58+2-year-old female had classic flatback syndrome from previous Harrington rod instrumentation and fusion for idiopathic scoliosis. At nearly 20 years postoperative, she had progression of her unfused lumbar spine below the rod, spinal stenosis, and both coronal and especially sagittal spinal imbalance. She underwent a complex two stage spinal reconstruction with a midlumbar PSO to reshape her scoliosis and her lumbar kyphosis into a more normal alignment allowing her coronal and sagittal balance to be perfect at nearly 10 years postoperative.