A Novel and Simple Technique to Correct Shoulder Balance in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis

A Novel and Simple Technique to Correct Shoulder Balance in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis | 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 A Novel and Simple Technique to Correct Shoulder Balance in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis Mubashar Ahmed Bajwa, JungWook Lim, Yun Jin Num, Muhammad Usama, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7762612/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 Objective : This study aims to analyze common radiographic parameters in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) and determine their role in postoperative shoulder imbalance. Methods : In this descriptive case series, all patients who underwent surgical correction of AIS in 2020 were retrospectively analyzed over a one-month period (June 20 to July 20, 2024). Results : A total of 62 patients were assessed. Significant changes were observed in radiographic shoulder height (RSH) from 7.18 ± 9.65 preoperatively to -0.03 ± 12.23 postoperatively (p = 0.001). Clavicle angle also showed significant changes (0.29 ± 2.19 to -1.85 ± 1.70, p < 0.001). Medial shoulder balance parameters, such as T1 tilt angle and 1st rib angle, also exhibited significant changes (T1 tilt: -0.34 ± 9.53 to 4.97 ± 5.77, 1st rib angle: -1.65 ± 6.53 to 3.76 ± 4.33, p < 0.001 for both). Pearson’s correlation analysis indicated that only the preoperative clavicle angle had a significant correlation with preoperative RSH (r = 0.526, p < 0.001). Conclusion : The clavicle angle is positively correlated with RSH and can be utilized to assess shoulder balance, thereby enhancing patient appearance and satisfaction. However, medial radiologic parameters such as T1 tilt and 1st rib angle do not show significant correlation with shoulder balance and should not be used as predictors. Orthopedic Surgery Neurosurgery Adolescent scoliosis shoulder spinal fusion Figures Figure 1 Figure 2 Introduction The primary management goal of adolescent idiopathic scoliosis (AIS) is to achieve and maintain coronal and sagittal balance through solid posterior spinal fusion (PSF). While the primary aim is to correct the overall coronal balance of the spine, postoperative shoulder balance is crucial due to its impact on both cosmetic outcomes and upper limb function. Previous studies have indicated that severe scoliosis can lead to social hypersensitivity and insecurity, affecting psychosocial health due to the severity of spinal curvature. Cosmesis remains one of the most common demands of scoliosis patients seeking surgical intervention, with shoulder imbalance being the most prominent deformity. Therefore, maintaining shoulder balance postoperatively is essential for patient satisfaction and optimal functional outcomes. Postoperative shoulder imbalance (PSI) has been reported in up to 25% of AIS cases, aligning radiologically with clinically observable imbalance. Various techniques, such as upper instrumented vertebra (UIV) tilt angle selection, upper thoracic spine leveling, systematic fusion level selection, and proximal thoracic (PT) and main thoracic (MT) level correction, have been employed to address this issue. Despite these advancements, a significant proportion of patients continue to experience shoulder imbalance postoperatively, necessitating further exploration of associated factors. This study aims to analyze common radiographic parameters in AIS patients undergoing PSF to determine their role in postoperative shoulder imbalance. Methods Before the study commenced, ethical approval was obtained from the institutional review board of the Scoliosis Research Institute and the Department of Orthopedics at Korea University Guro Hospital, Seoul, South Korea. This descriptive case series included all patients who underwent surgical correction of AIS in 2020, with data collected retrospectively over a one-month period (June 20 to July 20, 2024). Inclusion criteria required complete clinical and radiologic records and a minimum follow-up period of two years. Patients with congenital, neuromuscular, developmental, or secondary (tumor-related) scoliosis were excluded. Consecutive sampling was used, and a total of 62 patients were included. Informed consent was obtained from all patients regarding data collection and processing. Socio-demographic and clinical parameters recorded included identification details, age, gender, weight, height, body mass index (BMI), date of surgery, follow-up period, and postoperative complications. Radiographic data included the Lenke classification of the curve, Cobb’s angle of each lordotic and kyphotic curve, and preoperative, six-week postoperative, and final follow-up values of RSH, medial clavicle angle, T1 tilt angle, and 1st rib angle. These angles were calculated using magnitude-marked soft copies of images from the hospital’s radiology system (infinit PACS) (Fig. 1 ). Statistical analysis was performed using SPSS 23, with descriptive analysis used to present frequency/proportions of categorical variables and measures of central tendencies for