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Oeding JF, Pareek A, Nieboer MJ, Rhodes NG, Tiegs-Heiden CA, Camp CL, Martin RK, Moatshe G, Engebretsen L, Sanchez-Sotelo J. A Machine Learning Model Demonstrates Excellent Performance in Predicting Subscapularis Tears Based on Pre-Operative Imaging Parameters Alone. Arthroscopy 2024; 40:1044-1055. [PMID: 37716627 DOI: 10.1016/j.arthro.2023.08.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE To develop a machine learning model capable of identifying subscapularis tears before surgery based on imaging and physical examination findings. METHODS Between 2010 and 2020, 202 consecutive shoulders underwent arthroscopic rotator cuff repair by a single surgeon. Patient demographics, physical examination findings (including range of motion, weakness with internal rotation, lift/push-off test, belly press test, and bear hug test), and imaging (including direct and indirect signs of tearing, biceps status, fatty atrophy, cystic changes, and other similar findings) were included for model creation. RESULTS Sixty percent of the shoulders had partial or full thickness tears of the subscapularis verified during surgery (83% of these were upper third). Using only preoperative imaging-related parameters, the XGBoost model demonstrated excellent performance at predicting subscapularis tears (c-statistic, 0.84; accuracy, 0.85; F1 score, 0.87). The top 5 features included direct signs related to the presence of tearing as evidenced on magnetic resonance imaging (MRI) (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. CONCLUSIONS In this study, machine learning was successful in predicting subscapularis tears by MRI alone in 85% of patients, and this accuracy did not decrease by isolating the model to the top features. The top five features included direct signs related to the presence of tearing as evidenced on MRI (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Last, in advanced modeling, the addition of physical examination or patient characteristics did not make a significant difference in the predictive ability of this model. LEVEL OF EVIDENCE Level III, diagnostic case-control study.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A.; Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, U.S.A.; Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Micah J Nieboer
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | | | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A.; Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Gilbert Moatshe
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Lars Engebretsen
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Joaquin Sanchez-Sotelo
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A..
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Simon MJK, Regan WD. Utilization of MRI in surgical decision making in the shoulder. BMC Musculoskelet Disord 2022; 23:588. [PMID: 35717178 PMCID: PMC9206361 DOI: 10.1186/s12891-022-05541-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/08/2022] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study is to evaluate both the utility of MRI scans and reports used in the current practice routine of shoulder surgeons and their surgical decision-making process. Methods Ninety-three shoulder-specialised orthopaedic surgeons of the Canadian Shoulder and Elbow Society (CSES) Orthopaedic Association were surveyed in 2020 anonymously online to help identify the use of MR-imaging and reports in managing shoulder disorders and surgical decision process. Results Thirty out of 93 (32.25%) CSES fellowship-trained orthopaedic surgeons participated. Respondents request MRI scans in about 55% of rotator cuff (RC) pathology and 48% of shoulder instability cases. Fifty percent of patients with potential RC pathology arrive with a completed MRI scan prior first orthopaedic consult. Their surgical decision is primarily based on patient history (45–55%) and physical examination (23–42%) followed by MRI scan review (2.6–18%), reading MRI reports (0–1.6%) or viewing other imaging (3–23%) depending on the shoulder disease. Ninety percent of surgeons would not decide on surgery in ambiguous cases unless the MR-images were personally reviewed. Respondents stated that shoulder MRI scans are ordered too frequently prior specialist visit as identified in more than 50% of cases depending on pathology. Conclusions The decision-making process for shoulder surgery depends on the underlying pathology and patient history. The results demonstrate that orthopaedic surgeons are comfortable reviewing shoulder MRI scans without necessarily reading the MRI report prior to a surgical decision. MRI scans are becoming an increasingly important part of surgical management in shoulder pathologies but should not be used without assessment of patient history and or physical examination.
