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Oeding JF, Kunze KN, Messer CJ, Pareek A, Fufa DT, Pulos N, Rhee PC. Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review. J Hand Surg Am 2024; 49:411-422. [PMID: 38551529 DOI: 10.1016/j.jhsa.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 01/19/2024] [Accepted: 01/31/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE To review the existing literature to (1) determine the diagnostic efficacy of artificial intelligence (AI) models for detecting scaphoid and distal radius fractures and (2) compare the efficacy to human clinical experts. METHODS PubMed, OVID/Medline, and Cochrane libraries were queried for studies investigating the development, validation, and analysis of AI for the detection of scaphoid or distal radius fractures. Data regarding study design, AI model development and architecture, prediction accuracy/area under the receiver operator characteristic curve (AUROC), and imaging modalities were recorded. RESULTS A total of 21 studies were identified, of which 12 (57.1%) used AI to detect fractures of the distal radius, and nine (42.9%) used AI to detect fractures of the scaphoid. AI models demonstrated good diagnostic performance on average, with AUROC values ranging from 0.77 to 0.96 for scaphoid fractures and from 0.90 to 0.99 for distal radius fractures. Accuracy of AI models ranged between 72.0% to 90.3% and 89.0% to 98.0% for scaphoid and distal radius fractures, respectively. When compared to clinical experts, 13 of 14 (92.9%) studies reported that AI models demonstrated comparable or better performance. The type of fracture influenced model performance, with worse overall performance on occult scaphoid fractures; however, models trained specifically on occult fractures demonstrated substantially improved performance when compared to humans. CONCLUSIONS AI models demonstrated excellent performance for detecting scaphoid and distal radius fractures, with the majority demonstrating comparable or better performance compared with human experts. Worse performance was demonstrated on occult fractures. However, when trained specifically on difficult fracture patterns, AI models demonstrated improved performance. CLINICAL RELEVANCE AI models can help detect commonly missed occult fractures while enhancing workflow efficiency for distal radius and scaphoid fracture diagnoses. As performance varies based on fracture type, future studies focused on wrist fracture detection should clearly define whether the goal is to (1) identify difficult-to-detect fractures or (2) improve workflow efficiency by assisting in routine tasks.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN; Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gotenburg, Gothenburg, Sweden.
| | - Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Caden J Messer
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Duretti T Fufa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Nicholas Pulos
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
| | - Peter C Rhee
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
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Kunze KN, Fury MS, Pareek A, Camp CL, Altchek DW, Dines JS. Biomechanical Characteristics of Ulnar Collateral Ligament Injuries Treated With and Without Augmentation: A Network Meta-analysis of Controlled Laboratory Studies. Am J Sports Med 2024; 52:1624-1634. [PMID: 38304942 DOI: 10.1177/03635465231188691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Treatment of ulnar collateral ligament (UCL) tears with suture tape augmentation has gained interest given preliminary reports of favorable biomechanical characteristics. No study to date has quantitatively assessed the biomechanical effects of multiple augmentation techniques relative to the native UCL. PURPOSE To perform a systematic review and meta-analysis of controlled laboratory studies to assess and comparatively rank biomechanical effects of UCL repair or reconstruction with or without augmentation. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS PubMed, OVID/Medline, and Cochrane databases were queried in January 2023. A frequentist network meta-analytic approach was used to perform mixed-treatment comparisons of UCL repair and reconstruction techniques with and without augmentation, with the native UCL as the reference condition. Pooled treatment estimates were quantified under the random-effects assumption. Competing treatments were ranked in the network meta-analysis by using point estimates and standard errors to calculate P scores (greater P score indicates superiority of treatment for given outcome). RESULTS Ten studies involving 206 elbow specimens in which a distal UCL tear was simulated were included. UCL reconstruction with suture tape augmentation (AugRecon) restored load to failure to a statistically noninferior magnitude (mean difference [MD], -1.99 N·m; 95% CI, -10.2 to 6.2 N·m; P = .63) compared with the native UCL. UCL reconstruction (Recon) (MD, -12.7 N·m; P < .001) and UCL repair with suture tape augmentation (AugRepair) (MD, -14.8 N·m; P < .001) were both statistically inferior to the native UCL. The AugRecon condition conferred greater load to failure compared with Recon (P < .001) and AugRepair (P = .002) conditions. AugRecon conferred greater torsional stiffness relative to all other conditions and was not statistically different from the native UCL (MD, 0.32 N·m/deg; 95% CI, -0.30 to 0.95 N·m/deg; P = .31). Medial ulnohumeral gapping was not statistically different for the AugRepair (MD, 0.30 mm; 95% CI, -1.22 to 1.82 mm; P = .70), AugRecon (MD, 0.57 mm; 95% CI, -0.70 to 1.84 mm; P = .38), or Recon (MD, 1.02 mm; 95% CI, -0.02 to 2.05 mm; P = .055) conditions compared with the native UCL. P-score analysis indicated that AugRecon was the most effective treatment for increasing ultimate load to failure and torsional stiffness, whereas AugRepair was the most effective for minimizing medial gapping. CONCLUSION AugRecon restored load to failure and torsional stiffness most similar to the parameters of the native UCL, whereas Recon and AugRepair did not restore the same advantageous properties at time zero. Medial ulnohumeral gapping during a valgus load was minimized by all 3 treatments. Based on network interactions, AugRecon was the superior treatment approach for restoring important biomechanical features of the UCL at time zero that are jeopardized during a complete distal tear.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, New York, USA
| | - Matthew S Fury
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, New York, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, New York, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Altchek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, New York, USA
| | - Joshua S Dines
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, New York, USA
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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: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Oeding JF, Yang L, Sanchez-Sotelo J, Camp CL, Karlsson J, Samuelsson K, Pearle AD, Ranawat AS, Kelly BT, Pareek A. A practical guide to the development and deployment of deep learning models for the orthopaedic surgeon: Part III, focus on registry creation, diagnosis, and data privacy. Knee Surg Sports Traumatol Arthrosc 2024; 32:518-528. [PMID: 38426614 DOI: 10.1002/ksa.12085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 03/02/2024]
Abstract
Deep learning is a subset of artificial intelligence (AI) with enormous potential to transform orthopaedic surgery. As has already become evident with the deployment of Large Language Models (LLMs) like ChatGPT (OpenAI Inc.), deep learning can rapidly enter clinical and surgical practices. As such, it is imperative that orthopaedic surgeons acquire a deeper understanding of the technical terminology, capabilities and limitations associated with deep learning models. The focus of this series thus far has been providing surgeons with an overview of the steps needed to implement a deep learning-based pipeline, emphasizing some of the important technical details for surgeons to understand as they encounter, evaluate or lead deep learning projects. However, this series would be remiss without providing practical examples of how deep learning models have begun to be deployed and highlighting the areas where the authors feel deep learning may have the most profound potential. While computer vision applications of deep learning were the focus of Parts I and II, due to the enormous impact that natural language processing (NLP) has had in recent months, NLP-based deep learning models are also discussed in this final part of the series. In this review, three applications that the authors believe can be impacted the most by deep learning but with which many surgeons may not be familiar are discussed: (1) registry construction, (2) diagnostic AI and (3) data privacy. Deep learning-based registry construction will be essential for the development of more impactful clinical applications, with diagnostic AI being one of those applications likely to augment clinical decision-making in the near future. As the applications of deep learning continue to grow, the protection of patient information will become increasingly essential; as such, applications of deep learning to enhance data privacy are likely to become more important than ever before. Level of Evidence: Level IV.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linjun Yang
- Orthopedic Surgery Artificial Intelligence Laboratory (OSAIL), Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Andrew D Pearle
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Anil S Ranawat
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
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Martin RK, Wastvedt S, Pareek A, Persson A, Visnes H, Fenstad AM, Moatshe G, Wolfson J, Lind M, Engebretsen L. Unsupervised Machine Learning of the Combined Danish and Norwegian Knee Ligament Registers: Identification of 5 Distinct Patient Groups With Differing ACL Revision Rates. Am J Sports Med 2024; 52:881-891. [PMID: 38343270 DOI: 10.1177/03635465231225215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Most clinical machine learning applications use a supervised learning approach using labeled variables. In contrast, unsupervised learning enables pattern detection without a prespecified outcome. PURPOSE/HYPOTHESIS The purpose of this study was to apply unsupervised learning to the combined Danish and Norwegian knee ligament register (KLR) with the goal of detecting distinct subgroups. It was hypothesized that resulting groups would have differing rates of subsequent anterior cruciate ligament reconstruction (ACLR) revision. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS K-prototypes clustering was performed on the complete case KLR data. After performing the unsupervised learning analysis, the authors defined clinically relevant characteristics of each cluster using variable summaries, surgeons' domain knowledge, and Shapley Additive exPlanations analysis. RESULTS Five clusters were identified. Cluster 1 (revision rate, 9.9%) patients were young (mean age, 22 years; SD, 6 years), received hamstring tendon (HT) autograft (91%), and had lower baseline Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation (Sports) scores (mean, 25.0; SD, 15.6). Cluster 2 (revision rate, 6.9%) patients received HT autograft (89%) and had higher baseline KOOS Sports scores (mean, 67.2; SD, 16.5). Cluster 3 (revision rate, 4.7%) patients received bone-patellar tendon-bone (BPTB) or quadriceps tendon (QT) autograft (94%) and had higher baseline KOOS Sports scores (mean, 65.8; SD, 16.4). Cluster 4 (revision rate, 4.1%) patients received BPTB or QT autograft (88%) and had low baseline KOOS Sports scores (mean, 20.5; SD, 14.0). Cluster 5 (revision rate, 3.1%) patients were older (mean age, 42 years; SD, 7 years), received HT autograft (89%), and had low baseline KOOS Sports scores (mean, 23.4; SD, 17.6). CONCLUSION Unsupervised learning identified 5 distinct KLR patient subgroups and each grouping was associated with a unique ACLR revision rate. Patients can be approximately classified into 1 of the 5 clusters based on only 3 variables: age, graft choice (HT, BPTB, or QT autograft), and preoperative KOOS Sports subscale score. If externally validated, the resulting groupings may enable quick risk stratification for future patients undergoing ACLR in the clinical setting. Patients in cluster 1 are considered high risk (9.9%), cluster 2 patients medium risk (6.9%), and patients in clusters 3 to 5 low risk (3.1%-4.7%) for revision ACLR.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Orthopedic Surgery, CentraCare, Saint Cloud, Minnesota, USA
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Solvejg Wastvedt
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andreas Persson
