After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up

Abstract BACKGROUND In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO. OBJECTIVE To investigate if performance of 3CO surgeries improves with years of practice. METHODS Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis. RESULTS Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001). CONCLUSION Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.

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Male sex may not be associated with worse outcomes in primary all-posterior adult spinal deformity surgery: a multicenter analysis

Neurosurgical FOCUS ◽

10.3171/2017.9.focus17475 ◽

2017 ◽

Vol 43 (6) ◽

pp. E9 ◽

Cited By ~ 4

Author(s):

David B. Bumpass ◽

Lawrence G. Lenke ◽

Jeffrey L. Gum ◽

Christopher I. Shaffrey ◽

Justin S. Smith ◽

...

Keyword(s):

Sex Differences ◽

Spinal Deformity ◽

Operative Time ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Spine Deformity ◽

Complication Rates ◽

Female Patients ◽

Male Patients

OBJECTIVEAdolescent spine deformity studies have shown that male patients require longer surgery and have greater estimated blood loss (EBL) and complications compared with female patients. No studies exist to support this relationship in adult spinal deformity (ASD). The purpose of this study was to investigate associations between sex and complications, deformity correction, and health-related quality of life (HRQOL) in patients with ASD. It was hypothesized that male ASD patients would have greater EBL, longer surgery, and more complications than female ASD patients.METHODSA multicenter ASD cohort was retrospectively queried for patients who underwent primary posterior-only instrumented fusions with a minimum of 5 levels fused. The minimum follow-up was 2 years. Primary outcomes were EBL, operative time, intra-, peri-, and postoperative complications, radiographic correction, and HRQOL outcomes (Oswestry Disability Index, SF-36, and Scoliosis Research Society-22r Questionnaire). Poisson multivariate regression was used to control for age, comorbidities, and levels fused.RESULTSNinety male and 319 female patients met the inclusion criteria. Male patients had significantly greater mean EBL (2373 ml vs 1829 ml, p = 0.01). The mean operative time, transfusion requirements, and final radiographic measurements did not differ between sexes. Similarly, changes in HRQOL showed no significant differences. Finally, there were no sex differences in the incidence of complications (total, major, or minor) at any time point after controlling for age, body mass index, comorbidities, and levels fused.CONCLUSIONSDespite higher EBL, male ASD patients did not experience more complications or require less deformity correction at the 2-year follow-up. HRQOL scores similarly showed no sex differences. These findings differ from adolescent deformity studies, and surgeons can counsel patients that sex is unlikely to influence the outcomes and complication rates of primary all-posterior ASD surgery.

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Does the Global Alignment and Proportion score overestimate mechanical complications after adult spinal deformity correction?

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20538 ◽

2021 ◽

Vol 34 (1) ◽

pp. 96-102

Author(s):