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Affiliation(s)
- Maciej J K Simon
- Department of Orthopaedics and Trauma Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 3, 24105, Kiel, Germany. .,Department of Orthopaedics, University of British Columbia, Chan Gunn Pavilion, Allen McGavin Sports Medicine Clinic, 2553 Wesbrook Mall, Vancouver, BC, V6T1Z3, Canada.
| | - William D Regan
- Department of Orthopaedics, University of British Columbia, Chan Gunn Pavilion, Allen McGavin Sports Medicine Clinic, 2553 Wesbrook Mall, Vancouver, BC, V6T1Z3, Canada
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徐 文, 张 耀, 石 磊, 王 飞, 薛 庆. [Development of a risk stratification model for subscapularis tendon tear based on patient-specific data from 528 shoulder arthroscopy]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:729-738. [PMID: 35712931 PMCID: PMC9240835 DOI: 10.7507/1002-1892.202203091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/04/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To identify and screen sensitive predictors associated with subscapularis (SSC) tendon tear and develop a web-based dynamic nomogram to assist clinicians in early identification and intervention of SSC tendon tear. METHODS Between July 2016 and December 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with completely MRI and clinical data were retrospectively analyzed. Patients admitted between July 2016 and July 2019 were included in the training cohort, and patients admitted between August 2019 and December 2021 were included in the validation cohort. According to the diagnosis of arthroscopy, the patients were divided into SSC tear group and non-SSC tear group. Univariate analysis, least absolute shrinkage and selection operator (LASSO) method, and 10-fold cross-validation method were used to screen for reliable predictors highly associated with SSC tendon tear in a training set cohort, and R language was used to build a nomogram model for internal and external validation. The prediction performance of the nomogram was evaluated by concordance index (C-index) and calibration curve with 1 000 Bootstrap. Receiver operating curves were drawn to evaluate the diagnostic performance (sensitivity, specificity, predictive value, likelihood ratio) of the predictive model and MRI (based on direct signs), respectively. Decision curve analysis (DCA) was used to evaluate the clinical implications of predictive models and MRI. RESULTS The nomogram model showed good discrimination in predicting the risk of SSC tendon tear in patients [C-index=0.878; 95% CI(0.839, 0.918)], and the calibration curve showed that the predicted results were basically consistent with the actual results. The research identified 6 predictors highly associated with SSC tendon tears, including coracohumeral distance (oblique sagittal) reduction, effusion sign (Y-plane), subcoracoid effusion sign, biceps long head tendon displacement (dislocation/subluxation), multiple posterosuperior rotator cuff tears (≥2, supra/infraspinatus), and MRI suspected SSC tear (based on direct sign). Compared with MRI diagnosis based on direct signs of SSC tendon tear, the predictive model had superior sensitivity (80.2% vs. 57.0%), positive predictive value (53.9% vs. 53.3%), negative predictive value (92.7% vs. 86.3%), positive likelihood ratio (3.75 vs. 3.66), and negative likelihood ratio (0.25 vs. 0.51). DCA suggested that the predictive model could produce higher clinical benefit when the risk threshold probability was between 3% and 93%. CONCLUSION The nomogram model can reliably predict the risk of SSC tendon tear and can be used as an important tool for auxiliary diagnosis.
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Affiliation(s)
- 文南 徐
- 北京医院骨科 国家老年医学中心 中国医学科学院老年医学研究院 北京协和医学院研究生院(北京 100730)Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100730, P. R. China
| | - 耀南 张
- 北京医院骨科 国家老年医学中心 中国医学科学院老年医学研究院 北京协和医学院研究生院(北京 100730)Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100730, P. R. China
| | - 磊 石
- 北京医院骨科 国家老年医学中心 中国医学科学院老年医学研究院 北京协和医学院研究生院(北京 100730)Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100730, P. R. China
| | - 飞 王
- 北京医院骨科 国家老年医学中心 中国医学科学院老年医学研究院 北京协和医学院研究生院(北京 100730)Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100730, P. R. China
| | - 庆云 薛
- 北京医院骨科 国家老年医学中心 中国医学科学院老年医学研究院 北京协和医学院研究生院(北京 100730)Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100730, P. R. China
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Xu W, Zheng Z, Xue Q. Development and Validation of a Web-Based Dynamic Nomogram to Improve the Diagnostic Performance of Subscapularis Tendon Tear. Front Surg 2022; 9:874800. [PMID: 35711708 PMCID: PMC9194104 DOI: 10.3389/fsurg.2022.874800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on magnetic resonance imaging (MRI). The omission of SSC tendon tears can lead to muscle atrophy, fatty infiltration and increased tear accompanied by aggravated shoulder pain and loss of function. An effective noninvasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a dynamic nomogram to improve diagnostic performance. Methods From July 2016 to October 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with preoperative shoulder MRI were retrospectively analyzed. The least absolute shrinkage and selection operator (LASSO) method was used to identify the sensitive factors associated with SSC tendon tears, which were then incorporated into the nomogram. The prediction performance of the nomogram was evaluated by concordance index (C index) and calibrated with 1,000 bootstrap samples combined with external validation of another cohort. Results The LASSO method showed that six items including coracohumeral distance (oblique sagittal plane), effusion (Y-face), effusion (subcoracoid), malposition of the long head tendon of the biceps, multiple posterosuperior rotator cuff tears, and considering SSC tendon tears on MRI (based on direct signs) were determined as sensitive predictors. The nomogram achieved a good C index of 0.878 (95% CI, 0.839–0.918) with a good agreement on the risk estimation of calibration plots. The areas under the receiver operator characteristic (ROC) curves of the two methods showed that dynamic nomograms had better prediction performance than MRI diagnosis based on direct signs (training set 0.878 vs. 0.707, validation set 0.890 vs. 0.704). Conclusion The study identified sensitive predictors associated with SSC tendon tears and first developed a web-based dynamic nomogram as a good supplementary evaluation tool for imaging diagnosis that could provide an individualized risk estimate with superior prediction performance, even in patients with small or partial tears.
