Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors

Christopher T Martin, Kenneth Holton, Benjamin D. Elder, Jeremy L. Fogelson, Anthony L. Mikula, Christopher J. Kleck, David Calabrese, Evalina L. Burger, David Ou-Yang, Vikas V. Patel, Han Jo Kim, Francis Lovecchio, Serena S. Hu, Kirkham B. Wood, Robert Harper, S. Tim Yoon, Dheera Ananthakrishnan, Keith W. Michael, Adam J. Schell, Isador H. LiebermanStanley Kisinde, Christopher J. DeWald, Michael T. Nolte, Matthew W. Colman, Frank M. Phillips, Daniel E. Gelb, Jacob Bruckner, Lindsey B. Ross, J. Patrick Johnson, Terrence T. Kim, Neel Anand, Joseph S. Cheng, Zach Plummer, Paul Park, Mark E. Oppenlander, Jonathan N Sembrano, Kristen E. Jones, David W Polly

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


OBJECTIVE There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence–lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5–S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Original languageEnglish (US)
Pages (from-to)98-106
Number of pages9
JournalJournal of Neurosurgery: Spine
Issue number1
StatePublished - Jan 2023

Bibliographical note

Funding Information:
Medtronic, and Premia Spine; being on the editorial/governing board of the Journal of Biomaterials, Journal of Patient Safety, ISASS Journal, Orthopedics, and Springer; being a paid speaker for Medacta and Medtronic; receiving research support from Medicrea; being a board/committee member for SRS and SICOT; having stock/stock options with Medicrea; and receiving publishing royalties and financial/material support from Springer. Dr. Ou-Yang reports being a paid consultant for SeaSpine and Medtronic; receiving an implant royalty from, and having direct stock ownership in, SeaSpine; and receiving spine fellowship program support from Globus and SeaSpine. Dr. Patel reports speaker/paid presentations from Mainstay Medical (fees paid to the university); being a paid consultant to DePuy Synthes, Mainstay Medical, and SI-Bone (all paid to the university); receiving research support from Mainstay Medical, Orthofix, Pfizer, 3-Spine, and Premia (all paid to the university); being the Associate Editor of Orthopedics Journal; and being a board member of SIMEG. Dr. H. J. Kim reports receiving royalties from Zimmer Biomet, Stryker, and Acuity Surgical; being a consultant to NuVasive and Alphatec; receiving research support from SI-Bone and ISSGF; and being an advisory board member for NuVasive, Aspen Medical, and Viviex Biologics. Dr. Hu reports stock/stock options from NuVasive. Dr. Wood reports receiving IP royalties from Globus Medical; being a paid consultant to K2M, Stryker, and LifeSpine; being on the editorial/governing board of Spine Deformity and Spine; and receiving stock/stock options from TranS1. Dr. Yoon reports being a consultant to Alphatec and Meditech Spine; receiving royalties from Meditech Spine; having equity stock in Medyssey; and receiving research grants from AO Spine and Empiric Spine. Dr. Michael reports being a paid consultant to Medtronic Sofamor Danek, SeaSpine, Orthofix, Atec, and Stryker. Dr. Lieberman reports receiving royalties from Globus, SI-Bone, and Safe Orthopaedics; and being a consultant to Medtronic, Misonix, Globus, SI-Bone, and Safe Orthopaedics. Dr. DeWald reports being a paid consultant/presenter/speaker for Alphatec Spine; being a paid consultant for Kisco; having stock/stock options for Medtronic and Alphatech; and being on the editorial/governing board for Spine and the Journal of Spinal Disorders. Dr. Colman reports being a paid consultant for Alphatec Spine, K2M/Stryker Spine, Orthofix, Spinal Elements, and Xenix Medical; receiving research support from AO Spine North America and CSRS; being a board/committee member for AO Spine North America, CSRS, the Musculoskeletal Tumor Society, the North American Spine Society, and LSRS; being a paid presenter/speaker for Orthofix, K2M, and Johnson & Johnson; and receiving IP royalties from Alphatec Spine and Spinal Elements. Dr. Phillips reports receiving royalties from NuVasive and SI-Bone; being a consultant to NuVasive, SI-Bone, Medtronic, Globus, Stryker, Spinal Kinetics, and SpineArt; being on the board of directors/advisory board for NuVasive, SI-Bone, Theracell, Augmedics, Spinal Simplicity, and Surgio; and receiving stock/options from Edge Surgical. Dr. Gelb reports receiving royalties from DePuy Synthes Spine and being a committee member of AO Spine North America. Dr. Ross reports being on the physician advisory board of Johnson & Johnson. Dr. Johnson reports receiving research support from Medtronic and being on

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  • S2-alar-iliac
  • S2AI
  • adult spinal deformity
  • distal junctional failure
  • instrumentation failure
  • lumbar fusion
  • multicenter
  • pelvic fixation

PubMed: MeSH publication types

  • Multicenter Study
  • Journal Article


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