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Håvard Visnes
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
- Department of Orthopedics, Sorlandet Hospital, Kristiansand, Norway
| | - Anne Marie Fenstad
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
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Oeding JF, Varady NH, Fearington FW, Pareek A, Strickland SM, Nwachukwu BU, Camp CL, Krych AJ. Platelet-Rich Plasma Versus Alternative Injections for Osteoarthritis of the Knee: A Systematic Review and Statistical Fragility Index-Based Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2024:3635465231224463. [PMID: 38420745 DOI: 10.1177/03635465231224463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Based in part on the results of randomized controlled trials (RCTs) that suggest a beneficial effect over alternative treatment options, the use of platelet-rich plasma (PRP) for the management of knee osteoarthritis (OA) is widespread and increasing. However, the extent to which these studies are vulnerable to slight variations in the outcomes of patients remains unknown. PURPOSE To evaluate the statistical fragility of conclusions from RCTs that reported outcomes of patients with knee OA who were treated with PRP versus alternative nonoperative management strategies. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 2. METHODS All RCTs comparing PRP with alternative nonoperative treatment options for knee OA were identified. The fragility index (FI) and reverse FI were applied to assess the robustness of conclusions regarding the efficacy of PRP for knee OA. Meta-analyses were performed to determine the minimum number of patients from ≥1 trials included in the meta-analysis for which a modification on the event status would change the statistical significance of the pooled treatment effect. RESULTS In total, this analysis included outcomes from 1993 patients with a mean ± SD age of 58.0 ± 3.8 years. The mean number of events required to reverse significance of individual RCTs (FI) was 4.57 ± 5.85. Based on random-effects meta-analyses, PRP demonstrated a significantly higher rate of successful outcomes when compared with hyaluronic acid (P = .002; odds ratio [OR], 2.19; 95% CI, 1.33-3.62), as well as higher rates of patient-reported symptom relief (P = .019; OR, 1.55; 95% CI, 1.07-2.24), not requiring a reintervention after the initial injection treatment (P = .002; OR, 2.17; 95% CI, 1.33-3.53), and achieving the minimal clinically important difference (MCID) for pain improvement (P = .007; OR, 6.19; 95% CI, 1.63-23.42) when compared with all alternative nonoperative treatments. Overall, the mean number of events per meta-analysis required to change the statistical significance of the pooled treatment effect was 8.67 ± 4.50. CONCLUSION Conclusions drawn from individual RCTs evaluating PRP for knee OA demonstrated slight robustness. On meta-analysis, PRP demonstrated a significant advantage over hyaluronic acid as well as improved symptom relief, lower rates of reintervention, and more frequent achievement of the MCID for pain improvement when compared with alternative nonoperative treatment options. Statistically significant pooled treatment effects evaluating PRP for knee OA are more robust than approximately half of all comparable meta-analyses in medicine and health care. Future RCTs and meta-analyses should consider reporting FIs and fragility quotients to facilitate interpretation of results in their proper context.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nathan H Varady
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Forrest W Fearington
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Sabrina M Strickland
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Benedict U Nwachukwu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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7
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Pareek A, Ro DH, Karlsson J, Martin RK. Machine Learning/Artificial Intelligence in Sports Medicine: State of the Art and Future Directions. J ISAKOS 2024:S2059-7754(24)00013-0. [PMID: 38336099 DOI: 10.1016/j.jisako.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 12/30/2023] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
Machine learning (ML) is changing the way health care is practiced and recent applications of these novel statistical techniques have started to impact orthopaedic sports medicine. Machine learning enables the analysis of large volumes of data to establish complex relationships between "input" and "output" variables. These relationships may be more complex than could be established through traditional statistical analysis and can lead to the ability to predict the "output" with high levels of accuracy. Supervised learning is the most common ML approach for healthcare data and recent studies have developed algorithms to predict patient-specific outcome after surgical procedures such as hip arthroscopy and anterior cruciate ligament reconstruction. Deep learning is a higher-level ML approach that facilitates the processing and interpretation of complex datasets through artificial neural networks that are inspired by the way the human brain processes information. In orthopaedic sports medicine, deep learning has primarily been used for automatic image (computer vision) and text (natural language processing) interpretation. While applications in orthopaedic sports medicine have been increasing exponentially, one significant barrier to widespread adoption of ML remains clinician unfamiliarity with the associated methods and concepts. The goal of this review is to introduce these concepts, review current machine learning models in orthopaedic sport medicine, and discuss future opportunities for innovation within the specialty.
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Affiliation(s)
- Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea; CONNECTEVE Co., Ltd, Seoul, South Korea
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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8
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Martin RK, Marmura H, Wastvedt S, Pareek A, Persson A, Moatshe G, Bryant D, Wolfson J, Engebretsen L, Getgood A. External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial. Knee Surg Sports Traumatol Arthrosc 2024; 32:206-213. [PMID: 38226736 DOI: 10.1002/ksa.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE Level 3, cohort study.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Orthopaedic Surgery, CentraCare, Saint Cloud, Minnesota, USA
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Hana Marmura
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
| | - Solvejg Wastvedt
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andreas Persson
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Dianne Bryant
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Julian Wolfson
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Alan Getgood
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
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9
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Pareek A, Parkes CW, Slynarski K, Walawski J, Smigielski R, Merwe WVD, Krych AJ. Risk of Arthroplasty in Patients with Subchondral Insufficiency Fractures of the Knee: A Matched Study of the Implantable Shock Absorber using a Validated Predictive Model. J Knee Surg 2024; 37:73-78. [PMID: 36417980 DOI: 10.1055/a-1984-9980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Subchondral insufficiency fractures of the knee (SIFK) can result in high rates of osteoarthritis and arthroplasty. The implantable shock absorber (ISA) implant is a titanium and polycarbonate urethane device which reduces the load on the medial compartment of the knee by acting as an extra-articular load absorber while preserving the joint itself. The purpose of this study was to evaluate whether partially unloading the knee with the ISA altered the likelihood of progression to arthroplasty utilizing a validated predictive risk model (SIFK score). A retrospective case-control (2:1) study was performed on patients with SIFK without any previous surgery and on those implanted with the ISA with the primary outcome being progression to arthroplasty compared with nonoperative treatment at 2 years. Baseline and final radiographs, as well as magnetic resonance imagings, were reviewed for the evaluation of meniscus or ligament injuries, insufficiency fractures, and subchondral edema. Patients from a prospective study were matched using the exact SIFK Score, a validated predictive score for progression to arthroplasty in patients with SIFK, to those who received the ISA implant. Kaplan-Meier analysis was conducted to assess survival. A total of 57 patients (38 controls:19 ISA) with a mean age of 60.6 years and 54% female were included. The SIFK score was matched exactly between cases and controls for all patients. The 2-year survival rate of 100% for the ISA group was significantly higher than the corresponding rate of 61% for the control group (p < 0.01). In ISA, 0% of the patients converted to arthroplasty at 2 years, and 5% (one patient) had hardware removal at 1 year. When stratified by risk, the ISA group did not have a significantly higher survival compared with low-risk (p = 0.3) or medium-risk (p = 0.2) controls, though it had a significantly higher survival for high-risk groups at 2 years (100 vs. 15%, p < 0.01). SIFK of the medial knee can lead to significant functional limitation and high rates of conversion to arthroplasty. Implants such as the ISA have the potential to alter the progression to arthroplasty in these patients, especially those at high risk.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chad W Parkes
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
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10
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Kunze KN, Williams RJ, Ranawat AS, Pearle AD, Kelly BT, Karlsson J, Martin RK, Pareek A. Artificial intelligence (AI) and large data registries: Understanding the advantages and limitations of contemporary data sets for use in AI research. Knee Surg Sports Traumatol Arthrosc 2024; 32:13-18. [PMID: 38226678 DOI: 10.1002/ksa.12018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Riley J Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Anil S Ranawat
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D Pearle
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
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11
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Oeding JF, Dancy ME, Fearington FW, Pruneski JA, Pareek A, Hevesi M, Hangody L, Camp CL, Krych AJ. Autologous Osteochondral Transfer of the Knee Demonstrates Continued High Rates of Return to Sport and Low Rates of Conversion to Arthroplasty at Long-Term Follow-Up: A Systematic Review. Arthroscopy 2023:S0749-8063(23)00955-6. [PMID: 38056726 DOI: 10.1016/j.arthro.2023.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/30/2023] [Accepted: 11/19/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE To perform a systematic review of the literature to evaluate (1) activity level and knee function, (2) reoperation and failure rates, and (3) risk factors for reoperation and failure of autologous osteochondral transfer (AOT) at long-term follow-up. METHODS A comprehensive review of the long-term outcomes of AOT was performed. Studies reported on activity-based outcomes (Tegner Activity Scale) and clinical outcomes (Lysholm score and International Knee Documentation Committee score). Reoperation and failure rates as defined by the publishing authors were recorded for each study. Modified Coleman Methodology Scores were calculated to assess study methodological quality. RESULTS Twelve studies with a total of 495 patients and an average age of 32.5 years at the time of surgery and a mean follow-up of 15.1 years (range, 10.4-18.0 years) were included. The mean defect size was 3.2 cm2 (range, 1.9-6.9 cm2). The mean duration of symptoms before surgery was 5.1 years. Return to sport rates ranged from 86% to 100%. Conversion to arthroplasty rates ranged from 0% to 16%. The average preoperative International Knee Documentation Committee scores ranged from 32.9 to 36.8, and the average postoperative International Knee Documentation Committee scores at final follow-up ranged from 66.3 to 77.3. The average preoperative Lysholm scores ranged from 44.5 to 56.0 and the average postoperative Lysholm scores ranged from 70.0 to 96.5. The average preoperative Tegner scores ranged from 2.5 to 3.0, and the average postoperative scores ranged from 4.1 to 7.0. CONCLUSIONS AOT of the knee resulted in high rates of return to sport with correspondingly low rates of conversion to arthroplasty at long-term follow-up. In addition, AOT demonstrated significant improvements in long-term patient-reported outcomes from baseline. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A..