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Affiliation(s)
- Wennan Xu
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Zitian Zheng
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qingyun Xue
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
- Correspondence: Qingyun Xue
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Xu W, Wang F, Xue Q. Identifying key factors associated with subscapularis tendon tears and developing a risk prediction model to assist diagnosis. BMC Musculoskelet Disord 2022; 23:393. [PMID: 35477460 PMCID: PMC9044870 DOI: 10.1186/s12891-022-05351-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on MRI. The omission of SSC tendon tear can lead to muscle atrophy, fatty infiltration, and increased tearing accompanied by aggravated shoulder pain and loss of function. An effective non-invasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a risk prediction model to assist in diagnosis. Methods Data on 660 patients who received shoulder arthroscopic surgery with preoperative shoulder MRI were collected retrospectively. Of these, patients with SSC tendon tears were defined as the SSC tear group, and patients with intact SSC tendon were enrolled in the non-SSC tear group. Logistic regression analysis was used to identify the key predictors of SSC tendon tears which were then incorporated into the nomogram. Results Among 22 candidate factors, five independent factors including coracohumeral distance (CHD, oblique sagittal plane) (OR, 0.75; 95%CI, [0.67–0.84]), fluid accumulation (Y-face) (OR, 2.29; 95%CI, [1.20–4.38]), long head of biceps tendon (LHB) dislocation/subluxation (OR, 3.62; 95%CI, [1.96–6.68]), number of posterosuperior (PS) rotator cuff tears (OR, 5.36; 95%CI, [3.12–9.22]), and MRI diagnosis (based on direct signs) (OR, 1.88; 95%CI, [1.06–3.32]) were identified as key predictors associated with SSC tendon tears. Incorporating these predictors, the nomogram achieved a good C index with a good agreement on the risk estimation of calibration plots. Higher total points of the nomogram were associated with a greater risk of SSC tendon tears. Conclusion When evaluating the severity of SSC tendon injury, the combination of reliable predictors can improve the sensitivity and diagnostic performance of MRI. This model provides an individualized probability of risk prediction, which is convenient for clinicians to identify patients at high risk for SSC tendon tears to avoid missed diagnosis.
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Affiliation(s)
- Wennan Xu
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, NO.1 DaHua Road, Dong Dan, Beijing, 100730, PR China.,Graduate School of Peking Union Medical College, NO.1 DaHua Road, Dong Dan, Beijing, 100730, PR China
| | - Fei Wang
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, NO.1 DaHua Road, Dong Dan, Beijing, 100730, PR China
| | - Qingyun Xue
- Orthopaedics Department, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, NO.1 DaHua Road, Dong Dan, Beijing, 100730, PR China. .,Graduate School of Peking Union Medical College, NO.1 DaHua Road, Dong Dan, Beijing, 100730, PR China.
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Chellamuthu G, Sundar S, Rajan DV. Current concepts review in the management of subscapularis tears. J Clin Orthop Trauma 2022; 28:101867. [PMID: 35494488 PMCID: PMC9043658 DOI: 10.1016/j.jcot.2022.101867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.
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Affiliation(s)
- Girinivasan Chellamuthu
- Corresponding author. Ortho One Orthopaedic Speciality Centre, Singanallur, Coimbatore, 641005, Tamil Nadu, India.
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