Measuring the impact of surgical intervention on pediatric pectus excavatum using white light scanning.

BACKGROUND: Objective preoperative assessment of pectus excavatum (PE) deformity in patients is limited to preoperative measurement of severity using computed tomography (CT) or magnetic resonance imaging (MRI). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure and high cost to families. White Light Scanning (WLS) is a novel 3D imaging modality that offers an alternative that is a quick, nonionizing, inexpensive, and safe strategy for measurement both pre- and postsurgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate use of WLS to assess extent of correction of PE deformities after the Nuss procedure. METHODS: WLS scan data were gathered prospectively in pediatric patients with PE from 2015 to 2018. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data. RESULTS: A total of 71 patients received a preoperative CT scan and underwent surgery for PE. Of those, 63 (89%) received WLS preoperatively and 51 (72%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.35 (SD: 0.15) and 1.73 (SD: 1.03) in WLS-estimated HI. CONCLUSIONS: WLS is highly effective in objectively quantifying the extent of surgical correction in PE patients. LEVEL OF EVIDENCE: IV TYPE OF STUDY: Diagnostic Study.

A novel technique to measure severity of pediatric pectus excavatum using white light scanning.

BACKGROUND/PURPOSE: Computed tomography (CT) derived Haller Index (HI) remains the standard for quantifying severity in patient with pectus excavatum (PE). Optical scanning described in literature reports optimistic results and new indices that correlate with HI. This study assessed the feasibility of a handheld White Light Scanner (WLS) to obtain 3D measurements and indices of PE deformity. METHODS: From April 2015-April 2017, WLS scanning was conducted by orthotists during clinical visits. Included were children with PE up to 18 years. Analysis assessed correlation of a WLS-derived severity index, Hebal-Malas Index (HMI), with physician measured PE Depth (PED), and CT-derived HI. RESULTS: Of 195 participants, 185(94%) patients with PE were scanned and 127(69%) had complete WLS data. For 88 patients undergoing monitoring, HMI correlated with PED (r = 0.42, p = 0.004). For 39 patients with pre-operative CT, HMI demonstrated strong correlation with HI (r = 0.87, p<0.0001). CONCLUSIONS: WLS demonstrated high feasibility of scanning PE. WLS-derived HMI best correlates with HI for patients with severe pectus deformity. Our current data is suggestive that WLS is best applied for severe deformities and yet to be established for milder deformities. Future yearly WLS will provide data on deformity progression and surgical therapy. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Diagnostic Study.

Measuring the impact of brace intervention on pediatric pectus carinatum using white light scanning.

BACKGROUND: Evaluation of Pectus Carinatum (PC) deformity in patients undergoing bracing is limited to subjective assessment of the chest through physical exam and photography. White Light Scanning (WLS) is a novel 3D imaging modality and offers an objective alternative that is quick, inexpensive, and safe. We previously demonstrated the feasibility of using a WLS-derived proxy for Haller index, called the Hebal-Malas Index (HMI), in measuring the surgical correction of Pectus Excavatum. The purpose of this study was to demonstrate the use of WLS to measure the severity of pre- and postbracing intervention of PC deformities and assess corrected difference between the two scans. METHODS: We conducted a prospective review of preintervention WLS scans in pediatric patients with PC from 2015 to 2017. HMI was obtained from the preintervention and postintervention WLS scans. Analysis assessed the differences of pre- and postbracing intervention of measurements. RESULTS: Of 32 patients with both pre- and postbracing scans, 13 (34%) showed improvement of more than 10%, 21 (55%) showed slight improvement of 1%-10%, and 4 (11%) did not improve at follow-up. The average postbracing change in the WLS-derived HMI was 0.10 (SD:0.11). The average length of bracing days was 331.4 (SD: 127.3) with an average of 6.8 h worn per day. Compliance was defined as patient reported utilization of the brace. Patients who were compliant showed a significant improvement (p = 0.004) compared to those who were not compliant (Table 2). However, even patients with moderate compliance still improved in many instances. Change in height was a significant factor correlating with improvement. Children who grew more while wearing a brace showed greater improvement in their deformity. CONCLUSION: Using this technique, we have the ability to objectively quantify the impact of bracing on the severity of PC deformity and measure change in deformity over time. TYPE OF STUDY: Prospective study. LEVEL OF EVIDENCE: Level IV.

Suggested Guidelines for the Prescription of Orthotic Services, Device Delivery, Education, and Follow-up Care: A Multidisciplinary White Paper.

