Evaluation of Proximal and Distal Junctional Kyphosis After Posterior Instrumentation and Fusion in Scheuermann’s Kyphosis

Evaluation of Proximal and Distal Junctional Kyphosis After Posterior Instrumentation and Fusion in Scheuermann’s Kyphosis | 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 Evaluation of Proximal and Distal Junctional Kyphosis After Posterior Instrumentation and Fusion in Scheuermann’s Kyphosis Murat BAKIR, Hakan Serhat YANIK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6977064/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: To evaluate the frequency, risk factors and effects of distal junction kyphosis (DJK) and proximal junction kyphosis (PJK), which are common in patients who undergoposterior instrumentation and fusion due to Scheuerman kyphosis (SK), on patient quality of life. Patients and Methods: Sixty-threepatients who underwent posterior instrumentation and fusion due to Scheuerman kyphosis between 2012 and 2017 at The Health Sciences University, Haydarpaşa Numune Training and Research Hospital Orthopedics and Traumatology Clinic and who served asregular controls were retrospectively analyzed. All patients were operated on by the same surgical team. Twenty-sixof the patients were male,and 37 were female. The mean age was 26.83 ± 9.08 years (range: 17–50 years). Patients who had a follow-up period of less than 2 years, had intraspinal pathology on preoperative MR imaging, had kyphosis forother reasons and had previously undergone spinal surgery or combined surgery (anterior-posterior) were excluded. The patients were divided intotwo groups according to the detection of PJK and DJK. PJK developed in 22 patients, DJK in three patients, and both PJK and DJK in two patients. Results: The mean age of patients (36.4±12.54 years) with DJK was significantly greater than that of patients without DJK (p 0.05). There was no statistically significant difference between the patients who developed PJK and the other patients in terms of the mean age (25,96±8,05) or sex distribution (p> 0.05). Stablesagittal vertebrae (SSVs) were not included in the fusion in 80% of the patients who developed DJK. This differencewas statistically significant(p <0.05). Lumbar lordosis (LL) (24,46±8,01), sacral slope (SS) (26,36±6,55) and pelvic incidence (PI) (11,92±8,72) values were significantly lower in patients with DJK than in those without DJK (p <0.05). There was no statistically significant difference in the sagittal vertical axis (SVA) (-29,75±45,92), thoracickyphosis (TK) (51,32±11,26), pelvic tilt (PT) (12,05±4,49), LL (46,1±13,39), SS (38,09±7,55) or PI (50,14±9,71) parameters betweenpatients with PJK andother patients (p> 0.05). There was no statistically significant difference between the SRS-24 score and the SF-36 score in patients with PJK or DBK (p> 0.05). Conclusion: A significant relationship was found between low LL, SS, PI and DJK. The mean age of patients with DJK was significantly greater. There was no significant relationship between clinical evaluations of the SRS-24 and SF-36 scores and the development of DJK and PJK. Scheuermann kyphosis Proximal junctional kyphosis Distal junction kyphosis SF-36 SRS-24 1. Introduction In the treatment of Scheuermann's kyphosis (SK), treatment with posterior instrumentation and fusion has been successful with the development of surgical techniques. With the application of posterior instrumentation and fusion, the stress intensity increases in the proximal and distal regions of the transition from the fused segments to the mobile segments. Incorrectly planned distal instrumentation and fusion level selection, overcorrection of the deformity and unnecessary dissection of soft tissues are very important in terms of the risk of developing junctional kyphosis( 6 ). Our aim in this study was to evaluate the frequency, risk factors, and effects on patients’ quality of life and discuss the results of DJK and PJK, which are common in patients who undergo posterior instrumentation and fusion due to SK. DJK p (+) (-) Mena ± SD Mean ± SD Age 36,4 ± 12,54 26 ± 8,36 1 0,013* n (%) n (%) Gender Male 1 (%20) 25 (%43,1) 2 0,306 Female 4 (%80) 33 (%56,9) PJK Age 25,96 ± 8,05 27,36 ± 9,72 1 0,539 n (%) n (%) Gender Male 13 (%54,2) 13 (%33,3) 3 0,171 Female 11 (%45,8) 26 (%66,7) 1Student’s t test Fisher’s exact test Continuity (Yates) correction (dup: abstract ?) Table 1. Patient demographics 2. Materials and methods 2.1. Patients and Groups After institutional ethics committee review board approval, 214 patients underwent posterior instrumentation and fusion for indications of pain, unacceptable appearance, > 75° kyphosis, and progressive deformity between 2012 and 2017 at the Haydarpaşa Numune Health Practice and Research Center Orthopedics and Traumatology Clinic. Among the SK patients, 63 patients who met the inclusion criteria were retrospectively analyzed. The exclusion criteria for patients were scoliosis and prior spine surgery or implant failure. The operations were performed by the same surgical team. The mean follow-up period of the patients was 54.57 ± 12.48 (range: 25–63) months. The demographic characteristics of all patients are listed in Table 1. The patients were divided into groups according to whether they developed PJK or DJK during their postoperative follow-up. PJK was detected in 22 patients, PJK in three patients, and both PJK and DJK in two patients. 2.2. Surgical technique All surgeries were performed by the same surgeon via an identical surgical technique. After standard posterior exposure, all pedicle screw instrumentation was performed. Precontoured rods were inserted. A rod rotation maneuver was used. for scoliosis correction. No in situ rod contouring was performed in any of the patients. After decortication, allograft bone material was used for fusion. 2.3 . Radiographic and Clinical Outcome Measurements Measurements were made on anteroposterior and lateral whole-spine radiographs while the patient stood. One spinal surgeon who was not involved in the surgeries performed all the radiographic measurements. The parameters examined in the sagittal plane included the proximal junctional angle (PJA), distal junctional angle (DJA), sagittal vertical axis (SVA), T5–T12 kyphosis (TK), C7 plump line, L1–L5 lumbar lordosis (LL), and pelvic parameters such as the pelvic angle of the upper and lower instrumented vertebrae, the pelvic tilt (PT), the sacral slope (SS), and the pelvic incidence (PI). SVA was measured in millimeters between the C7 plumb line and the posterior corner of S1( 21 ). The T1 pelvic angle is a new method used in the evaluation of sagittal balance. It is the angle formed by the line joining the center of the femoral head and the midpoint of the sacral plateau and the line joining the center of the femoral head and the corpus center of the vertebra to be measured( 24 ). Pelvic parameters were measured as described by Duval-Beaupere ( 20 ). PJA was defined as the angle between the lower endplate of the UEV and the upper endplate of the adjacent vertebra two levels above ( 26 ). The DBA is considered the angle between the upper endplate of the lower instrumented vertebra and the lower endplate of the vertebra one level below it( 24 ). TK and LL were measured via the Cobb method( 19 ). Quality of life was evaluated with the SF-36 and SRS-22 scores at the final postoperative follow-up. 3 Statistical Analyses While the findings obtained in the study were being evaluated, the IBM SPSS Statistics 22 (IBM SPSS, Turkey) program was used for statistical analysis. While evaluating the study data, the conformity of the parameters to the normal distribution was evaluated with the Shapiro Wilks test. While evaluating the study data, in addition to descriptive statistical methods (mean, standard deviation, frequency), Student's t test was used for comparisons between two groups with a normal distribution in the comparison of quantitative data, and the Mann‒Whitney U test was used for comparisons between two groups of parameters that did not have a normal distribution. Fisher's exact test, Fisher Freeman Halton test and continuity (Yates) correction were used to compare qualitative data. Significance was evaluated at the p < 0.05 level. As a result of the power analysis via the G*Power program, when the effect size d (effect size):0.883 and SD:5.8 for the Disk Angle Below were taken, the minimum number of samples determined for powers:0.80 and α:0.05 was found to be n = 44. 