plusmn; 24.5 mm), TPA (17.81\u0026deg; \u0026plusmn; 9.56\u0026deg;), and PI-LL (12.16\u0026deg; \u0026plusmn; 12.3\u0026deg;) at the 3rd month postoperatively, consistent with previous findings. Furthermore, patients in groups B and C demonstrated greater postoperative improvements in HRQOL and maintained better outcomes at the final follow-up.\u003c/p\u003e \u003cp\u003ePJF significantly worsens HRQoL in patients with ASD.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Previous studies demonstrated that spinopelvic risk factors for PJK/PJF included larger TK, SVA, global sagittal alignment (GSA, PI\u0026thinsp;+\u0026thinsp;TK+LL\u0026thinsp;\u0026gt;\u0026thinsp;45\u0026deg;) and PI.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] In the present study, although perioperative correction of spinopelvic parameters was similar among the three groups, patients in the group A‒those with the W-line located completely behind the sacrum (22 cases) or deviating forward from the hip joints (1 case)‒had the smallest PI, SVA, TPA, and PI-LL at the 3rd month postoperatively. Moreover, group A showed the highest incidence of PJF (12/22 \u003cem\u003evs.\u003c/em\u003e 3/46 \u003cem\u003evs.\u003c/em\u003e 1/22, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the shortest PJF-free survival time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011, log-rank test). Carender \u003cem\u003eet al.\u003c/em\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] reported that a lower PI is significantly correlated with PJF, and based on our findings, this may be due to suboptimal W-line positioning after surgery.\u003c/p\u003e \u003cp\u003eWith aging, the human torso naturally inclines forward, leading to gradual increases in SVA, PI-LL, and TPA.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Recent evidence suggests that corrections in radiographic parameters should consider both patient age and PI in ASD surgery.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] The mean age in our study was approximately 65 years (45‒79 years). Spinopelvic alignment in group A may have been inconsistent with age-related biomechanical adaptation, as 35.3% (12/34) of these patients developed PJF within 24 months postoperatively. Conversely, patients in groups B and C‒with mildly inclined posture and W-line passing through the hip joints‒had a much lower incidence of PJF and better ODI and VAS outcomes. Therefore, maintaining the W-line around the hip joints postoperatively may represent the most physiologically balanced spine-pelvis-hip alignment in ASD correction.\u003c/p\u003e \u003cp\u003eThis study had some limitations. The sample size and retrospective design may limit the generalizability of our findings. Although significant postoperative changes in full-body alignment were observed, surgical strategies were not analyzed, which was beyond the study\u0026rsquo;s scope. Future prospective studies with larger cohorts and long-term follow-up are needed to confirm the optimal full-body alignment in ASD correction.\u003c/p\u003e \u003cp\u003eIn conclusion, for patients with ASD, maintaining the W-line around the hip joints may provide optimal full-body alignment after long-segment fusion surgery. Conversely, a postoperative W-line located entirely within the pelvis or deviating forward from the hip joints may increase the risk of HRQoL deterioration and PJF development during follow-up.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Ethics Committee of Chinese PLA General Hosptial with the approval number S2024-556-01 and was also registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2400090679). Written informed consent was obtained from all participants for publication of identifiable images in this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from the patient for publication of this research and anyaccompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eEach author certifies that neither he, nor any member of his immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was sponsored by the postdoctoral foundation of affiliated hospital of Jining medical university (321210), the National Key Research and Development Program Fund of China (2020YFC1107404), the Youth Science Fund of National Natural Science Foundation of China (82102184), and Fund projects in the field of Foundation Strengthening Program (2020-JCJQ-JJ-356).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. ZFZ contributed to the study design. GQZ, YQZ, ZFZ performed the surgery. HY and THW were responsible for the collection and analysis of the data, as well as writing and revising the manuscript for important intellectual content. JCL and CX were contributed to the critical revision of the article. All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the participants who generously agreed to be interviewed for this current study. Z. F. Zhang appreciate the instructions given by the professor Y. Wang, working in the Chinese PLA general hospital, during his PhD.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/01.brs.0000160842.43482.cd\u003c/span\u003e\u003cspan address=\"/10.1097/01.brs.0000160842.43482.cd\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQiu GX. Scoliosis in China: History and Present Status. Chin Med J (Engl). 