Griffin R. Baum ◽

Alex S. Ha ◽

Meghan Cerpa ◽

Scott L. Zuckerman ◽

James D. Lin ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

External Validation ◽

Global Alignment ◽

Mechanical Complication ◽

Complication Rates ◽

Mechanical Complications ◽

Significant Difference ◽

Chi Square Analysis

OBJECTIVEThe goal of this study was to validate the Global Alignment and Proportion (GAP) score in a cohort of patients undergoing adult spinal deformity (ASD) surgery. The GAP score is a novel measure that uses sagittal parameters relative to each patient’s lumbosacral anatomy to predict mechanical complications after ASD surgery. External validation is required.METHODSAdult ASD patients undergoing > 4 levels of posterior fusion with a minimum 2-year follow-up were included. Six-week postoperative standing radiographs were used to calculate the GAP score, classified into a spinopelvic state as proportioned (P), moderately disproportioned (MD), or severely disproportioned (SD). A chi-square analysis, receiver operating characteristic curve, and Cochran-Armitage analysis were performed to assess the relationship between the GAP score and mechanical complications.RESULTSSixty-seven patients with a mean age of 52.5 years (range 18–75 years) and a mean follow-up of 2.04 years were included. Patients with < 2 years of follow-up were included only if they had an early mechanical complication. Twenty of 67 patients (29.8%) had a mechanical complication. The spinopelvic state breakdown was as follows: P group, 21/67 (31.3%); MD group, 23/67 (34.3%); and SD group, 23/67 (34.3%). Mechanical complication rates were not significantly different among all groups: P group, 19.0%; MD group, 30.3%; and SD group, 39.1% (χ2 = 1.70, p = 0.19). The rates of mechanical complications between the MD and SD groups (30.4% and 39.1%) were less than those observed in the original GAP study (MD group 36.4%–57.1% and SD group 72.7%–100%). Within the P group, the rates in this study were higher than in the original study (19.0% vs 4.0%, respectively).CONCLUSIONSThe authors found no statistically significant difference in the rate of mechanical complications between the P, MD, and SD groups. The current validation study revealed poor generalizability toward the authors’ patient population.

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Utility of the MISDEF2 Algorithm and Extent of Fusion in Open Adult Spinal Deformity Surgery With Minimum 2-Year Follow-up

Neurospine ◽

10.14245/ns.2142508.254 ◽

2021 ◽

Vol 18 (4) ◽

pp. 824-832

Author(s):

Bo Li ◽

Gregory Hawryluk ◽

Praveen V. Mummaneni ◽

Michael Wang ◽

Ratnesh Mehra ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Class Ii ◽

Class I ◽

Complication Rates ◽

Class Iii ◽

Full Correction ◽

Class Iv

Objective: Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.Methods: A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.Results: A total of 136 patients met inclusion criteria. Mean follow-up was 46 ± 15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p = 0.03) and revision surgery rates (p = 0.047). This difference was not seen in class III patients (p > 0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p < 0.019), comparable revision surgery rates (p = 0.27), and better radiographic realignment (p < 0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p < 0.001).Conclusion: The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.

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Continuous lengthening potential after four years of magnetically controlled spinal deformity correction in children with spinal muscular atrophy

Scientific Reports ◽

10.1038/s41598-020-79821-x ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Heiko M. Lorenz ◽

Marina M. Hecker ◽

Lena Braunschweig ◽

Batoul Badwan ◽

Konstantinos Tsaknakis ◽

...

Keyword(s):

Spinal Muscular Atrophy ◽

Spinal Deformity ◽

Muscular Atrophy ◽

Deformity Correction ◽

Pelvic Obliquity ◽

Complication Rates ◽

Scoliotic Curve ◽

Level Of Evidence ◽

Growing Rods

AbstractMagnetically controlled growing rods (MCGR) are commonly implanted for the treatment of early-onset scoliosis. While most authors report favorable short-term results, little is known about long-term deformity correction. This prospective cohort study assesses spinal deformity control in a homogeneous spinal muscular atrophy (SMA) patient group treated with MCGR implants, a standardized lengthening protocol and a minimum follow-up of four years. 17 SMA patients with progressive scoliosis were treated with MCGR implanted parallel to the spine with rib-to-pelvis fixation. Radiologic measurements were performed before and after MCGR implantation and during external lengthening procedures. These included measurements of the scoliotic curve, kyphosis, lordosis, pelvic obliquity and the spinal length. Additional clinical data of the complications were also analyzed. 17 children (mean age 7.4 years) were surgically treated and underwent a total of 376 lengthenings. Complication rates were 3.5% in respect to all interventions or 41% of the patients had complications during 3.5% of the lengthening sessions. The initial implantation significantly reduced the main scoliotic curve by 59%, with the correction remaining constant throughout the follow-up. Pelvic obliquity was also significantly and permanently corrected by 72%, whereas kyphosis and lordosis were not influenced. The spinal length could be significantly increased mostly during the first year of treatment. Bilateral implantation of MCGRs for correction of spinal deformity in children with SMA showed no decrease of the lengthening potential during a four-year follow-up. Therefore, the previously described ‘law of diminishing returns’ could not be applied to this patient population.Level of Evidence/Clinical relevance: Therapeutic Level IV.

