Altug Yucekul, Alp Ozpinar, Fevzi Duhan Berkan Kilickan, Mohammed Dalla, Nallammai Muthiah, Tais Zulemyan, Yasemin Yavuz, Javier Pizones, Ibrahim Obeid, Frank Kleinstück, Francisco Javier Sánchez Pérez-Grueso, Ferran Pellisé, Caglar Yilgor, Ahmet Alanay

October 2023, Volume 32, Issue 10, pp 3599 - 3607 Original Article Read Full Article 10.1007/s00586-023-07677-6

First Online: 11 April 2023


In response to sagittal malalignment, compensatory spinal and lower extremity mechanisms are recruited. Thoracolumbar realignment surgery has been shown to yield reciprocal changes in these compensations. Thus, whole-body radiographic assessment has come to the fore. This study aimed to evaluate the relationship between spinopelvic parameters and lower extremity compensation angles and to examine their coupled change with deformity correction.


This was a multicenter retrospective analysis of patients who had ≥ 4 levels posterior fusion, whole-body radiographs, and ≥ 2 years follow-up. Relative Pelvic Version (RPV), Relative Lumbar Lordosis (RLL), Relative Spinopelvic Alignment (RSA), Femoral Obliquity Angle (FOA), Knee Flexion Angle (KFA) and Global Sagittal Axis (GSA) were measured preoperatively and 6 week postoperatively. Kruskal–Wallis tests were performed to assess the relation of relative spinopelvic parameters to global sagittal alignment and lower extremity compensation angles. Spearman’s correlations were performed to assess correlations of pre-to-postoperative changes.


193 patients (156F, 37 M) were included. The mean age was 57.2 ± 16.6 years. The mean follow-up duration was 50.6 (24–90) months. On average, 10.3 ± 3.8 levels were fused. Among the cohort, 124 (64.2%) had a sacral or sacroiliac fixation, and 43 (22.3%) had 3-column osteotomies. Preoperative FOA, KFA and GSA significantly differed between RPV, RLL and RSA categories. Significant weak-to-strong correlations were observed between spinopelvic parameters, global sagittal alignment and lower extremity compensation angles (rho range: − 0.351 to 0.767).


PI-adjusted relative spinopelvic parameters significantly correlated with measurements of the lower extremity compensation. Postoperative changes in RPV, RLL and RSA reflected changes in FOA, KFA and GSA. These measurements may serve as a valuable proxy for surgical planning when whole-body imaging is not available.

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