Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy.

PURPOSE: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). METHODS: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. RESULTS: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. CONCLUSIONS: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. LEVEL OF EVIDENCE: III.

Clinical outcomes measurement in pediatric lower limb prosthetics: A scoping review.

PURPOSE: This study aimed to identify clinical measures that have been used to evaluate function, health related quality of life (HRQoL), and/or satisfaction in children who use lower limb prostheses (LLP). The data reported on psychometric properties for children who use LLP were collected for each measure. METHODS: First, PubMed, CINAHL, and Web of Science databases were searched using broad search terms to identify standardized outcome measures of function, HRQoL, and/or satisfaction with treatment used in pediatric LLP research published in 2001 or after. For each of the eligible measures found, a second search was performed to identify psychometric properties (e.g., validity, reliability) assessed with children who use LLP. RESULTS: Forty-four standardized outcome measures were identified from 41 pediatric LLP research articles. Five measures (i.e., Gait Outcomes Assessment for Lower Limb Differences, Functional Mobility Assessment, Child Amputee Prosthetics Project- Prosthesis Satisfaction Inventory, Child Amputee Prosthetics Project- Functional Scale Index, and Lower Limb Function Questionnaire) had data on psychometric properties for children who use LLP. CONCLUSIONS: Few studies report psychometric data for assessing the overall HRQoL, function, and/or satisfaction for children who use LLP. Further research is needed to validate or create new outcome measures that assess the HRQoL, satisfaction, and/or function of children who use LLP.

Use of standardized outcome measures for people with lower-limb amputation: A survey of prosthetic practitioners in Canada.

BACKGROUND: Outcome measures (OMs) are useful tools; however, clinicians may find implementing them into clinical practice challenging. OBJECTIVES: To characterize Canadian prosthetists' use of OMs for people with lower-limb amputation, including motivations for use, comfort selecting OMs, resources available for administration, and barriers to implementation. METHODS: A cross-sectional study was conducted between March and July 2021. Orthotics Prosthetics Canada sent Canadian prosthetists an invitation to take the online survey. RESULTS: Forty-nine Certified Prosthetists completed the survey. Only 16% of participants reported that they were expected to use OMs. Participants reported being more comfortable administering performance-based OMs than self-report surveys. More than two-thirds of participants agreed that OMs "can be administered with knowledge they have" and are "within their scope of practice." However, less than 25% agreed that OMs are "administered in a standardized way in the profession," and less than 40% indicated they are "easy to make part of my routine." Participants reported they generally have time and space to do OMs, but there was no agreed-on reason to use them. CONCLUSIONS: Use of OMs among Canadian prosthetists seems to be low relative to prosthetists in the United States. Education, financial incentives, or changes to professional expectations are likely needed to increase routine OM use. Efforts to improve the standardization of OM administration and ease the incorporation of OMs into routine practice may also increase use. Canadian prosthetists may elevate their standards of clinical practice and better understand the impact of prosthetic treatments on their patients by more routinely using OMs.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Development and initial validation of the Orthotic Patient-Reported Outcomes-Mobility (OPRO-M): An item bank for evaluating mobility of people who use lower-limb orthoses.

Lower limb orthoses (LLOs) are externally-applied leg braces that are designed to improve or maintain mobility in people with a variety of health conditions that affect lower limb function. Clinicians and researchers are therefore often motivated to measure LLO users' mobility to select or assess the effectiveness of these devices. Patient-reported outcome measures (PROMs) can provide insights into important aspects of a LLO user's mobility for these purposes. However, few PROMs are available to measure mobility of LLO users. Those few that exist have issues that may limit their clinical or scientific utility. The objective of this study was to create a population-specific item bank for measuring mobility of LLO users. Previously-developed candidate items were administered in a cross-sectional study to a large national sample of LLO users. Responses from study participants (n = 1036) were calibrated to a graded response statistical model using Item Response Theory methods. A set of 39 items was found to be unidimensional, locally independent, and function without bias due to characteristics unrelated to mobility. The set of final calibrated items, termed the Orthotic Patient-Reported Outcomes-Mobility (OPRO-M) item bank, was evaluated for initial evidence of convergent, divergent, and known groups construct validity. OPRO-M was strongly correlated with existing PROMs designed to measure aspects of physical function. Conversely, OPRO-M was weakly correlated with PROMs that measured unrelated constructs, like sleep disturbance and depression. OPRO-M also showed an ability to differentiate groups with expected mobility differences. Two fixed-length short forms were created from the OPRO-M item bank. Items on the short forms were selected based on statistical and clinical criteria. Collectively, results from this study indicate that OPRO-M can effectively measure mobility of LLO users, and OPRO-M short forms can now be recommended for use in routine clinical practice and research studies.