quantitative variables. Paired sample t-tests were applied to evaluate differences in RSH, clavicle angle, T1 tilt angle, and 1st rib angle before and after PSF. Pearson’s correlation analysis assessed the relationship between medial and lateral shoulder balance parameters and RSH at preoperative, six-week postoperative, and final follow-up assessments. Results The descriptive analysis of the 62 studied cases demonstrated that 60 (96.8%) of the patients were females, and 61 (98.4%) had right-sided scoliotic deformity. The mean age of the sample was 16.61 ± 4.30 years. Mean height and weight were 1.61 ± 0.06 m and 47.70 ± 6.27 Kg, respectively, resulting in a mean BMI of 18.33 ± 2.31 Kg/m². Lenke classification of the curves showed that 37 (59.7%) had Lenke 1, 1 (1.6%) had Lenke 2, 14 (22.6%) had Lenke 3, 1 (1.6%) had Lenke 4, 6 (9.7%) had Lenke 5, and 3 (4.8%) had Lenke 6 curves. Mean Cobb’s angle of primary, secondary, and tertiary curves were 58.13 ± 9.9, 14.66 ± 22.7, and 0.74 ± 5.8, respectively. The mean kyphotic angle was 22.82 ± 9.2. Complications included pneumothorax in 6 (9.7%) patients, hemothorax in 6 (9.7%), pneumonia in 2 (3.2%), and failure of realignment in 1 (1.6%) patient. Table 1 Descriptive analysis of socio-demographic variables of the study population. Variable N (%) Mean ± SD Gender Female 60 (96.8%) Male 2 (3.2%) Age (yrs.) 16.61 ± 4.30 Weight (Kg) 47.70 ± 6.27 Height (m) 1.61 ± 0.06 BMI (Kg/m²) 18.33 ± 2.31 Curve convexity Left 1 (1.6%) Right 61 (98.4%) Lenke type 1 37 (59.7%) 2 1 (1.6%) 3 14 (22.6%) 4 1 (1.6%) 5 6 (9.7%) 6 3 (4.8%) Complications Pneumothorax 6 (9.7%) Hemothorax 6 (9.7%) Pneumonia 2 (3.2%) Failure of realignment 1 (1.6%) The preoperative, 6-week postoperative, and final follow-up RSH, clavicle angle, T1 tilt angle, and 1st rib angles were compared (Table 2 ). RSH values changed significantly (p = 0.001) from 7.18 ± 9.65 to -0.03 ± 12.23. Clavicle angle showed statistically significant changes (0.29 ± 2.19 to -1.85 ± 1.70, p < 0.001). Similarly, T1 tilt angle and 1st rib angle exhibited significant changes (T1 tilt: -0.34 ± 9.53 to 4.97 ± 5.77, p < 0.001; 1st rib angle: -1.65 ± 6.53 to 3.76 ± 4.33, p < 0.001). Pearson’s correlation with RSH of each shoulder balance parameter (clavicle angle, T1 tilt angle, and 1st rib angle) was analyzed for each temporal reading (pre-op, 6-week post-op, and final follow-up) (Table 3 ). Only the preoperative clavicle angle had a statistically significant correlation with the preoperative RSH (r = 0.526, p < 0.001). (Fig. 2 ) Table 2 Changes in radiologic parameters from pre-op to final post-operative follow-up. Variable Pre-op value 6-week post-op Final follow-up p-value RSH 7.18 ± 9.65 -2.89 ± 11.43 -0.03 ± 12.23 0.001 Clavicle angle 0.29 ± 2.19 -1.79 ± 1.64 -1.85 ± 1.70 < 0.001 T1 tilt angle 0.34 ± 9.53 -5.44 ± 5.48 -4.97 ± 5.77 < 0.001 1st rib angle 1.65 ± 6.53 -3.82 ± 4.32 -3.76 ± 4.33 < 0.001 * Statistically significant p-value is written in BOLD Table 3 Pearson’s correlation of various radiographic parameters with RSH. Variable Pre-op Correlation (r = Pearson’s coefficient: p = p-value) 6-week post-op Correlation (r = Pearson’s coefficient: p = p-value) Final follow-up Correlation (r = Pearson’s coefficient: p = p-value) Clavicle angle r = 0.526, p < 0.001 r = 0.062, p = 0.634 r=-0.158, p = 0.219 T1 tilt angle r = 0.242, p = 0.059 r=-0.031, p = 0.812 r = 0.013, p = 0.92 1st rib angle r = 0.249, p = 0.051 r=-0.032, p = 0.804 r=-0.114, p = 0.37 * Statistically significant p-value is written in BOLD Discussion Adolescent idiopathic scoliosis patients often present with torso deformity, primarily managed through surgical fusion. However, postoperative shoulder imbalance (PSI) remains a concern, reported in up to 25% of cases. Kontodimopoulos et al. found that surgically treated AIS patients were more satisfied than non-operated patients, but dissatisfaction was still noted among some due to rib prominence and shoulder imbalance. The correction of shoulder imbalance is critical, as it has significant implications for patient satisfaction. This study assessed various radiographic parameters to predict shoulder balance intraoperatively, considering RSH as the most reliable parameter. Improvement in RSH was noted in 93.6% of our sample, comparable to results by Gajaseeni et al., who reported improvement in 95.8% of cases. The clavicle angle showed a significant correlation with RSH, supporting its use as a predictor of shoulder balance. Contrarily, T1 tilt and 1st rib angles, which correspond more closely with spinal curvature, showed no significant correlation with shoulder balance. These findings are consistent with previous studies by Luhmann et al. and Gajaseeni et al., which also did not find significant correlations between these parameters and RSH. The concept of medial and lateral shoulder balance is supported by our results. Lateral radiographic measures, such as the clavicle angle, strongly correlate with shoulder balance, while medial parameters, such as T1 tilt and 1st rib angle, do not. This discrepancy may be due to the fixed connection of the clavicle to the shoulder, which is less prominent with T1 tilt and 1st rib