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.

Measurements of Best, Worst, and Average Socket Comfort Are More Reliable Than Current Socket Comfort in Established Lower Limb Prosthesis Users.

OBJECTIVE: To evaluate test-retest reliability and related measurement properties of items developed to assess best, worst, and average prosthetic socket comfort. DESIGN: Methodological research to assess test-retest reliability of 4 individual socket comfort survey items. Socket comfort items were included in a self-report paper survey, which was administered to participants 2 to 3 days apart. SETTING: General community. PARTICIPANTS: A minimum convenience sample of participants (N=63) was targeted for this study; 72 lower limb prosthesis users (>1y postamputation) completed the survey and were included in the final dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The expanded socket comfort score (ESCS) was adapted from the original socket comfort score (SCS). The original SCS is a single-item self-report instrument developed to assess a lower limb prosthesis user's current socket comfort. Three additional items were designed to assess the user's best, worst, and average socket comfort over the previous 7 days. RESULTS: Best, worst, and average socket comfort items demonstrated better reliability, as indicated by higher intraclass correlation coefficients. As such, these items also exhibited lower measurement error and smaller minimal detectable change values than the item that measured current socket comfort. However, test-retest coefficients for all 4 ESCS items were below the level desired for evaluation of within-individual changes of socket comfort. CONCLUSIONS: Items that assess best, worst, and average comfort provide a more stable measurement of socket fit than the existing SCS instrument. Although administration of all 4 ESCS items may provide more comprehensive assessment of a lower limb prosthesis user's socket fit, administrators should expect variations in scores over time owing to the variable nature of the underlying construct over time. Future research should examine whether the ESCS provides an improved overall assessment of socket fit.

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.

A Comparison of the Two-Minute Walk Test (2MWT) and Comprehensive High-level Activity Mobility Predictor (CHAMP) in People with a Leg Prosthesis.

OBJECTIVE: To determine if the two-minute walk test (2MWT) could serve as an alternative measure of high-level mobility in lower limb prosthesis users when circumstances preclude administration of the Comprehensive High-level Activity Mobility Predictor (CHAMP). DESIGN: Cross-sectional study. SETTING: Indoor recreational athletic field and gymnasium. SUBJECTS: Fifty-eight adult lower limb prosthesis users with unilateral or bilateral lower limb amputation who participate in recreational athletic activities. INTERVENTION: N/A. MAIN MEASURES: The 2MWT and CHAMP while using their preferred prosthesis(es) on an indoor artificial athletic field or hardwood gymnasium floor. RESULTS: Thirty-nine men and nineteen women with a median age of 38.3 years participated in the study. Most participants experienced amputation(s) due to trauma (62%) or tumor (10%) and were generally higher functioning (K4 (91.4%) and K3 (8.6%)). The median (range) score for the CHAMP was 23.0 points (1.5-33.5) and the mean ± standard deviation (range) 2MWT distance walked was 188.6 ± 33.9 m (100.2-254.3 m). The CHAMP demonstrated a strong positive relationship with 2MWT (r = 0.83, p < 0.001). The 2MWT distance predicted 70% of the variance in CHAMP score. CONCLUSIONS: Although the 2MWT does not test multi-directional agility like the CHAMP, they were found to be highly correlated. If space is limited, the two-minute walk test can serve as an alternative measure for assessing high-level mobility capabilities in lower limb prosthesis users.

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.

Cross-Sectional Assessment of Factors Related to Pain Intensity and Pain Interference in Lower Limb Prosthesis Users.

OBJECTIVE: To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs). DESIGN: Cross-sectional survey. SETTING: Community. PARTICIPANTS: Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain. RESULTS: Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported. CONCLUSIONS: Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.

Construct Validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M) in Adults With Lower Limb Amputation.

OBJECTIVE: To assess construct validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M), a self-report mobility measure for people with lower limb amputation (LLA). DESIGN: Cross-sectional study. SETTING: Private prosthetic clinics (n=37). PARTICIPANTS: Current lower limb prosthesis users (N=199; mean age ± SD, 55.4±14.3y; 71.4% men) were assessed before receiving a replacement prosthesis, prosthetic socket, and/or prosthetic knee. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Convergent construct validity was examined using correlations between participants' PLUS-M T-scores and measures of physical function, mobility, and balance, including the Amputee Mobility Predictor (AMP), timed Up and Go (TUG), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Prosthesis Evaluation Questionnaire-Mobility Subscale (PEQ-MS), and Activities-specific Balance Confidence (ABC) Scale. Known-groups construct validity was evaluated by comparing differences in PLUS-M T-scores among participants grouped by Medicare Functional Classification Level (MFCL). RESULTS: PLUS-M T-scores demonstrated a moderate positive relationship with AMP scores (ρ=.54, P<.001) and a moderate negative relationship with TUG times (ρ=-.56, P<.001). The PLUS-M also showed a strong positive relationship with PEQ-MS scores (ρ=.78, P<.001), ABC Scale scores (ρ=.81, P<.001), and PROMIS-PF T-scores (ρ=.81, P<.001). Significant differences (P<.05) in PLUS-M T-scores were found among groups of people classified by different MFCLs. CONCLUSIONS: Study results support the validity of the PLUS-M as a self-report measure of prosthetic mobility. Correlations between PLUS-M and measures of physical function, mobility, and balance indicate convergent construct validity. Similarly, significant differences in PLUS-M T-scores across MFCL groups provide evidence of known-groups construct validity. In summary, evidence indicates that PLUS-M has good construct validity among people with LLA.