2017;130(21):2521\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.4103/0366-6999.217081\u003c/span\u003e\u003cspan address=\"/10.4103/0366-6999.217081\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdogwa O, Karikari IO, Elsamadicy AA, Sergesketter AR, Galan D, Bridwell KH. Correlation of 2-year SRS-22r and ODI patient-reported outcomes with 5-year patient-reported outcomes after complex spinal fusion: a 5-year single-institution study of 118 patients. J Neurosurg Spine. 2018;29(4):422\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.3171/2018.2.SPINE171142\u003c/span\u003e\u003cspan address=\"/10.3171/2018.2.SPINE171142\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeles AR, Mattei TA, Righesso O, Falavigna A. Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature. Global Spine J. 2017;7(2):170\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1177/2192568217699182\u003c/span\u003e\u003cspan address=\"/10.1177/2192568217699182\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V. Adult spinal deformity. Lancet. 2019;394(10193):160\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1016/s0140-6736(19)31125-0\u003c/span\u003e\u003cspan address=\"/10.1016/s0140-6736(19)31125-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang HC, Yu HL, Yang HF, Sun PF, Wu HT, Zhan Y, Wang Z, Xiang LB. Short-segment decompression/fusion versus long-segment decompression/fusion and osteotomy for Lenke-Silva type VI adult degenerative scoliosis. Chin Med J (Engl). 2019;132(21):2543\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/CM9.0000000000000474\u003c/span\u003e\u003cspan address=\"/10.1097/CM9.0000000000000474\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugawara R, Takeshita K, Takahashi J, Arai Y, Watanabe K, Yamato Y, Oba H, Matsumoto M. The complication trends of adult spinal deformity surgery in Japan - The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017. J Orthop Sci;S. 2020;0949\u0026ndash;2658(20):30145\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1016/j.jos.2020.05.006\u003c/span\u003e\u003cspan address=\"/10.1016/j.jos.2020.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharosky S, Guigui P, Blamoutier A, Roussouly P, Chopin D, Study Group on S. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976). 2012;37(8):693\u0026ndash;700. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0b013e31822ff5c1\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0b013e31822ff5c1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyun SJ, Lee BH, Park JH, Kim KJ, Jahng TA, Kim HJ. Proximal Junctional Kyphosis and Proximal Junctional Failure Following Adult Spinal Deformity Surgery. Korean J Spine. 2017;14(4):126\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.14245/kjs.2017.14.4.126\u003c/span\u003e\u003cspan address=\"/10.14245/kjs.2017.14.4.126\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafage R, Schwab F, Glassman S, Bess S, Harris B, Sheer J, Hart R, Line B, Henry J, Burton D, Kim H, Klineberg E, Ames C, Lafage V, International Spine Study G. Age-Adjusted Alignment Goals Have the Potential to Reduce PJK. Spine (Phila Pa 1976). 2017;42(17):1275\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000002146\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000002146\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36(1):E60\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0b013e3181eeaee2\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0b013e3181eeaee2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavarese LG, Menezes-Reis R, Bonugli GP, Herrero C, Defino HLA, Nogueira-Barbosa MH. Spinopelvic sagittal balance: what does the radiologist need to know? Radiol Bras. 2020;53(3):175\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1590/0100-3984.2019.0048\u003c/span\u003e\u003cspan address=\"/10.1590/0100-3984.2019.0048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishida N, Izumiyama T, Asahi R, Iwanaga H, Yamagata H, Mihara A, Nakashima D, Imajo Y, Suzuki H, Funaba M, Sugimoto S, Fukushima M, Sakai T. Changes in the global spine alignment in the sitting position in an automobile. Spine J. 2020;20(4):614\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1016/j.spinee.2019.11.016\u003c/span\u003e\u003cspan address=\"/10.1016/j.spinee.2019.11.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu CJ, Zhu ZQ, Wang KF, Duan S, Xu S, Liu HY. Radiological Analysis of Thoracolumbar Junctional Degenerative Kyphosis in Patients with Lumbar Degenerative Kyphosis. Chin Med J (Engl). 2017;130(21):2535\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.4103/0366-6999.217090\u003c/span\u003e\u003cspan address=\"/10.4103/0366-6999.217090\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe Huec JC, Saddiki R, Franke J, Rigal J, Aunoble S. Equilibrium of the human body and the gravity line: the basics. Eur Spine J. 2011;20(Suppl 5):558\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1007/s00586-011-1939-7\u003c/span\u003e\u003cspan address=\"/10.1007/s00586-011-1939-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuntz Ct, Levin LS, Ondra SL, Shaffrey CI, Morgan CJ. Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J Neurosurg Spine. 