| | - Malik E Dancy
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Forrest W Fearington
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A
| | - James A Pruneski
- Department of Orthopedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, U.S.A
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Mario Hevesi
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Laszlo Hangody
- Semmelweis University, Department of Traumatology, Uzsoki Hospital, Department of Orthopedics, Budapest, Hungary
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Lu Y, Pareek A, Yang L, Rouzrokh P, Khosravi B, Okoroha KR, Krych AJ, Camp CL. Deep Learning Artificial Intelligence Tool for Automated Radiographic Determination of Posterior Tibial Slope in Patients With ACL Injury. Orthop J Sports Med 2023; 11:23259671231215820. [PMID: 38107846 PMCID: PMC10725654 DOI: 10.1177/23259671231215820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 12/19/2023] Open
Abstract
Background An increased posterior tibial slope (PTS) corresponds with an increased risk of graft failure after anterior cruciate ligament (ACL) reconstruction (ACLR). Validated methods of manual PTS measurements are subject to potential interobserver variability and can be inefficient on large datasets. Purpose/Hypothesis To develop a deep learning artificial intelligence technique for automated PTS measurement from standard lateral knee radiographs. It was hypothesized that this deep learning tool would be able to measure the PTS on a high volume of radiographs expeditiously and that these measurements would be similar to previously validated manual measurements. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods A deep learning U-Net model was developed on a cohort of 300 postoperative short-leg lateral radiographs from patients who underwent ACLR to segment the tibial shaft, tibial joint surface, and tibial tuberosity. The model was trained via a random split after an 80 to 20 train-validation scheme. Masks for training images were manually segmented, and the model was trained for 400 epochs. An image processing pipeline was then deployed to annotate and measure the PTS using the predicted segmentation masks. Finally, the performance of this combined pipeline was compared with human measurements performed by 2 study personnel using a previously validated manual technique for measuring the PTS on short-leg lateral radiographs on an independent test set consisting of both pre- and postoperative images. Results The U-Net semantic segmentation model achieved a mean Dice similarity coefficient of 0.885 on the validation cohort. The mean difference between the human-made and computer-vision measurements was 1.92° (σ = 2.81° [P = .24]). Extreme disagreements between the human and machine measurements, as defined by ≥5° differences, occurred <5% of the time. The model was incorporated into a web-based digital application front-end for demonstration purposes, which can measure a single uploaded image in Portable Network Graphics format in a mean time of 5 seconds. Conclusion We developed an efficient and reliable deep learning computer vision algorithm to automate the PTS measurement on short-leg lateral knee radiographs. This tool, which demonstrated good agreement with human annotations, represents an effective clinical adjunct for measuring the PTS as part of the preoperative assessment of patients with ACL injuries.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linjun Yang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Pouria Rouzrokh
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Bardia Khosravi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R. Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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de Marinis R, Marigi EM, Atwan Y, Yang L, Oeding JF, Gupta P, Pareek A, Sanchez-Sotelo J, Sperling JW. Current clinical applications of artificial intelligence in shoulder surgery: what the busy shoulder surgeon needs to know and what's coming next. JSES Rev Rep Tech 2023; 3:447-453. [PMID: 37928999 PMCID: PMC10625013 DOI: 10.1016/j.xrrt.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background Artificial intelligence (AI) is a continuously expanding field with the potential to transform a variety of industries-including health care-by providing automation, efficiency, precision, accuracy, and decision-making support for simple and complex tasks. Basic knowledge of the key features as well as limitations of AI is paramount to understand current developments in this field and to successfully apply them to shoulder surgery. The purpose of the present review is to provide an overview of AI within orthopedics and shoulder surgery exploring current and forthcoming AI applications. Methods PubMed and Scopus databases were searched to provide a narrative review of the most relevant literature on AI applications in shoulder surgery. Results Despite the enormous clinical and research potential of AI, orthopedic surgery has been a relatively late adopter of AI technologies. Image evaluation, surgical planning, aiding decision-making, and facilitating patient evaluations over time are some of the current areas of development with enormous opportunities to improve surgical practice, research, and education. Furthermore, the advancement of AI-driven strategies has the potential to create a more efficient medical system that may reduce the overall cost of delivering and implementing quality health care for patients with shoulder pathology. Conclusion AI is an expanding field with the potential for broad clinical and research applications in orthopedic surgery. Many challenges still need to be addressed to fully leverage the potential of AI to clinical practice and research such as privacy issues, data ownership, and external validation of the proposed models.
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Affiliation(s)
- Rodrigo de Marinis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Shoulder and Elbow Unit, Hospital Dr. Sótero del Rio, Santiago, Chile
| | - Erick M. Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Yousif Atwan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Linjun Yang
- Orthopedic Surgery Artificial Intelligence Lab (OSAIL), Mayo Clinic, Rochester, MN, USA
| | - Jacob F. Oeding
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Puneet Gupta
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - John W. Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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14
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Kunze KN, Jang SJ, Li TY, Pareek A, Finocchiaro A, Fu MC, Taylor SA, Dines JS, Dines DM, Warren RF, Gulotta LV. Artificial intelligence for automated identification of total shoulder arthroplasty implants. J Shoulder Elbow Surg 2023; 32:2115-2122. [PMID: 37172888 DOI: 10.1016/j.jse.2023.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Accurate and rapid identification of implant manufacturer and model is critical in the evaluation and management of patients requiring revision total shoulder arthroplasty (TSA). Failure to correctly identify implant designs in these circumstances may lead to delay in care, unexpected intraoperative challenges, increased morbidity, and excess health care costs. Deep learning (DL) permits automated image processing and holds the potential to mitigate such challenges while improving the value of care rendered. The purpose of this study was to develop an automated DL algorithm to identify shoulder arthroplasty implants from plain radiographs. METHODS A total of 3060 postoperative images from patients who underwent TSA between 2011 and 2021 performed by 26 fellowship-trained surgeons at 2 independent tertiary academic hospitals in the Pacific Northwest and Mid-Atlantic Northeast were included. A DL algorithm was trained using transfer learning and data augmentation to classify 22 different reverse TSA and anatomic TSA prostheses from 8 implant manufacturers. Images were split into training and testing cohorts (2448 training and 612 testing images). Optimized model performance was assessed using standardized metrics including the multiclass area under the receiver operating characteristic curve (AUROC) and compared with a reference standard of implant data from operative reports. RESULTS The algorithm classified implants at a mean speed of 0.079 seconds (±0.002 seconds) per image. The optimized model discriminated between 8 manufacturers (22 unique implants) with AUROCs of 0.994-1.000, accuracy of 97.1%, and sensitivities between 0.80 and 1.00 on the independent testing set. In the subset of single-institution implant predictions, a DL model identified 6 specific implants with AUROCs of 0.999-1.000, accuracy of 99.4%, and sensitivity >0.97 for all implants. Saliency maps revealed key differentiating features across implant manufacturers and designs recognized by the algorithm for classification. CONCLUSION A DL model demonstrated excellent accuracy in identifying 22 unique TSA implants from 8 manufacturers. This algorithm may provide a clinically meaningful adjunct in assisting with preoperative planning for the failed TSA and allows for scalable expansion with additional radiographic data and validation efforts.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA.
| | | | - Tim Y Li
- Weill Cornell College of Medicine, New York, NY, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Anthony Finocchiaro
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Michael C Fu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Samuel A Taylor
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Joshua S Dines
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - David M Dines
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Russell F Warren
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Lawrence V Gulotta
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
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15
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Longo UG, Di Naro C, Campisi S, Casciaro C, Bandini B, Pareek A, Bruschetta R, Pioggia G, Cerasa A, Tartarisco G. Application of Machine Learning Algorithms for Prognostic Assessment in Rotator Cuff Pathologies: A Clinical Data-Based Approach. Diagnostics (Basel) 2023; 13:2915. [PMID: 37761282 PMCID: PMC10530213 DOI: 10.3390/diagnostics13182915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
AIM The overall aim of this proposal is to ameliorate the care of rotator cuff (RC) tear patients by applying an innovative machine learning approach for outcome prediction after arthroscopic repair. MATERIALS AND METHODS We applied state-of-the-art machine learning algorithms to evaluate the best predictors of the outcome, and 100 RC patients were evaluated at baseline (T0), after 1 month (T1), 3 months (T2), 6 months (T3), and 1 year (T4) from surgical intervention. The outcome measure was the Costant-Murley Shoulder Score, whereas age, sex, BMI, the 36-Item Short-Form Survey, the Simple Shoulder Test, the Hospital Anxiety and Depression Scale, the American Shoulder and Elbow Surgeons Score, the Oxford Shoulder Score, and the Shoulder Pain and Disability Index were considered as predictive factors. Support vector machine (SVM), k-nearest neighbors (k-NN), naïve Bayes (NB), and random forest (RF) algorithms were employed. RESULTS Across all sessions, the classifiers demonstrated suboptimal performance when using both the complete and shrunken sets of features. Specifically, the logistic regression (LR) classifier achieved a mean accuracy of 46.5% ± 6%, while the random forest (RF) classifier achieved 51.25% ± 4%. For the shrunken set of features, LR obtained a mean accuracy of 48.5% ± 6%, and RF achieved 45.5% ± 4.5%. No statistical differences were found when comparing the performance metrics of ML algorithms. CONCLUSIONS This study underlines the importance of extending the application of AI methods to new predictors, such as neuroimaging and kinematic data, in order to better record significant shifts in RC patients' prognosis. LIMITATIONS The data quality within the cohort could represent a limitation, since certain variables, such as smoking, diabetes, and work injury, are known to have an impact on the outcome.
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Affiliation(s)
- Umile Giuseppe Longo
- Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (C.D.N.); (C.C.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Calogero Di Naro
- Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (C.D.N.); (C.C.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Simona Campisi
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.C.); (R.B.); (G.P.); (A.C.)
- Department of Engineering, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Carlo Casciaro
- Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (C.D.N.); (C.C.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Benedetta Bandini
- Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (C.D.N.); (C.C.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Ayoosh Pareek
- Hospital for Special Surgery, New York, NY 10021, USA;
| | - Roberta Bruschetta
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.C.); (R.B.); (G.P.); (A.C.)
- Department of Engineering, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.C.); (R.B.); (G.P.); (A.C.)
| | - Antonio Cerasa
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.C.); (R.B.); (G.P.); (A.C.)
- S’Anna Institute, 88900 Crotone, Italy
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Arcavacata di Rende, Italy
| | - Gennaro Tartarisco
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.C.); (R.B.); (G.P.); (A.C.)
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Oeding JF, Lu Y, Pareek A, Marigi EM, Okoroha KR, Barlow JD, Camp CL, Sanchez-Sotelo J. Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning. J Shoulder Elbow Surg 2023; 32:e437-e450. [PMID: 36958524 DOI: 10.1016/j.jse.2023.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/07/2023] [Accepted: 03/18/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. MATERIAL & METHODS A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. RESULTS Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. CONCLUSION Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.
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Affiliation(s)
- Jacob F Oeding
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA; Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway.
