• Se-Jun Park, Jin-Sung Park, Minwook Kang, Kyunghun Jung, Chong-Suh Lee, and Dong-Ho Kang.
• Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
• Spine. 2025 Jan 1; 50 (1): 101810-18.

Study DesignRetrospective study.ObjectivesTo investigate the incidence and risk factors of mechanical failure (MF) following anterior column realignment (ACR) in patients with severe degenerative sagittal imbalance (DSI).Summary Of Background DataConsidering the biomechanical properties of the procedure, ACR may increase the risk of MF, including proximal junctional kyphosis (PJK) and rod fracture (RF). However, this issue has been poorly documented in the literature.MethodsWe included patients aged ≥60 years with severe DSI radiographically defined by pelvic incidence (PI)-lumbar lordosis (LL) ≥20° undergoing ≥5-level fusion, including the sacrum. PJK was defined radiographically as a proximal junctional angle (PJA) >28° plus Δ PJA of >22°. RF was evaluated at ACR levels performed. Clinical and radiographic variables were compared with identify the risk factors for PJK and RF, then multivariate analysis was performed by combining PJK and RF into a single composite outcome of MF.ResultsWe included a total of 147 patients in the final study cohort. The mean age was 70.3 years, and there were 126 women (90.6%). The median fusion length was 8 levels. After surgery, PI-LL was corrected from 48.1° to 4.3°. MF developed in 49 patients (33.3%); PJK in 41 (27.9%), RF in 11 (7.5%), and both PJK and RF in 3 (2.0%) patients. Multivariate analyses revealed that osteoporosis (odds ratio [OR]=2.361, 95% confidence interval [CI]=1.270-5.590, P =0.048) and an increased number of ACR levels (OR=1.762, 95% CI=1.039-3.587, P =0.036) were significant risk factors for MF.ConclusionsA considerable number of patients (33.3%) developed MF after deformity correction using ACR procedures. Therefore, appropriate surgical strategies are necessary to prevent MF in patients undergoing deformity correction using ACR, with special attention to the risk factors we identified here.Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

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