angles. Limitations of our study include the retrospective design, which can introduce bias. Additionally, the uni-centric nature of the study limits the generalizability of results, although uniformity in the posterior spinal fusion technique reduces surgical technique variation and associated bias. Conclusion The clavicle angle is positively correlated with RSH and can be used to assess shoulder balance, improving patient appearance and satisfaction. However, medial radiologic parameters, such as T1 tilt and 1st rib angle, do not demonstrate significant correlation with shoulder balance and should not be used as predictors. References Lee HR, Hwang CJ, Seok SY, Gwak HW, Cho JH, Lee DH, Lee CS (2024) Can We Control Lateral Shoulder Balance Through Proximal Thoracic Curve Correction in Lenke Type 2 Adolescent Idiopathic Scoliosis? J Pediatr Orthop 44(1):28–36. 10.1097/BPO.0000000000002544 Hwang CJ, Lee HR, Lee SK, Seok SY, Cho JH, Lee DH, Lee CS (2024) Does Sacral Slanting Affect Postoperative Shoulder Balance in Patients With Lenke Type 2A Adolescent Idiopathic. Scoliosis? Neurospine 21(1):286–292. 10.14245/ns.2347072.536 Lee HR, Hwang CJ, Seok SY, Kim GJ, Cho JH, Lee DH, Lee CS (2024) Shoulder balance in Lenke type 2 adolescent idiopathic scoliosis: correlations among radiological indices, cosmetic indices, and patient-reported outcomes. J Neurosurg Spine 40(6):700–707. 10.3171/2024.1.SPINE231010 Erşen Ö, Yüzügüldü U, Başak AM, Güveli R, Ege T (2023) Effect of clinical and radiological parameters on the quality of life in adolescent patients with untreated adolescent idiopathic scoliosis: a cross-sectional study. Eur Spine J 32(4):1196–1203. 10.1007/s00586-023-07571-1 Xu Y, Liu C, Li D, Cai Y, Hu Z, Zhu Z, Qiu Y, Liu Z (2023) Cosmetic evaluation in type II congenital scoliosis with long-spanned curve: a case-matched comparison with adolescent idiopathic scoliosis. Quant Imaging Med Surg 13(9):6164–6175. 10.21037/qims-23-116 Menon KV, Tahasildar NS (2020) What Constitutes Shoulder Imbalance in Adolescent Idiopathic Scoliosis? Aesthetic Threshold for Surgical Correction. World Neurosurg 138:e827–e838. 10.1016/j.wneu.2020.03.106 Kuklo TR, Lenke LG, Graham EJ et al (2002) Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis. Spine 27(18):2013–2020. 10.1097/00007632-200209150-00009 Zhang S, Zhang L, Feng X, Yang H (2018) Incidence and risk factors for postoperative shoulder imbalance in scoliosis: a systematic review and meta-analysis. Eur Spine J 27(2):358–369. 10.1007/s00586-017-5289-y Kontodimopoulos N, Damianou K, Stamatopoulou E, Kalampokis A, Loukos I (2018) Children’s and parents’ perspectives of health-related quality of life in newly diagnosed adolescent idiopathic scoliosis. J Orthop 15(2):319–323. 10.1016/j.jor.2018.02.002 Misterska E, Glowacki M, Harasymczuk J (2011) Assessment of spinal appearance in female patients with adolescent idiopathic scoliosis treated operatively. Med Sci Monit 17(7):CR404–CR410. 10.12659/MSM.881852 Gajaseni P, Labianca L, Kalakoti P, Weinstein S (2022) Achieving Shoulder Balance Using Medial and Lateral Radiological Measures in Adolescent Idiopathic Scoliosis. Iowa Orthop J 42(1):47–51 Luhmann SJ, Sucato DJ, Johnston CE et al (2016) Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance? J Pediatr Orthop 36(7):691–694. 10.1097/BPO.0000000000000519 Gajaseni P, Labianca L, Kalakoti P, Pugely AJ, Weinstein SL (2021) Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis. Eur Spine J 30(3):686–691. 10.1007/s00586-020-06442-3 Ginsburg HH, Goldstein LA, Robinson P et al (1979) Back Pain in Post-Operative Idiopathic Scoliosis: Long Term Follow-up Study. Spine 6:518–523 Ono T, Bastrom TP, Newton PO (2012) Defining 2 components of shoulder imbalance: clavicle tilt and trapezial prominence. Spine (Phila Pa 1976) 37:E1511–E1516. 10.1097/BRS.0b013e31826e2bbb Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7762612","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":523568945,"identity":"bfb37638-ab93-4d64-b2e1-599d100f2f36","order_by":0,"name":"Mubashar Ahmed Bajwa","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mubashar","middleName":"Ahmed","lastName":"Bajwa","suffix":""},{"id":523568946,"identity":"fdf49dd6-2b30-4521-aa15-9960ab23b2e8","order_by":1,"name":"JungWook Lim","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"JungWook","middleName":"","lastName":"Lim","suffix":""},{"id":523568947,"identity":"171d6823-8f0b-4af5-97fb-491ddeb6136c","order_by":2,"name":"Yun Jin Num","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yun","middleName":"Jin","lastName":"Num","suffix":""},{"id":523568948,"identity":"e13002b6-3924-4a2d-a35d-be0427b832fa","order_by":3,"name":"Muhammad Usama","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYFACHjDJ2ACmDGrq+0F0QgHRWgqOMc4EsRIMiNbygZlxwwGwdbg16M7IPfjpZo6d7Ibzh59u+GHAxmx8fnXihwcGDPL8YgewajG7kZcsnbst2XjDjTSzmz0GMmxmN95ulgA6zHDm7AQcWnIMgFqYEzfcALJ5DNh4zG6c3QDSkmBwG6cW49+52+oTN5w//u3mHwNmCeMZZzf/IKDFDGjL4cQNB3LMbvMYMBsY8Pduw2/LmTdm1rnbjhvPvJFTdlvG4FiCxA3ebRYJBhK4/XI8x/h27rZq2b7zx7fdfPOnJoG//+zmmz8qbOT5pbFrwQIkwColiFUOAvwHSFE9CkbBKBgFIwAAAOnFaeww+/SIAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0001-9790-7466","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Usama","suffix":""},{"id":523568949,"identity":"67051025-c6de-44d0-8bde-115e9d87a7f2","order_by":4,"name":"Chang