Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors
Authors: Martin Christopher T. , Holton Kenneth J. , Elder Benjamin D. , Fogelson Jeremy L. , Mikula Anthony L. , Kleck Christopher J. , Calabrese David , Burger Evalina L. , Ou-Yang David , Patel Vikas V. , Kim Han Jo , Lovecchio Francis , Hu Serena S. , Wood Kirkham B. , Harper Robert , Yoon S. Tim , Ananthakrishnan Dheera , Michael Keith W. , Schell Adam J. , Lieberman Isador H. , Kisinde Stanley , DeWald Christopher J. , Nolte Michael T. , Colman Matthew W. , Phillips Frank M. , Gelb Daniel E. , Bruckner Jacob , Ross Lindsey B. , Johnson J. Patrick , Kim Terrence T. , Anand Neel , Cheng Joseph S. , Plummer Zach , Park Paul , Oppenlander Mark E. , Sembrano Jonathan N. , Jones Kristen E. , Polly David W. 
Published: September 2022

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.