{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T13:35:32Z","timestamp":1793799332257,"version":"4.6.1"},"reference-count":41,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"23","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,12,4]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Our understanding of the relationship between sagittal alignment and mechanical complications is evolving. In normal spines, the L1-pelvic angle (L1PA) accounts for the magnitude and distribution of lordosis and is strongly associated with pelvic incidence (PI), and the T4-pelvic angle (T4PA) is within 4\u00b0 of the L1PA. We aimed to examine the clinical implications of realignment to a normal L1PA and T4-L1PA mismatch.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>A prospective multicenter adult spinal deformity registry was queried for patients who underwent fixation from the T1-T5 region to the sacrum and had 2-year radiographic follow-up. Normal sagittal alignment was defined as previously described for normal spines: L1PA = PI \u00d7 0.5 \u2212 21\u00b0, and T4-L1PA mismatch = 0\u00b0. Mechanical failure was defined as severe proximal junctional kyphosis (PJK), displaced rod fracture, or reoperation for junctional failure, pseudarthrosis, or rod fracture within 2 years. Multivariable nonlinear logistic regression was used to define target ranges for L1PA and T4-L1PA mismatch that minimized the risk of mechanical failure. The relationship between changes in T4PA and changes in global sagittal alignment according to the C2-pelvic angle (C2PA) was determined using linear regression. Lastly, multivariable regression was used to assess associations between initial postoperative C2PA and patient-reported outcomes at 1 year, adjusting for preoperative scores and age.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      The median age of the 247 included patients was 64 years (interquartile range, 57 to 69 years), and 202 (82%) were female. Deviation from a normal L1PA or T4-L1PA mismatch in either direction was associated with a significantly higher risk of mechanical failure, independent of age. Risk was minimized with an L1PA of PI \u00d7 0.5 \u2212 (19\u00b0 \u00b1 2\u00b0) and T4-L1PA mismatch between \u22123\u00b0 and +1\u00b0. Changes in T4PA and in C2PA at the time of final follow-up were strongly associated (r\n                      <jats:sup>2<\/jats:sup>\n                      = 0.96). Higher postoperative C2PA was independently associated with more disability, more pain, and worse self-image at 1 year.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>We defined sagittal alignment targets using L1PA (relative to PI) and the T4-L1PA mismatch, which are both directly modifiable during surgery. In patients undergoing long fusion to the sacrum, realignment based on these targets may lead to fewer mechanical failures.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>\n                      Therapeutic\n                      <jats:underline>Level III<\/jats:underline>\n                      . See Instructions for Authors for a complete description of levels of evidence.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.23.00372","type":"journal-article","created":{"date-parts":[[2024,9,18]],"date-time":"2024-09-18T14:00:36Z","timestamp":1726668036000},"page":"e48","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":59,"title":["The T4-L1-Hip Axis: Sagittal Spinal Realignment Targets in Long-Construct Adult Spinal Deformity Surgery"],"prefix":"10.2106","volume":"106","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1191-1139","authenticated-orcid":false,"given":"Jeffrey","family":"Hills","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery, University of Texas, San Antonio, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1483-7245","authenticated-orcid":false,"given":"Gregory M.","family":"Mundis","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Scripps Clinic, La Jolla, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1408-106X","authenticated-orcid":false,"given":"Eric O.","family":"Klineberg","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California Davis, Sacramento, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0467-5534","authenticated-orcid":false,"given":"Justin S.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Virginia, Charlottesville, Virginia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0395-1066","authenticated-orcid":false,"given":"Breton","family":"Line","sequence":"additional","affiliation":[{"name":"Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke\u2019s\/Rocky Mountain Hospital for Children, Denver, Colorado"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0471-9437","authenticated-orcid":false,"given":"Jeffrey L.","family":"Gum","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4978-2600","authenticated-orcid":false,"given":"Themistocles S.","family":"Protopsaltis","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7713-7252","authenticated-orcid":false,"given":"D. Kojo","family":"Hamilton","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex","family":"Soroceanu","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2359-1707","authenticated-orcid":false,"given":"Robert","family":"Eastlack","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Scripps Clinic, La Jolla, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8670-5532","authenticated-orcid":false,"given":"Pierce","family":"Nunley","sequence":"additional","affiliation":[{"name":"Spine Institute of Louisiana, Shreveport, 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