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Outcomes after Minimally Invasive Chevron/Akin Procedure and Strategies to Optimize Outcomes

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00264 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0026

Author(s):

Syed H. Hussaini ◽

Steven K. Neufeld ◽

Daniel M. Dean ◽

Stephen D. Lockey

Keyword(s):

Minimally Invasive ◽

Low Frequency ◽

Deformity Correction ◽

Retrospective Chart Review ◽

Categorical Variables ◽

Surgical Removal ◽

Complication Rates ◽

Continuous Variables ◽

Chi Square

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Minimally invasive surgery (MIS) is being increasingly used for bunion deformity correction. New third generation minimally invasive chevron/akin (MICA) techniques are used but limited data on patient outcomes have been reported. The goal of this IRB-approved study was to look at outcomes of percutaneous, extra-articular distal metatarsal osteotomies for mild to moderate bunion deformity, including the degree of deformity correction obtained, patient pain control, and complication rates. We also describe strategies for avoiding the intra-operative and post-operative complications that may arise with MIS bunion surgery. Methods: The participants were the treating surgeon’s first 75 consecutive patients 18 years and older who were treated with MICA procedures. Via retrospective chart review, outcome measures including pre and final post-operative intermetatarsal angles (IMA), hallux valgus angles (HVA), visual analogue scale (VAS) score, and complication rates were assessed. Statistical analysis was done utilizing student’s t-test for continuous variables and chi square test for categorical variables. Results: Average follow-up was 105.0 days. VAS scores dropped one week post-operatively, from 5.4 pre-operatively to 2.5 (p< 0.05). IMA angles improved from 12.7 degrees (range 6.1-18.1) pre-op to 6.1 (range 1.2-12.5) at final follow-up (p< 0.05). HVA angles improved from 27.2 degrees (range 9.7-43.4) to 10.4 (range 1.3-25.9) (p<0.05). A major infectious complication occurred in one patient, requiring operative irrigation/debridement and hardware removal. Another patient had a DVT treated successfully with medication. Minor complications included intra-operative fracture (3 patients), persistant paresthesias (3), cellulitis (1), minor loss of reduction (2), hardware prominence/backout (3) and medial prominence pain (3). One patient had surgical removal of a prominent screw head one year after surgery. Complication rates were similar between the first and second half of patients chronologically. Conclusion: Our data suggests that MICA osteotomies are associated with rapid, significant improvement in pain scores, significant deformity correction, and low frequency of major complications. While there is a learning curve, MICA is a reproducible technique, is safe, and allows immediate post-operative weightbearing. All osteotomies achieved union, and there were no tendon injuries. Only two patients required a second surgery. We also present strategies to avoid and limit pitfalls and complications encountered with the procedure. Although our data is exciting, additional studies looking at long-term outcomes, larger sample sizes, and more physicians should be conducted.

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Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature

Journal of Neurosurgery Spine ◽

10.3171/2020.3.spine2016 ◽

2020 ◽

Vol 33 (5) ◽

pp. 560-571

Author(s):

Ivan Cheng ◽

Martin N. Stienen ◽

Zachary A. Medress ◽

Kunal Varshneya ◽

Allen L. Ho ◽

...

Keyword(s):

Health Status ◽

Emergency Room ◽

Pain Score ◽

Spinal Deformity ◽

Deformity Correction ◽

Complication Rates ◽

Emergency Room Visits ◽

Discharge Disposition ◽

Dual Versus

OBJECTIVEAdult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD.METHODSThe authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed.RESULTSThe study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors’ literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported.CONCLUSIONSEstablishing a dual-attending care management platform for ASD correction was feasible at the authors’ institution. Results of the use of a dual-attending strategy at the authors’ institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

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New Perspectives on Risk Factors for Non-fatal Strangulation and Post-assault Imaging