4. Results Table 2 Distribution of general characteristics Min–Max Mean ± SS Age 17–50 26,83 ± 9,08 Follow-up (month) 25–80 54,57 ± 12,48 PJA (median) 0,4–28,1 9,49 ± 6,8 ( 7 , 6 ) DJA (median) 0,4–25,5 7,82 ± 5,48 ( 7 , 1 ) n % Gender Male 26 41,3 Female 37 58,7 PJK present 24 38,1 absent 39 61,9 DJK present 5 7,9 absent 58 92,1 The general characteristics of the patients are shown in Table 2 . 4.1 Analysis of demographic characteristics DJK p (+) (-) Mean ± SD Mean ± SD Age 36,4 ± 12,54 26 ± 8,36 1 0,013* n (%) n (%) Gender Male 1 (%20) 25 (%43,1) 2 0,306 Female 4 (%80) 33 (%56,9) PJK Age 25,96 ± 8,05 27,36 ± 9,72 1 0,539 n (%) n (%) Gender Male 13 (%54,2) 13 (%33,3) 3 0,171 Female 11 (%45,8) 26 (%66,7) 1Student’s t test Fisher’s exact test Continuity (Yates) correction Table 3. Age and sex evaluation according to the presence of PBK and DBK The mean age of the patients who developed DJK was significantly greater (p 0.05) (Table 3). 4.2 Sagittal plan analysis DJK p (+) (-) Mean ± SD Mean ± SD UIV pelvic angle 7,08 ± 5,92 ( 6 , 4 ) 4,18 ± 3,23 ( 3 , 8 ) 1 0,237 LIV pelvic angle 5,34 ± 4,54 ( 7 , 5 ) 4,83 ± 4,33 ( 4 ) 1 0,770 SVA6 -20,98 ± 43,5 -24,06 ± 51,6 2 0,898 TK 53,5 ± 16,27 48,43 ± 10,15 2 0,311 LL 24,46 ± 8,01 45,06 ± 11,42 2 0,000* PT 11,92 ± 8,72 ( 9 , 6 ) 11,57 ± 4,22 ( 10 , 7 ) 1 0,584 SS 26,36 ± 6,55 38,23 ± 7,84 2 0,002* PI 39,72 ± 7,47 49,67 ± 8,84 2 0,018* PJK UIV pelvic angle 4,63 ± 3,67 ( 4 ) 4,28 ± 3,49 ( 3 , 4 ) 1 0,692 LIV pelvic angle 5,25 ± 4,67 ( 4 , 2 ) 4,64 ± 4,11 ( 3 , 9 ) 1 0,661 SVA -29,75 ± 45,92 -20,16 ± 53,69 2 0,470 TK 51,32 ± 11,26 47,3 ± 10,11 2 0,148 LL 46,1 ± 13,39 41,77 ± 11,75 2 0,183 PT 12,05 ± 4,49 ( 11 ) 11,32 ± 4,73 ( 10 , 5 ) 1 0,376 SS 38,09 ± 7,55 36,79 ± 8,87 2 0,555 PI 50,14 ± 9,71 48,11 ± 8,73 2 0,393 1 Mann-Whitney U test 2Student’s t test *p < 0.05 Table 4. Evaluation of the study parameters according to the presence of PJK and DJK LL, SS, and PI values were found to be significantly lower in patients who developed DJK than in other patients (p < 0.05) (Table 4). 4.2.1. Analysis of Fusion Levels DJK p (+) (-) Mean ± SD Mean ± SD n (%) n (%) UIV T2 5 (%100) 48 (%82,8) 2 1,000 T3 0 (%0) 9 (%15,5) T5 0 (%0) 1 (%1,7) LIV L1 0 (%0) 1 (%1,7) 2 0,615 L2 5 (%100) 47 (%81) L3 0 (%0) 10 (%17,2) SSV Fusion (+) 4 (%80) 1 (%1,7) 1 0,000* (-) 1 (%20) 57 (%98,3) PJK UIV T2 19 (%79,2) 34 (%87,2) 1 0,452 T3 4 (%16,7) 5 (%12,8) T5 1 (%4,2) 0 (%0) LIV L1 0 (%0) 1 (%2,6) 1 0,684 L2 19 (%79,2) 33 (%84,6) L3 5 (%20,8) 5 (%12,8) SSV Fusion (+) 1 (%4,2) 4 (%10,3) 2 0,363 (-) 23 (%95,8) 35 (%89,7) 1 Fisher Freeman Halton Test 2 Fisher’s Exact Test Table 5. Evaluation of the relationships between the fusion levels and PJK and DJK DBC developed in 80% of patients in whom the SSV was not included in the fusion, and it was found to be significantly greater (p 0.05). There was no statistically significant difference in terms of UIV fusion levels or LIV fusion levels between patients with PJK and other patients (p > 0.05). There was no statistically significant difference between patients who developed PJK and other patients in terms of including the SSV in the fusion (p > 0.05) (Table 5). 4.3. Evaluation of quality of life DJK p (+) (-) Mean ± SD Mean ± SD SRS-24 4,22 ± 0,66 ( 4 , 3 ) 4,41 ± 0,52 ( 4 , 6 ) 1 0,483 SF-36 PF 81 ± 8,22 (75) 83,88 ± 15,92 (90) 1 0,379 SF 85 ± 27,1 (100) 85,25 ± 21,49 (100) 1 0,803 PAIN 78 ± 32,37 (90) 77,59 ± 23,65 (77,5) 1 0,745 PJK SR-24 4,29 ± 0,67 ( 4 , 5 ) 4,46 ± 0,41 ( 4 , 6 ) 1 0,744 SF-36 PF 80,42 ± 14,59 (82,5) 85,64 ± 15,78 (90) 1 0,092 SF 83,31 ± 17,18 (87,5) 86,41 ± 24,24 (100) 1 0,098 PAIN 72,4 ± 26,89 (77,5) 80,83 ± 21,99 (90) 1 0,187 1Mann‒Whitney U test 2Student’s t test Fisher Freeman Halton test *p < 0.057 Table 6. Evaluation of the relationships of SRS-24 and SF-36 scores with PJK and DJK scores There was no statistically significant difference in the SF-36 score or SRS-24 score between patients with DJK and other patients (p > 0.05) (Table 6). There was no statistically significant difference in the SF-36 score or SRS-24 score between patients with PJK and other patients (p > 0.05) (Table 6). 5. Discussion DJK is defined as a disc distal to the LIV that is lordotic preoperatively but kyphotic postoperatively. Progressive loss of LL, disc degeneration, fractures and excessive soft tissue dissection are some of the causes of DJK. PJK, on the other hand, is more common and is defined as a kyphotic angle of more than 10° between the endplate of the UIV and the endplate of the vertebrae one or two levels above. The causes and clinical outcomes of these two complications, which are frequently encountered in spine surgery, are not fully understood. The incidence of PJK has been reported to be 30–32% after SK surgery, 17–39% after adult scoliosis surgery, and 27–28% after adolescent idiopathic scoliosis (AIS) surgery(28,37,38,39,40). The frequency of DJK has been reported to be 5–50% after SK surgery and 6.9% after AIS surgery(41,42). In our study, the frequency of PJK was 38.1%, and the frequency of DJK was 7.9%. Bridwell K et al. and Kim YJ et al. identified being over 55 years of age as a risk factor for PBC (43,44). Kim HJ et al. reported that there was no significant relationship between DJK and age(42). Gender was not considered a risk factor in studies conducted to determine the risk factors for PJK and DJK(5,37,40,42,45). No significant relationship was found between PJK development and age. In this study, we believe that age is not effective, since there were no patients aged > 50 years. The mean age of the patients who developed DJK was significantly greater. Three of the five patients who developed DJK were over the age of 40, possibly because of degenerative pathologies of the lumbar region, which are more common as age increases. There was no significant relationship between sex and the development of DJK and/or PJK Liu FY et al., in their meta-analysis, reported that a TK > 40° is a risk factor for the development of PJK (36). Ghasemi A et al. reported that TK was significantly lower in patients who developed DJK (46). Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and preoperative or postoperative TK (42,35). In this study, no significant relationship was found between TK and the development of PJK and/or DJK. We may have reached such a conclusion because of the avoidance of overcorrection. Denis F et al. reported that LL did not contribute to the development of PJK (38). Lonner B et al. suggested that the PI is associated with the development of PJK (39). Ghasemi et al. reported a significant relationship between DJK and preoperative and postoperative LL changes. (46) Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and preoperative and postoperative LL changes(42,35). No significant correlation was found between LL, SS, PT, or PI measured postoperatively and the development of PJK. The relationship between LL and DJK was evaluated, and following the study of Ghasemi A et al., LL was found to be significantly lower in patients who developed DJK. A low LL may predispose patients to DJK by increasing the stress on the distal junction. Yang J et al. reported that a significant relationship between PI and DJK was not detected (35). Ghasemi A. et al. reported that they did not find a significant relationship between DJK and PT, PI, or SS(46). In this study, the PI and SS values were found to be significantly lower in patients who developed DJK, and no significant relationship was found between DJK and PT. The effect of sagittal balance on the resulting kyphosis has not been fully explained. However, owing to the correlation between SS reduction and LL, the stress in the distal junction may increase, which may predispose patients to DJK. Ghasemi A et al. reported that the SVA was significantly negative preoperatively in patients who developed DJK. However, they reported that they did not detect a significant difference in the postoperative SVA (46). Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and SVA(42,35). LA Nasto et al. reported that there is no relationship between SVA and PJK (47). In our study, no significant relationship was found between SVA and the development of PJK or DJK. The absence of major postoperative SVA changes and good sagittal balance in our patients may have caused this result. Denis F et al. and Lonner B et al. reported that not including the proximal end vertebrae in instrumentation and fusion is a risk factor for the development of PJK (38,39). Kim HJ et al. conducted a meta-analysis and reported that a UIV between T1 and T3 was a risk factor for the development of PJK (28). All patients in our study underwent proximal-end vertebral fusion. No significant correlation was found between the UIV and the development of PJK. We believe that careful posterior soft tissue dissection is more important than the level of instrumentation in the development of PJK. Wang J et al. reported that LIV at L3 and below was a risk factor for the development of PJK (40). No significant correlation was found between the level of LIV and the development of PJK. In addition, no significant relationship was found between the inclusion of the SSV in the fusion system and the development of PJK. In our study, instrumentation and fusion were performed by providing appropriate LL. For this reason, we think that we allow adaptive changes in the lumbar region after surgery, as described by Lee's general balance theory, so that we do not cause PJK. Cho KJ et al. stated that the SSV should be included in fusion( 6 ). In our study, 80% of the patients who developed DJK were not included in the SSV fusion. In this study, no significant relationships were found between LIV or UIV levels and DJK. SSV fusion was found to be more important in preventing the development of DJK. When the first lordotic vertebra is detected, compensatory LL increases due to thoracic hyperkyphosis can be misleading. We believe that SSV fusion is safer in terms of preventing the development of DJK. The T1 pelvic angle is a new measurement technique that reflects sagittal balance and pelvic retroversion. It effectively combines sagittal alignment and the pelvic tilt. Ryan et al. reported that the target T1 pelvic angle of operated patients is 10°. Patients with a T1 pelvic angle greater than 20° are considered to have severe deformities ( 22 , 23 ). When we measured the pelvic angles of the UIV and LIV and examined their relationships with PJK and DJK, no significant relationships were found. This finding suggests that the relationship between sagittal balance and junctional kyphosis is not clear. Many scoring systems are used to determine the quality of life of control patients who have undergone surgery for SK. The scores used to determine the clinical results of the patients in the studies did not differ significantly according to the presence or absence of PJK (5,44). Glattes et al. reported that SRS-24 scores were lower in the PJK (+) group( 26 ). Kim YJ et al. and Hassanzadeh et al. reported that the SRS-22 score was lower in patients with PJK (48,49). No significant relationship was found in studies examining the SF-36 and PJK (5,40). Kim HJ et al. reported that there was no significant relationship between DJK scores and SRS-22R scores(42). No significant difference was found in the SF-36 subscores or SRS-24 scores of the patients who developed PJK and/or DJK. DJK and PJK are radiologically defined, and they are usually asymptomatic and are not directly reflected in the clinic. Therefore, the SF-36 and SRS-24 scores were not correlated with the resulting kyphosis. The limitations of our study include its retrospective nature, the large number of patients, and the fact that Haydarpaşa Numune S.U.A.M. The preoperative and early postoperative radiographs could not be evaluated since we could not obtain the radiology records before October 2018. The strength of our study is that all the patients were treated by the same surgeon via the same surgical technique and same type of implant. 6. Conclusion Advanced age and postoperative low LL, SS, and PI were found to be risk factors for the development of DJK. Considering these parameters can prevent DJK. The inclusion of the SSV in fusion is important for preventing the development of DJK. Preoperative planning of the fusion level is essential. In conclusion, these complications can be reduced by careful surgical dissection, selection of the correct fusion level, an appropriate surgical technique, and appropriate sagittal balance to prevent the development of both PJK and DJK. Abbreviations SK Scheuermann Kyphosis AIS adolescent idiopathic scoliosis TK Thoracic Kyphosis LL Lumbar lordosis PI Pelvic incidence SS sacral slope UIV Upper Instrumented Vertebra LIV Lower Instrumented Vertebra SSV Stable sagittal vertebra DJK distal junctional kyphosis DJA Distal junctional angle PJK Proximal junctional kyphosis PJA Proximal junctional angle SVA Sagittal vertical axis SRS Scoliosis Research Society mm Millimeter cm Centimeter et al. And others Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision). Ethical approval was obtained from the Ethics Committee of the University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, with the protocol number HNEAH-KAEK 2020/208, dated 12.10.2020. Written informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions M.B. and H.S.Y. contributed to the study conception and design. M.B. collected the data. M.B. and H.S.Y. performed the analysis and interpreted the results. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Cho KJ, Lenke LG, Park SR, Moon KH, Kang JS, Ban JH. Selection of the Optimal Distal Fusion Level in Posterior Instrumentation and Fusion for Thoracic Hyperkyphosis: The Sagittal Stable Vertebra Concept. J Korean Soc Spine Surg. 2004;11(4):253. Ryan DJ, Protopsaltis TS, Ames CP, et al. T1 Pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographic surgical outcomes longitudinally. 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Ba JY, Md LMA, Alexander MB, Md NR, Gonsalves Md, Kody K, Barrett Md AG, Georgiadis, Md et al. Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis. Nasto LA, Perez-Romera AB, Shalabi ST, Quraishi NA, Mehdian H. Correlation between preoperative spinopelvic alignment and risk of proximal junctional kyphosis after posterior-only surgical correction of Scheuermann kyphosis. Spine J [Internet]. 2016 Apr;1(4):S26–33. [cited 2020 Dec 14];. Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EMSA. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine. 2012;37:S144–64. Ryan DJ, Protopsaltis TS, Ames CP, et al. T1 Pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographic surgical outcomes longitudinally. Spine. 2014;39(15):1203–10. Protopsaltis TS, Schwab FJ, Bronsard N et al. The T1 pelvic angle (TPA), a novel radiographic measure of global sagittal deformity, accounts for both pelvic retroversion and truncal inclination and correlates strongly with HRQOL. Presented at the Annual Meeting of the Scoliosis Research Society, Lyon. Kim HJ, Bridwell KH, Lenke LG, Park MS, Ahmad A, Song KS, Piyaskulkaew C, Hershman S, Fogelson JMA. Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine. 2013;38(11):896–901. Hassanzadeh H, Gupta S, Jain A, El Dafrawy M, Skolasky RLKK. Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform. 2013;1(4):299–30. Additional Declarations No competing interests reported. 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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-6977064","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492478957,"identity":"51f39df7-8b31-4c51-a570-be5ca8c74f78","order_by":0,"name":"Murat BAKIR","email":"data:image/png;base64,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","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":true,"prefix":"","firstName":"Murat","middleName":"","lastName":"BAKIR","suffix":""},{"id":492478958,"identity":"c8967fc4-0a4c-4ebe-b6bc-47c7b916c909","order_by":1,"name":"Hakan Serhat YANIK","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Hakan","middleName":"Serhat","lastName":"YANIK","suffix":""}],"badges":[],"createdAt":"2025-06-25 17:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6977064/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6977064/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92890046,"identity":"9b12b849-b911-4157-af4c-939d5a6cae6b","added_by":"auto","created_at":"2025-10-06 17:38:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1196617,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6977064/v1/f5a444f8-bb81-498b-b0e9-412f0582d086.