Lori A. Dolan

Background: Whether the sensory and behavioral traits of autism spectrum disorder (ASD) affect bracing outcomes in adolescent idiopathic scoliosis (AIS) remains unclear. This study evaluated the impact of ASD on bracing success, curve progression, and patient-reported outcomes in patients with AIS. Methods: This retrospective study included patients 10 to 18 years of age who were treated for AIS with bracing between 2011 and 2024. A total of 58 patients with ASD were matched in a 1:2 ratio to 116 controls with use of nearest-neighbor matching based on BrAIST-Calc predicted probabilities. Exclusions included non-idiopathic scoliosis, early-onset scoliosis, kyphoscoliosis, a Risser stage of >2, pre-treatment curves of 40°, and inadequate follow-up. Progression to the surgical threshold was defined as a major curve of ≥45°. Firth logistic regression was used to model the association between ASD and progression to the surgical threshold, adjusting for residual imbalances. Results: The matched cohort (n = 174; 51% male; 40% White, 25% Hispanic, 21% Black, 10% Asian, and 5% not specified) demonstrated balanced propensity scores (SMD = 0.006). Compared with patients without ASD, those with ASD had higher rates of progression to the surgical threshold (40% versus 20%; p = 0.005), a curve progression of ≥6° (60% versus 38%; p = 0.005), noncompliance (36% versus 22%; p = 0.04), brace-related issues (22% versus 8%; p = 0.006), and surgery being recommended or performed (33% versus 13%; p = 0.002). In the multivariable analysis, ASD (odds ratio [OR], 3.12 [95% confidence interval (CI), 1.32 to 7.35]; p = 0.009), noncompliance (OR, 4.00 [95% CI, 1.65 to 9.71]; p = 0.002), and a greater initial curve magnitude (OR per degree, 1.26 [95% CI, 1.15 to 1.38]; p < 0.001) significantly increased the odds of progression to the surgical threshold. Within the ASD group, Scoliosis Research Society-22 revised (SRS-22r) self-image, management, and total scores improved significantly over time. No significant between-group differences in change scores were observed. Conclusions: Adolescents with ASD were >3 times more likely to progress to the surgical threshold and had higher rates of noncompliance, brace-related issues, and surgery being recommended or performed. ASD may represent a risk factor for bracing failure, potentially related to sensory or behavioral intolerance. Nonetheless, 60% of patients with ASD avoided progression to the surgical threshold, and within-group improvements in SRS-22r scores were observed. These findings support bracing as a viable treatment option for patients with ASD, although it is likely best paired with individualized care and closer follow-up. Future studies should aim to improve brace tolerance and adherence in this population. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Study Design.: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. Objective.: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). Summary of Background Data.: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. Materials and Methods.: Logistic regression was used to predict curve progression to c-statistics 0.83–0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. Conclusion.: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

Purpose While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management. Methods 1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring. Free-text responses were analyzed and collated into common themes. Data were analyzed using Microsoft Excel 2013. Results Of 218 respondents; 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing. 99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both %-Cobb correction and fit criteria to evaluate brace adequacy. In contrast, other aspects of brace management demonstrated a high degree of practice variability. This was seen with a radiographic assessment of maturity level, hours prescribed, timing and frequency of radiographic evaluation, the use of nighttime bracing only, and the method and timing of brace discontinuation. Conclusion Although there is consensus in brace management amongst SRS members with respect to brace initiation and evaluation of adequacy, there is striking variability in how bracing for AIS is used. This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS. Level of evidence III.

Background: Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. Methods: In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. Results: At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. Conclusions: Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prognostic study and validation using prospective clinical trial data. To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89-0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71-0.72 and NPVs of 0.85-0.93. This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. Level 1, prognostic.

Weinstein and colleagues (Oct. 17 issue)¹ reported a study evaluating the effect of bracing to decrease curve progression in patients with adolescent idiopathic scoliosis. In the primary analysis, the authors combined data from randomized and preference cohorts and performed a propensity-score analysis to evaluate the effect of bracing. The resulting estimated effect in the primary analysis, which included both cohorts (odds ratio for a successful outcome, 1.93), appears quite different, at least numerically, from that in the randomized cohort alone (odds ratio, 4.11). This suggests either that the model used to create the propensity score may not appropriately capture factors affecting the decision to use bracing or not in each of the two cohorts, or that the underlying true effect of bracing might differ between the two cohorts. In our opinion, the two cohorts should be analyzed separately, providing one odds ratio for the randomized cohort (which was reported) and one for the preference cohort (not reported). Then, with the use of meta-analysis, these two estimates might be combined with appropriate caution if there are no concerns about the heterogeneity of the effect between cohorts, or if there are such concerns, potential sources of heterogeneity should be evaluated.