Self-Reported Cognitive Concerns in People With Lower Limb Loss.

OBJECTIVES: To investigate differences between self-reported cognitive concerns in people with lower limb loss (LLL) and normative data derived from the U.S. general population, and secondarily to determine whether there were cognitive differences based on amputation etiology or age. DESIGN: Survey. SETTING: General community. PARTICIPANTS: A volunteer sample of persons with LLL (N=1086) resulting from trauma or dysvascular complications who regularly use a prosthetic limb. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Quality of Life in Neurological Disorders Applied Cognition-General Concerns Short Form version 1.0 (Neuro-QoL ACGC), an 8-item self-report measure of general cognitive concerns. RESULTS: People with LLL reported significantly more cognitive concerns than the Quality of Life in Neurological Disorders normative sample. Mean Neuro-QoL ACGC scores were significantly lower than normative values (P<.001) across subgroups defined by age (ie, <40, 40-49, 50-59, 60-69, and 70+ years) and subgroups defined by etiology (ie, traumatic and dysvascular LLL). However, there were no significant differences in cognitive concerns among age subgroups (P=.84) or between the etiology subgroups (P=.58). CONCLUSIONS: When compared with the Quality of Life in Neurological Disorders normative sample, individuals with LLL report greater concerns with cognitive health. Cognitive concerns were not differentially affected by age or cause of amputation. The presence of cognitive concerns in people with LLL suggests a need to assess perceived cognitive function in order to tailor education and training in prosthetic use and care.

Health-related profiles of people with lower limb loss.

OBJECTIVES: To construct profiles of self-reported health indicators to examine differences and similarities between people with lower limb loss and a normative sample (hereafter called the norm) and to compare health indicators between subgroups based on level and etiology of limb loss. DESIGN: Survey. SETTING: General community. PARTICIPANTS: Adults with unilateral lower limb loss (N=1091) participated in this study. Eligibility criteria included lower limb loss due to trauma or dysvascular complications and regular use of a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Patient-Reported Outcomes Measurement Information System 29-item Health Profile version 1.0 measures physical function, pain interference, fatigue, sleep disturbance, anxiety, depression, and satisfaction with participation in social roles. The norm includes 5239 individuals representative of the U.S. general population in sex, age, race, ethnicity, and education. RESULTS: People with lower limb loss reported statistically significantly worse physical function, pain interference, and satisfaction with participation in social roles and significantly less fatigue than did the norm. People with transfemoral (ie, above-knee) amputation significantly differed in physical function from people with transtibial (ie, below-knee) amputation. Similarly, people with amputation due to trauma and dysvascular etiology significantly differed in physical function and satisfaction with social roles after adjusting for relevant clinical characteristics. CONCLUSIONS: People with lower limb loss generally report worse physical function, pain interference, and satisfaction with social roles than do the norm. People with dysvascular amputation reported worse physical function and satisfaction with social roles than did people with traumatic amputation. Health indicator profiles are an efficient way of providing clinically meaningful information about numerous aspects of self-reported health in people with lower limb loss.

Use of cognitive interviews in the development of the PLUS-M item bank.

PURPOSE: Measuring constructs such as mobility with patient-reported outcomes (PROs) can enhance clinical and scientific understanding of how health conditions, like lower limb amputation, impact patients' lives. When developing PRO questionnaires, cognitive interviews (CIs) are used to examine whether survey items are understandable, clear, and meaningful. The aim of this study was to use CIs to inform item development for the Prosthetic Limb Users Survey of Mobility (PLUS-M), a PRO that measures mobility in prosthetic limb users. METHODS: Thirty-six CIs were conducted with 30 prosthetic limb users. Each participant responded to up to 30 items from the PLUS-M candidate item set. Each item was reviewed by a minimum of five participants who differed in self-reported mobility, literacy, level of amputation, and time since amputation. Items were revised based on participant feedback, and substantially revised items were re-evaluated through additional CIs. RESULTS: Feedback from CIs identified substantial issues in 76 of the total 156 items. These items were subsequently modified or eliminated. CONCLUSION: Cognitive interviews were an essential qualitative step in the development of the PLUS-M item bank and resulted in better functioning items.

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

OBJECTIVE: 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.

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.

Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

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.

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.

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.

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 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.