Effects of high-profile crossover feet on gait biomechanics in 2 individuals with Syme amputation.

BACKGROUND: Prosthetic treatment options for people with ankle disarticulation (i.e., Syme amputation) are limited. Prosthetic feet designed for people with Syme amputation are often low profile to accommodate build-height restrictions, resulting in decreased energy return during gait. High-profile crossover feet that attach to the posterior proximal aspect of the prosthetic socket can bypass these restrictions and may promote a more physiologic gait pattern. OBJECTIVES: To compare level-ground gait biomechanics and patient-reported outcomes between crossover and traditional energy-storing feet in people with Syme amputation. STUDY DESIGN: Within-participant pilot study. METHODS: Both participants were fit with energy-storing and crossover feet and were randomized to the order they used the feet. Participants used each foot for 2 weeks before assessment. Step length symmetry, prosthetic ankle range of motion, prosthetic-side energy return, and peak sound-side loading were determined from motion capture data obtained in a laboratory. Mobility and balance confidence were measured using standardized patient-reported outcome measures. Foot preference was assessed with an ad hoc survey. RESULTS: Two participants with Syme amputations completed the study. Prosthetic ankle peak dorsiflexion and push-off power increased with the crossover foot compared with the energy-storing foot for both participants. Both participants reported an overall preference of the crossover foot. Changes in patient-reported outcomes did not exceed published minimum detectable change values. CONCLUSION: Crossover feet increased prosthetic ankle range of motion and energy return compared with traditional energy-storing feet in this pilot investigation of 2 participants. Crossover feet seem to promote physiologic gait and may be a promising alternative to traditional low-profile feet for people with Syme amputation.

An in vivo analysis of implanted programmable device interference during magnetically controlled growing rod lengthenings: a story of 129 lengthenings.

PURPOSE: Early-onset scoliosis (EOS) is often treated with magnetically controlled growing rods (MCGR) which can be lengthened with a magnetic external remote control (ERC). Many individuals with EOS have concomitant medical conditions which are managed with other implanted programmable devices (IPD). Some providers are concerned that the magnetic field generated during MCGR lengthening may interfere with other IPD, such as ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), vagal nerve stimulators (VNS), and cochlear implants (CI). The aim of this study was to evaluate the safety of MCGR lengthenings in patients with EOS and other IPD. METHODS: This single-center, single-surgeon case series followed 12 patients with 13 IPD as they underwent treatment with MCGR. Post MCGR lengthening, monitoring of patient symptoms, and interrogation of IPD were conducted to evaluate for magnetic interference. RESULTS: After 129 MCGR lengthenings, post-lengthening VPS interrogation found 2 instances of potential interference in settings (both in Medtronic Strata shunts); however, no pre-lengthening interrogation was completed to confirm if these changes occurred prior to or during the lengthening procedure. ITBP interrogation found no changes, and there were no patient-reported adverse effects related to VNS or CI function. CONCLUSION: It is safe and effective to utilize MCGR in patients with IPD. However, the possibility of magnetic interference must be considered, particularly in individuals with VPS. We recommend approaching with the ERC from a caudal direction to minimize potential interference and all patients be monitored during treatment. If possible, IPD settings should be assessed pre-lengthening, confirmed afterwards and readjusted if necessary. LEVEL OF EVIDENCE: Level IV.

