Patients With Femoral Neck Fractures Are at Risk for Conversion to Arthroplasty After Internal Fixation: A Machine‐learning Algorithm. Issue 12 (21st December 2022)

• Record Type: Journal Article
• Authors: van de Kuit, Anouk; Oosterhoff, Jacobien H. F.; Dijkstra, Hidde; Sprague, Sheila; Bzovsky, Sofia; Bhandari, Mohit; Swiontkowski, Marc; Schemitsch, Emil H.; IJpma, Frank F. A.; Poolman, Rudolf W.; Doornberg, Job N.; Hendrickx, Laurent A. M.
• Other Names: Bhandari Mohit author non-byline.; Bulstra Anne Eva J. author non-byline.; Bzovsky Sofia author non-byline.; Doornberg Job N. author non-byline.; Goslings J. Carel author non-byline.; Hendrickx Laurent A.M. author non-byline.; Jaarsma Ruurd L. author non-byline.; Jeray Kyle J. author non-byline.; Kerkhoffs Gino M.M.J. author non-byline.; Oosterhoff Jacobien H.F. author non-byline.; Petrisor Brad author non-byline.; Ring David author non-byline.; Schemitsch Emil H. author non-byline.; Swiontkowski Marc author non-byline.; Sanders David author non-byline.; Sprague Sheila author non-byline.; Tornetta Paul author non-byline.; Walter Stephen D. author non-byline.; Bhandari Mohit author non-byline.; Devereaux PJ author non-byline.; Guyatt Gordon author non-byline.; Thabane Lehana author non-byline.; Walter Stephen D. author non-byline.; Heetveld Martin J. author non-byline.; Jeray Kyle J. author non-byline.; Liew Susan author non-byline.; Schemitsch Emil H. author non-byline.; Tornetta Paul author non-byline.; Della Rocca Gregory J. author non-byline.; Buckley Richard E. author non-byline.; McCormack Robert author non-byline.; Oliver Todd M. author non-byline.; Segers Michiel J.M. author non-byline.; Rangan Amar author non-byline.; Richardson Martin author non-byline.; Sprague Sheila author non-byline.; Slobogean Gerard P. author non-byline.; Scott Taryn author non-byline.; Agel Julie author non-byline.; Garibaldi Alisha author non-byline.; Zhou Qi author non-byline.; Heels-Ansdell Diane author non-byline.; Viveiros Helena author non-byline.; Zielinski Stephanie M. author non-byline.; Van Lieshout Esther M.M. author non-byline.; Johal Herman author non-byline.; Hanusch Birgit C. author non-byline.; Swiontkowski Marc author non-byline.; Bhandari Mohit author non-byline.; Swiontkowski Marc author non-byline.; Devereaux PJ author non-byline.; Guyatt Gordon author non-byline.; Heetveld Martin J. author non-byline.; Jeray Kyle author non-byline.; Liew Susan author non-byline.; Richardson Martin author non-byline.; Schemitsch Emil H. author non-byline.; Thabane Lehana author non-byline.; Tornetta Paul author non-byline.; Walter Stephen D. author non-byline.; Bhandari Mohit author non-byline.; Sprague Sheila author non-byline.; McKay Paula author non-byline.; Scott Taryn author non-byline.; Garibaldi Alisha author non-byline.; Viveiros Helena author non-byline.; Swinton Marilyn author non-byline.; Gichuru Mark author non-byline.; Bzovsky Sofia author non-byline.; Heels-Ansdell Diane author non-byline.; Zhou Qi author non-byline.; Buckingham Lisa author non-byline.; Duraikannan Aravin author non-byline.; Maddock Deborah author non-byline.; Simunovic Nicole author non-byline.; Swiontkowski Marc author non-byline.; Agel Julie author non-byline.; Heetveld Martin J. author non-byline.; M.M Esther author non-byline.; Lieshout Van author non-byline.; Zielinski Stephanie M. author non-byline.; Rangan Amar author non-byline.; Hanusch Birgit C. author non-byline.; Kottam Lucksy author non-byline.; Clarkson Rachel author non-byline.; Della Rocca Gregory J. author non-byline.; Haverlag Robert author non-byline.; Liew Susan author non-byline.; Slobogean Gerard P. author non-byline.; Jeray Kyle author non-byline.;
• Is Part Of: Clinical orthopaedics and related research. Volume 480:Issue 12(2022)
• Page Start: 2350
• Page End: 2360
• Publication Date: 2022-12-21
• Subjects: Orthopedic surgery -- Periodicals; Orthopedics -- Periodicals; Orthopedics -- Research -- Periodicals; Orthopedics -- Periodicals; Research -- Periodicals; Chirurgie orthopédique -- Périodiques; 616.7005
• DOI: 10.1097/CORR.0000000000002283
• Languages: English
• ISSNs: 0009-921X