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvaluation of Proximal and Distal Junctional Kyphosis After Posterior Instrumentation and Fusion in Scheuermann’s Kyphosis\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn the treatment of Scheuermann's kyphosis (SK), treatment with posterior instrumentation and fusion has been successful with the development of surgical techniques. With the application of posterior instrumentation and fusion, the stress intensity increases in the proximal and distal regions of the transition from the fused segments to the mobile segments. Incorrectly planned distal instrumentation and fusion level selection, overcorrection of the deformity and unnecessary dissection of soft tissues are very important in terms of the risk of developing junctional kyphosis(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur aim in this study was to evaluate the frequency, risk factors, and effects on patients\u0026rsquo; quality of life and discuss the results of DJK and PJK, which are common in patients who undergo posterior instrumentation and fusion due to SK.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eDJK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ep\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(-)\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMena\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36,4\u0026thinsp;\u0026plusmn;\u0026thinsp;12,54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u0026thinsp;\u0026plusmn;\u0026thinsp;8,36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,013*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (%20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (%43,1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,306\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (%56,9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25,96\u0026thinsp;\u0026plusmn;\u0026thinsp;8,05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27,36\u0026thinsp;\u0026plusmn;\u0026thinsp;9,72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,539\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (%54,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (%33,3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,171\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (%45,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (%66,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e1Student’s t test Fisher’s exact test Continuity (Yates) correction (dup: abstract ?)\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;1. Patient demographics\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Patients and Groups\u003c/h2\u003e\u003cp\u003eAfter institutional ethics committee review board approval, 214 patients underwent posterior instrumentation and fusion for indications of pain, unacceptable appearance, \u0026gt;\u0026thinsp;75\u0026deg; kyphosis, and progressive deformity between 2012 and 2017 at the Haydarpaşa Numune Health Practice and Research Center Orthopedics and Traumatology Clinic. Among the SK patients, 63 patients who met the inclusion criteria were retrospectively analyzed. The exclusion criteria for patients were scoliosis and prior spine surgery or implant failure. The operations were performed by the same surgical team. The mean follow-up period of the patients was 54.57\u0026thinsp;\u0026plusmn;\u0026thinsp;12.48 (range: 25\u0026ndash;63) months. The demographic characteristics of all patients are listed in Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eThe patients were divided into groups according to whether they developed PJK or DJK during their postoperative follow-up. PJK was detected in 22 patients, PJK in three patients, and both PJK and DJK in two patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Surgical technique\u003c/h2\u003e\u003cp\u003eAll surgeries were performed by the same surgeon via an identical surgical technique. After standard posterior exposure, all pedicle screw instrumentation was performed. Precontoured rods were inserted. A rod rotation maneuver was used. for scoliosis correction. No in situ rod contouring was performed in any of the patients. After decortication, allograft bone material was used for fusion.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.3\u003c/b\u003e. \u003cb\u003eRadiographic and Clinical Outcome Measurements\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eMeasurements were made on anteroposterior and lateral whole-spine radiographs while the patient stood. One spinal surgeon who was not involved in the surgeries performed all the radiographic measurements. The parameters examined in the sagittal plane included the proximal junctional angle (PJA), distal junctional angle (DJA), sagittal vertical axis (SVA), T5\u0026ndash;T12 kyphosis (TK), C7 plump line, L1\u0026ndash;L5 lumbar lordosis (LL), and pelvic parameters such as the pelvic angle of the upper and lower instrumented vertebrae, the pelvic tilt (PT), the sacral slope (SS), and the pelvic incidence (PI).\u003c/p\u003e\u003cp\u003eSVA was measured in millimeters between the C7 plumb line and the posterior corner of S1(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The T1 pelvic angle is a new method used in the evaluation of sagittal balance. It is the angle formed by the line joining the center of the femoral head and the midpoint of the sacral plateau and the line joining the center of the femoral head and the corpus center of the vertebra to be measured(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Pelvic parameters were measured as described by Duval-Beaupere (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). PJA was defined as the angle between the lower endplate of the UEV and the upper endplate of the adjacent vertebra two levels above (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The DBA is considered the angle between the upper endplate of the lower instrumented vertebra and the lower endplate of the vertebra one level below it(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). TK and LL were measured via the Cobb method(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eQuality of life was evaluated with the SF-36 and SRS-22 scores at the final postoperative follow-up.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Statistical Analyses","content":"\u003cp\u003eWhile the findings obtained in the study were being evaluated, the IBM SPSS Statistics 22 (IBM SPSS, Turkey) program was used for statistical analysis. While evaluating the study data, the conformity of the parameters to the normal distribution was evaluated with the Shapiro Wilks test. While evaluating the study data, in addition to descriptive statistical methods (mean, standard deviation, frequency), Student's t test was used for comparisons between two groups with a normal distribution in the comparison of quantitative data, and the Mann‒Whitney U test was used for comparisons between two groups of parameters that did not have a normal distribution. Fisher's exact test, Fisher Freeman Halton test and continuity (Yates) correction were used to compare qualitative data. Significance was evaluated at the p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e\u003cp\u003eAs a result of the power analysis via the G*Power program, when the effect size d (effect size):0.883 and SD:5.8 for the Disk Angle Below were taken, the minimum number of samples determined for powers:0.80 and α:0.05 was found to be n\u0026thinsp;=\u0026thinsp;44.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of general characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMin\u0026ndash;Max\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26,83\u0026thinsp;\u0026plusmn;\u0026thinsp;9,08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFollow-up (month)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026ndash;80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54,57\u0026thinsp;\u0026plusmn;\u0026thinsp;12,48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePJA\u003c/b\u003e \u003csub\u003e\u003cb\u003e(median)\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0,4\u0026ndash;28,1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9,49\u0026thinsp;\u0026plusmn;\u0026thinsp;6,8 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDJA\u003c/b\u003e \u003csub\u003e\u003cb\u003e(median)\u003c/b\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0,4\u0026ndash;25,5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,82\u0026thinsp;\u0026plusmn;\u0026thinsp;5,48 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58,7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003epresent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eabsent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003epresent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eabsent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92,1\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\u003eThe