Hwa Hum","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Chang","middleName":"Hwa","lastName":"Hum","suffix":""},{"id":523568950,"identity":"033fa763-838c-4262-8ef1-6f756ce4db30","order_by":5,"name":"Seung Woo Suh","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Woo","lastName":"Suh","suffix":""}],"badges":[],"createdAt":"2025-10-01 22:39:51","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7762612/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7762612/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92802055,"identity":"c2e35038-cb0f-4d85-90e5-3710bb99bab4","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":365077,"visible":true,"origin":"","legend":"","description":"","filename":"3.ForEuropeanspineManuscriptScoliosisLJW.docx","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/d214866025dee761e915dd08.docx"},{"id":92802051,"identity":"aba9e9ed-8ab3-4b27-9d48-d2278597ba73","added_by":"auto","created_at":"2025-10-05 11:40:17","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7762612.json","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/c4021d9f4b59c30b9b46c400.json"},{"id":92802052,"identity":"c34cd018-e6dc-46cd-a46d-c1ef19e9e953","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63217,"visible":true,"origin":"","legend":"","description":"","filename":"rs77626120enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/065a6369c4c9d56257864fa7.xml"},{"id":92802057,"identity":"63da2028-002f-4538-95b4-ab92177c2461","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":824966,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/9ca24d30e39c844da1173edb.jpeg"},{"id":92802941,"identity":"025dce13-f973-424e-aabb-d06c7e29748e","added_by":"auto","created_at":"2025-10-05 11:48:18","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":202946,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/0eef0ecbb5801ce574923aa7.jpeg"},{"id":92803367,"identity":"af3b1b02-590e-40a7-880e-c9fc2ae15f74","added_by":"auto","created_at":"2025-10-05 11:56:18","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":265954,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/fa2cd6b8ba036b267f622642.png"},{"id":92802061,"identity":"4ce50a60-8d3b-4952-a46c-f940c92090c6","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82445,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/ce30d453521c1e174873c3a8.png"},{"id":92802939,"identity":"22b5fde5-c6d5-4c8f-b337-d1cdcc5dfe09","added_by":"auto","created_at":"2025-10-05 11:48:18","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60662,"visible":true,"origin":"","legend":"","description":"","filename":"rs77626120structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/a3dab6ff728e71c190352d0c.xml"},{"id":92802053,"identity":"441089df-8998-4683-86d3-592bf0c99f3f","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67257,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/615ea578175d6d92d09199d9.html"},{"id":92802056,"identity":"8bee98a6-0b5f-4a57-beb8-5441174e795a","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":376658,"visible":true,"origin":"","legend":"\u003cp\u003eRadiographic parameters considered in the study: from left to right are (a) Radiographic shoulder height. (b) Clavicle angle. (c) T1 tilt angle. (d) 1\u003csup\u003est\u003c/sup\u003e rib angle\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/acffdca5a6658bed3ec730ed.png"},{"id":92802062,"identity":"93f55071-46b8-4ae9-a78c-fe2a12c9ecec","added_by":"auto","created_at":"2025-10-05 11:40:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28330,"visible":true,"origin":"","legend":"\u003cp\u003eScatter plot depicting correlation of clavicle angle with RSH measurements at pre-op, 6-week postop and final follow-up assessment.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/9385fe0a116c9f722a0f6a86.png"},{"id":92803369,"identity":"fb6bc09f-f535-42a0-804a-0d61b1b5fbb7","added_by":"auto","created_at":"2025-10-05 11:56:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1004654,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7762612/v1/1f08602b-f697-4df1-859a-5b949cdfe37b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA Novel and Simple Technique to Correct Shoulder Balance in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe primary management goal of adolescent idiopathic scoliosis (AIS) is to achieve and maintain coronal and sagittal balance through solid posterior spinal fusion (PSF). While the primary aim is to correct the overall coronal balance of the spine, postoperative shoulder balance is crucial due to its impact on both cosmetic outcomes and upper limb function. Previous studies have indicated that severe scoliosis can lead to social hypersensitivity and insecurity, affecting psychosocial health due to the severity of spinal curvature. Cosmesis remains one of the most common demands of scoliosis patients seeking surgical intervention, with shoulder imbalance being the most prominent deformity. Therefore, maintaining shoulder balance postoperatively is essential for patient