Journal of Interpersonal Violence ◽

10.1177/0886260520966673 ◽

2020 ◽

pp. 088626052096667

Author(s):

Grace B. McKee ◽

Kathy Gill-Hopple ◽

Daniel W. Oesterle ◽

Leah E. Daigle ◽

Amanda K. Gilmore

Keyword(s):

Sexual Assault ◽

Partner Violence ◽

Intimate Partner ◽

Chi Square ◽

Factors Associated ◽

Bodily Injury ◽

Weapon Use ◽

Chi Square Analysis ◽

Assault Characteristics

Strangulation has long been associated with death in the context of sexual assault and intimate partner violence (IPV). Non-fatal strangulation (NFS) during sexual assault, which refers to strangulation or choking that does not result in death, is common and has been associated with IPV and with bodily injury; however, other factors associated with NFS are unknown. The current study examined demographic and sexual assault characteristics associated with NFS among women who received a sexual assault medical forensic exam (SAMFE). A second purpose of this study was to explore factors associated with receiving follow-up imaging orders after NFS was identified during a SAMFE. Participants ( N = 882) ranged in age from 18 to 81 ( M = 28.85), with the majority identifying as non-Hispanic White (70.4%) or Black/African American (23.4%). A total of 75 women (8.5%) experienced NFS during the sexual assault. Of these, only 13 (17.3%) received follow-up imaging orders for relevant scans. Results from a logistic regression analysis demonstrated that NFS was positively associated with report of anal penetration, intimate partner perpetration, non-genital injury, and weapon use during the assault. Results from chi-square analysis showed that among sexual assaults involving women who experienced NFS, those whose assaults involved weapon use were over four times more likely to receive imaging orders compared to assaults without weapon use. These findings have implications for criminal justice, and if incorporated into danger assessments, could potentially reduce fatalities linked to sexual assault and/or IPV. Additional work is needed to ensure that all assaults with NFS trigger a referral for imaging regardless of other assault characteristics.

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Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2020.8.spine201037 ◽

2021 ◽

pp. 1-10

Author(s):

Ki Young Lee ◽

Jung-Hee Lee ◽

Kyung-Chung Kang ◽

Sang-Kyu Im ◽

Hae Seong Lim ◽

...

Keyword(s):

Spinal Deformity ◽

Interbody Fusion ◽

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Lumbar Interbody Fusion ◽

Patient Factors ◽

Rod Fracture ◽

Cobalt Chrome

OBJECTIVERestoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD.METHODSThe authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed.RESULTSThe overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF.CONCLUSIONSGreater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

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Comparison of Radiographic And Clinical Outcomes Observed After Adult Spinal Deformity Correction Using Iliac Screw Versus S2-Alar-Iliac Screw

10.21203/rs.3.rs-492643/v1 ◽

2021 ◽

Author(s):

Qiang Luo ◽

Yong-Chan Kim ◽

Ki-Tack Kim ◽

Kee-Yong Ha ◽

Joonghyun Ahn ◽

...

Keyword(s):

Clinical Outcomes ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Postoperative Change ◽

Iliac Screw ◽

Vas Scores ◽

Correction Surgery

Abstract Background: To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation.Methods: A retrospective review of consecutive patients underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change <5°. In subgroup analyses, the 2 different types of postoperative change of PI were directly compared.Results: A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26, 39.8 ± 13.8) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9, 30.3 ± 9.9) (p<0.05). In subgroup (C), PI significantly increased from 53° preoperatively to 59° postoperatively at least 50% of IS cohort, with a mean change of 5.8° (p<0.05). The clinical outcomes at the last follow-up were significantly better in IS group than in S2AI group in terms of VAS scores for back and leg. The occurrence of sacroiliac joint pain and pelvic screw fracture were significantly greater in S2AI group than in IS group (25.8% vs 9%, p<0.05) and (16.1% vs 3.6%, p<0.05).Conclusions: IS fixation showed a greater change in LL and ULL than S2AI fixation in ASD surgery. PI may be changed under certain circumstances.

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