OBJECTIVES: This article establishes needed guidelines for determining orthotic prescriber authority, documenting medical necessity, and ensuring continuity of care for patients needing orthoses. It also identifies "off-the-shelf" (OTS) devices that can safely and appropriately be delivered to patients without professional adjustment as well as those that cannot. METHODS: A multidisciplinary task force made up of experts in orthopedics and physical medicine physicians, along with therapists and certified orthotists, applied a consensus approach to answer key questions: (i) When can a device be safely, effectively delivered to the patient OTS without professional guidance or education, and which caregivers have a role in that decision? (ii) What documentation is appropriate for physicians and other caregivers to determine medical necessity? (iii) What documentation/communication ensures continuity of care among physicians, therapists, and orthotists? RESULTS: Guidelines developed for consideration of OTS orthoses include accepting documentation from collaborating caregivers, including therapists and orthotists; keeping that documentation as part of the patient's total medical record for clinical, medical necessity determinations and reimbursement purposes; and using the physician's prescription for the device as the key determinant of whether a device is delivered OTS or as a custom-fitted device. CONCLUSION: This review provides expert guidance for patient safety, minimizing wasted expenditures, maximizing clinical outcomes, and providing efficient delivery of care for Medicare and other patients. Centers for Medicare and Medicaid Services guidelines should be directed toward recognizing the level of expertise of the orthotist, the value of their patient encounters, and their role in facilitating the timely, safe, and effective use of orthotic devices.

What variables influence the ability of an AFO to improve function and when are they indicated?

BACKGROUND: Children with spina bifida often present with functional deficits of the lower limb associated with neurosegmental lesion levels and require orthotic management. The most used orthosis for children with spina bifida is the ankle-foot orthosis (AFO). The AFO improves ambulation and reduces energy cost while walking. Despite the apparent benefits of using an AFO, limited evidence documents the influence of factors predicting the ability of an AFO to improve function and when they are indicated. These variables include AFO design, footwear, AFO-footwear combination, and data acquisition. When these variables are not adequately considered in clinical decision-making, there is a risk the AFO will be abandoned prematurely or the patient's stability, function, and safety compromised. PURPOSE: The purposes of this study are to (1) describe the functional deficits based on lesion levels; (2) identify and describe variables that influence the ability of an AFO to control deformities; and (3) describe what variables are indicated for the AFO to control knee flexion during stance, hyperpronation, and valgus stress at the knee. METHODS: A selective literature review was undertaken searching MEDLINE and Cochrane databases using terms related to "orthosis" and "spina bifida." RESULTS: Based on previous studies and gait analysis data, suggestions can be made regarding material selection/geometric configuration, sagittal alignment, footplate length, and trim lines of an AFO for reducing knee flexion, hyperpronation, and valgus stress at the knee. CONCLUSION: Further research is required to determine what variables allow an AFO to improve function.

Effect of ankle-foot orthosis alignment and foot-plate length on the gait of adults with poststroke hemiplegia.

OBJECTIVE: To investigate the effect of ankle-foot orthosis (AFO) alignment and foot-plate length on sagittal plane knee kinematics and kinetics during gait in adults with poststroke hemiplegia. DESIGN: Repeated measures, quasi-experimental study. SETTING: Motion analysis laboratory. PARTICIPANTS: Volunteer sample of adults with poststroke hemiplegia (n=16) and able-bodied adults (n=12) of similar age. INTERVENTIONS: Subjects with hemiplegia were measured walking with standardized footwear in 4 conditions: (1) no AFO (shoes only); (2) articulated AFO with 90 degrees plantar flexion stop and full-length foot-plate-conventionally aligned AFO (CAFO); (3) the same AFO realigned with the tibia vertical in the shoe-heel-height compensated AFO (HHCAFO); and (4) the same AFO (tibia vertical) with 3/4 length foot-plate-3/4 AFO. Gait of able-bodied control subjects was measured on a single occasion to provide a normal reference. MAIN OUTCOME MEASURES: Sagittal plane ankle and knee kinematics and kinetics. RESULTS: In adults with hemiplegia, walking speed was unaffected by the different conditions (P=.095). Compared with the no AFO condition, all AFOs decreased plantar flexion at initial contact and mid-swing (P<.001) and changed the peak knee moment in early stance from flexor to extensor (P<.000). Both AFOs with full-length foot-plates significantly increased the peak stance phase plantar flexor moment compared with no AFO and resulted in a peak knee extensor moment in early stance that was significantly greater than control subjects, whereas the AFO with three-quarter length foot-plate resulted in ankle dorsiflexion during stance and swing that was significantly less than control subjects. CONCLUSIONS: These findings suggest that when an articulated AFO is to be used, a full-length foot-plate in conjunction with a plantar flexion stop may be considered to improve early stance knee moments for people with poststroke hemiplegia.