satisfaction and optimal functional outcomes. Postoperative shoulder imbalance (PSI) has been reported in up to 25% of AIS cases, aligning radiologically with clinically observable imbalance. Various techniques, such as upper instrumented vertebra (UIV) tilt angle selection, upper thoracic spine leveling, systematic fusion level selection, and proximal thoracic (PT) and main thoracic (MT) level correction, have been employed to address this issue. Despite these advancements, a significant proportion of patients continue to experience shoulder imbalance postoperatively, necessitating further exploration of associated factors. This study aims to analyze common radiographic parameters in AIS patients undergoing PSF to determine their role in postoperative shoulder imbalance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Before the study commenced, ethical approval was obtained from the institutional review board of the Scoliosis Research Institute and the Department of Orthopedics at Korea University Guro Hospital, Seoul, South Korea. This descriptive case series included all patients who underwent surgical correction of AIS in 2020, with data collected retrospectively over a one-month period (June 20 to July 20, 2024). Inclusion criteria required complete clinical and radiologic records and a minimum follow-up period of two years. Patients with congenital, neuromuscular, developmental, or secondary (tumor-related) scoliosis were excluded. Consecutive sampling was used, and a total of 62 patients were included. Informed consent was obtained from all patients regarding data collection and processing. Socio-demographic and clinical parameters recorded included identification details, age, gender, weight, height, body mass index (BMI), date of surgery, follow-up period, and postoperative complications. Radiographic data included the Lenke classification of the curve, Cobb\u0026rsquo;s angle of each lordotic and kyphotic curve, and preoperative, six-week postoperative, and final follow-up values of RSH, medial clavicle angle, T1 tilt angle, and 1st rib angle. These angles were calculated using magnitude-marked soft copies of images from the hospital\u0026rsquo;s radiology system (infinit PACS) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Statistical analysis was performed using SPSS 23, with descriptive analysis used to present frequency/proportions of categorical variables and measures of central tendencies for quantitative variables. Paired sample t-tests were applied to evaluate differences in RSH, clavicle angle, T1 tilt angle, and 1st rib angle before and after PSF. Pearson\u0026rsquo;s correlation analysis assessed the relationship between medial and lateral shoulder balance parameters and RSH at preoperative, six-week postoperative, and final follow-up assessments.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe descriptive analysis of the 62 studied cases demonstrated that 60 (96.8%) of the patients were females, and 61 (98.4%) had right-sided scoliotic deformity. The mean age of the sample was 16.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30 years. Mean height and weight were 1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06 m and 47.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27 Kg, respectively, resulting in a mean BMI of 18.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31 Kg/m\u0026sup2;. Lenke classification of the curves showed that 37 (59.7%) had Lenke 1, 1 (1.6%) had Lenke 2, 14 (22.6%) had Lenke 3, 1 (1.6%) had Lenke 4, 6 (9.7%) had Lenke 5, and 3 (4.8%) had Lenke 6 curves. Mean Cobb\u0026rsquo;s angle of primary, secondary, and tertiary curves were 58.13\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9, 14.66\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7, and 0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8, respectively. The mean kyphotic angle was 22.82\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2. Complications included pneumothorax in 6 (9.7%) patients, hemothorax in 6 (9.7%), pneumonia in 2 (3.2%), and failure of realignment in 1 (1.6%) patient.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive analysis of socio-demographic variables of the study population.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\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\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60 (96.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (yrs.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e16.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (Kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e47.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (m)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (Kg/m\u0026sup2;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e18.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurve convexity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61 (98.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLenke type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37 (59.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (22.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (9.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (4.