Abstract

Abstract: Background: Femoral neck fractures are common and are frequently treated with internal fixation. A major disadvantage of internal fixation is the substantially high number of conversions to arthroplasty because of nonunion, malunion, avascular necrosis, or implant failure. A clinical prediction model identifying patients at high risk of conversion to arthroplasty may help clinicians in selecting patients who could have benefited from arthroplasty initially. Question/purpose: What is the predictive performance of a machine‐learning (ML) algorithm to predict conversion to arthroplasty within 24 months after internal fixation in patients with femoral neck fractures? Methods: We included 875 patients from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial. The FAITH trial consisted of patients with low-energy femoral neck fractures who were randomly assigned to receive a sliding hip screw or cancellous screws for internal fixation. Of these patients, 18% (155 of 875) underwent conversion to THA or hemiarthroplasty within the first 24 months. All patients were randomly divided into a training set (80%) and test set (20%). First, we identified 27 potential patient and fracture characteristics that may have been associated with our primary outcome, based on biomechanical rationale and previous studies. Then, random forest algorithms (an ML learning, decision tree–based algorithm that selects variables) identified 10 predictors of conversion: BMI, cardiac disease, Garden classification, use of cardiac medication, use of pulmonary medication, age, lung disease, osteoarthritis, sex, and the level of the fracture line. Based on these variables, five different ML algorithms were trained to identify patterns related to conversion. The predictive performance of these trained ML algorithms was assessed on the training and test sets based on the following performance measures: (1) discrimination (the model's ability to distinguish patients who had conversion from those who did not; expressed with the area under the receiver operating characteristic curve [AUC]), (2) calibration (the plotted estimated versus the observed probabilities; expressed with the calibration curve intercept and slope), and (3) the overall model performance (Brier score: a composite of discrimination and calibration). Results: None of the five ML algorithms performed well in predicting conversion to arthroplasty in the training set and the test set; AUCs of the algorithms in the training set ranged from 0.57 to 0.64, slopes of calibration plots ranged from 0.53 to 0.82, calibration intercepts ranged from -0.04 to 0.05, and Brier scores ranged from 0.14 to 0.15. The algorithms were further evaluated in the test set; AUCs ranged from 0.49 to 0.73, calibration slopes ranged from 0.17 to 1.29, calibration intercepts ranged from -1.28 to 0.34, and Brier scores ranged from 0.13 to 0.15. Conclusion: The predictive performance of the trained algorithms was poor, despite the use of one of the best datasets available worldwide on this subject. If the current dataset consisted of different variables or more patients, the performance may have been better. Also, various reasons for conversion to arthroplasty were pooled in this study, but the separate prediction of underlying pathology (such as, avascular necrosis or nonunion) may be more precise. Finally, it may be possible that it is inherently difficult to predict conversion to arthroplasty based on preoperative variables alone. Therefore, future studies should aim to include more variables and to differentiate between the various reasons for arthroplasty. Level of Evidence: Level III, prognostic study.