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Thomas J. Buell, Justin S. Smith, Christopher I. Shaffrey, Han Jo Kim, Eric O. Klineberg, Virginie Lafage, Renaud Lafage, Themistocles S. Protopsaltis, Peter G. Passias, Gregory M. Mundis Jr., Robert K. Eastlack, Vedat Deviren, Michael P. Kelly, Alan H. Daniels, Jeffrey L. Gum, Alex Soroceanu, D. Kojo Hamilton, Munish C. Gupta, Douglas C. Burton, Richard A. Hostin, Khaled M. Kebaish, Robert A. Hart, Frank J. Schwab, Shay Bess, Christopher P. Ames, and the International Spine Study Group (ISSG)

patients often have concurrent severe global sagittal malalignment, which seems to be the significant driver for worse HRQOL. Surgical correction of severe ASD often entails complex reconstruction with long-segment posterior fusion, multiple osteotomies, and pelvic fixation. 39 This description accurately characterizes the operations in this study, with over a third (36%) of patients undergoing 3CO, a mean of 13.2 ± 3.8 fused levels, upper thoracic (T2–5) UIV in 55% of patients, lower thoracic (T9–11) UIV in 39%, and iliac fixation in 90%. Increased sagittal

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screws. Failure-free survival rate was 92.5% at 1 year, 85.9% at 2 years, and 78.2% at 3 years. Failure was more common in patients with iliac bolts than those with S2AI screws (9 vs. 2; p=0.026). Four patients with iliac bolts developed nonunion at L5-S1. Placement of iliac bolts (OR 12.8, 95% CI [1.81, 191.42]), number of levels fused (1.6, [1.15, 2.40]), and age (0.9, [0.78, 0.97]) were significantly associated with failure. Reason for pelvic fixation, pelvic screw length, number of previous fusion operations, smoking, and use of BMP were not associated with