general characteristics of the patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Analysis of demographic characteristics\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eDJK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ep\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(-)\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36,4\u0026thinsp;\u0026plusmn;\u0026thinsp;12,54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u0026thinsp;\u0026plusmn;\u0026thinsp;8,36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,013*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (%20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (%43,1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,306\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (%56,9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25,96\u0026thinsp;\u0026plusmn;\u0026thinsp;8,05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27,36\u0026thinsp;\u0026plusmn;\u0026thinsp;9,72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,539\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (%54,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (%33,3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,171\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (%45,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (%66,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e1Student’s t test Fisher’s exact test Continuity (Yates) correction\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;3. Age and sex evaluation according to the presence of PBK and DBK\u003c/p\u003e\u003cp\u003eThe mean age of the patients who developed DJK was significantly greater (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference between the patients who developed DJK and the other patients in terms of sex distribution (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;3).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Sagittal plan analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eDJK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c7\" namest=\"c6\" rowspan=\"3\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUIV pelvic angle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e7,08\u0026thinsp;\u0026plusmn;\u0026thinsp;5,92 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4,18\u0026thinsp;\u0026plusmn;\u0026thinsp;3,23 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,237\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLIV pelvic angle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e5,34\u0026thinsp;\u0026plusmn;\u0026thinsp;4,54 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4,83\u0026thinsp;\u0026plusmn;\u0026thinsp;4,33 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,770\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSVA6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e-20,98\u0026thinsp;\u0026plusmn;\u0026thinsp;43,5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e-24,06\u0026thinsp;\u0026plusmn;\u0026thinsp;51,6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,898\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e53,5\u0026thinsp;\u0026plusmn;\u0026thinsp;16,27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e48,43\u0026thinsp;\u0026plusmn;\u0026thinsp;10,15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,311\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e24,46\u0026thinsp;\u0026plusmn;\u0026thinsp;8,01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e45,06\u0026thinsp;\u0026plusmn;\u0026thinsp;11,42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,000*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e11,92\u0026thinsp;\u0026plusmn;\u0026thinsp;8,72 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e11,57\u0026thinsp;\u0026plusmn;\u0026thinsp;4,22 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,584\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e26,36\u0026thinsp;\u0026plusmn;\u0026thinsp;6,55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e38,23\u0026thinsp;\u0026plusmn;\u0026thinsp;7,84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,002*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e39,72\u0026thinsp;\u0026plusmn;\u0026thinsp;7,47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e49,67\u0026thinsp;\u0026plusmn;\u0026thinsp;8,84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,018*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUIV pelvic angle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4,63\u0026thinsp;\u0026plusmn;\u0026thinsp;3,67 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4,28\u0026thinsp;\u0026plusmn;\u0026thinsp;3,49 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,692\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLIV pelvic angle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e5,25\u0026thinsp;\u0026plusmn;\u0026thinsp;4,67 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4,64\u0026thinsp;\u0026plusmn;\u0026thinsp;4,11 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,661\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSVA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e-29,75\u0026thinsp;\u0026plusmn;\u0026thinsp;45,92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e-20,16\u0026thinsp;\u0026plusmn;\u0026thinsp;53,69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,470\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e51,32\u0026thinsp;\u0026plusmn;\u0026thinsp;11,26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e47,3\u0026thinsp;\u0026plusmn;\u0026thinsp;10,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,148\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e46,1\u0026thinsp;\u0026plusmn;\u0026thinsp;13,39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e41,77\u0026thinsp;\u0026plusmn;\u0026thinsp;11,75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,183\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e12,05\u0026thinsp;\u0026plusmn;\u0026thinsp;4,49 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e11,32\u0026thinsp;\u0026plusmn;\u0026thinsp;4,73 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,376\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e38,09\u0026thinsp;\u0026plusmn;\u0026thinsp;7,55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e36,79\u0026thinsp;\u0026plusmn;\u0026thinsp;8,87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,555\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e50,14\u0026thinsp;\u0026plusmn;\u0026thinsp;9,71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e48,11\u0026thinsp;\u0026plusmn;\u0026thinsp;8,73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,393\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eMann-Whitney U test 2Student\u0026rsquo;s t test *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;4. Evaluation of the study parameters according to the presence of PJK and DJK\u003c/p\u003e\u003cp\u003eLL, SS, and PI values were found to be significantly lower in patients who developed DJK than in other patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;4).\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e4.2.1. Analysis of Fusion Levels\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e\u003ccolgroup cols=\"15\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c12\" namest=\"c5\"\u003e\u003cp\u003eDJK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c14\" namest=\"c13\" rowspan=\"3\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUIV\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e5 (%100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e48 (%82,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e1,000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e9 (%15,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e1 (%1,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLIV\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e1 (%1,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,615\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e5 (%100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e47 (%81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003e10 (%17,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSSV Fusion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e(+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e4 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e\u003cp\u003e1 (%1,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,000*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e(-)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e1 (%20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e\u003cp\u003e57 (%98,3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUIV\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e19 (%79,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e34 (%87,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,452\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e4 (%16,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e5 (%12,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e1 (%4,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLIV\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e1 (%2,6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,684\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e19 (%79,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e33 (%84,6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eL3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e\u003cp\u003e5 (%20,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u003cp\u003e5 (%12,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSSV Fusion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e(+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e1 (%4,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e\u003cp\u003e4 (%10,3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,363\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e(-)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e23 (%95,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e\u003cp\u003e35 (%89,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c15\" namest=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"15\"\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eFisher Freeman Halton Test\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eFisher\u0026rsquo;s Exact Test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;5. Evaluation of the relationships between the fusion levels and PJK and DJK\u003c/p\u003e\u003cp\u003eDBC developed in 80% of patients in whom the SSV was not included in the fusion, and it was found to be significantly greater (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no statistically significant difference in terms of UIV fusion levels or LIV fusion levels between patients with DJK and other patients (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). There was no statistically significant difference in terms of UIV fusion levels or LIV fusion levels between patients with PJK and other patients (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). There was no statistically significant difference between patients who developed PJK and other patients in terms of including the SSV in the fusion (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;5).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Evaluation of quality of life\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eDJK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e(+)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e(-)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSRS-24\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4,22\u0026thinsp;\u0026plusmn;\u0026thinsp;0,66 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4,41\u0026thinsp;\u0026plusmn;\u0026thinsp;0,52 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,483\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF-36\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e81\u0026thinsp;\u0026plusmn;\u0026thinsp;8,22 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e83,88\u0026thinsp;\u0026plusmn;\u0026thinsp;15,92 (90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,379\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e85\u0026thinsp;\u0026plusmn;\u0026thinsp;27,1 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e85,25\u0026thinsp;\u0026plusmn;\u0026thinsp;21,49 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,803\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePAIN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e78\u0026thinsp;\u0026plusmn;\u0026thinsp;32,37 (90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e77,59\u0026thinsp;\u0026plusmn;\u0026thinsp;23,65 (77,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,745\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePJK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSR-24\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4,29\u0026thinsp;\u0026plusmn;\u0026thinsp;0,67 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4,46\u0026thinsp;\u0026plusmn;\u0026thinsp;0,41 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,744\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF-36\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e80,42\u0026thinsp;\u0026plusmn;\u0026thinsp;14,59 (82,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e85,64\u0026thinsp;\u0026plusmn;\u0026thinsp;15,78 (90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,092\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e83,31\u0026thinsp;\u0026plusmn;\u0026thinsp;17,18 (87,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e86,41\u0026thinsp;\u0026plusmn;\u0026thinsp;24,24 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,098\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePAIN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e72,4\u0026thinsp;\u0026plusmn;\u0026thinsp;26,89 (77,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e80,83\u0026thinsp;\u0026plusmn;\u0026thinsp;21,99 (90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0,187\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e1Mann‒Whitney U test 2Student’s t test Fisher Freeman Halton test *p \u003c 0.057\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;6. Evaluation of the relationships of SRS-24 and SF-36 scores with PJK and DJK scores\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference in the SF-36 score or SRS-24 score between patients with DJK and other patients (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;6).\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference in the SF-36 score or SRS-24 score between patients with PJK and other patients (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;6).\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eDJK is defined as a disc distal to the LIV that is lordotic preoperatively but kyphotic postoperatively. Progressive loss of LL, disc degeneration, fractures and excessive soft tissue dissection are some of the causes of DJK. PJK, on the other hand, is more common and is defined as a kyphotic angle of more than 10\u0026deg; between the endplate of the UIV and the endplate of the vertebrae one or two levels above. The causes and clinical outcomes of these two complications, which are frequently encountered in spine surgery, are not fully understood.\u003c/p\u003e\u003cp\u003eThe incidence of PJK has been reported to be 30\u0026ndash;32% after SK surgery, 17\u0026ndash;39% after adult scoliosis surgery, and 27\u0026ndash;28% after adolescent idiopathic scoliosis (AIS) surgery(28,37,38,39,40). The frequency of DJK has been reported to be 5\u0026ndash;50% after SK surgery and 6.9% after AIS surgery(41,42). In our study, the frequency of PJK was 38.1%, and the frequency of DJK was 7.9%.\u003c/p\u003e\u003cp\u003eBridwell K et al. and Kim YJ et al. identified being over 55 years of age as a risk factor for PBC (43,44). Kim HJ et al. reported that there was no significant relationship between DJK and age(42). Gender was not considered a risk factor in studies conducted to determine the risk factors for PJK and DJK(5,37,40,42,45). No significant relationship was found between PJK development and age. In this study, we believe that age is not effective, since there were no patients aged\u0026thinsp;\u0026gt;\u0026thinsp;50 years. The mean age of the patients who developed DJK was significantly greater. Three of the five patients who developed DJK were over the age of 40, possibly because of degenerative pathologies of the lumbar region, which are more common as age increases. There was no significant relationship between sex and the development of DJK and/or PJK\u003c/p\u003e\u003cp\u003eLiu FY et al., in their meta-analysis, reported that a TK\u0026thinsp;\u0026gt;\u0026thinsp;40\u0026deg; is a risk factor for the development of PJK (36). Ghasemi A et al. reported that TK was significantly lower in patients who developed DJK (46). Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and preoperative or postoperative TK (42,35). In this study, no significant relationship was found between TK and the development of PJK and/or DJK. We may have reached such a conclusion because of the avoidance of overcorrection.\u003c/p\u003e\u003cp\u003eDenis F et al. reported that LL did not contribute to the development of PJK (38). Lonner B et al. suggested that the PI is associated with the development of PJK (39). Ghasemi et al. reported a significant relationship between DJK and preoperative and postoperative LL changes. (46) Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and preoperative and postoperative LL changes(42,35). No significant correlation was found between LL, SS, PT, or PI measured postoperatively and the development of PJK. The relationship between LL and DJK was evaluated, and following the study of Ghasemi A et al., LL was found to be significantly lower in patients who developed DJK. A low LL may predispose patients to DJK by increasing the stress on the distal junction.\u003c/p\u003e\u003cp\u003eYang J et al. reported that a significant relationship between PI and DJK was not detected (35). Ghasemi A. et al. reported that they did not find a significant relationship between DJK and PT, PI, or SS(46). In this study, the PI and SS values were found to be significantly lower in patients who developed DJK, and no significant relationship was found between DJK and PT. The effect of sagittal balance on the resulting kyphosis has not been fully explained. However, owing to the correlation between SS reduction and LL, the stress in the distal junction may increase, which may predispose patients to DJK.\u003c/p\u003e\u003cp\u003eGhasemi A et al. reported that the SVA was significantly negative preoperatively in patients who developed DJK. However, they reported that they did not detect a significant difference in the postoperative SVA (46). Kim HJ et al. and Yang J et al. reported that they did not detect a significant relationship between DJK and SVA(42,35). LA Nasto et al. reported that there is no relationship between SVA and PJK (47). In our study, no significant relationship was found between SVA and the development of PJK or DJK. The absence of major postoperative SVA changes and good sagittal balance in our patients may have caused this result.\u003c/p\u003e\u003cp\u003eDenis F et al. and Lonner B et al. reported that not including the proximal end vertebrae in instrumentation and fusion is a risk factor for the development of PJK (38,39). Kim HJ et al. conducted a meta-analysis and reported that a UIV between T1 and T3 was a risk factor for the development of PJK (28). All patients in our study underwent proximal-end vertebral fusion. No significant correlation was found between the UIV and the development of PJK. We believe that careful posterior soft tissue dissection is more important than the level of instrumentation in the development of PJK.\u003c/p\u003e\u003cp\u003eWang J et al. reported that LIV at L3 and below was a risk factor for the development of PJK (40). No significant correlation was found between the level of LIV and the development of PJK. In addition, no significant relationship was found between the inclusion of the SSV in the fusion system and the development of PJK. In our study, instrumentation and fusion were performed by providing appropriate LL. For this reason, we think that we allow adaptive changes in the lumbar region after surgery, as described by Lee's general balance theory, so that we do not cause PJK.\u003c/p\u003e\u003cp\u003eCho KJ et al. stated that the SSV should be included in fusion(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In our study, 80% of the patients who developed DJK were not included in the SSV fusion. In this study, no significant relationships were found between LIV or UIV levels and DJK. SSV fusion was found to be more important in preventing the development of DJK. When the first lordotic vertebra is detected, compensatory LL increases due to thoracic hyperkyphosis can be misleading. We believe that SSV fusion is safer in terms of preventing the development of DJK.\u003c/p\u003e\u003cp\u003eThe T1 pelvic angle is a new measurement technique that reflects sagittal balance and pelvic retroversion. It effectively combines sagittal alignment and the pelvic tilt. Ryan et al. reported that the target T1 pelvic angle of operated patients is 10\u0026deg;. Patients with a T1 pelvic angle greater than 20\u0026deg; are considered to have severe deformities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). When we measured the pelvic angles of the UIV and LIV and examined their relationships with PJK and DJK, no significant relationships were found. This finding suggests that the relationship between sagittal balance and junctional kyphosis is not clear.\u003c/p\u003e\u003cp\u003eMany scoring systems are used to determine the quality of life of control patients who have undergone surgery for SK. The scores used to determine the clinical results of the patients in the studies did not differ significantly according to the presence or absence of PJK (5,44). Glattes et al. reported that SRS-24 scores were lower in the PJK (+) group(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Kim YJ et al. and Hassanzadeh et al. reported that the SRS-22 score was lower in patients with PJK (48,49). No significant relationship was found in studies examining the SF-36 and PJK (5,40). Kim HJ et al. reported that there was no significant relationship between DJK scores and SRS-22R scores(42). No significant difference was found in the SF-36 subscores or SRS-24 scores of the patients who developed PJK and/or DJK. DJK and PJK are radiologically defined, and they are usually asymptomatic and are not directly reflected in the clinic. Therefore, the SF-36 and SRS-24 scores were not correlated with the resulting kyphosis.\u003c/p\u003e\u003cp\u003eThe limitations of our study include its retrospective nature, the large number of patients, and the fact that Haydarpaşa Numune S.U.A.M. The preoperative and early postoperative radiographs could not be evaluated since we could not obtain the radiology records before October 2018. The strength of our study is that all the patients were treated by the same surgeon via the same surgical technique and same type of implant.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eAdvanced age and postoperative low LL, SS, and PI were found to be risk factors for the development of DJK. Considering these parameters can prevent DJK.\u003c/p\u003e\u003cp\u003eThe inclusion of the SSV in fusion is important for preventing the development of DJK. Preoperative planning of the fusion level is essential.\u003c/p\u003e\u003cp\u003eIn conclusion, these complications can be reduced by careful surgical dissection, selection of the correct fusion level, an appropriate surgical technique, and appropriate sagittal balance to prevent the development of both PJK and DJK.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eScheuermann Kyphosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eadolescent idiopathic scoliosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThoracic Kyphosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLumbar lordosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePelvic incidence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003esacral slope\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUpper Instrumented Vertebra\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLower Instrumented Vertebra\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStable sagittal vertebra\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDJK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edistal junctional kyphosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDJA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDistal junctional angle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePJK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProximal junctional kyphosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePJA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProximal junctional angle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSagittal vertical axis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eScoliosis Research Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003emm\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMillimeter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ecm\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentimeter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eet al.