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Zhong XL, Qian BP, Qiu Y, Huang JC, Liu ZJ. Is the pelvic incidence a determinant factor for kyphosis curve patterns of ankylosing spondylitis patients? J Clin Neurosci 2023; 117:32-39. [PMID: 37748356 DOI: 10.1016/j.jocn.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 08/01/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
To investigate the influence of pelvic incidence (PI) on the kyphosis curve patterns and clinical outcomes in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis and to construct a classification of AS according to the PI value for surgical decision-making. 107 AS patients underwent single-level lumbar pedicle subtraction osteotomy (PSO) and finished a minimal of 2-year follow-up. All patients were divided into three groups: low PI (PI ≤ 40°), moderate PI (40° < PI ≤ 60°), and high PI (PI > 60°). Standing lateral radiographs were taken to evaluate the location of kyphotic apex, thoracic kyphosis (TK), lumbar lordosis (LL), C7 sagittal vertical axis (SVA), spino-sacral angle (SSA), global kyphosis (GK), PI, sacral slope (SS), and pelvic tilt (PT). Visual Analogue Scale (VAS) score, Oswestry Disability Index (ODI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were used to evaluate quality of life. Before surgery, a significant difference was shown in the average LL and the mean GK in high PI group was the largest among the three groups. Correction of SVA, GK and LL in high PI group was the smallest among the three group. No significant difference in clinical outcomes was found among the three groups before surgery and at the final follow-up. Regarding the preoperative sagittal profile, the kyphosis curve pattern of moderate PI group is similar to that of low PI group. For AS patients in these two groups, harmonious sagittal alignment can be restored by a single-level PSO. However, the sagittal imbalance is insufficiently realigned by a single-level PSO in a patient with high PI.
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Affiliation(s)
- Xiao-Lin Zhong
- Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China; Medical School of Nanjing University, Nanjing, China; Division of Spine Surgery, Department of Orthopaedics, Guangzhou First People's Hospital, School of Medicine, South China of University of Technology, Guangzhou, China
| | - Bang-Ping Qian
- Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Yong Qiu
- Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ji-Chen Huang
- Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China; Medical School of Nanjing University, Nanjing, China
| | - Zhuo-Jie Liu
- Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China; Medical School of Nanjing University, Nanjing, China
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Si G, Qiu W, Shen Q, Wang Y, Li W, Yu M, Wang Y. Mini-open Pedicle Subtraction Osteotomy versus Standard Posterior Approach for Ankylosing Spondylitis-related Spinal Kyphosis: A Comparative Study. Orthop Surg 2023; 15:2656-2664. [PMID: 37681279 PMCID: PMC10549849 DOI: 10.1111/os.13873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/19/2023] [Accepted: 07/29/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE Surgical strategy for spinal kyphosis in patients with ankylosing spondylitis (AS) has been challenging. Pedicle subtraction osteotomy (PSO) through a minimally invasive (MI) approach has been developed with promising clinical outcomes. We aimed to compare the effectiveness and safety of PSO via an MI approach and a standard posterior approach (SPA) for treating AS-related spinal kyphosis. METHODS A total of 41 patients with AS-related spinal kyphosis who underwent PSO through an MI approach (MI surgery [MIS] group: n = 25) or SPA (SPA group: n = 16) between January 2015 and July 2020 were retrospectively included. Spinopelvic parameters were evaluated before the surgery, immediately after the surgery, and at the 2-year follow-up. Clinical data including operative time, estimated blood loss, blood transfusion, level of fusion, incision length, bed rest period, length of hospitalization, and surgical complications were compared between the two groups. The Scoliosis Research Society outcomes instrument-22 (SRS-22) was administered to assess patients' quality of life at the latest follow-up. Comparisons between the two groups were performed using independent sample t-test or Chi-square test. RESULTS Characteristics and baseline kyphosis of the two groups were matched. At the 2-year follow-up, in the MIS group, the average correction values of the sagittal vertical axis and global kyphosis (GK) were 9.5 cm and 44.3°, respectively. Compared with the SPA group, the MIS group had similar correction values and correction losses after surgery. No obvious differences were observed in any radiographic parameters, except for GK, immediately after surgery and at the 2-year follow-up between the two groups (p > 0.05). The MIS group had a significantly shorter operative time, lesser blood loss, lesser transfusion volume, shorter fusion level, and lesser time to mobilization than did the SPA group. Higher average functional activity scores of SRS-22 were obtained in the MIS group than in the SPA group. CONCLUSION Mini-open PSO may be an effective alternative to the SPA for treating AS-related spinal kyphosis, with comparable correction effect, lesser surgical trauma and faster recovery. This comparative study may provide valuable guidance for surgical decision-making and patient counseling.
