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Do the benefits of hook-hybrid construct justify their use over all-pedicle screws constructs in maintaining postoperative curve correction for adolescent idiopathic scoliosis patients from an Asian population?


Study design

Retrospective study.


(1) Compare outcomes of all-pedicle screws (PS) and hook-hybrid (H) constructs in adolescent idiopathic scoliosis (AIS) patients; and (2) investigate whether BMI, height or pedicle size may modify the effect of the type of surgical construct on the extent of curve decompensation.


AIS patients who underwent surgical fixation with H or PS constructs at a single tertiary institution were reviewed. Patients with implant density of at least 70% and 2-year follow-up were included. Demographic and perioperative data collected were age, sex, height, BMI, implant density and pedicle diameter. Cobb’s angles and curve correction were compared preoperatively, postoperatively and at follow-up.


In total, 59 patients were included. H group had a lower pedicle size at the highest level of construct and at T4 compared to PS group. Postoperatively, H group (30.2° ± 11.7°) and PS group (32.1° ± 10.4°) had similar correction (mean diff. 2.0°, p = 0.516). At 2-year follow-up, H group (1.6° ± 3.5°) and PS group (0.1° ± 2.8°) had similar curve deterioration (mean diff. 1.5°, p = 0.079). Uni- and multivariate analyses revealed that BMI and height were not associated with curve deterioration at 2-year follow-up among the H and PS groups.


H constructs provided similar maintenance of curve correction at 2-year follow-up compared to PS constructs. BMI and Stature did not modify curve deterioration between both groups at follow-up. This study supports the use of H constructs when faced with difficult pedicle morphology associated with shorter stature as it provides comparable and satisfactory long-term maintenance of curve correction.

Level of evidence

Level III, retrospective cohort study.

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  1. Ohrt-Nissen S, Hallager DW, Karbo T et al (2017) Radiographic and functional outcome in adolescent idiopathic scoliosis operated with hook/hybrid versus all-pedicle screw instrumentation—a retrospective study in 149 patients. Spine Deform 5:401–408.

    Article  PubMed  Google Scholar 

  2. Kim YJ, Lenke LG, Cho SK et al (2004) Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 29:2040–2048.

    Article  PubMed  Google Scholar 

  3. Yilmaz G, Borkhuu B, Dhawale AA et al (2012) Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis. J Pediatr Orthop 32:490–499.

    Article  PubMed  Google Scholar 

  4. Li G, Lv G, Passias P, Kozanek M et al (2010) Complications associated with thoracic pedicle screws in spinal deformity. Eur Spine J 19:1576–1584.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Di Silvestre M, Parisini P, Lolli F et al (2007) Complications of thoracic pedicle screws in scoliosis treatment. Spine 32:1655–1661.

    Article  PubMed  Google Scholar 

  6. Hicks JM, Singla A, Shen FH et al (2010) Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine 35:E465-470.

    Article  PubMed  Google Scholar 

  7. Tan SH, Teo EC, Chua HC (2004) Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans. Eur Spine J 13:137–146.

    CAS  Article  PubMed  Google Scholar 

  8. Zhang K, Chang Y, Fan F et al (2015) Estimation of stature from radiologic anthropometry of the lumbar vertebral dimensions in Chinese. Leg Med Tokyo Jpn 17:483–488.

    Article  Google Scholar 

  9. Storer SK, Vitale MG, Hyman JE et al (2005) Correction of adolescent idiopathic scoliosis using thoracic pedicle screw fixation versus hook constructs. J Pediatr Orthop 25:415–419.

    Article  PubMed  Google Scholar 

  10. Cheng I, Kim Y, Gupta MC et al (2005) Apical sublaminar wires versus pedicle screws–which provides better results for surgical correction of adolescent idiopathic scoliosis? Spine 30:2104–2112.

    Article  PubMed  Google Scholar 

  11. Palmisani M, Dema E, Cervellati S et al (2018) Hybrid constructs pedicle screw with apical sublaminar bands versus pedicle screws only for surgical correction of adolescent idiopathic scoliosis. Eur Spine J 27:150–156.

    Article  PubMed  Google Scholar 

  12. Trent CG. Spine Surgery. Techniques, Complication Avoidance, and Management. Vols. 1 and 2. Edited by Edward C. Benzel. New York, Churchill Livingstone, 1999. $325.00, 1538 pp. JBJS 2000;82:756

  13. Ferrando A, Bas P, Bas T (2017) Late neurological complications due to laminar hook compression in idiopathic scoliosis surgery. Spinal Cord Ser Cases 3:17081.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hyun S-J, Lee BH, Park J-H et al (2017) Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery. Korean J Spine 14:126–132.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Helgeson MD, Shah SA, Newton PO et al (2010) Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation. Spine 35:177–181.

    Article  PubMed  Google Scholar 

  16. Kim YJ, Bridwell KH, Lenke LG et al (2005) Proximal junctional kyphosis in adolescent idiopathic scoliosis following segmental posterior spinal instrumentation and fusion: minimum 5-year follow-up. Spine 30:2045–2050.

    Article  PubMed  Google Scholar 

  17. Polly DW, Potter BK, Kuklo T et al (2004) Volumetric spinal canal intrusion: a comparison between thoracic pedicle screws and thoracic hooks. Spine 29:63–69.

    Article  PubMed  Google Scholar 

  18. Jackson KL, Devine JG (2016) The effects of obesity on spine surgery: a systematic review of the literature. Glob Spine J 6:394–400.

    Article  Google Scholar 

  19. Upasani VV, Caltoum C, Petcharaporn M et al (2008) Does obesity affect surgical outcomes in adolescent idiopathic scoliosis? Spine 33:295–300.

    Article  PubMed  Google Scholar 

  20. Obesity Negatively Affects Spinal Surgery in Idiopathic Scoliosis n.d. Accessed 9 Apr 2020

  21. Tarrant RC, Queally JM, Moore DP et al (2018) Prevalence and impact of low body mass index on outcomes in patients with adolescent idiopathic scoliosis: a systematic review. Eur J Clin Nutr 72:1463–1484.

    Article  PubMed  Google Scholar 

  22. Clark EM, Taylor HJ, Harding I et al (2014) Association between components of body composition and scoliosis: a prospective cohort study reporting differences identifiable before the onset of scoliosis. J Bone Miner Res 29:1729–1736.

    Article  PubMed  Google Scholar 

  23. Zheng Y, Dang Y, Wu X et al (2017) Epidemiological study of adolescent idiopathic scoliosis in Eastern China. J Rehabil Med 49:512–519.

    Article  PubMed  Google Scholar 

  24. Hengwei F, Zifang H, Qifei W et al (2016) Prevalence of idiopathic scoliosis in Chinese schoolchildren: a large, population-based study. Spine 41:259–264.

    Article  PubMed  Google Scholar 

  25. Albano J, Lentz J, Stockton R et al (2019) Demographic analysis of lumbar pedicle diameters in a diverse population. Asian Spine J 13:410–416.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Body Mass Index and sagittal lumbar balance (2020) A geometric morphometrics approach. Eur J Anat 22:37–49

    Google Scholar 

  27. Soh TLT, Kho KC, Lim ZK et al (2021) Morphological parameters of the thoracic pedicle in an Asian population: a magnetic resonance imaging-based study of 3324 pedicles. Glob Spine J 11:437–441.

    Article  Google Scholar 

  28. Schmid SL, Buck FM, Böni T, Farshad M (2016) Radiographic measurement error of the scoliotic curve angle depending on positioning of the patient and the side of scoliotic curve. Eur Spine J 25:379–384.

    Article  PubMed  Google Scholar 

  29. Brown JC, Axelgaard J, Howson DC (1984) Multicenter trial of a noninvasive stimulation method for idiopathic scoliosis. A summary of early treatment results. Spine 9:382–387.

    CAS  Article  PubMed  Google Scholar 

  30. Liljenqvist U, Hackenberg L, Link T et al (2001) Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg 67:157–163

    CAS  PubMed  Google Scholar 

  31. Hackenberg L, Link T, Liljenqvist U (2002) Axial and tangential fixation strength of pedicle screws versus hooks in the thoracic spine in relation to bone mineral density. Spine 27:937–942.

    Article  PubMed  Google Scholar 

  32. Tai C-L, Chen L-H, Lee D-M et al (2014) Biomechanical comparison of different combinations of hook and screw in one spine motion unit—an experiment in porcine model. BMC Musculoskelet Disord 15:197.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Ashman R, Galpin R, Corin J et al (1990) Biomechanical analysis of pedicle screw instrumentation systems in a Corpectomy model. Spine 14:1398–1405.

    Article  Google Scholar 

  34. Clements DH, Betz RR, Newton PO et al (2009) Correlation of scoliosis curve correction with the number and type of fixation anchors. Spine 34:2147–2150.

    Article  PubMed  Google Scholar 

  35. Lee J, Park Y-S (2016) Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment. Asian Spine J 10:593.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kim YJ, Lenke LG, Bridwell KH et al (2007) Proximal junctional kyphosis in adolescent idiopathic scoliosis after 3 different types of posterior segmental spinal instrumentation and fusions: incidence and risk factor analysis of 410 cases. Spine 32:2731–2738.

    Article  PubMed  Google Scholar 

  37. Polly DW, Larson AN, Sponseller PD et al (2019) 147. Prospective randomized controlled trial of implant density in AIS: results of the Minimize Implants Maximize Outcomes study. Spine J 19:70–71.

    Article  Google Scholar 

  38. Morrissy RT, Goldsmith GS, Hall EC et al (1990) Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error. J Bone Jt Surg Am 72:320–327

    CAS  Article  Google Scholar 

  39. Carman DL, Browne RH, Birch JG (1990) Measurement of scoliosis and kyphosis radiographs. Intraobserver and interobserver variation. J Bone Jt Surg Am 72:328–333

    CAS  Article  Google Scholar 

  40. Kang KS, Song K-S, Lee JS et al (2011) Comparison of radiographic and computed tomographic measurement of pedicle and vertebral body dimensions in Koreans: the ratio of pedicle transverse diameter to vertebral body transverse diameter. Eur Spine J 20:414–421.

    Article  PubMed  Google Scholar 

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Authors and Affiliations



SWHT, GSG, LJ, RCCS: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new softward used in the work. SWHT, GSG, LJ, RCCS: drafted the work or revised it critically for important intellectual content. SWHT, GSG, LJ, RCCS: Approved the version to be published. SWHT, GSG, LJ, RCCS: agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Samuel Wei Han Tan.

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The authors declare that there is no conflict of interest.

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Centralised institutional review board (IRB) approval (CIRB 2018/2356) was obtained for this study. Waiver of informed consent was approved for this retrospective study.

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Tan, S.W.H., Goh, G.S., Jiang, L. et al. Do the benefits of hook-hybrid construct justify their use over all-pedicle screws constructs in maintaining postoperative curve correction for adolescent idiopathic scoliosis patients from an Asian population?. Spine Deform 10, 865–871 (2022).

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  • Adolescent idiopathic scoliosis
  • Posterior spinal fusion
  • Body mass index
  • Stature
  • Hooks
  • Pedicle screws
  • Small pedicle size