Development of an item bank for measuring prosthetic mobility in people with lower limb amputation: The Prosthetic Limb Users Survey of Mobility (PLUS-M).

BACKGROUND: Achieving mobility with a prosthesis is a common post-amputation rehabilitation goal and primary outcome in prosthetic research studies. Patient-reported outcome measures (PROMs) available to measure prosthetic mobility have practical and psychometric limitations that inhibit their use in clinical care and research. OBJECTIVE: To develop a brief, clinically meaningful, and psychometrically robust PROM to measure prosthetic mobility. DESIGN: A cross-sectional study was conducted to administer previously developed candidate items to a national sample of lower limb prosthesis users. Items were calibrated to an item response theory model and two fixed-length short forms were created. Instruments were assessed for readability, effective range of measurement, agreement with the full item bank, ceiling and floor effects, convergent validity, and known groups validity. SETTING: Participants were recruited using flyers posted in hospitals and prosthetics clinics across the United States, magazine advertisements, notices posted to consumer websites, and direct mailings. PARTICIPANTS: Adult prosthesis users (N = 1091) with unilateral lower limb amputation due to traumatic or dysvascular causes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Candidate items (N = 105) were administered along with the Patient Reported Outcome Measurement Information System Brief Profile, Prosthesis Evaluation Questionnaire - Mobility Subscale, and Activities-Specific Balance Confidence Scale, and questions created to characterize respondents. RESULTS: A bank of 44 calibrated self-report items, termed the Prosthetic Limb Users Survey of Mobility (PLUS-M), was produced. Clinical and statistical criteria were used to select items for 7- and 12-item short forms. PLUS-M instruments had an 8th grade reading level, measured with precision across a wide range of respondents, exhibited little-to-no ceiling or floor effects, correlated expectedly with scores from existing PROMs, and differentiated between groups of respondents expected to have different levels of mobility. CONCLUSION: The PLUS-M appears to be well suited to measuring prosthetic mobility in people with lower limb amputation. PLUS-M instruments are recommended for use in clinical and research settings.

Prevalence of secondary prosthesis use in lower limb prosthesis users.

PURPOSE: Prostheses designed for daily use are often inappropriate for high-level activities and/or are susceptible to water damage and mechanical failure. Secondary prostheses, such as activity-specific or back-up prostheses, are typically required to facilitate uninterrupted participation in desired life pursuits. This study estimated the prevalence of secondary prosthesis use in a large, national sample of lower limb prosthesis users (LLPUs). METHODS: We conducted a secondary analysis of survey data from three cross-sectional studies that assessed mobility in LLPUs. Descriptive statistics were used to determine the percentage of secondary prosthesis users and percentages of LLPUs that used different type(s) of secondary prosthesis(es). Secondary prosthesis users and non-users were compared to identify differences in participant characteristics between groups. RESULTS: Of participants in the analysis (n = 1566), most (65.8%) did not use a secondary prosthesis. The most common secondary prosthesis types were back-up (19.2%) and activity-specific prostheses (13.5%). Secondary prosthesis users differed significantly from non-users with respect to gender, race, and other characteristics. CONCLUSIONS: Results suggest that secondary prosthesis use for most LLPUs is limited and may differ based on users' demographic and clinical characteristics. Future research should determine how LLPUs' health-related quality-of-life outcomes are affected by access to and use of secondary prostheses.Implications for RehabilitationSecondary prostheses, including activity-specific, back-up, and shower prostheses, have the potential to improve function, mobility, and participation for people who use lower limb prostheses.Most lower limb prosthesis users do not use secondary prostheses, and access to these devices may be related to users' demographic and clinical characteristics.Rehabilitation professionals play a key role in facilitating prosthesis users' access to secondary prostheses and should advocate for those who need them.

Modifying the five-time sit-to-stand test to allow use of the upper limbs: Assessing initial evidence of construct validity among lower limb prosthesis users.

