title: Preventing Fusion Mass Shift Avoids Postoperative Distal Curve Adding-on in Adolescent Idiopathic Scoliosis.
abstract: BACKGROUND
  Surgery for adolescent idiopathic scoliosis (AIS) is only complete after achieving fusion to maintain the correction obtained intraoperatively. The instrumented or fused segments can be referred to as the "fusion mass". In patients with AIS, the ideal fusion mass strategy has been established based on fulcrum-bending radiographs for main thoracic curves. Ideally, the fusion mass should achieve parallel endplates of the upper and lower instrumented vertebra and correct any "shift" for truncal balance. Distal adding-on is an important element to consider in AIS surgery. This phenomenon represents a progressive increase in the number of vertebrae included distally in the primary curvature and it should be avoided as it is associated with unsatisfactory cosmesis and an increased risk of revision surgery. However, it remains unknown whether any fusion mass shift, or shift in the fusion mass or instrumented segments, affects global spinal balance and distal adding-on after curve correction surgery in patients with AIS.
  
  
  OBJECTIVE
  (1) To investigate the relationship among postoperative fusion mass shift, global balance, and distal adding-on phenomenon in patients with AIS; and (2) to identify a cutoff value of fusion mass shift that will lead to distal adding-on.
  
  
  METHODS
  This was a retrospective study of patients with AIS from a single institution. Between 2006 and 2011 we performed 69 selective thoracic fusions for patients with main thoracic AIS. All patients were evaluated preoperatively and at 2 years postoperatively. The Cobb angle between the cranial and caudal endplates of the fusion mass and the coronal shift between them, which was defined as "fusion mass shift", were measured. Patients with a fusion mass Cobb angle greater than 20° were excluded to specifically determine the effect of fusion mass shift on distal adding-on phenomenon. Fusion mass shift was empirically set as 20 mm for analysis. Therefore, of the 69 patients who underwent selective thoracic fusion, only 52 with a fusion mass Cobb angle of 20° or less were recruited for study. We defined patients with a fusion mass shift of 20 mm or less as the balanced group and those with a fusion mass shift greater than 20 mm as the unbalanced group. A receiver operating characteristic (ROC) curve was used to determine the cutoff point of fusion mass shift for adding-on.
  
  
  RESULTS
  Of the 52 patients studied, fusion mass shift (> 20 mm) was noted in 11 (21%), and six of those patients had distal adding-on at final followup. Although global spinal balance did not differ significantly between patients with or without fusion mass shift, the occurrence of adding-on phenomenon was significantly higher in the unbalanced group (55% (six of 11 patients), odds ratio [OR], 8.6; 95% CI, 2-39; p < 0.002) than the balanced group (12% [five of 41 patients]). Based on the ROC curve analysis, a fusion mass shift more than 18 mm was observed as the cutoff point for distal adding-on phenomenon (area under the curve, 0.70; 95% CI, 0.5-0.9; likelihood ratio, 5.0; sensitivity, 0.64; specificity, 0.73; positive predictive value, 39% [seven of 18 patients]; negative predictive value, 88% [30 of 34 patients]; OR, 4.8; 95% CI, 1-20; p = 0.02).
  
  
  CONCLUSIONS
  Our study illustrates the substantial utility of the fulcrum-bending radiograph in determining fusion levels that can avoid fusion mass shift; thereby, underlining its importance in designing personalized surgical strategies for patients with scoliosis. Preoperatively, determining fusion levels by fulcrum-bending radiographs to avoid residual fusion mass shift is imperative. Intraoperatively, any fusion mass shift should be corrected to avoid distal adding-on, reoperation, and elevated healthcare costs.
  
  
  METHODS
  Level II, prognostic study.
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.|Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Shigematsu
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.
authors.forename: Jason Pui Yin
authors.initials: JP
authors.lastname: Cheung
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.|Department of Orthopaedics, Hospital Español de Buenos Aires, Buenos Aires, Argentina.
authors.forename: Mauro
authors.initials: M
authors.lastname: Bruzzone
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.|Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Matsumori
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.
authors.forename: Kin-Cheung
authors.initials: KC
authors.lastname: Mak
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.
authors.forename: Dino
authors.initials: D
authors.lastname: Samartzis
authors.affiliation: Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China. hrmoldk@hku.hk.
authors.forename: Keith Dip Kei
authors.initials: KD
authors.lastname: Luk
mesh_terms: D000293:Adolescent; D019540:Area Under Curve; D001696:Biomechanical Phenomena; D006723:Hong Kong; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D004856:Postural Balance; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D012600:Scoliosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome