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Page 1: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Adult Deformity CorrectionOsteotomies and Complications

Wayne Cheng, MD

Professor

Bones & Spine Surgery

Page 2: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

CONCEPTBALANCED SPINE

Page 3: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Cone of Balance/Zone of Economy

Dubousset J. Three-dimensional analysis of the scoliotic deformity. In: Weinstein

SL, ed. Pediatric Spine: Principles and Practice. New York, NY: Raven

Press; 1994.

Page 4: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Presentation-flat back

Page 5: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

kyphoscoliosis

Page 6: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Presentation-Scoliosis

Page 7: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Presentation-hyperlordosis

Page 8: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Presentation-leaning

Page 9: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Radiographs

• 36 “ standing xray

• CT myelogram

• CT + MRI

• DEXA

Page 10: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Radiographs - flexibility

Page 11: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Sagital Balance

Page 12: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pelvic Perimeters

Page 13: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pelvic Retroversion

Page 14: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Which One is most important?

Based on HRQL

(health related quality

of Life) tools.

1. T1-SP incidence

2. SVA

3. Pelvic Tilt

Page 15: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Goals

F. Schwab et al. Spine 35:25 2010

Page 16: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Goal If Hyperkyphotic (TK >40)

• LL<45 – TK –PIBridwell et al. Spine 34:8 2009 (

Page 17: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Type of Osteotomy• Posterior Column (Smith-Petersen/ponte)

– (mobile disc) – 5 to 15 deg.

– (Ankylosing sp) – 20 to 35 deg

• PSO – 25 to 40 degree

– Biplain

– Triplain

• VCR – 40 to 60 degree

• Anterior/posterior 10 to 25 degree

• Combination +/- multi-level

Page 18: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Calculation

• Measure

• Surgimap –

spine

• Tracing paper

Page 19: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 20: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Posterior Column OsteotomySmith-Petersen Vs. Ponte

Page 21: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Smith Petersen Osteotomy44 yo m, jewelry polisher with

AS

Page 22: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Ponte Osteotomy

Page 23: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

1 Level PSO54 yo F, 10 prior back surgeries, h/o MRSA, failed osteotomy, pain

pump. Severe back pain

• TK 5 deg (20-40)

• LL 35 deg(30-80)

• SVA 10 cm( <5)

• PI 70 (42+10)

• PT 45 (13+7)

Page 24: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Failed PSO

Page 25: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Fusion mass

Page 26: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO - Bony resection

Page 27: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO

Page 28: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Osteotomy

Page 29: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO

Page 30: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO

Page 31: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

1 level pedicle subtraction osteotomy

Page 32: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

5 years Post op

Page 33: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO variationBone Disc Bone Osteotomy

Meric Enercan • Cagatay Ozturk • Sinan Kahraman • Mercan Sarı er

Page 34: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PSO53 YO F, 16 prior back surgery

Page 35: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Thoracic osteotomy

Page 36: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Thoracic osteotomy

Page 37: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

2 Level PSO

• PI 73

• Expected

lordosis 83

• Need additional

50 lordosis

Page 38: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

2 level pso

Page 39: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

2 level pso

• PI: 75 83

• LL:36 81

• PT: 50 25

• SVA:15 5

Page 40: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

2 level PSO

Page 41: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Multi-plain PSO

Page 42: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 43: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 44: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 45: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Multi-plain PSO

Page 46: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

VCR

Page 47: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

VCR

Page 48: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

VCR

Page 49: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 50: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 51: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

FRONT & BACK25 year old F, previous scoliosis reconstruction.

Page 52: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Front & Back

Page 53: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Lateral & Back67 yo female w back pain, and neurogenic claudication

Page 54: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pre op MRI

Page 55: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

INTRA-OP

Page 56: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

INTRA OP

Page 57: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 58: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 59: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 60: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Lateral w ALL release/back

Page 61: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Complication

• Major complication 34 to 61%

• AVG EBL 1.5 to 3.5 Liter for PSO

• Death , blindness, Medical issues.

• Neuro deficit, Pseudarthrosis, PJK.

Page 62: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

pseudarthrosis

Page 63: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pseudarthrosis

Page 64: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

pseudarthrosis

Page 65: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pseudarthrosis

Page 66: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Pseudarthrosis

Page 67: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 68: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PJK/PJF

Page 69: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

PJK/PJF

Page 70: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 71: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 72: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Over Correction

Page 73: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance
Page 74: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Conclusion

• Define the Problem.

• Know your osteotomy

• Look out for complication

Page 75: Adult Deformity Correction€¦ · Adult Deformity Correction Osteotomies and Complications Wayne Cheng, MD Professor Bones & Spine Surgery. CONCEPT BALANCED SPINE. Cone of Balance

Thank You


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