The Five-time Sit-to-Stand (5xSTS) Test is a performance-based measure used by clinicians and researchers to assess the body functions needed to accomplish sit-to-stand transitions (e.g., lower limb strength, balance, and trunk control). The current requirements for performance of the 5xSTS Test (i.e., crossing arms over the chest) may not be appropriate for many, if not most lower limb prosthesis (LLP) users. The study aims were to (1) develop a modified five-time sit-to-stand (m5xSTS) Test protocol; (2) to examine initial evidence of known-groups construct validity among LLP users by comparing differences in performance by amputation level, amputation etiology, and functional level; and (3) to assess initial evidence of convergent construct validity by examining the correlations between m5xSTS performance with self-reported mobility (Prosthetic Limb Users Survey of Mobility (PLUS-M)), self-reported balance confidence (Activities-balance Confidence Scale (ABC)) and functional capability (comfortable walking speed). Three-hundred sixty-one LLP users participated in this cross-sectional study. The investigators developed a m5xSTS Test protocol that allows tested individuals to use different assistance strategies (i.e., use of upper limbs to push off thighs, push up from the armrests, or use a walker) when needed to perform the test. The investigators recorded m5xSTS Test times and assistance strategies. Significant differences in m5xSTS Test times were found between those who did and did not use an assistance strategy, as well as between participants grouped by different amputation level, etiology, and functional level. Significant moderate negative correlations were found between m5xSTS Test times and PLUS-M T-score (ρ = -0.42, p<0.001), ABC score (ρ = -0.42, p<0.001), and comfortable walking speed (ρ = -0.64, p<0.001), respectively. The m5xSTS Test allows LLP users to perform sit-to-stand transitions in a manner that accounts for their functional impairments, is consistent with post-amputation training, and is safe for the tested individual. Results from this study provide preliminary evidence of known groups and convergent construct validity for the m5xSTS Test with a large national sample of LLP users.

Policies, Practices, and Attitudes Related to Parental Leave for Practicing Pediatric Orthopaedic Surgeons.

BACKGROUND: Parental leave impacts family engagement, bonding, stress, and happiness. Because parental leave benefits are important to all surgeons regardless of sex, understanding parental leave practices in pediatric orthopaedic surgery is critical to promote equity within the profession and supporting balance in work and family life. The aim of this study was to survey pediatric orthopaedic surgeons about their knowledge of parental leave policies, attitudes towards parental leave, and their individual experiences taking leave. METHODS: A 34-question anonymous survey was distributed to the Pediatric Orthopaedic Society of North America membership. Eligible respondents were attending pediatric orthopaedic surgeons practicing in the United States or Canada. The survey gathered information about employer parental leave policies, perceptions about and experiences with parental leave while practicing as a surgeon, and demographic information about respondents. RESULTS: A total of 77 responses were completed and used for analysis. Most respondents were men (59.7%), <50 years old (67.5%), married (90.9%), and in urban communities (75.3%). A large majority were practicing in the United States (97.4%). Most respondents were unfamiliar with employer parental leave policies (maternity: 53.3%; paternity: 67.5%; and adoption: 85.7%). Those familiar with policies reported that employers offered 7 to 12 weeks for maternity leave (45.7%) and <1 week for paternity leave (50%) and adoption leave (45.5%). Most respondents believed 7 to 12 weeks should be offered for maternity leave (66.2%), 1 to 6 weeks for paternity leave (54.6%), and 7 to 12 weeks for adoption leave (46.8%). Many respondents reported taking 1 to 6 weeks of parental leave as a surgeon (53.3%) and that their colleagues were supportive of their parental leave (40.3%). CONCLUSIONS: Most pediatric orthopaedic surgeons were unfamiliar with parental leave benefits provided by employers. Respondents who were familiar with these policies believed that more parental leave should be provided, especially for men who may feel social pressure to take less time for leave. Although respondents reported that their work environments were supportive, this study identified opportunities for improvement to support surgeons who wish to balance parental experiences with work responsibilities. LEVEL OF EVIDENCE: Level V.