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ayoosh Pareek
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway; Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Martin RK, Wastvedt S, Pareek A, Persson A, Visnes H, Fenstad AM, Moatshe G, Wolfson J, Lind M, Engebretsen L. Ceiling Effect of the Combined Norwegian and Danish Knee Ligament Registers Limits Anterior Cruciate Ligament Reconstruction Outcome Prediction. Am J Sports Med 2023; 51:2324-2332. [PMID: 37289071 DOI: 10.1177/03635465231177905] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Clinical tools based on machine learning analysis now exist for outcome prediction after primary anterior cruciate ligament reconstruction (ACLR). Relying partly on data volume, the general principle is that more data may lead to improved model accuracy. PURPOSE/HYPOTHESIS The purpose was to apply machine learning to a combined data set from the Norwegian and Danish knee ligament registers (NKLR and DKRR, respectively), with the aim of producing an algorithm that can predict revision surgery with improved accuracy relative to a previously published model developed using only the NKLR. The hypothesis was that the additional patient data would result in an algorithm that is more accurate. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Machine learning analysis was performed on combined data from the NKLR and DKRR. The primary outcome was the probability of revision ACLR within 1, 2, and 5 years. Data were split randomly into training sets (75%) and test sets (25%). There were 4 machine learning models examined: Cox lasso, random survival forest, gradient boosting, and super learner. Concordance and calibration were calculated for all 4 models. RESULTS The data set included 62,955 patients in which 5% underwent a revision surgical procedure with a mean follow-up of 7.6 ± 4.5 years. The 3 nonparametric models (random survival forest, gradient boosting, and super learner) performed best, demonstrating moderate concordance (0.67 [95% CI, 0.64-0.70]), and were well calibrated at 1 and 2 years. Model performance was similar to that of the previously published model (NKLR-only model: concordance, 0.67-0.69; well calibrated). CONCLUSION Machine learning analysis of the combined NKLR and DKRR enabled prediction of the revision ACLR risk with moderate accuracy. However, the resulting algorithms were less user-friendly and did not demonstrate superior accuracy in comparison with the previously developed model based on patients from the NKLR alone, despite the analysis of nearly 63,000 patients. This ceiling effect suggests that simply adding more patients to current national knee ligament registers is unlikely to improve predictive capability and may prompt future changes to increase variable inclusion.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Orthopedics, CentraCare, St Cloud, Minnesota, USA
| | - Solvejg Wastvedt
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andreas Persson
- Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Håvard Visnes
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Gilbert Moatshe
- Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
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Pareek A, Parkes CW, Gomoll AH, Krych AJ. Improved 2-Year Freedom from Arthroplasty in Patients with High-Risk SIFK Scores and Medial Knee Osteoarthritis Treated with an Implantable Shock Absorber versus Non-Operative Care. Cartilage 2023; 14:164-171. [PMID: 37198901 PMCID: PMC10416199 DOI: 10.1177/19476035231154513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVE Subchondral insufficiency fracture of the knee (SIFK) is associated with high rates of osteoarthritis (OA) and arthroplasty. The implantable shock absorber (ISA) is an extra-capsular implant that unloads the medial knee compartment. This study compared the 2-year freedom from arthroplasty rates in subjects with medial knee OA and SIFK when treated with an ISA versus a matched cohort of patients treated non-surgically. DESIGN This retrospective case-control study compared 2-year conversion rates to arthroplasty in SIFK score-, age-, and body mass index (BMI)-matched control subjects without prior surgical history with ISA-implanted subjects from an ongoing prospective study. Baseline and final radiographs, and MRIs were reviewed for evaluation of meniscus or ligament injuries, insufficiency fractures, and subchondral edema. Kaplan-Meier analysis assessed survival. RESULTS Forty-two patients (21 Control: 21 ISA), mean age = 52.3 ± 8.7 years, BMI = 29.5 ± 3.9 kg/m2, 40% female were evaluated. Both ISA and Control arms had the same numbers of low (n = 4), medium (n = 11), and high-risk (n = 6) SIFK scores. One- and 2-year freedom-from-arthroplasty rates were both 100% for ISA subjects, and 76% and 55%, respectively, for Controls (P = 0.001 for cross-group comparison). Control knees with low, medium, and high-risk SIFK scores had respective 1- and 2-year survival rates of 100% and 100%, 90% and 68% (P = 0.07 vs. ISA), and 33% and 0% (P = 0.002 vs. ISA). CONCLUSIONS ISA intervention was strongly associated with avoidance of arthroplasty at a minimum 2 years, especially in patients with high-risk SIFK scores. SIFK severity scoring predicted relative risk of conversion to arthroplasty through at least 2 years in non-surgically treated subjects.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chad W. Parkes
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Aaron J. Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
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Kunze KN, Kay J, Pareek A, Dahmen J, Chahla J, Nho SJ, Williams RJ, de Sa D, Karlsson J. A guide to appropriately planning and conducting meta-analyses: part 3. Special considerations-the network meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07419-7. [PMID: 37193822 DOI: 10.1007/s00167-023-07419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/14/2023] [Indexed: 05/18/2023]
Abstract
The meta-analysis has become one of the predominant studies designs in orthopaedic literature. Within recent years, the network meta-analysis has been implicated as a powerful approach to comparing multiple treatments for an outcome of interest when conducting a meta-analysis (as opposed to two competing treatments which is typical of a traditional meta-analysis). With the increasing use of the network meta-analysis, it is imperative for readers to possess the ability to independently and critically evaluate these types of studies. The purpose of this article is to provide the necessary foundation of knowledge to both properly conduct and interpret the results of a network meta-analysis.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70Th Street, New York, NY, 10021, USA.
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70Th Street, New York, NY, 10021, USA
| | - Jari Dahmen
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Shane J Nho
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Riley J Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70Th Street, New York, NY, 10021, USA
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Kunze KN, Moran J, Polce EM, Pareek A, Strickland SM, Williams RJ. Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07402-2. [PMID: 37000243 DOI: 10.1007/s00167-023-07402-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
PURPOSE To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR). METHODS PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups. RESULTS Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.). CONCLUSION ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, East 70th Street, New York, NY, 53510021, USA.
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA.
| | - Jay Moran
- Yale School of Medicine, New Haven, CT, USA
| | - Evan M Polce
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, East 70th Street, New York, NY, 53510021, USA
| | - Sabrina M Strickland
- Department of Orthopaedic Surgery, Hospital for Special Surgery, East 70th Street, New York, NY, 53510021, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
| | - Riley J Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, East 70th Street, New York, NY, 53510021, USA
- Sports Medicine and Shoulder Institute, Hospital for Special Surgery, New York, NY, USA
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21
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Kunze KN, Kay J, Pareek A, Dahmen J, Nwachukwu BU, Williams RJ, Karlsson J, de Sa D. A guide to appropriately planning and conducting meta-analyses: part 2-effect size estimation, heterogeneity and analytic approaches. Knee Surg Sports Traumatol Arthrosc 2023; 31:1629-1634. [PMID: 36988628 DOI: 10.1007/s00167-023-07328-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/27/2023] [Indexed: 03/30/2023]
Abstract
Meta-analyses by definition are a subtype of systematic review intended to quantitatively assess the strength of evidence present on an intervention or treatment. Such analyses may use individual-level data or aggregate data to produce a point estimate of an effect, also known as the combined effect, and measure precision of the calculated estimate. The current article will review several important considerations during the analytic phase of a meta-analysis, including selection of effect estimators, heterogeneity and various sub-types of meta-analytic approaches.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jari Dahmen
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Riley J Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Pruneski JA, Varady NH, Pareek A, Gulotta LV, Pearle AD, Karlsson J, Sherman SL, Chahla J, Williams RJ. Survival analyses and their applications in orthopaedics. Knee Surg Sports Traumatol Arthrosc 2023; 31:2053-2059. [PMID: 36947234 DOI: 10.1007/s00167-023-07371-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
Survival analyses are a powerful statistical tool used to analyse data when the outcome of interest involves the time until an event. There is an array of models fit for this goal; however, there are subtle differences in assumptions, as well as a number of pitfalls, that can lead to biased results if researchers are unaware of the subtleties. As larger amounts of data become available, and more survival analyses are published every year, it is important that healthcare professionals understand how to evaluate these models and apply them into their practice. Therefore, the purpose of this study was to present an overview of survival analyses, including required assumptions and important pitfalls, as well as examples of their use within orthopaedic surgery.
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Affiliation(s)
- James A Pruneski
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Nathan H Varady
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Lawrence V Gulotta
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew D Pearle
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Seth L Sherman
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Dahmen J, Kayaalp ME, Ollivier M, Pareek A, Hirschmann MT, Karlsson J, Winkler PW. Artificial intelligence bot ChatGPT in medical research: the potential game changer as a double-edged sword. Knee Surg Sports Traumatol Arthrosc 2023; 31:1187-1189. [PMID: 36809511 DOI: 10.1007/s00167-023-07355-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/10/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Jari Dahmen
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands. .,Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands. .,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, The Netherlands.
| | - M Enes Kayaalp
- Department for Orthopaedics and Traumatology, Istanbul Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | | | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Michael T Hirschmann
- Department of Orthopedic Surgery and Traumatology, Head Knee Surgery and DKF Head of Research, Kantonsspital Baselland, Bruderholz, 4101, Bottmingen, Switzerland
| | - Jon Karlsson
- Department for Orthopaedics, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Philipp W Winkler
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
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24
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Eckhardt CM, Madjarova SJ, Williams RJ, Ollivier M, Karlsson J, Pareek A, Nwachukwu BU. Unsupervised machine learning methods and emerging applications in healthcare. Knee Surg Sports Traumatol Arthrosc 2023; 31:376-381. [PMID: 36378293 DOI: 10.1007/s00167-022-07233-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Unsupervised machine learning methods are important analytical tools that can facilitate the analysis and interpretation of high-dimensional data. Unsupervised machine learning methods identify latent patterns and hidden structures in high-dimensional data and can help simplify complex datasets. This article provides an overview of key unsupervised machine learning techniques including K-means clustering, hierarchical clustering, principal component analysis, and factor analysis. With a deeper understanding of these analytical tools, unsupervised machine learning methods can be incorporated into health sciences research to identify novel risk factors, improve prevention strategies, and facilitate delivery of personalized therapies and targeted patient care.Level of evidence: I.
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Affiliation(s)
- Christina M Eckhardt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons Irving Medical Center, New York, NY, USA
| | - Sophia J Madjarova
- Sports Medicine Fellow and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Riley J Williams
- Sports Medicine Fellow and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Mattheu Ollivier
- Institut du Movement et de l'appareil locomoteur, Aix-Marseille Université, Marseille, France
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Ayoosh Pareek
- Sports Medicine Fellow and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Benedict U Nwachukwu
- Sports Medicine Fellow and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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25
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Oeding JF, Williams RJ, Nwachukwu BU, Martin RK, Kelly BT, Karlsson J, Camp CL, Pearle AD, Ranawat AS, Pareek A. A practical guide to the development and deployment of deep learning models for the Orthopedic surgeon: part I. Knee Surg Sports Traumatol Arthrosc 2023; 31:382-389. [PMID: 36427077 DOI: 10.1007/s00167-022-07239-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022]
Abstract
Deep learning has a profound impact on daily life. As Orthopedics makes use of this rapid escalation in technology, Orthopedic surgeons will need to take leadership roles on deep learning projects. Moreover, surgeons must possess an understanding of what is necessary to design and implement deep learning-based project pipelines. This review provides a practical guide for the Orthopedic surgeon to understand the steps needed to design, develop, and deploy a deep learning pipeline for clinical applications. A detailed description of the processes involved in defining the problem, building the team, acquiring and curating the data, labeling the data, establishing the ground truth, pre-processing and augmenting the data, and selecting the required hardware is provided. In addition, an overview of unique considerations involved in the training and evaluation of deep learning models is provided. This review strives to provide surgeons with the groundwork needed to identify gaps in the clinical landscape that deep learning models may be able to fill and equips them with the knowledge needed to lead an interdisciplinary team through the process of creating novel deep-learning-based solutions to fill those gaps.
