BACKGROUND CONTEXT Sagittal malalignment has been discussed extensively in adult spinal deformity (ASD) literature, while coronal malalignment (CM) and fractional curve (FC) have received less attention. As a result, little guidance currently exists for surgical indications in managing CM, despite it being a relatively common occurrence that can considerably impact patient wellbeing. Patients with CM significantly affected by FC are at particular risk for continued CM postoperatively, along with its complications. PURPOSE Assess types of approach to fusion of the fractional curve in ASD surgery and their relation to coronal alignment and sagittal alignment. STUDY DESIGN/SETTING Retrospective review at single institution. PATIENT SAMPLE A total of 82 ASD patients undergoing primary spinal fusion of 4 or more levels to sacrum or pelvis. OUTCOME MEASURES Baseline (BL), 1-year (Y1) postoperatively and BL-Y1 difference (ΔBL-Y1) in magnitudes of FC, coronal alignment (CA) and sagittal alignment (SA) parameters: pelvic incidence-LL (PI-LL), cervical sagittal vertical axis (cSVA), T1 pelvic angle (TPA). METHODS Patients ≥18 years old undergoing primary ≥4-level fusion to sacrum/pelvis between October 2011 and January 2018 with minimum 6-month follow-up included. Chart review performed for operative dates and details and patient follow-up information. Coronal and sagittal parameters measured using deformity measuring software program. FC measured as segmental angle between L4 and S1. CA measured as distance between C7 plumb line and central sacral vertical line. CA≥20mm designated as CM, per guidelines in literature. Chi-squared test used to compare percentages and ANOVA used to compare means, with significance set at p RESULTS A total of 82 patients studied (68.3%F, age 62.6±13.3, BMI 28.1±6.6, Charlson comorbidity index 0.80±1.16). Nine patients (10.98%) had anterior-posterior fusion (AP), 41 (50%) posterior-only fusion with interbody device (PIB), 32 (39.02%) PSF without interbody (PSF). Twenty-three patients (28.04%) had FC≥15° at BL, 7 (8.54%) at Y1. Forty-one patients (50%) had CM at BL, 35 (42.68%) at Y1. AP fusion patients had least levels fused (6.4 AP, 11.4 PIB, 11.8 PSF, p CONCLUSIONS Fusion to the sacrum/pelvis improves sagittal alignment, fractional curve and coronal alignment in most patients. However, while fractional curve and sagittal alignment are better corrected, coronal malalignment, particularly more severe malalignment at baseline, tends to persist postoperatively. Type of approach and use of interbody device does not appear to significantly impact these results. This should be considered in preoperative planning for patients with coronal deformity. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.