Pitfalls and management of corrective spinal surgery in trisomy 9 mosaicism: a report of three cases.

PURPOSE: The aim of this case series is to present the outcomes of surgical correction of hyperkyphosis, and subsequent management of complications for three patients with a rare chromosomopathy, Trisomy 9 Mosaicism (T9M). METHODS: Case series with 2 year outcomes following index surgery. RESULTS: Case 1 presented at 9 years of age with 103° of kyphosis (T3-T10), which progressed to 118° despite bracing. Case 2 presented at 7 years of age with 113° of kyphosis (T3-T11). Case 3 presented at 4 years of age with 103° of kyphosis (T1-T11). Cases 1 and 2 underwent T2-L2 posterior instrumented spinal fusion (PISF). Upon follow up, radiographs for Cases 1 and 2 revealed severe, symptomatic proximal junctional kyphosis (PJK) of 71° and 50°, respectively, requiring surgical revision proximally to the C4 level. Case 3 underwent placement of magnetically controlled growing rods given young age and growth potential. Surgical levels for Case 3 were extended from C4-pelvis in an attempt to prevent development of symptomatic PJK. Most recent radiographs for Case 3 taken 21 months postoperatively demonstrate a stable 50° of kyphosis. PJK above C4 was noted but is stable and asymptomatic. CONCLUSION: T9M often presents with progressive hyperkyphosis. Despite instrumentation above the upper end vertebra (UEV), PJK may be a common complication in this small patient population. This novel report on spine deformity correction in the T9M population may provide preliminary guidance for the treatment of hyperkyphosis in patients with T9M and help surgeons avoid common pitfalls. LEVEL OF EVIDENCE: IV.

Development of a candidate item bank for measuring mobility of lower limb orthosis users.

BACKGROUND: Orthoses are often prescribed to improve mobility of people with chronic health conditions that affect lower limb function. Patient-reported survey instruments can be used to measure aspects of mobility that cannot be easily assessed in clinical or research settings. A population-specific item bank could be designed to measure aspects of mobility that are most important to lower limb orthosis users and used to evaluate the effects of orthoses. OBJECTIVE: To develop items for a new survey instrument to measure mobility of lower limb orthosis users. DESIGN: Survey items were developed using a qualitative item review process. SETTING: Focus groups were held by video conferencing. Cognitive interviews were conducted by telephone. PARTICIPANTS: Focus group and cognitive interview participants were adults with at least 6 months of experience using a lower limb orthosis that extended from the foot to a level above the ankle. METHODS: Research methods included focus groups with lower limb orthosis users, an item generation and reduction process that involved a stakeholder advisory panel, and cognitive interviews with target respondents. RESULTS: A total of 1180 extant items were identified in a literature review. Focus group participants (n = 29) provided feedback that informed the suitability of a construct definition and conceptual model. An advisory panel contributed to the selection of 118 candidate items for measuring orthotic mobility. Feedback from cognitive interview participants (n = 30) informed removal or revision of problematic items, resulting in a candidate bank of 100 mobility items. CONCLUSIONS: The rigorous qualitative methods applied here resulted in a large set of candidate items that spanned a range of situations relevant to moving with a lower limb orthosis. Next steps include administration of the candidate items to a large sample of lower limb orthosis users and calibration of the item bank.

Clinical Resources for Assessing Mobility of People with Lower-Limb Amputation: Interviews with Rehabilitation Clinicians.