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Affiliation(s)
- Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Benedict U Nwachukwu
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Bryan T Kelly
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Rochester, MN, USA
| | - Andrew D Pearle
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Anil S Ranawat
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Ramkumar PN, Berrier AS, Helm JM, Koolmees DS, Pareek A, Krych AJ, Makhni EC, Harris JD, Nwachukwu BU. Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis. Orthop J Sports Med 2023; 11:23259671221144776. [PMID: 36655021 PMCID: PMC9841845 DOI: 10.1177/23259671221144776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 01/13/2023] Open
Abstract
Background Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design Cohort study; Level of evidence, 3. Methods Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.
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Affiliation(s)
- Prem N. Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Prem N. Ramkumar, MD, MBA, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA () (Twitter: @prem_ramkumar)
| | - Ava S. Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - J. Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, USA
| | - Dylan S. Koolmees
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric C. Makhni
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua D. Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, USA
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Khorana A, Pareek A, Ollivier M, Madjarova SJ, Kunze KN, Nwachukwu BU, Karlsson J, Marigi EM, Williams RJ. Choosing the appropriate measure of central tendency: mean, median, or mode? Knee Surg Sports Traumatol Arthrosc 2023; 31:12-15. [PMID: 36322179 DOI: 10.1007/s00167-022-07204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
Mean, median, and mode are among the most basic and consistently used measures of central tendency in statistical analysis and are crucial for simplifying data sets to a single value. However, there is a lack of understanding of when to use each metric and how various factors can impact these values. The aim of this article is to clarify some of the confusion related to each measure and explain how to select the appropriate metric for a given data set. The authors present this work as an educational resource, ensuring that these common statistical concepts are better understood throughout the Orthopedic research community.
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Affiliation(s)
- Arjun Khorana
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA.
| | - Matthieu Ollivier
- Institut du Movement et de l'appareil Locomoteur, Aix-Marseille Université, Marseille, France
| | - Sophia J Madjarova
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA
| | - Kyle N Kunze
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA
| | - Benedict U Nwachukwu
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Erick M Marigi
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, USA
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Varady NH, Pareek A, Eckhardt CM, Williams RJ, Madjarova SJ, Ollivier M, Martin RK, Karlsson J, Nwachukwu BU. Multivariable regression: understanding one of medicine's most fundamental statistical tools. Knee Surg Sports Traumatol Arthrosc 2023; 31:7-11. [PMID: 36323796 DOI: 10.1007/s00167-022-07215-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
Multivariable regression is a fundamental tool that drives observational research in orthopaedic surgery. However, regression analyses are not always implemented correctly. This study presents a basic overview of regression analyses and reviews frequent points of confusion. Topics include linear, logistic, and time-to-event regressions, causal inference, confounders, overfitting, missing data, multicollinearity, interactions, and key differences between multivariable versus multivariate regression. The goal is to provide clarity regarding the use and interpretation of multivariable analyses for those attempting to increase their statistical literacy in orthopaedic research.
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Affiliation(s)
- Nathan H Varady
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
- Sports Medicine Fellow, Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Christina M Eckhardt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Sophia J Madjarova
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Matthieu Ollivier
- Institut du Movement Et de L'appareil Locomoteur, Aix-Marseille Université, Marseille, France
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Benedict U Nwachukwu
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
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Pruneski JA, Pareek A, Nwachukwu BU, Martin RK, Kelly BT, Karlsson J, Pearle AD, Kiapour AM, Williams RJ. Natural language processing: using artificial intelligence to understand human language in orthopedics. Knee Surg Sports Traumatol Arthrosc 2022; 31:1203-1211. [PMID: 36477347 DOI: 10.1007/s00167-022-07272-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Natural language processing (NLP) describes the broad field of artificial intelligence by which computers are trained to understand and generate human language. Within healthcare research, NLP is commonly used for variable extraction and classification/cohort identification tasks. While these tools are becoming increasingly popular and available as both open-source and commercial products, there is a paucity of the literature within the orthopedic space describing the key tasks within these powerful pipelines. Curation and navigation of the electronic medical record are becoming increasingly onerous, and it is important for physicians and other healthcare professionals to understand potential methods of harnessing this large data resource. The purpose of this study is to provide an overview of the tasks required to develop an NLP pipeline for orthopedic research and present recent examples of successful implementations.
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Affiliation(s)
- James A Pruneski
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA. .,Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Benedict U Nwachukwu
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Bryan T Kelly
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Andrew D Pearle
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Ata M Kiapour
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
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Therrien E, Pareek A, Song BM, Wilbur RR, Till SE, Krych AJ, Stuart MJ, Levy BA. Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement. Orthop J Sports Med 2022; 10:23259671221137357. [PMID: 36479468 PMCID: PMC9720802 DOI: 10.1177/23259671221137357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. Purpose To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Study Design Cohort study; Level of evidence, 3. Methods A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Results Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. Conclusion All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.
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Affiliation(s)
- Erik Therrien
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryant M. Song
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan R. Wilbur
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara E. Till
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA. ,Bruce A. Levy, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA ()
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Pruneski JA, Pareek A, Kunze KN, Martin RK, Karlsson J, Oeding JF, Kiapour AM, Nwachukwu BU, Williams RJ. Supervised machine learning and associated algorithms: applications in orthopedic surgery. Knee Surg Sports Traumatol Arthrosc 2022; 31:1196-1202. [PMID: 36222893 DOI: 10.1007/s00167-022-07181-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
Supervised learning is the most common form of machine learning utilized in medical research. It is used to predict outcomes of interest or classify positive and/or negative cases with a known ground truth. Supervised learning describes a spectrum of techniques, ranging from traditional regression modeling to more complex tree boosting, which are becoming increasingly prevalent as the focus on "big data" develops. While these tools are becoming increasingly popular and powerful, there is a paucity of literature available that describe the strengths and limitations of these different modeling techniques. Typically, there is no formal training for health care professionals in the use of machine learning models. As machine learning applications throughout medicine increase, it is important that physicians and other health care professionals better understand the processes underlying application of these techniques. The purpose of this study is to provide an overview of commonly used supervised learning techniques with recent case examples within the orthopedic literature. An additional goal is to address disparities in the understanding of these methods to improve communication within and between research teams.
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Affiliation(s)
- James A Pruneski
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ayoosh Pareek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Kyle N Kunze
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jón Karlsson
- Orthopaedic Research Department, Göteborg University, Göteborg, Sweden
| | - Jacob F Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Ata M Kiapour
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Benedict U Nwachukwu
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Martin RK, Wastvedt S, Lange J, Pareek A, Wolfson J, Lund B. Limited clinical utility of a machine learning revision prediction model based on a national hip arthroscopy registry. Knee Surg Sports Traumatol Arthrosc 2022; 31:2079-2089. [PMID: 35947158 PMCID: PMC10183422 DOI: 10.1007/s00167-022-07054-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/10/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Accurate prediction of outcome following hip arthroscopy is challenging and machine learning has the potential to improve our predictive capability. The purpose of this study was to determine if machine learning analysis of the Danish Hip Arthroscopy Registry (DHAR) can develop a clinically meaningful calculator for predicting the probability of a patient undergoing subsequent revision surgery following primary hip arthroscopy. METHODS Machine learning analysis was performed on the DHAR. The primary outcome for the models was probability of revision hip arthroscopy within 1, 2, and/or 5 years after primary hip arthroscopy. Data were split randomly into training (75%) and test (25%) sets. Four models intended for these types of data were tested: Cox elastic net, random survival forest, gradient boosted regression (GBM), and super learner. These four models represent a range of approaches to statistical details like variable selection and model complexity. Model performance was assessed by calculating calibration and area under the curve (AUC). Analysis was performed using only variables available in the pre-operative clinical setting and then repeated to compare model performance using all variables available in the registry. RESULTS In total, 5581 patients were included for analysis. Average follow-up time or time-to-revision was 4.25 years (± 2.51) years and overall revision rate was 11%. All four models were generally well calibrated and demonstrated concordance in the moderate range when restricted to only pre-operative variables (0.62-0.67), and when considering all variables available in the registry (0.63-0.66). The 95% confidence intervals for model concordance were wide for both analyses, ranging from a low of 0.53 to a high of 0.75, indicating uncertainty about the true accuracy of the models. CONCLUSION The association between pre-surgical factors and outcome following hip arthroscopy is complex. Machine learning analysis of the DHAR produced a model capable of predicting revision surgery risk following primary hip arthroscopy that demonstrated moderate accuracy but likely limited clinical usefulness. Prediction accuracy would benefit from enhanced data quality within the registry and this preliminary study holds promise for future model generation as the DHAR matures. Ongoing collection of high-quality data by the DHAR should enable improved patient-specific outcome prediction that is generalisable across the population. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA. .,Department of Orthopaedic Surgery, CentraCare, Saint Cloud, MN, USA.