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePneumothorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (9.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemothorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (9.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailure of realignment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe preoperative, 6-week postoperative, and final follow-up RSH, clavicle angle, T1 tilt angle, and 1st rib angles were compared (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). RSH values changed significantly (p\u0026thinsp;=\u0026thinsp;0.001) from 7.18\u0026thinsp;\u0026plusmn;\u0026thinsp;9.65 to -0.03\u0026thinsp;\u0026plusmn;\u0026thinsp;12.23. Clavicle angle showed statistically significant changes (0.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19 to -1.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, T1 tilt angle and 1st rib angle exhibited significant changes (T1 tilt: -0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;9.53 to 4.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 1st rib angle: -1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;6.53 to 3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003ePearson\u0026rsquo;s correlation with RSH of each shoulder balance parameter (clavicle angle, T1 tilt angle, and 1st rib angle) was analyzed for each temporal reading (pre-op, 6-week post-op, and final follow-up) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Only the preoperative clavicle angle had a statistically significant correlation with the preoperative RSH (r\u0026thinsp;=\u0026thinsp;0.526, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChanges in radiologic parameters from pre-op to final post-operative follow-up.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-op value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6-week post-op\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFinal follow-up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRSH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e7.18\u0026thinsp;\u0026plusmn;\u0026thinsp;9.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-2.89\u0026thinsp;\u0026plusmn;\u0026thinsp;11.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.03\u0026thinsp;\u0026plusmn;\u0026thinsp;12.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClavicle angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-1.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT1 tilt angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;9.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-5.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-4.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st rib angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;6.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e*\u003c/b\u003eStatistically significant p-value is written in \u003cb\u003eBOLD\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePearson\u0026rsquo;s correlation of various radiographic parameters with RSH.\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\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-op Correlation (r\u0026thinsp;=\u0026thinsp;Pearson\u0026rsquo;s coefficient: p\u0026thinsp;=\u0026thinsp;p-value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6-week post-op Correlation (r\u0026thinsp;=\u0026thinsp;Pearson\u0026rsquo;s coefficient: p\u0026thinsp;=\u0026thinsp;p-value)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFinal follow-up Correlation (r\u0026thinsp;=\u0026thinsp;Pearson\u0026rsquo;s coefficient: p\u0026thinsp;=\u0026thinsp;p-value)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClavicle angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u0026thinsp;=\u0026thinsp;0.526, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003er\u0026thinsp;=\u0026thinsp;0.062, p\u0026thinsp;=\u0026thinsp;0.634\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003er=-0.158, p\u0026thinsp;=\u0026thinsp;0.219\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT1 tilt angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u0026thinsp;=\u0026thinsp;0.242, p\u0026thinsp;=\u0026thinsp;0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003er=-0.031, p\u0026thinsp;=\u0026thinsp;0.812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003er\u0026thinsp;=\u0026thinsp;0.013, p\u0026thinsp;=\u0026thinsp;0.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st rib angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u0026thinsp;=\u0026thinsp;0.249, p\u0026thinsp;=\u0026thinsp;0.051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003er=-0.032, p\u0026thinsp;=\u0026thinsp;0.804\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003er=-0.114, p\u0026thinsp;=\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003e*\u003c/b\u003eStatistically significant p-value is written in \u003cb\u003eBOLD\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdolescent idiopathic scoliosis patients often present with torso deformity, primarily managed through surgical fusion. However, postoperative shoulder imbalance (PSI) remains a concern, reported in up to 25% of cases. Kontodimopoulos et al. found that surgically treated AIS patients were more satisfied than non-operated patients, but dissatisfaction was still noted among some due to rib prominence and shoulder imbalance. The correction of shoulder imbalance is critical, as it has significant implications for patient satisfaction.