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Affiliation(s)
- Gao Si
- Peking University Third Hospital, Department of OrthopaedicsBeijingChina
- Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Weipeng Qiu
- Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
- Peking University Health Science CenterBeijingChina
| | - Qixian Shen
- Peking University Health Science CenterBeijingChina
| | - Yongqiang Wang
- Peking University Third Hospital, Department of OrthopaedicsBeijingChina
- Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Weishi Li
- Peking University Third Hospital, Department of OrthopaedicsBeijingChina
- Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Miao Yu
- Peking University Third Hospital, Department of OrthopaedicsBeijingChina
- Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Yu Wang
- Peking University First Hospital, Department of OrthopaedicsBeijingChina
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Zhang W, Yin W, Cui X, Chai Z, Zheng G, Ding Y, Wang H, Zhai Y, Yu H. Operative strategies for ankylosing spondylitis-related thoracolumbar kyphosis: focus on the cervical stiffness, coronal imbalance and hip involvement. BMC Musculoskelet Disord 2023; 24:723. [PMID: 37697276 PMCID: PMC10494390 DOI: 10.1186/s12891-023-06810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 08/18/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Cervical stiffness, coronal imbalance and limited hip movement all play crucial roles in designing the corrective surgery for ankylosing spondylitis-related thoracolumbar kyphosis (AS-TLK). However, a comprehensive classification and tailored strategies for directing clinical work are lacking. This study aims to investigate the types and surgical strategies for AS-TLK that consider cervical stiffness, coronal imbalance and hip involvement as the key factors. METHODS 25 consecutive AS-TLK patients were divided into three types according to their accompanying features: Type I: with a flexible cervical spine; Type IIA: with a stiff cervical spine; Type IIB: with coronal imbalance; Type IIC: with limited hip movement. Type III is the mixed type with at least two conditions of Type II. Individual strategies were given correspondingly. Spinal-pelvic-femoral parameters were measured, Scoliosis Research Society outcome instrument-22 (SRS-22) was used and complications were recorded and analysed. RESULTS All patients (Type I 10, Type II 8 and Type III 7) underwent surgery successfully. 13 cases with 16 complications were recorded and cured. The patients were followed up for 24-65 months with an average of 33.0 ± 9.6 months. Both the sagittal and coronal parameters were corrected and decreased significantly (all, p < 0.05). SRS-22 scores showed a satisfactory outcome. CONCLUSION Thoracolumbar kyphosis secondary to ankylosing spondylitis are complex and variable. Considering the factors of cervical stiffness, coronal imbalance and hip involvement assists in making decisions individually and achieving a desired surgical result.
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Affiliation(s)
- Wei Zhang
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Wen Yin
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Xilong Cui
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Zihao Chai
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Guohui Zheng
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Ya Ding
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Hongliang Wang
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Yunlei Zhai
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China
| | - Haiyang Yu
- Department of Orthopaedics, Fuyang People's Hospital Affiliated to Anhui Medical University, Anhui, 236000, China.
- Clinical Research Center for Spinal Deformity of Anhui Province, Anhui, 236000, China.