| | - Solvejg Wastvedt
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,CAAIR, Horsens Regional Hospital, Horsens, Denmark
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Bent Lund
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopedic Surgery, H-HiP, Horsens Regional Hospital, Horsens, Denmark
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Lu Y, Pareek A, Lavoie-Gagne OZ, Forlenza EM, Patel BH, Reinholz AK, Forsythe B, Camp CL. Machine Learning for Predicting Lower Extremity Muscle Strain in National Basketball Association Athletes. Orthop J Sports Med 2022; 10:23259671221111742. [PMID: 35923866 PMCID: PMC9340342 DOI: 10.1177/23259671221111742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background In professional sports, injuries resulting in loss of playing time have serious implications for both the athlete and the organization. Efforts to quantify injury probability utilizing machine learning have been met with renewed interest, and the development of effective models has the potential to supplement the decision-making process of team physicians. Purpose/Hypothesis The purpose of this study was to (1) characterize the epidemiology of time-loss lower extremity muscle strains (LEMSs) in the National Basketball Association (NBA) from 1999 to 2019 and (2) determine the validity of a machine-learning model in predicting injury risk. It was hypothesized that time-loss LEMSs would be infrequent in this cohort and that a machine-learning model would outperform conventional methods in the prediction of injury risk. Study Design Case-control study; Level of evidence, 3. Methods Performance data and rates of the 4 major muscle strain injury types (hamstring, quadriceps, calf, and groin) were compiled from the 1999 to 2019 NBA seasons. Injuries included all publicly reported injuries that resulted in lost playing time. Models to predict the occurrence of a LEMS were generated using random forest, extreme gradient boosting (XGBoost), neural network, support vector machines, elastic net penalized logistic regression, and generalized logistic regression. Performance was compared utilizing discrimination, calibration, decision curve analysis, and the Brier score. Results A total of 736 LEMSs resulting in lost playing time occurred among 2103 athletes. Important variables for predicting LEMS included previous number of lower extremity injuries; age; recent history of injuries to the ankle, hamstring, or groin; and recent history of concussion as well as 3-point attempt rate and free throw attempt rate. The XGBoost machine achieved the best performance based on discrimination assessed via internal validation (area under the receiver operating characteristic curve, 0.840), calibration, and decision curve analysis. Conclusion Machine learning algorithms such as XGBoost outperformed logistic regression in the prediction of a LEMS that will result in lost time. Several variables increased the risk of LEMS, including a history of various lower extremity injuries, recent concussion, and total number of previous injuries.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota,
USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota,
USA
| | - Ophelie Z. Lavoie-Gagne
- Harvard Combined Orthopaedic Surgery Program, Harvard Medical
School, Boston, Massachusetts, USA
| | - Enrico M. Forlenza
- Department of Orthopaedic Surgery, Rush University Medical Center,
Chicago, Illinois, USA
| | - Bhavik H. Patel
- Department of Orthopedic Surgery, University of Illinois at Chicago,
Chicago, Illinois, USA
| | - Anna K. Reinholz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota,
USA
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Rush University Medical Center,
Chicago, Illinois, USA
| | - Christopher L. Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota,
USA.,∥Christopher L. Camp, MD, Mayo Clinic, 200
First Street SW, Rochester, MN 55905, USA (
)
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Lu Y, Lavoie-Gagne O, Forlenza EM, Pareek A, Kunze KN, Forsythe B, Levy BA, Krych AJ. Duration of Care and Operative Time Are the Primary Drivers of Total Charges After Ambulatory Hip Arthroscopy: A Machine Learning Analysis. Arthroscopy 2022; 38:2204-2216.e3. [PMID: 34921955 DOI: 10.1016/j.arthro.2021.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities. METHODS A retrospective review of the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features. RESULTS A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 [95% confidence interval, $3,700-$3,900]; logarithmic root-mean-square error, 0.249 [95% confidence interval, 0.24-0.26]; R2 = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income. CONCLUSIONS The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Yining Lu
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A..
| | | | | | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Kyle N Kunze
- Hospital for Special Surgery, New York, New York, U.S.A
| | - Brian Forsythe
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bruce A Levy
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
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35
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Ezuma CO, Lu Y, Pareek A, Wilbur R, Krych AJ, Forsythe B, Camp CL. A Machine Learning Algorithm Outperforms Traditional Multiple Regression to Predict Risk of Unplanned Overnight Stay Following Outpatient Medial Patellofemoral Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e1103-e1110. [PMID: 35747652 PMCID: PMC9210490 DOI: 10.1016/j.asmr.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/28/2022] [Indexed: 12/21/2022] Open
Abstract
Purpose To determine whether conventional logistic regression or machine learning algorithms were more precise in identifying the risk factors for unplanned overnight admission after medial patellofemoral ligament (MPFL) reconstruction. Methods A retrospective review of the prospectively collected National Surgical Quality Improvement Program database was performed to identify patients who underwent outpatient MPFL reconstruction from 2006–2018. Patients admitted overnight were identified as those with length of stay of 1 or more days. Models were generated using random forest, extreme gradient boosting, adaptive boosting, or elastic net penalized logistic regression, and an additional model was produced as a weighted ensemble of the 4 final algorithms. The predictive capacity of these models was compared to that of logistic regression. Results Of the 1307 patients identified, 221 (16.9%) required at least one overnight stay after MPFL reconstruction. Multivariate logistic regression found the following variables to be predictors of inpatient admission: age (odds ratio [OR] = 1.03 [95% confidence interval {CI} 1.02-1.04]; P <.001), spinal anesthesia (OR = 3.42 [95% CI 1.98-6.08]; P < .001), American Society of Anesthesiologists (ASA) class 3/4 (OR = 1.96 [95% CI 1.25-3.06]; P < .001), history of chronic obstructive pulmonary disease (COPD) (OR = 6.44 [95% CI 1.58-26.17]; P = .02), and body mass index (BMI) (OR = 1.03 [95% CI 1.01-1.05]; P < .001). The ensemble model achieved the best performance based on discrimination assessed via internal validation (area under the curve = 0.722). The variables determined most important by the ensemble model were increasing BMI, increasing age, ASA class, anesthesia, smoking, hypertension, lateral release, and history of COPD. Conclusions An internally validated machine learning algorithm outperformed logistic regression modeling in predicting the need for unplanned overnight hospitalization after MPFL reconstruction. In this model, the most significant risk factors for admission were age, BMI, ASA class, smoking status, hypertension, lateral release, and history of COPD. This tool can be deployed to augment provider assessment to identify high-risk candidates and appropriately set postoperative expectations for patients. Clinical Relevance Identifying and mitigating patient risk factors to prevent adverse surgical outcomes and hospitalizations is one of our primary goals. There may be a key role for machine learning algorithms to help successfully and efficiently risk stratify patients to decrease costs, appropriately set postoperative expectations, and increase the quality of delivered care.
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Affiliation(s)
- Chimere O Ezuma
- School of Medicine, Vagelos Columbia College of Physicians and Surgeons, New York, New York
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, and Rochester, Minnesota
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, and Rochester, Minnesota
| | - Ryan Wilbur
- Department of Orthopedic Surgery, Mayo Clinic, and Rochester, Minnesota
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, and Rochester, Minnesota
| | - Brian Forsythe
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
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Pareek A, Martin RK. Editorial Commentary: Machine Learning in Medicine Requires Clinician Input, Faces Barriers, and High-Quality Evidence Is Required to Demonstrate Improved Patient Outcomes. Arthroscopy 2022; 38:2106-2108. [PMID: 35660191 DOI: 10.1016/j.arthro.2022.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023]
Abstract
Machine learning (ML) and artificial intelligence (AI) may be described as advanced statistical techniques using algorithms to "learn" to evaluate and predict relationships between input and results without explicit human programming, often with high accuracy. The potentials and pitfalls of ML continue to be explored as predictive modeling grows in popularity. While use of and optimism for AI continues to increase in orthopaedic surgery, there remains little high-quality evidence of its ability to improve patient outcome. It is up to us as clinicians to provide context for ML models and guide the use of these technologies to optimize the outcome for our patients. Barriers to widespread adoption of ML include poor quality data, limits to compliant data sharing, few clinicians who are expert in ML statistical techniques, and computing costs including technology, infrastructure, personnel, energy, and updates.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - R Kyle Martin
- Department of Orthopedic, University of Minnesota, Minneapolis, Minnesota, U.S.A.; Department of Orthopaedic Surgery, CentraCare, Saint Cloud, Minnesota, U.S.A
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Leland DP, Pareek A, Therrien E, Wilbur R, Stuart MJ, Krych AJ, Levy BA, Camp CL. Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment. Sports Med Arthrosc Rev 2022; 30:e1-e8. [PMID: 35113840 PMCID: PMC9128250 DOI: 10.1097/jsa.0000000000000322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Arthroscopy of the shoulder, elbow, hip, and knee has become increasingly utilized due to continued advancements in technique, training, and instrumentation. In addition, arthroscopy is generally safe and effective in the utilization of joint preservation surgical techniques. The arthroscopist must utilize a thorough understanding of the surgical anatomy, detailed care with patient positioning, and safe instrumentation portals to prevent associated neurological injury. In the event of postoperative neurological complications, the physician must carefully document the patient history and physical examination while considering the utilization of additional imaging, testing, or surgical nerve exploration with a specialized team depending upon the severity of neurological injury. In this review, we discuss the prevention, evaluation, and treatment of neurological complications related for arthroscopic procedures of the shoulder, elbow, hip, and knee.
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Affiliation(s)
- Devin P Leland
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ayoosh Pareek
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erik Therrien
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ryan Wilbur
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A Levy
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
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Ley C, Martin RK, Pareek A, Groll A, Seil R, Tischer T. Machine learning and conventional statistics: making sense of the differences. Knee Surg Sports Traumatol Arthrosc 2022; 30:753-757. [PMID: 35106604 DOI: 10.1007/s00167-022-06896-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/13/2022] [Indexed: 11/24/2022]
Abstract
The application of machine learning (ML) to the field of orthopaedic surgery is rapidly increasing, but many surgeons remain unfamiliar with the nuances of this novel technique. With this editorial, we address a fundamental topic-the differences between ML techniques and traditional statistics. By doing so, we aim to further familiarize the reader with the new opportunities available thanks to the ML approach.
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Affiliation(s)
- Christophe Ley
- Department of Mathematics, University of Luxembourg, Esch-sur-Alzette, Luxembourg.