2007;6(2):104\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.3171/spi.2007.6.2.104\u003c/span\u003e\u003cspan address=\"/10.3171/spi.2007.6.2.104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuntz Ct, Shaffrey CI, Ondra SL, Durrani AA, Mummaneni PV, Levin LS, Pettigrew DB. (2008) Spinal deformity: a new classification derived from neutral upright spinal alignment measurements in asymptomatic juvenile, adolescent, adult, and geriatric individuals. Neurosurgery;63(3 Suppl):25\u0026ndash;39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1227/01.NEU.0000313120.81565.D7\u003c/span\u003e\u003cspan address=\"/10.1227/01.NEU.0000313120.81565.D7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2. nd.(2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976);30(14):1643-9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/01.brs.0000169451.76359.49\u003c/span\u003e\u003cspan address=\"/10.1097/01.brs.0000169451.76359.49\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarks M, Stanford C, Newton P. Which lateral radiographic positioning technique provides the most reliable and functional representation of a patient's sagittal balance? Spine (Phila Pa 1976). 2009;34(9):949\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0b013e318199650a\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0b013e318199650a\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu H, Wang Q, Fan Y, Qi D, Wang T, Li B, Huang Y, Wang Z, Xue C, Zheng G. Vertebral Column Decancellation for Correcting Cervicothoracic Kyphotic Deformity in Patients With Ankylosing Spondylitis. Orthop Surg. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1111/os.14306\u003c/span\u003e\u003cspan address=\"/10.1111/os.14306\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwab F, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D, DeWald C, Mehdian H, Shaffrey C, Tribus C, Lafage V. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37(12):1077\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0b013e31823e15e2\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0b013e31823e15e2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuval-Beaupere G, Schmidt C, Cosson P. A Barycentremetric study of the sagittal shape of spine and pelvis: the conditions required for an economic standing position. Ann Biomed Eng. 1992;20(4):451\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1007/BF02368136\u003c/span\u003e\u003cspan address=\"/10.1007/BF02368136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/01.brs.0000152379.54463.65\u003c/span\u003e\u003cspan address=\"/10.1097/01.brs.0000152379.54463.65\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProtopsaltis TS, Lafage R, Smith JS, Passias PG, Shaffrey CI, Kim HJ, Mundis GM, Ames CP, Burton DC, Bess S, Klineberg E, Hart RA, Schwab FJ, Lafage V, International Spine Study G.. (2018) The Lumbar Pelvic Angle, the Lumbar Component of the T1 Pelvic Angle, Correlates With HRQOL, PI-LL Mismatch, and it Predicts Global Alignment. Spine (Phila Pa 1976);43(10):681-7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000002346\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000002346\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakemoto M, Boissiere L, Vital JM, Pellise F, Perez-Grueso FJS, Kleinstuck F, Acaroglu ER, Alanay A, Obeid I. Are sagittal spinopelvic radiographic parameters significantly associated with quality of life of adult spinal deformity patients? Multivariate linear regression analyses for pre-operative and short-term post-operative health-related quality of life. Eur Spine J. 2017;26(8):2176\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1007/s00586-016-4872-y\u003c/span\u003e\u003cspan address=\"/10.1007/s00586-016-4872-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanno T, Hasegawa T, Yamato Y, Kobayashi S, Togawa D, Oe S, Mihara Y, Matsuyama Y. (2016) T1 Pelvic Angle Is a Useful Parameter for Postoperative Evaluation in Adult Spinal Deformity Patients. Spine (Phila Pa 1976);41(21):1641-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000001608\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000001608\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599\u0026ndash;606. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0b013e3181aad219\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0b013e3181aad219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBai H, Li Y, Liu C, Zhao Y, Zhao X, Lei W, Feng Y, Wu Z. (2020) Surgical Management of Degenerative Lumbar Scoliosis Associated With Spinal Stenosis: Does the PI-LL Matter? Spine (Phila Pa 1976);45(15):1047\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000003465\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000003465\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang HC, Zhang ZF, Wang ZH, Cheng JY, Wu YC, Fan YM, Wang TH, Wang Z. Optimal Pelvic Incidence Minus Lumbar Lordosis Mismatch after Long Posterior Instrumentation and Fusion for Adult Degenerative Scoliosis. Orthop Surg. 2017;9(3):304\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1111/os.12343\u003c/span\u003e\u003cspan address=\"/10.1111/os.12343\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarender CN, Morris WZ, Poe-Kochert C, Thompson GH, Son-Hing JP, Liu RW. (2016) Low Pelvic Incidence Is Associated With Proximal Junctional Kyphosis in Patients Treated With Growing Rods. Spine (Phila Pa 1976);41(9):792-7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000001352\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000001352\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang ZF, Qi DB, Wang TH, Wang Z, Zheng GQ, Wang Y. Correlation of Acetabular Anteversion and Thoracic Kyphosis Postoperatively with Proximal Junctional Failure in Adult Spinal Deformity Fused to Pelvis. Orthop Surg. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1111/os.13159\u003c/span\u003e\u003cspan address=\"/10.1111/os.13159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J. (2006) The vertical projection of the sum of the ground reactive forces of a standing patient is not the same as the C7 plumb line: a radiographic study of the sagittal alignment of 153 asymptomatic volunteers. Spine (Phila Pa 1976);31(11):E320-5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/01.brs.0000218263.58642.ff\u003c/span\u003e\u003cspan address=\"/10.1097/01.brs.0000218263.58642.ff\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIyer S, Lenke LG, Nemani VM, Albert TJ, Sides BA, Metz LN, Cunningham ME, Kim HJ. (2016) Variations in Sagittal Alignment Parameters Based on Age: A Prospective Study of Asymptomatic Volunteers Using Full-Body Radiographs. Spine (Phila Pa 1976);41(23):1826-36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000001642\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000001642\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProtopsaltis TS, Soroceanu A, Tishelman JC, Buckland AJ, Mundis GM Jr., Smith JS, Daniels A, Lenke LG, Kim HJ, Klineberg EO, Ames CP, Hart RA, Bess S, Shaffrey CI, Schwab FJ, Lafage V, International Spine Study G. (2020) Should Sagittal Spinal Alignment Targets for Adult Spinal Deformity Correction Depend on Pelvic Incidence and Age? Spine (Phila Pa 1976);45(4):250-7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/10.1097/BRS.0000000000003237\u003c/span\u003e\u003cspan address=\"/10.1097/BRS.0000000000003237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adult spinal deformity, Oswestry disability index, Full-body alignment, Proximal junctional failure, W-line.","lastPublishedDoi":"10.21203/rs.3.rs-9388030/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9388030/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the optimal full-body alignment (FBA) for adult spinal deformity (ASD) underwent deformity surgical procedures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients with ASD who underwent long-segment fusion involving the thoracolumbar spine were retrospectively reviewed. The FBA was converted to numeric value by the formula: N-FBA\u0026thinsp;=\u0026thinsp;WHD/WSD. HRQoL was evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) at baseline and final follow-up. All patients were assigned into the group A, B, and C by the optimal N-FBA. A Kaplan-Meier curve and log-rank test was used to analyze the differences in PJF-free survival time among groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 106 patients were included. According to the excellent improvement in Oswestry disability index (E-ODI\u0026ge;50%) peri-operatively, ROC analysis determined the optimal value of 0.65 for N-FBA (sensitivity\u0026thinsp;=\u0026thinsp;73.8%, specificity\u0026thinsp;=\u0026thinsp;71.4%, AUC\u0026thinsp;=\u0026thinsp;0.732, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Because the W-line were expressed as positive (+) or negative (-) values, the optimal threshold of N-FBA was recorded as \u0026plusmn; 0.65. There were 34, 49, and 23 patients in the group A (N-FBA\u0026ge;0.65), B (-0.65\u0026thinsp;\u0026lt;\u0026thinsp;N-FBA\u0026thinsp;\u0026lt;\u0026thinsp;0.65), and C (N-FBA\u0026le;-0.65) respectively. Patients in the group A showed the highest incidence of PJF (12/22 vs. 3/46 vs. 1/22, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the shortest PJF-free survival time (P\u0026thinsp;=\u0026thinsp;0.011, log-rank test).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe mild inclining posture forwardly, W-line going through hip joints peripherally, may be the optimal full-body alignment for ASD patients who have undergone long-fusion surgical procedures.\u003c/p\u003e","manuscriptTitle":"The Optimal Full-body Alignment for Adult Spinal Deformity after Surgical Treatment--A clinical and radiographic analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 16:40:35","doi":"10.21203/rs.3.rs-9388030/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10d57e42-9296-44cd-9e85-efa9a83e23ee","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-11T11:16:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T16:18:43+00:00","index":35,"fulltext":""},{"type":"reviewerAgreed","content":"126777342864790225797865359632628519389","date":"2026-04-30T10:01:45+00:00","index":33,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T12:31:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 16:40:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9388030","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9388030","identity":"rs-9388030","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}