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Song DY, Zhang ZF, Wang TH, Qi DB, Wang Y, Zheng GQ. Pedicle Subtraction Osteotomy in Lateral Position: A New Strategy for Correcting Severe Thoracolumbar Kyphosis Combined with Hip Flexion Contracture in Ankylosing Spondylitis. Orthop Surg 2021; 13:2396-2404. [PMID: 34816604 PMCID: PMC8654652 DOI: 10.1111/os.13169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/05/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To describe spinal osteotomy in lateral position, which might be a new strategy for correcting thoracolumbar kyphotic deformity combined with severe hip flexion contracture, and to present two cases in which this method was successfully performed. Methods Spinal osteotomies in lateral position were performed in two patients with severe thoracolumbar kyphosis combined with hip flexion contracture, which was not suitable for operation in the prone position. Case 1: a 33‐year‐old female AS patient still had severe hip flexion contracture due to poor rehabilitation after total hip replacement (THR). The range of movement of the hip was only about 15° in right and 10° in left. Pre‐operativethoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), and sagittal vertical axis (SVA) were 52.4°, 49.1°, 42.7°, and 315 mm, respectively. Pedicle subtraction osteotomy (PSO) at L3 was performed in the lateral position. The eggshell procedure was used during osteotomy. Case 2: a 45‐year‐old male AS patient presented coexisting rigid thoracolumbar kyphosis and hip flexion contracture. The range of movement of the hip was only about 20° in right and 25° in left. Pre‐operativeTK, TLK, LL and SVA were 34.9°, 66.8°, 58.8° and 290.8 mm, respectively. PSO at L2 was performed in lateral position. The eggshell procedure was also used. Results Sagittal malalignments of both patients were greatly improved. For case 1, the total operation time was 5.5 h. The blood loss was 1500 mL and the amount of allogeneic blood transfusion was 1580 mL during the operation. SVA was reduced to 127 mm and LL decreased from preoperative 42.7° to −28.4°. The correction angle through L3 was 34.7° and the correction angle through the osteotomy segment was 62.9°. For case 2, the duration of surgery was 6.5 h. The operative blood loss was 2000 mL and the total amount of blood transfusion was 2020 mL. SVA was reduced to 209.8 mm and LL decreased from preoperative 58.8° to 9.2°.The correction angle through L2 was 37.1° and the correction angle through the osteotomy segment was 55°. No intra‐operative or post‐operative complications were observed. Six months after PSO, case 1 had good posture for standing and sitting. The case 2 underwent bilateral THRs nine months after PSO. Conclusion PSO could be performed in the lateral position successfully. For AS patients who cannot be placed in the prone position due to coexisting severe thoracolumbar kyphosis and hip flexion contracture, performing spinal osteotomy in the lateral position as the first step is an alternative.
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Affiliation(s)
- Di-Yu Song
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China.,Department of Orthopaedics, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Zi-Fang Zhang
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China.,The School of Medicine, Nankai University, Tianjin, China
| | - Tian-Hao Wang
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Deng-Bin Qi
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yan Wang
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guo-Quan Zheng
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Jami SA, Zhou Z, Mobarak SA, Tabassum M, Ali F. RETRACTED ARTICLE: Osteotomy in lateral position for correcting severe thoracolumbar kyphosis combined with hip flexion contracture in ankylosing spondylitis: a case report and literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3415. [PMID: 34228190 DOI: 10.1007/s00586-021-06913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Sayed Abdulla Jami
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Ningxia Medical University, 804 Shengli Street, Xingqing District, Yinchuan, 750004, Ningxia, People's Republic of China.
| | - Zhanwen Zhou
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Ningxia Medical University, 804 Shengli Street, Xingqing District, Yinchuan, 750004, Ningxia, People's Republic of China
| | - Siam Al Mobarak
- 1St Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China
| | - Mahzabin Tabassum
- Clinical Medicine, Xuzhou Medical University, 209 Tongshang Road, Xuzhou, 221004, Jiangsu, People's Republic of China
| | - Fawad Ali
- Department of Chemistry, Bacha Khan University, Charsadda, 24461, Pakistan
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Patients with ankylosing spondylitis treatment by golimumab: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1813-1822. [DOI: 10.1007/s00586-020-06466-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/05/2020] [Accepted: 05/11/2020] [Indexed: 01/15/2023]
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Song D, Zheng G, Wang T, Qi D, Wang Y. Increasing pelvic incidence is associated with more global sagittal imbalance in ankylosing spondylitis with thoracolumbar kyphosis: an observational retrospective study of 94 cases. BMC Musculoskelet Disord 2020; 21:192. [PMID: 32220255 PMCID: PMC7102437 DOI: 10.1186/s12891-020-03226-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/19/2020] [Indexed: 11/10/2022] Open
