{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T18:07:22Z","timestamp":1784657242019,"version":"3.55.0"},"reference-count":24,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"\n Background:<\/jats:title>\n In asymptomatic adults, a harmonious T4-L1-hip axis requires a T4-pelvic angle (T4PA) within 4\u00b0 of the L1-pelvic angle (L1PA). We evaluated whether T4PA-L1PA mismatch is associated with mechanical complications (MCs) and patient-reported outcomes (PROs) after long-segment surgery for adult spinal deformity (ASD).<\/jats:p>\n <\/jats:sec>\n \n Methods:<\/jats:title>\n This single-center retrospective study involved a cohort of patients with ASD undergoing >6-level posterior spinal fusion (PSF) for spinal deformity. T4PA \u2212 L1PA was assessed at 6 weeks and followed for \u22652 years. The primary outcome was MCs (implant-related reoperations, with a particular focus on proximal junctional failure [PJF]) events. Multivariable logistic regression included linear and quadratic terms for T4PA \u2212 L1PA, adjusted for the Charlson Comorbidity Index (CCI), preoperative alignment, upper instrumented vertebra (UIV), pelvic fixation, and correction magnitude. Predicted probability curves depicted MC risk across the T4PA \u2212 L1PA spectrum. Secondary outcomes were attainment of the minimal clinically important difference (MCID) for the Scoliosis Research Society (SRS)-22r and Oswestry Disability Index (ODI).<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n The study included 427 patients (mean age, 61.16 \u00b1 14.82 years; 285 [66.7%] female; mean of 12.50 \u00b1 4.16 instrumented levels), with 78.7% undergoing pelvic fixation; 66 (15.5%) underwent MC-related reoperations. In multivariable analysis (area under the curve [AUC] = 0.72, p < 0.001), higher CCI (OR = 1.21, p = 0.029), pelvic fixation (OR = 2.78, p = 0.022), and greater (T4PA \u2212 L1PA)\n 2<\/jats:sup>\n (OR = 1.01, p < 0.001) independently predicted MCs; the modeled risk suggested that both under- and overcorrection increased the risk of MCs. (T4PA \u2212 L1PA)\n 2<\/jats:sup>\n was not associated with MCID attainment for the PROs.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions:<\/jats:title>\n Construct- and patient-related factors\u2014particularly pelvic fixation\u2014were associated with MCs. T4PA-L1PA deviation conferred additional nonlinear (U-shaped) risk: normalization was associated with fewer MCs, undercorrection was associated with implant-related failure, and overcorrection was associated with proximal junctional complications. Normalization was not associated with PRO improvement or attainment of the MCIDs for the SRS-22r and ODI.<\/jats:p>\n <\/jats:sec>\n \n Level of Evidence:<\/jats:title>\n \n Prognostic\n Level IV<\/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.25.01263","type":"journal-article","created":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T18:00:39Z","timestamp":1784656839000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Impact of T4-L1-Hip Axis Normalization on Outcomes and Complications in Adult Spinal Deformity"],"prefix":"10.2106","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5839-1556","authenticated-orcid":false,"given":"Sarthak","family":"Mohanty","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zeeshan M.","family":"Sardar","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6596-6488","authenticated-orcid":false,"given":"Justin L.","family":"Reyes","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3928-8972","authenticated-orcid":false,"given":"Fthimnir M.","family":"Hassan","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6221-7406","authenticated-orcid":false,"given":"Michael P.","family":"Kelly","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Rady Children\u2019s Hospital, San Diego, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4033-4905","authenticated-orcid":false,"given":"Josephine R.","family":"Coury","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6725-5038","authenticated-orcid":false,"given":"Elisabeth","family":"Geraghty","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan J.","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Midwest Orthopedics at Rush University, Chicago, Illinois"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2536-601X","authenticated-orcid":false,"given":"Justin K.","family":"Scheer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven G.","family":"Roth","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Florida, Gainesville, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chun Wai","family":"Hung","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Houston Methodist, Houston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5799-9885","authenticated-orcid":false,"given":"Ronald A.","family":"Lehman","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0484-3027","authenticated-orcid":false,"given":"Joseph M.","family":"Lombardi","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia University Irving Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5595-4958","authenticated-orcid":false,"given":"Lawrence G.","family":"Lenke","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Columbia 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