Introduction: Mobility tests are increasingly used in prosthetic rehabilitation to evaluate patient outcomes. Knowledge of the space, equipment, and time resources available to clinicians who work in different settings can guide recommendations for which tests are most clinically-feasible and promote coordination of mobility testing among members of the rehabilitation team. The primary aim of this study was to characterize the different resources available to clinicians for measuring mobility of people with lower limb amputation. A secondary aim was to identify performance tasks that clinicians use to evaluate prosthetic mobility. Materials and methods: Semi-structured interviews were conducted with prosthetists, physical therapists, and physiatrists who treat people with lower limb amputation. Researchers used convenience and snowball sampling to identify participants. Interviews included questions about the resources available for conducting mobility tests, as well as questions about which tasks clinicians deemed valuable to assessing mobility of patients with lower limb amputation. Interviews were audio-recorded and transcribed. Summary and frequency statistics were calculated for quantitative data; explanatory comments were summarized. Results: Interviews were conducted with 25 clinicians (8 prosthetists, 9 physical therapists, and 8 physiatrists). Participants had access to multiple spaces and basic measurement equipment. The maximum time participants were willing to spend on performance tests varied. Physiatrists reported less time available (median=10 minutes, range 5-30 minutes) than prosthetists and physical therapists (median=30 minutes, range 5-60 minutes for both professions). Mobility tasks commonly used to evaluate patients with lower limb amputation included sit-to-stand, standing balance, walking, and varying speed. Participant comments suggested that mobility tests need to be quick, simple, and add value; existing mobility tests are beneficial but challenging to incorporate into practice; mobility tests should reflect real-world activities; and technological advancements could improve mobility testing. Conclusions: Clinicians generally had small-to-medium spaces, basic measurement equipment, and sufficient training to administer mobility tests in their clinics. A limiting factor was time, which can be addressed through selection of efficient measures and collaboration within the rehabilitation team.

Use of Standardized Outcome Measures for People With Lower Limb Amputation: A Survey of Prosthetic Practitioners in the United States.

OBJECTIVE: To assess the clinical resources available for the assessment of health outcomes in people with lower limb amputation and to understand barriers and facilitators associated with use of standardized outcome measures in clinical practice. DESIGN: Cross-sectional survey. SETTING: General community (online). PARTICIPANTS: A volunteer sample of prosthetic practitioners was recruited through national professional organizations. Eligible participants were practitioners certified by a professional prosthetics organization and currently practicing as a prosthetist, prosthetist-orthotist, or prosthetic assistant. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A custom-designed online survey on clinical use of patient-reported and performance-based standardized outcome measures to assess patients with lower limb amputation. RESULTS: A total of 375 participants completed the survey. Most participants (79%) reported that they are encouraged or required to administer standardized outcome measures in their clinic or facility. Most participants reported that use of patient-reported and performance-based outcome measures are within their scope of practice (88%) and that they have the knowledge required for outcomes measurement (84%). Few participants agreed that outcomes measurement is standardized across the profession (30%). Most participants had access to small spaces and equipment for outcomes measurement, such as short hallways (65%-94%), stairs (69%), and tablets with wireless internet connection (83%). Most participants reported that they would be willing to spend between 5 (36% of participants) and 10 (43% of participants) minutes on self-reported surveys, and between 10 (41% of participants) and 20 (28% of participants) minutes on performance-based tests. CONCLUSIONS: Outcomes measurement is encouraged or expected in contemporary prosthetic practice. Strategies to improve standardization and efficiency of administration are needed to facilitate routine use of outcome measures in clinical care.

Determining educational assessment criteria for patellar-tendon-bearing impressions for transtibial prosthetic sockets: A Delphi study.