The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score–adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.)

Study Design. Descriptive. Objective. To describe the design and development of Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST). Summary of Background Data. Bracing has remained the standard of care for the nonoperative treatment of adolescent idiopathic scoliosis since the introduction of the Milwaukee brace in the late 1940s, but it has never been subjected to a rigorous evaluation of either its efficacy or its effectiveness. The BrAIST was designed to address the primary question: Do braces (specifically a thoracolumbosacral orthosis) lower the risk of curve progression to a surgical threshold (≥50°) in patients with adolescent idiopathic scoliosis relative to watchful waiting alone? Methods. The authors describe the rationale for BrAIST, including the limitations of the current literature evaluating bracing for adolescent idiopathic scoliosis. Second, the authors describe the preliminary work, including the preparation of the National Institutes of Health clinical trials planning grant. Finally, the authors describe the trial design in detail. Results. BrAIST was conducted in 25 sites in North America. Subjects were treated either with a thoracolumbosacral orthosis or watchful waiting and followed every 6 months until they reached skeletal maturity or the surgical threshold of 50° Cobb angle. Conclusion. Clinical decision making will be improved by translation of the BrAIST results into evidence-based prognosis and estimates of how the prognosis, specifically the risk of progressing to surgery, may be altered by the use of bracing. Level of Evidence: N/A

The "Gothic Arch" is a radio-graphic finding on AP pelvis x-rays postulated to be predictive of hip osteoarthritis. The purpose of this study was to determine the reliability of measurement of the Gothic Arch in patients with no known hip pathology and patients with unilateral developmental dysplasia of the hip (DDH). After obtaining IRB approval, nine skeletally mature patients (18 hips) with no known hip pathology were selected to serve as the control group. The AP pelvis x-rays at skeletal maturity of eight patients (16 hips) with unilateral DDH treated with closed reduction and casting comprised the comparison group. A digitizing program was designed to measure the Gothic Arch based on landmarks identified by the user. Two pediatric orthopaedic surgeons and two orthopaedic residents completed the program on two separate occasions. Intra-and interobserver reliability were determined using intraclass cor-relation coefficients (ICC) for continuous variables. Both the unilateral DDH group and the control group demonstrated excellent inter- and intraobserver reliability (ICC >0.70) for base, height, area, and orientation of the Gothic Arch, but poor reliability (ICC <0.40) for medial and lateral sharpness. The Gothic Arch can be reliably measured on AP pelvis x-rays of patients with normal and dysplastic hips. III, Diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Use of Computed Tomography (CT) to evaluate syndesmotic reduction following injury has significantly increased in recent years. The aim of this study was to compare existing clinical measurements of syndesmotic reduction to gold standard measurements of fibular motion obtained from a full 3D model. Three common clinical measures for assessing syndesmotic congruity on axial CT slices were identified in the literature. Each measure was manually performed on 170 cadaveric ankle CT scans obtained with variable degrees of simulated syndesmotic displacement. Clinical measures were assessed for intraobserver and interobserver reliability and compared to objective measures of true medial/lateral and anterior/posterior translation and fibular rotation that were obtained from a 3D model. Pearson correlation coefficients (PCC) were computed to determine which clinical measurements were most accurate for describing syndesmotic motion obtained from the 3D model. All three clinical measurement techniques demonstrated good to excellent interobserver and intraobserver reliability. Medial/lateral displacement of the fibula was best correlated with the difference between the anterior and posterior tibiofibular joint space measurements described by Elgafy et al (PCC = 0.29 small correlation). Anterior/posterior displacement of the fibula was well correlated with the anterior/posterior measurement described by Phisitkul et al (PCC = 0.69 large correlation). Fibular rotation was best correlated with the average of the Elgafy anterior and posterior tibiofibular joint space measurements (PCC = 0.33, moderate correlation). Proximal/ distal displacement of the lateral malleolus was best correlated with the Elgafy posterior tibiofibular joint space measurement (PCC = 0.49, moderate correlation). While the clinical measurements were adequately reproducible, they showed only moderate to small correlations with the 3D measurements of movement of the fibula in the longitudinal, medial/lateral or rotational directions. The only fibular translation measured by the 3D model that was well described by the three clinical measures was fibular movement in the anterior/ posterior direction. This work demonstrates a need for improved clinical measurements of syndesmotic congruity on axial CT scans to serve as surrogates for the true movement of the fibula.