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andreas Groll
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg and Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Thomas Tischer
- Department of Orthopaedic and Traumatologic Surgery, Waldkrankenhaus, Erlangen, Germany
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Ko S, Pareek A, Ro DH, Lu Y, Camp CL, Martin RK, Krych AJ. Artificial intelligence in orthopedics: three strategies for deep learning with orthopedic specific imaging. Knee Surg Sports Traumatol Arthrosc 2022; 30:758-761. [PMID: 35022826 DOI: 10.1007/s00167-021-06838-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Sunho Ko
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea.,CONNECTEVE Co., Ltd, Seoul, South Korea
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea.,CONNECTEVE Co., Ltd, Seoul, South Korea
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Martin RK, Ley C, Pareek A, Groll A, Tischer T, Seil R. Artificial intelligence and machine learning: an introduction for orthopaedic surgeons. Knee Surg Sports Traumatol Arthrosc 2022; 30:361-364. [PMID: 34528133 DOI: 10.1007/s00167-021-06741-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/02/2021] [Indexed: 01/15/2023]
Abstract
The application of artificial intelligence (AI) and machine learning to the field of orthopaedic surgery is rapidly increasing. While this represents an important step in the advancement of our specialty, the concept of AI is rich with statistical jargon and techniques unfamiliar to many clinicians. This knowledge gap may limit the impact and potential of these novel techniques. We aim to narrow this gap in a way that is accessible for all orthopaedic surgeons. With this manuscript, we introduce the concept of AI and machine learning and give examples of how it can impact clinical practice and patient care.Level of evidence VI.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Christophe Ley
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andreas Groll
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Thomas Tischer
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg and Luxembourg Institute of Health, Luxembourg, Luxembourg
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Martin RK, Wastvedt S, Pareek A, Persson A, Visnes H, Fenstad AM, Moatshe G, Wolfson J, Engebretsen L. Predicting Anterior Cruciate Ligament Reconstruction Revision: A Machine Learning Analysis Utilizing the Norwegian Knee Ligament Register. J Bone Joint Surg Am 2022; 104:145-153. [PMID: 34662318 DOI: 10.2106/jbjs.21.00113] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several factors are associated with an increased risk of anterior cruciate ligament (ACL) reconstruction revision. However, the ability to accurately translate these factors into a quantifiable risk of revision at a patient-specific level has remained elusive. We sought to determine if machine learning analysis of the Norwegian Knee Ligament Register (NKLR) can identify the most important risk factors associated with subsequent revision of primary ACL reconstruction and develop a clinically meaningful calculator for predicting revision of primary ACL reconstruction. METHODS Machine learning analysis was performed on the NKLR data set. The primary outcome was the probability of revision ACL reconstruction within 1, 2, and/or 5 years. Data were split randomly into training sets (75%) and test sets (25%). Four machine learning models were tested: Cox Lasso, survival random forest, generalized additive model, and gradient boosted regression. Concordance and calibration were calculated for all 4 models. RESULTS The data set included 24,935 patients, and 4.9% underwent a revision surgical procedure during a mean follow-up (and standard deviation) of 8.1 ± 4.1 years. All 4 models were well-calibrated, with moderate concordance (0.67 to 0.69). The Cox Lasso model required only 5 variables for outcome prediction. The other models either used more variables without an appreciable improvement in accuracy or had slightly lower accuracy overall. An in-clinic calculator was developed that can estimate the risk of ACL revision (Revision Risk Calculator). This calculator can quantify risk at a patient-specific level, with a plausible range from near 0% for low-risk patients to 20% for high-risk patients at 5 years. CONCLUSIONS Machine learning analysis of a national knee ligament registry can predict the risk of ACL reconstruction revision with moderate accuracy. This algorithm supports the creation of an in-clinic calculator for point-of-care risk stratification based on the input of only 5 variables. Similar analysis using a larger or more comprehensive data set may improve the accuracy of risk prediction, and future studies incorporating patients who have experienced failure of ACL reconstruction but have not undergone subsequent revision may better predict the true risk of ACL reconstruction failure. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota.,Department of Orthopedic Surgery, CentraCare, Saint Cloud, Minnesota
| | - Solvejg Wastvedt
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andreas Persson
- Department of Orthopedic Surgery, Martina Hansens Hospital, Bærum, Norway.,Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway.,Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Håvard Visnes
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway.,Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway.,Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
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Markes AR, Pareek A, Mesfin A, Benjamin Ma C, Ward D. Racial and Gender Shoulder Arthroplasty Utilization Disparities of High- and Low-Volume Centers in New York State. J Shoulder Elb Arthroplast 2022; 5:24715492211041901. [PMID: 34993381 PMCID: PMC8492025 DOI: 10.1177/24715492211041901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction The literature has consistently demonstrated utilization disparities in joint replacement procedures, though no studies have evaluated disparities in total shoulder arthroplasty with regard to operative volume. Methods We queried the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database for 32 410 total shoulder arthroplasties performed between 2009 and 2017. Patients were identified using Clinical Classifications Software code 154 for Non-Hip/Knee Arthroplasty and All Patient Refined-Diagnosis Related Group code 322 for Shoulder. Racial groups included Hispanic, non-Hispanic white, non-Hispanic black, and Other. High-volume centers were facilities that performed 2 standard deviations above the mean annual procedures. Utilization rates were calculated by dividing total shoulder arthroplasties per group by the 2010 NY Census population of that group. The Fisher exact test was used to determine significance. Results Total shoulder arthroplasty utilization increased from 43/100 000 to 73/100 000, two-thirds of which was driven by an increase in white resident utilization. More White residents per 100 000 underwent shoulder arthroplasty than Black, Hispanic, and Other residents per 100 000 residents of their respective race. White residents were 90% more likely than Hispanic residents to undergo total shoulder arthroplasty at high-volume centers (P = .04). There were no differences in utilization rate regarding operative volume comparing Black or Other residents to White residents. More females underwent total shoulder arthroplasty than males, though there was no difference in utilization rate regarding operative volume. Conclusion Though total shoulder arthroplasty utilization nearly doubled, disparities persisted across gender and minority groups particularly in Hispanic utilization as White residents were 90% more likely than Hispanic residents to undergo shoulder arthroplasty at high-volume centers.
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Affiliation(s)
- Alexander R Markes
- University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158, USA
| | - Ayoosh Pareek
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Addisu Mesfin
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - C Benjamin Ma
- University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158, USA
| | - Derek Ward
- University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158, USA
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Martin RK, Wastvedt S, Pareek A, Persson A, Visnes H, Fenstad AM, Moatshe G, Wolfson J, Lind M, Engebretsen L. Machine learning algorithm to predict anterior cruciate ligament revision demonstrates external validity. Knee Surg Sports Traumatol Arthrosc 2022; 30:368-375. [PMID: 34973096 PMCID: PMC8866372 DOI: 10.1007/s00167-021-06828-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/26/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE External validation of machine learning predictive models is achieved through evaluation of model performance on different groups of patients than were used for algorithm development. This important step is uncommonly performed, inhibiting clinical translation of newly developed models. Machine learning analysis of the Norwegian Knee Ligament Register (NKLR) recently led to the development of a tool capable of estimating the risk of anterior cruciate ligament (ACL) revision ( https://swastvedt.shinyapps.io/calculator_rev/ ). The purpose of this study was to determine the external validity of the NKLR model by assessing algorithm performance when applied to patients from the Danish Knee Ligament Registry (DKLR). METHODS The primary outcome measure of the NKLR model was probability of revision ACL reconstruction within 1, 2, and/or 5 years. For external validation, all DKLR patients with complete data for the five variables required for NKLR prediction were included. The five variables included graft choice, femur fixation device, KOOS QOL score at surgery, years from injury to surgery, and age at surgery. Predicted revision probabilities were calculated for all DKLR patients. The model performance was assessed using the same metrics as the NKLR study: concordance and calibration. RESULTS In total, 10,922 DKLR patients were included for analysis. Average follow-up time or time-to-revision was 8.4 (± 4.3) years and overall revision rate was 6.9%. Surgical technique trends (i.e., graft choice and fixation devices) and injury characteristics (i.e., concomitant meniscus and cartilage pathology) were dissimilar between registries. The model produced similar concordance when applied to the DKLR population compared to the original NKLR test data (DKLR: 0.68; NKLR: 0.68-0.69). Calibration was poorer for the DKLR population at one and five years post primary surgery but similar to the NKLR at two years. CONCLUSION The NKLR machine learning algorithm demonstrated similar performance when applied to patients from the DKLR, suggesting that it is valid for application outside of the initial patient population. This represents the first machine learning model for predicting revision ACL reconstruction that has been externally validated. Clinicians can use this in-clinic calculator to estimate revision risk at a patient specific level when discussing outcome expectations pre-operatively. While encouraging, it should be noted that the performance of the model on patients undergoing ACL reconstruction outside of Scandinavia remains unknown. LEVEL OF EVIDENCE III.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA.
- Department of Orthopaedic Surgery, CentraCare, Saint Cloud, MN, USA.
| | - Solvejg Wastvedt
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andreas Persson
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Håvard Visnes
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- Norwegian Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
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Lu Y, Pareek A, Wilbur RR, Leland DP, Krych AJ, Camp CL. Understanding Anterior Shoulder Instability Through Machine Learning: New Models That Predict Recurrence, Progression to Surgery, and Development of Arthritis. Orthop J Sports Med 2021; 9:23259671211053326. [PMID: 34888391 PMCID: PMC8649098 DOI: 10.1177/23259671211053326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/02/2021] [Indexed: 01/06/2023] Open
Abstract
Background Management of anterior shoulder instability (ASI) aims to reduce risk of future recurrence and prevent complications via nonoperative and surgical management. Machine learning may be able to reliably provide predictions to improve decision making for this condition. Purpose To develop and internally validate a machine-learning model to predict the following outcomes after ASI: (1) recurrent instability, (2) progression to surgery, and (3) the development of symptomatic osteoarthritis (OA) over long-term follow-up. Study Design Cohort study (prognosis); Level of evidence, 2. Methods An established geographic database of >500,000 patients was used to identify 654 patients aged <40 years with an initial diagnosis of ASI between 1994 and 2016; the mean follow-up was 11.1 years. Medical records were reviewed to obtain patient information, and models were generated to predict the outcomes of interest. Five candidate algorithms were trained in the development of each of the models, as well as an additional ensemble of the algorithms. Performance of the algorithms was assessed using discrimination, calibration, and decision curve analysis. Results Of the 654 included patients, 443 (67.7%) experienced multiple instability events, 228 (34.9%) underwent surgery, and 39 (5.9%) developed symptomatic OA. The ensemble gradient-boosted machines achieved the best performances based on discrimination (via area under the receiver operating characteristic curve [AUC]: AUCrecurrence = 0.86), AUCsurgery = 0.76, AUCOA = 0.78), calibration, decision curve analysis, and Brier score (Brierrecurrence = 0.138, Briersurgery = 0.185, BrierOA = 0.05). For demonstration purposes, models were integrated into a single web-based open-access application able to provide predictions and explanations for practitioners and researchers. Conclusion After identification of key features, including time from initial instability, age at initial instability, sports involvement, and radiographic findings, machine-learning models were developed that effectively and reliably predicted recurrent instability, progression to surgery, and the development of OA in patients with ASI. After careful external validation, these models can be incorporated into open-access digital applications to inform patients, clinicians, and researchers regarding quantifiable risks of relevant outcomes in the clinic.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan R Wilbur