BACKGROUND: Validated criteria to guide assessment of student performance in clinical tasks in prosthetics and orthotics education have not been established. Lack of established criteria and assessment methods presents challenges in evaluating student performance on clinical tasks, such as taking impressions for patellar-tendon-bearing (PTB) sockets. OBJECTIVES: To establish assessment criteria for the PTB impression process for use in educational settings. STUDY DESIGN: Delphi consensus process. METHODS: Initial Delphi survey items were based on interviews with prosthetic instructors and focus groups with prosthetic students. Expert prosthetic educators were then identified by purposive sampling to complete multiple-round Internet-based Delphi surveys. The Delphi surveys asked experts to indicate their level of agreement on various assessment methods and criteria in PTB education. Consensus for survey items was reviewed after each survey round and used to determine the content of and need for subsequent rounds. RESULTS: Fourteen experts completed two Delphi survey rounds. Items were categorized into educational materials/strategies, impression stages/materials, measurement tools, measurements taken, assessment during impression, assessment after impression, feedback, student self-assessment, and grading. In two survey rounds, 40 items guiding assessment methods and criteria for PTB impressions achieved 80% consensus. CONCLUSIONS: A high level of consensus was achieved in two survey rounds. Lower levels of consensus were reached on specific objective criteria, such as use of measurement thresholds when evaluating student impressions. Standardized assessment of student performance on PTB impression-taking instead relies primarily on qualitative assessments based on instructor expertise.

Does the presence of programmable implanted devices in patients with early onset scoliosis alter typical operative and postoperative practices? A survey of spine surgeons.

PURPOSE: Operative and postoperative management of early onset scoliosis (EOS) patients with programmable implanted devices has not been well characterized in the literature. The aim of this study was to describe current practices for pediatric spine surgeons who operate on patients with these devices. METHODS: An electronic survey was distributed to 167 pediatric spine surgeons between January and March of 2021. The survey queried participants on operative and postoperative management of patients with the following implanted devices: vagal nerve stimulators, ventriculoperitoneal shunts, intrathecal baclofen pumps, pacemakers, and cochlear implants. Descriptive statistics were used to assess survey data. RESULTS: Fifty-three respondents (31.7% response rate) with a mean 16.5 (SD 12.0) years in practice completed the survey. Depending on the type of device present, surgeons report changing their operative plan anywhere from 28.6 to 60.1% of the time when inserting magnetically controlled growing rods. Most respondents reported performing transcranial motor evoked potentials (80.0-98.0%) and monopolar cautery (70.0-92.9%) across implanted devices. Only 10% (n = 5) of surgeons reported complications related to operative and/or postoperative management of these patients. No complications were related to cautery, neuromonitoring, or surgical placement of MCGRs. CONCLUSIONS: This study demonstrates variation in operative and postoperative management of these patients with various programmable implanted devices. Much of this inconsistency in practice is likely due to decades old case reports, constantly changing device manufacturer recommendations, and/or published simulation studies. Reported heterogeneity in management across surgeons necessitates development of published guidelines regarding proper operative and postoperative management of patients with EOS and implanted devices.

Is nighttime bracing effective in the treatment of adolescent idiopathic scoliosis? A meta-analysis and systematic review based on scoliosis research society guidelines.

PURPOSE: Standard treatment for skeletally immature adolescents with moderate Adolescent Idiopathic Scoliosis (AIS) is a full-time spinal orthosis. However, adherence to full-time wear (≥ 18 h/day) is often challenging for these patients. Nighttime bracing is an alternative option that may improve patient adherence and/or satisfaction. This systematic review and meta-analysis assessed the effectiveness of nighttime bracing in patients with AIS. METHODS: A systematic review of studies evaluating nighttime bracing was performed. PubMed, Medline, Embase, CINAHL and Cochrane library databases were searched (01/1975-03/2020); two reviewers assessed eligibility. Eligible articles were peer reviewed, in English, and reported outcomes for patients who met Scoliosis Research Society (SRS) criteria. The primary outcome was curve progression ≥ 6°. Pooled progression rates were calculated from random effects meta-analyses with inverse-variance weights; 95% CIs were calculated. RESULTS: Nine studies (n = 595) were included. The overall pooled progression rate to ≥ 6° was 40.7% (95% CI: 30.4-51.5%). The pooled progression rate to surgical magnitude was 24.8% (95% CI: 4.5-53.6%). The most successful outcomes were in subjects with thoracolumbar/lumbar curves and subjects who initiated bracing at Risser 1/2 (pooled progression rates were 27.8% (95% CI: 17.0-40.0%) and 16.5% (95% CI: 11.7-21.8%), respectively). Univariate sub-analyses were conducted due to sample sizes. CONCLUSIONS: Progression rates in patients with primary thoracolumbar/lumbar curves and in patients who initiated nighttime bracing at Risser 1/2 were comparable to published progression rates for full-time bracing, indicating that nighttime bracing may be equally effective for these patients. However, the strength of these conclusions is limited by the sample size and the overall quality of included studies.