Abstract
Background Ankylosing spondylitis (AS) patients with kyphosis have an abnormal spinopelvic alignment and pelvic morphology. Most studies focus on the relationship of pelvic tilt (PT) or sacral slope (SS) and deformity, and relatively few studies have addressed the relationship between pelvic incidence (PI) and kyphosis in AS patients. The purpose of this study is to analyze the correlation between pelvic incidence (PI) and the spinopelvic parameters describing local deformity or global sagittal balance in AS patients with thoracolumbar kyphosis. Methods A total of 94 patients with AS (91 males and 3 females) and 30 controls (27 males and 3 females) were reviewed. The mean age was 36.8 years in AS patients and 34.4 years in controls. Gender ratios and mean age were similar in both group. Sagittal spinopelvic parameters, including PI, PT, SS, thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sagittal vertical axis (SVA), the first thoracic vertebra pelvic angle (TPA), spinosacral angle (SSA) and spinopelvic angle (SPA) were measured. The same spine surgeons measured all the parameters of the AS and control group. All the sagittal spinopelvic parameters were compared between the groups. The relationship between PI and other spinopelvic parameters was analyzed with Pearson correlation (r) and unary linear regression model. Results All the sagittal parameters were found to be significantly different between AS patients and controls. Compared with the control group, the AS patients had significantly higher PI(47.4° vs. 43.2°, P < 0.001). Correlation analysis revealed that PI in AS patients was significantly positively correlated with TPA(r = 0.533, R2 = 0.284, P < 0.001), and negatively correlated with SPA(r = − 0.504, R2 = 0.254, P < 0.001). However, no correlations were found between PI and SVA, SSA, TK, TLK or LL in AS patients. Conclusion This study revealed that increasing PI was significantly correlated with more global sagittal imbalance, not with the local deformity in AS patients with thoracolumbar kyphosis.
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Affiliation(s)
- Diyu Song
- Medical School of Chinese PLA, No.28 Fuxing Road, Beijing, 100853, China.,Department of Orthopedics, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Guoquan Zheng
- Department of Orthopedics, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Tianhao Wang
- Department of Orthopedics, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Dengbin Qi
- Department of Orthopedics, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Yan Wang
- Medical School of Chinese PLA, No.28 Fuxing Road, Beijing, 100853, China. .,Department of Orthopedics, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
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Wang T, Zheng G, Wang Y, Zhang X, Hu F, Wang Y. Comparison of 2 Surgeries in Correction of Severe Kyphotic Deformity Caused by Ankylosing Spondylitis: Vertebral Column Decancellation and Pedicle Subtraction Osteotomy. World Neurosurg 2019; 127:e972-e978. [PMID: 30965170 DOI: 10.1016/j.wneu.2019.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the treatment results between 1-level vertebral column decancellation (VCD) and pedicle subtraction osteotomy (PSO) for correcting severe kyphotic deformity in ankylosing spondylitis (AS). VCD and PSO have been used to correct AS-related kyphotic deformity, but the differences on correcting results between VCD and PSO are not clear. METHODS Between 2013 and 2015, 57 patients underwent 1-level spinal osteotomy (VCD: n = 30; PSO: n = 27) for correcting kyphotic deformity. Sagittal parameters, fusion results, surgical information, and clinical outcomes were documented and compared. All data were obtained before and 1 week after surgery, 6 months after surgery, and at final follow-up (at least 2 years). RESULTS VCD provided significantly greater osteotomy angle (50.8° ± 9.7°) than PSO (38.5° ± 6.1°). In the VCD group, the change of the anterior column was 5.0 ± 1.3 mm, which was larger than the PSO group. The middle column was shortened by 9.9 ± 2.0 mm and 19.1 ± 3.3 mm in the VCD group and PSO group, respectively. There was no significant difference in operating time and blood loss between the 2 groups. All cases had solid fusion. Between the 2 groups, Scoliosis Research Society Outcomes Instrument-22 scores were similar at the final follow-up. No major acute complications occurred in both groups. CONCLUSIONS VCD is a safe and effective method in treating rigid kyphotic deformity secondary to AS. VCD provides a larger correction angle in one segment and preserves more height of osteotomized vertebrae than PSO.
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Affiliation(s)
- Tianhao Wang
- Southwest Hospital, Third Military Medical University, Chongqing, China; Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Guoquan Zheng
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Yao Wang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Xuesong Zhang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Fanqi Hu
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Yan Wang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Beijing, China.
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