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnd others\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision). Ethical approval was obtained from the Ethics Committee of the University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, with the protocol number HNEAH-KAEK 2020/208, dated 12.10.2020.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.B. and H.S.Y. contributed to the study conception and design. M.B. collected the data. M.B. and H.S.Y. performed the analysis and interpreted the results. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCho KJ, Lenke LG, Park SR, Moon KH, Kang JS, Ban JH. Selection of the Optimal Distal Fusion Level in Posterior Instrumentation and Fusion for Thoracic Hyperkyphosis: The Sagittal Stable Vertebra Concept. J Korean Soc Spine Surg. 2004;11(4):253.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRyan DJ, Protopsaltis TS, Ames CP, et al. T1 Pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographic surgical outcomes longitudinally. Spine. 2014;39(15):1203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKyu-Jung Cho MD, Lenke LG, Keith MD, Bridwell H. 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Glob Spine J [Internet]. 2017 May 1 [cited 2020 Oct 26];7(3):254\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBridwell KH, Lenke LG, Cho SK, et al. Proximal junctional kyphosis in primary adult deformity surgery: Evaluation of 20 degrees as a critical angle. Neurosurgery. 2013;72(6):899\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim SCG. Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal 44 instrumentation and fusion: Minimum five-year follow-up. Spine. 2008;33(20):2179\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHollenbeck SM, Glattes RC, Asher MA, Lai SM, Burton DC. The prevalence of increased proximal junctional flexion following posterior instrumentation and arthrodesis for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33(15):1675\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiguo Zhu MD, b 1,, Pan XSMD1W, Md MD, Md ZL, Md YQ et al. Curve patterns deserve attention when determining the optimal distal fusion level in correction surgery for Scheuermann kyphosis.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu FY, Wang T, Yang SD, Wang H, Yang DL, Ding WY. Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J. 2016;25(8):2376\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhasemi A, Stubig T, Nasto LA, Malik Ahmed HM. Distal junctional kyphosis in patients with Scheuermann\u0026rsquo;s disease: a retrospective radiographic analysis.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBa JY, Md LMA, Alexander MB, Md NR, Gonsalves Md, Kody K, Barrett Md AG, Georgiadis, Md et al. Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNasto LA, Perez-Romera AB, Shalabi ST, Quraishi NA, Mehdian H. Correlation between preoperative spinopelvic alignment and risk of proximal junctional kyphosis after posterior-only surgical correction of Scheuermann kyphosis. Spine J [Internet]. 2016 Apr;1(4):S26\u0026ndash;33. [cited 2020 Dec 14];.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim HJ, Lenke LG, Shaffrey CI, Van Alstyne EMSA. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine. 2012;37:S144\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRyan DJ, Protopsaltis TS, Ames CP, et al. T1 Pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographic surgical outcomes longitudinally. Spine. 2014;39(15):1203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProtopsaltis TS, Schwab FJ, Bronsard N et al. The T1 pelvic angle (TPA), a novel radiographic measure of global sagittal deformity, accounts for both pelvic retroversion and truncal inclination and correlates strongly with HRQOL. Presented at the Annual Meeting of the Scoliosis Research Society, Lyon.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim HJ, Bridwell KH, Lenke LG, Park MS, Ahmad A, Song KS, Piyaskulkaew C, Hershman S, Fogelson JMA. Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine. 2013;38(11):896\u0026ndash;901.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHassanzadeh H, Gupta S, Jain A, El Dafrawy M, Skolasky RLKK. Type of anchor at the proximal fusion level has a significant effect on the incidence of proximal junctional kyphosis and outcome in adults after long posterior spinal fusion. Spine Deform. 2013;1(4):299\u0026ndash;30.\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":"Scheuermann kyphosis, Proximal junctional kyphosis, Distal junction kyphosis, SF-36, SRS-24","lastPublishedDoi":"10.21203/rs.3.rs-6977064/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6977064/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo evaluate the frequency, risk factors and effects of distal junction kyphosis (DJK) and proximal junction kyphosis (PJK), which are common in patients who undergoposterior instrumentation and fusion due to Scheuerman kyphosis (SK), on patient quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods: \u003c/strong\u003eSixty-threepatients who underwent posterior instrumentation and fusion due to Scheuerman kyphosis between 2012 and 2017 at The Health Sciences University, Haydarpaşa Numune Training and Research Hospital Orthopedics and Traumatology Clinic and who served asregular controls were retrospectively analyzed. All patients were operated on by the same surgical team. Twenty-sixof the patients were male,and 37 were female. The mean age was 26.83 ± 9.08 years (range: 17–50 years). Patients who had a follow-up period of less than 2 years, had intraspinal pathology on preoperative MR imaging, had kyphosis forother reasons and had previously undergone spinal surgery or combined surgery (anterior-posterior) were excluded.\u003c/p\u003e\n\u003cp\u003eThe patients were divided intotwo groups according to the detection of PJK and DJK. PJK developed in 22 patients, DJK in three patients, and both PJK and DJK in two patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe mean age of patients (36.4±12.54 years) with DJK was significantly greater than that of patients without DJK (p \u0026lt;0.05). There was no statistically significant difference in sex between the groups with DJK (p\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between the patients who developed PJK and the other patients in terms of the mean age (25,96±8,05) or sex distribution (p\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eStablesagittal vertebrae (SSVs) were not included in the fusion in 80% of the patients who developed DJK. This differencewas statistically significant(p \u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eLumbar lordosis (LL) (24,46±8,01), sacral slope (SS) (26,36±6,55) and pelvic incidence (PI) (11,92±8,72) values were significantly lower in patients with DJK than in those without DJK (p \u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference in the sagittal vertical axis (SVA) (-29,75±45,92), thoracickyphosis (TK) (51,32±11,26), pelvic tilt (PT) (12,05±4,49), LL (46,1±13,39), SS (38,09±7,55) or PI (50,14±9,71) parameters betweenpatients with PJK andother patients (p\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between the SRS-24 score and the SF-36 score in patients with PJK or DBK (p\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eA significant relationship was found between low LL, SS, PI and DJK. The mean age of patients with DJK was significantly greater. There was no significant relationship between clinical evaluations of the SRS-24 and SF-36 scores and the development of DJK and PJK.\u003c/p\u003e","manuscriptTitle":"Evaluation of Proximal and Distal Junctional Kyphosis After Posterior Instrumentation and Fusion in Scheuermann’s Kyphosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 21:38:19","doi":"10.21203/rs.3.rs-6977064/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":"49d06ee1-90ca-42e2-8048-bcc05db00213","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T17:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 21:38:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6977064","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6977064","identity":"rs-6977064","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}