Effects of prosthetic feet on metabolic energy expenditure in people with transtibial amputation: A systematic review and meta-analysis.

OBJECTIVE: To assess the effects of different prosthetic feet on energy costs associated with walking and running in people with transtibial amputation. LITERATURE SURVEY: The Pubmed, CINAHL, and Web-of-Science bibliographic databases were searched for original research published through June 30, 2018. References from identified articles were also reviewed. METHODOLOGY: Two reviewers screened titles, abstracts, and articles for pertinent studies. Details were extracted with a standardized template. Risk of bias was assessed using domain-based methods. Prosthetic feet were grouped into categories and compared according to energy costs associated with walking or running over various terrain conditions. Meta-analyses were conducted when data quantity and homogeneity permitted. Evidence statements were formed when results were consistent or undisputed. SYNTHESIS: Fifteen studies were included. Participants (n = 141) were predominantly male (87.9%), had unilateral amputation (95.7%) from non-dysvascular causes (87.9%), and were classified as unlimited community ambulators or active adults (56.0%). Participants were often young but varied in age (mean age 24.8-66.6 years). Available evidence indicates that feet with powered dorsiflexion reduce energy costs relative to dynamic response feet in unlimited community ambulators or active adults when walking on level or declined surfaces. Dynamic response feet do not significantly reduce energy costs compared to energy storing, flexible keel, or solid ankle feet when walking on level terrain. Running feet do not reduce energy costs relative to dynamic response in active adults when running. Select feet may reduce energy costs under specific conditions, but additional research is needed to confirm preliminary results. CONCLUSIONS: The overall body of evidence is based on small samples, comprised mostly of participants who may not well represent the population of prosthesis users and test conditions that may not well reflect how prostheses are used in daily life. However, evidence suggests energy costs are affected by prosthetic foot type only under select conditions.

Mobility with a lower limb prosthesis: experiences of users with high levels of functional ability.

PURPOSE: The Prosthetic Limb Users Survey of Mobility (PLUS-M) is a self-report item bank designed to measure the abilities with which people with lower limb amputation perform physical activities. Although PLUS-M includes items that span a range of mobility, additional items are needed to accurately measure mobility of highly active prosthesis users, such as athletes and service members with lower limb amputation. The aim of this study was to understand mobility in highly active lower limb prosthesis users to inform the development of new items for the PLUS-M item bank. METHODS: Focus groups were conducted with active, lower limb prosthesis users from across the USA. In-person and online focus groups were conducted by a trained facilitator using a semi-structured guide. Focus group transcripts were reviewed and coded by two researchers. Thematic analysis was used to identify important experiences across participants. RESULTS: Twenty-nine participants took part in four focus groups. Three resultant themes were identified: mobility after amputation, mobility characteristics, and healthcare providers and systems. CONCLUSIONS: Identified themes inform clinician and researcher understanding of mobility in highly active lower limb prosthesis users. The results of this study will be used to inform development of high-activity items for the PLUS-M item bank.Implications for rehabilitationParticipants described engagement in high-level activities as a learning process that included elements such as equipment challenges and modifications, pain and injury, and the need to trust the prosthetic limb.Participants with lower limb amputation who use prostheses identified mobility characteristics, such as postural changes, terrain, and obstacles, that influenced their ability to perform high-level activities.High-level mobility characteristics identified in these focus groups can be integrated into a revised version of the Prosthetic Limb Users Survey of Mobility to assess mobility in active adults and athletes with amputation.Rehabilitation professionals play an important role in facilitating access to specialized prosthetic components and training that can help patients achieve their mobility goals and potential.