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Devin P Leland
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Pareek A, Parkes CW, Leontovich AA, Krych AJ, Conte S, Steubs JA, Wulf CA, Camp CL. Are Baseball Statistics an Appropriate Tool for Assessing Return to Play in Injured Pitchers? Analysis of Statistical Variability in Healthy Players. Orthop J Sports Med 2021; 9:23259671211050933. [PMID: 34820461 PMCID: PMC8607485 DOI: 10.1177/23259671211050933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Basic pitcher statistics have been used to assess performance in pitchers
after injury or surgery without being validated. Even among healthy
pitchers, the normal variability of these parameters has not yet been
established. Purpose: To determine (1) the normal variability of basic and advanced pitcher
statistics in healthy professional baseball pitchers and (2) the minimum
pitches needed to predict these parameters. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Publicly available data from the MLB Statcast and PITCHf/x databases were
used to analyze MLB pitchers during the 2015 and 2016 seasons who recorded a
minimum of 100 innings without injury. Basic and advanced baseball pitcher
statistics were analyzed. The variability of each parameter was assessed by
computing the coefficient of variation (CV) between individual pitchers and
across all pitchers. A CV <10 was indicative of a relatively constant
parameter, and parameters with a CV >10 were generally considered
inconsistent and unreliable. The minimum number of pitches needed to be
followed for each variable was also analyzed. Results: A total of 118 pitchers, 55 baseball-specific statistical metrics (38 basic
and 17 advanced), and 7.5 million pitches were included and analyzed. Of the
38 basic pitcher statistics, only fastball velocity demonstrated a CV <10
(CV = 1.5), while 6 of 17 (35%) advanced metrics demonstrated acceptable
consistency (CV <10). Release position from plate and velocity from the
plate were the 2 most consistent advanced parameters. When separated by
pitch type, these 2 parameters were the most constant (lowest CV) across
every pitch type. Conclusion: We recommend against utilizing nonvalidated statistical measures to assess
performance after injury, as they demonstrated unacceptably high variability
even among healthy, noninjured professional baseball pitchers. It is our
hope that this study will serve as the foundation for the identification and
implementation of validated pitcher-dependent statistical measures that can
be used to assess return-to-play performance after injury in the future.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad W Parkes
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexey A Leontovich
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stan Conte
- Conte Injury Analytics, San Carlos, California, USA
| | - John A Steubs
- TRIA Orthopaedic Center, Minneapolis, Minnesota, USA
| | - Corey A Wulf
- Minnesota Orthopedic Sports Medicine Institute, Twin Cities Orthopedics, Minneapolis, Minnesota, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Ko S, Pareek A, Jo C, Han HS, Lee MC, Krych AJ, Ro DH. Automated Risk Stratification of Hip Osteoarthritis Development in Patients With Femoroacetabular Impingement Using an Unsupervised Clustering Algorithm: A Study From the Rochester Epidemiology Project. Orthop J Sports Med 2021; 9:23259671211050613. [PMID: 34778477 PMCID: PMC8573500 DOI: 10.1177/23259671211050613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Studies evaluating the natural history of femoroacetabular impingement (FAI) are limited. Purpose: To stratify the risk of progression to osteoarthritis (OA) in patients with FAI using an unsupervised machine-learning algorithm, compare the characteristics of each subgroup, and validate the reproducibility of staging. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: A geographic database from the Rochester Epidemiology Project was used to identify patients with hip pain between 2000 and 2016. Medical charts were reviewed to obtain characteristic information, physical examination findings, and imaging details. The patient data were randomly split into 2 mutually exclusive sets: train set (70%) for model development and test set (30%) for validation. The data were transformed via Uniform Manifold Approximation and Projection and were clustered using Hierarchical Density-based Spatial Clustering of Applications with Noise. Results: The study included 1071 patients with a mean follow-up period of 24.7 ± 12.5 years. The patients were clustered into 5 subgroups based on train set results: patients in cluster 1 were in their early 20s (20.9 ± 9.6 years), female dominant (84%), with low body mass index (<19
); patients in cluster 2 were in their early 20s (22.9 ± 6.7 years), female dominant (95%), and pincer-type FAI (100%) dominant; patients in cluster 3 were in their mid 20s (26.4 ± 9.7) and were mixed-type FAI dominant (92%); patients in cluster 4 were in their early 30s (32.7 ± 7.8), with high body mass index (≥29
), and diabetes (17%); and patients in cluster 5 were in their early 30s (30.0 ± 9.1), with a higher percentage of males (43%) compared with the other clusters and with limited internal rotation (14%). Mean survival for clusters 1 to 5 was 17.9 ± 0.6, 18.7 ± 0.3, 17.1 ± 0.4, 15.0 ± 0.5, and 15.6 ± 0.5 years, respectively, in the train set. The survival difference was significant between clusters 1 and 4 (P = .02), 2 and 4 (P < .005), 2 and 5 (P = .01), and 3 and 4 (P < .005) in the train set and between clusters 2 and 5 (P = .03) and 3 and 4 (P = .01) in the test set. Cluster characteristics and prognosis was well reproduced in the test set. Conclusion: Using the clustering algorithm, it was possible to determine the prognosis for OA progression in patients with FAI in the presence of conflicting risk factors acting in combination.
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Affiliation(s)
- Sunho Ko
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Changwung Jo
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
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Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA .,Department of Orthopaedic Surgery, CentraCare Health System, St Cloud, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.,Sports Medicine Center, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Hilal Maradit Kremers
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway
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48
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Barras LA, Pareek A, Parkes CW, Song BM, Camp CL, Saris DBF, Stuart MJ, Krych AJ. Post-arthroscopic Subchondral Insufficiency Fractures of the Knee Yield High Rate of Conversion to Arthroplasty. Arthroscopy 2021; 37:2545-2553. [PMID: 33774060 DOI: 10.1016/j.arthro.2021.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate both the potential causes and resultant outcomes in patients in whom subchondral insufficiency fracture of the knee (SIFK) develops after arthroscopy. METHODS We performed a retrospective review of all patients with a magnetic resonance imaging diagnosis of SIFK after arthroscopic meniscectomy and chondroplasty over a 12-year period. RESULTS A total of 28 patients were included, with a mean age of 61 years and mean follow-up period of 5.7 years. SIFK showed a predilection for the medial compartment (n = 25, 89%), specifically the medial femoral condyle (n = 21, 75%). In 7 patients (25%), SIFK developed in both the femoral condyle and tibial plateau in the ipsilateral compartment. Fifteen patients (54%) went on to conversion to arthroplasty at a mean of 0.72 years. The rate of survival free of conversion to arthroplasty was 57%, 45%, and 40% at 1 year, 2 years, and 5 years, respectively. Furthermore, 63% of patients with a meniscal tear and SIFK in the same compartment went on to arthroplasty (P = .04). There was an increased risk of conversion to arthroplasty if SIFK was present in both the femur and tibia in the same compartment (P = .04). A higher Kellgren-Lawrence grade at the time of the SIFK diagnosis increased the likelihood of eventual arthroplasty (P = .03). The presence of SIFK in both the femur and tibia in the ipsilateral compartment, an increased Kellgren-Lawrence grade, and a meniscal tear or prior meniscectomy in the same compartment as SIFK were associated with an increased risk of eventual arthroplasty. CONCLUSIONS Post-arthroscopic SIFK most commonly occurs in the medial compartment, particularly in patients who underwent a prior meniscectomy. The presence of meniscal root and radial tears in these patients is notable (75%). Ultimately, there is a high rate of progression of arthrosis (33%) and eventual conversion to arthroplasty. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Laurel A Barras
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Chad W Parkes
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bryant M Song
- 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
| | - Daniel B F Saris
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A..
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49
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Abstract
Many different techniques with multiple graft types have been described for the reconstruction of the injured posterior cruciate ligament (PCL); autograft versus allograft, single- versus double-bundle, open inlay versus arthroscopic inlay versus arthroscopic transtibial, and recently described the arthroscopic "all-inside" socket technique. Reported clinical outcomes have demonstrated no significant difference in any of these PCL reconstruction techniques, likely because of the heterogeneity in injury characteristics and patient population. The ideal surgical technique should be safe, simple, and reproducible while allowing treatment of concomitant knee injuries resulting and return to function.
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Affiliation(s)
- Erik Therrien
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ayoosh Pareek
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bryant M Song
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan R Wilbur
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Stuart
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce A Levy
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota
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50
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Zarifkar P, Kamath A, Robinson C, Morgulchik N, Shah SFH, Cheng TKM, Dominic C, Fehintola AO, Bhalla G, Ahillan T, Mourgue d'Algue L, Lee J, Pareek A, Carey M, Hughes DJ, Miller M, Woodcock VK, Shrotri M. Clinical Characteristics and Outcomes in Patients with COVID-19 and Cancer: a Systematic Review and Meta-analysis. Clin Oncol (R Coll Radiol) 2021; 33:e180-e191. [PMID: 33261978 PMCID: PMC7674130 DOI: 10.1016/j.clon.2020.11.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 01/08/2023]
Abstract
Much of routine cancer care has been disrupted due to the perceived susceptibility to SARS-CoV-2 infection in cancer patients. Here, we systematically review the current evidence base pertaining to the prevalence, presentation and outcome of COVID-19 in cancer patients, in order to inform policy and practice going forwards. A keyword-structured systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 in cancer patients. Studies were critically appraised using the NIH National Heart, Lung and Blood Institute's quality assessment tool set. The pooled prevalence of cancer as a co-morbidity in patients with COVID-19 and pooled in-hospital mortality risk of COVID-19 in cancer patients were derived by random-effects meta-analyses. In total, 110 studies from 10 countries were included. The pooled prevalence of cancer as a co-morbidity in hospitalised patients with COVID-19 was 2.6% (95% confidence interval 1.8%, 3.5%, I2: 92.0%). Specifically, 1.7% (95% confidence interval 1.3%, 2.3%, I2: 57.6.%) in China and 5.6% (95% confidence interval 4.5%, 6.7%, I2: 82.3%) in Western countries. Patients most commonly presented with non-specific symptoms of fever, dyspnoea and chest tightness in addition to decreased arterial oxygen saturation, ground glass opacities on computer tomography and non-specific changes in inflammatory markers. The pooled in-hospital mortality risk among patients with COVID-19 and cancer was 14.1% (95% confidence interval 9.1%, 19.8%, I2: 52.3%). We identified impeding questions that need to be answered to provide the foundation for an iterative review of the developing evidence base, and inform policy and practice going forwards. Analyses of the available data corroborate an unfavourable outcome of hospitalised patients with COVID-19 and cancer. Our findings encourage future studies to report detailed social, demographic and clinical characteristics of cancer patients, including performance status, primary cancer type and stage, as well as a history of anti-cancer therapeutic interventions.
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Affiliation(s)
- P Zarifkar
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.
| | - A Kamath
- Faculty of Medicine, University of Oxford, Medical Sciences Divisional Office, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - C Robinson
- Faculty of Medicine, University of Oxford, Medical Sciences Divisional Office, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - N Morgulchik
- Imperial College London, Department of Chemistry, Molecular Sciences Research Hub, London, UK
| | - S F H Shah
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - T K M Cheng
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - C Dominic
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - A O Fehintola
- College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - G Bhalla
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - T Ahillan
- University College London Medical School, London, UK
| | | | - J Lee
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - A Pareek
- Department of Radiology Stanford University School of Medicine, Stanford, California, USA
| | - M Carey
- Department of Palliative Care Oxford University Hospitals NHS Foundation Trust, Sobell House Hospice, Churchill Hospital, Oxford, UK
| | - D J Hughes
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - M Miller
- Department of Palliative Care Oxford University Hospitals NHS Foundation Trust, Sobell House Hospice, Churchill Hospital, Oxford, UK
| | - V K Woodcock
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - M Shrotri
- London School of Hygiene & Tropical Medicine, London, UK
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