\u003c/p\u003e\u003cp\u003eThis study assessed various radiographic parameters to predict shoulder balance intraoperatively, considering RSH as the most reliable parameter. Improvement in RSH was noted in 93.6% of our sample, comparable to results by Gajaseeni et al., who reported improvement in 95.8% of cases. The clavicle angle showed a significant correlation with RSH, supporting its use as a predictor of shoulder balance.\u003c/p\u003e\u003cp\u003eContrarily, T1 tilt and 1st rib angles, which correspond more closely with spinal curvature, showed no significant correlation with shoulder balance. These findings are consistent with previous studies by Luhmann et al. and Gajaseeni et al., which also did not find significant correlations between these parameters and RSH.\u003c/p\u003e\u003cp\u003eThe concept of medial and lateral shoulder balance is supported by our results. Lateral radiographic measures, such as the clavicle angle, strongly correlate with shoulder balance, while medial parameters, such as T1 tilt and 1st rib angle, do not. This discrepancy may be due to the fixed connection of the clavicle to the shoulder, which is less prominent with T1 tilt and 1st rib angles.\u003c/p\u003e\u003cp\u003eLimitations of our study include the retrospective design, which can introduce bias. Additionally, the uni-centric nature of the study limits the generalizability of results, although uniformity in the posterior spinal fusion technique reduces surgical technique variation and associated bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe clavicle angle is positively correlated with RSH and can be used to assess shoulder balance, improving patient appearance and satisfaction. However, medial radiologic parameters, such as T1 tilt and 1st rib angle, do not demonstrate significant correlation with shoulder balance and should not be used as predictors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee HR, Hwang CJ, Seok SY, Gwak HW, Cho JH, Lee DH, Lee CS (2024) Can We Control Lateral Shoulder Balance Through Proximal Thoracic Curve Correction in Lenke Type 2 Adolescent Idiopathic Scoliosis? J Pediatr Orthop 44(1):28\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/BPO.0000000000002544\u003c/span\u003e\u003cspan address=\"10.1097/BPO.0000000000002544\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHwang CJ, Lee HR, Lee SK, Seok SY, Cho JH, Lee DH, Lee CS (2024) Does Sacral Slanting Affect Postoperative Shoulder Balance in Patients With Lenke Type 2A Adolescent Idiopathic. Scoliosis? Neurospine 21(1):286\u0026ndash;292. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14245/ns.2347072.536\u003c/span\u003e\u003cspan address=\"10.14245/ns.2347072.536\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee HR, Hwang CJ, Seok SY, Kim GJ, Cho JH, Lee DH, Lee CS (2024) Shoulder balance in Lenke type 2 adolescent idiopathic scoliosis: correlations among radiological indices, cosmetic indices, and patient-reported outcomes. J Neurosurg Spine 40(6):700\u0026ndash;707. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2024.1.SPINE231010\u003c/span\u003e\u003cspan address=\"10.3171/2024.1.SPINE231010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErşen \u0026Ouml;, Y\u0026uuml;z\u0026uuml;g\u0026uuml;ld\u0026uuml; U, Başak AM, G\u0026uuml;veli R, Ege T (2023) Effect of clinical and radiological parameters on the quality of life in adolescent patients with untreated adolescent idiopathic scoliosis: a cross-sectional study. Eur Spine J 32(4):1196\u0026ndash;1203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00586-023-07571-1\u003c/span\u003e\u003cspan address=\"10.1007/s00586-023-07571-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu Y, Liu C, Li D, Cai Y, Hu Z, Zhu Z, Qiu Y, Liu Z (2023) Cosmetic evaluation in type II congenital scoliosis with long-spanned curve: a case-matched comparison with adolescent idiopathic scoliosis. Quant Imaging Med Surg 13(9):6164\u0026ndash;6175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/qims-23-116\u003c/span\u003e\u003cspan address=\"10.21037/qims-23-116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMenon KV, Tahasildar NS (2020) What Constitutes Shoulder Imbalance in Adolescent Idiopathic Scoliosis? Aesthetic Threshold for Surgical Correction. World Neurosurg 138:e827\u0026ndash;e838. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2020.03.106\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2020.03.106\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuklo TR, Lenke LG, Graham EJ et al (2002) Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis. Spine 27(18):2013\u0026ndash;2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00007632-200209150-00009\u003c/span\u003e\u003cspan address=\"10.1097/00007632-200209150-00009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang S, Zhang L, Feng X, Yang H (2018) Incidence and risk factors for postoperative shoulder imbalance in scoliosis: a systematic review and meta-analysis. Eur Spine J 27(2):358\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00586-017-5289-y\u003c/span\u003e\u003cspan address=\"10.1007/s00586-017-5289-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKontodimopoulos N, Damianou K, Stamatopoulou E, Kalampokis A, Loukos I (2018) Children\u0026rsquo;s and parents\u0026rsquo; perspectives of health-related quality of life in newly diagnosed adolescent idiopathic scoliosis. J Orthop 15(2):319\u0026ndash;323. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jor.2018.02.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jor.2018.02.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMisterska E, Glowacki M, Harasymczuk J (2011) Assessment of spinal appearance in female patients with adolescent idiopathic scoliosis treated operatively. Med Sci Monit 17(7):CR404\u0026ndash;CR410. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12659/MSM.881852\u003c/span\u003e\u003cspan address=\"10.12659/MSM.881852\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGajaseni P, Labianca L, Kalakoti P, Weinstein S (2022) Achieving Shoulder Balance Using Medial and Lateral Radiological Measures in Adolescent Idiopathic Scoliosis. Iowa Orthop J 42(1):47\u0026ndash;51\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuhmann SJ, Sucato DJ, Johnston CE et al (2016) Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance? J Pediatr Orthop 36(7):691\u0026ndash;694. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/BPO.0000000000000519\u003c/span\u003e\u003cspan address=\"10.1097/BPO.0000000000000519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGajaseni P, Labianca L, Kalakoti P, Pugely AJ, Weinstein SL (2021) Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis. Eur Spine J 30(3):686\u0026ndash;691. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00586-020-06442-3\u003c/span\u003e\u003cspan address=\"10.1007/s00586-020-06442-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGinsburg HH, Goldstein LA, Robinson P et al (1979) Back Pain in Post-Operative Idiopathic Scoliosis: Long Term Follow-up Study. Spine 6:518\u0026ndash;523\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOno T, Bastrom TP, Newton PO (2012) Defining 2 components of shoulder imbalance: clavicle tilt and trapezial prominence. Spine (Phila Pa 1976) 37:E1511\u0026ndash;E1516. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/BRS.0b013e31826e2bbb\u003c/span\u003e\u003cspan address=\"10.1097/BRS.0b013e31826e2bbb\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Korea University Guro Hospital Seoul South Korea","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":"Adolescent, scoliosis, shoulder, spinal fusion","lastPublishedDoi":"10.21203/rs.3.rs-7762612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7762612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This study aims to analyze common radiographic parameters in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) and determine their role in postoperative shoulder imbalance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In this descriptive case series, all patients who underwent surgical correction of AIS in 2020 were retrospectively analyzed over a one-month period (June 20 to July 20, 2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 62 patients were assessed. Significant changes were observed in radiographic shoulder height (RSH) from 7.18 ± 9.65 preoperatively to -0.03 ± 12.23 postoperatively (p = 0.001). Clavicle angle also showed significant changes (0.29 ± 2.19 to -1.85 ± 1.70, p \u0026lt; 0.001). Medial shoulder balance parameters, such as T1 tilt angle and 1st rib angle, also exhibited significant changes (T1 tilt: -0.34 ± 9.53 to 4.97 ± 5.77, 1st rib angle: -1.65 ± 6.53 to 3.76 ± 4.33, p \u0026lt; 0.001 for both). Pearson’s correlation analysis indicated that only the preoperative clavicle angle had a significant correlation with preoperative RSH (r = 0.526, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The clavicle angle is positively correlated with RSH and can be utilized to assess shoulder balance, thereby enhancing patient appearance and satisfaction. However, medial radiologic parameters such as T1 tilt and 1st rib angle do not show significant correlation with shoulder balance and should not be used as predictors.\u003c/p\u003e","manuscriptTitle":"A Novel and Simple Technique to Correct Shoulder Balance in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-05 11:40:13","doi":"10.21203/rs.3.rs-7762612/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":"5871d5fe-810b-4404-a628-778ca6a55473","owner":[],"postedDate":"October 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55701919,"name":"Orthopedic Surgery"},{"id":55701920,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2025-10-05T11:40:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-05 11:40:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7762612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7762612","identity":"rs-7762612","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}