Inter- and intra-observer variation in classification systems for impending fractures of bone metastases

El-Husseiny, M; Coleman, Nigel

doi:10.1007/s00256-009-0823-6

Cited by 26 publications

(15 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…All of the six fractures occurred within 4 months of the CTRA evaluation and were correctly predicted by CTRA reductions of C 35% and all had Mirels scores C 8 points (8,8,10,12,12,12). Five of the six fractures occurred through lytic proximal femoral lesions and one through a diaphyseal mixed lesion.…”

Section: Methodsmentioning

confidence: 88%

“…Hence, up to two-thirds of patients predicted as being at increased risk by Mirels criteria do not fracture and potentially receive unnecessary surgery. Other studies suggest Mirels is less predictive than other criteria but agree that a more specific predictor accounting for comorbidities and prognosis is needed [10,29]. Although finite element modeling has been used successfully for accurate fracture risk prediction in the laboratory, it has yet to be applied in human subjects and suffers from the potential to be a cumbersome, slow means of evaluation for individual patients in real time [18,22].…”

Section: Discussionmentioning

confidence: 99%

“…Classically, this determination has been based on the clinician's assessment of the plain radiographs, but these criteria have proven lacking in both sensitivity and specificity [1-4, 6, 8, 9, 12-15, 17, 25, 28-30]. Although Mirels criteria (also based on plain radiographs) have improved sensitivity of fracture prediction in the appendicular skeleton, specificity has remained poor [5,6,10,11,21,23,24]. Hence, highly sensitive and more specific criteria are needed for the evaluation of long bone lesions at potential risk for fracture in the setting of disseminated malignancy.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions

Damron

Nazarian

Entezari

et al. 2016

Clinical Orthopaedics &Amp; Related Research

View full text Add to dashboard Cite

Background Controversy continues regarding the appropriate assessment of fracture risk in long bone lesions affected by disseminated malignancy. Questions/purposes The purpose of this ongoing Musculoskeletal Tumor Society-sponsored, multi-institutional prospective cross-sectional clinical study is to compare CT-based structural rigidity analysis (CTRA) with physician-derived Mirels scoring for predicting pathologic fracture in femoral bone lesions. We hypothesized CTRA would be superior to Mirels in predicting fracture risk within the first year based on (1) sensitivity, specificity, positive predictive value, and negative predictive value; (2) receiver operator characteristic (ROC) analysis; and (3) fracture prediction after controlling for potential confounding variables such as age and lesion size. Methods Consented patients with femoral metastatic lesions were assigned Mirels scores by the individual enrolling orthopaedic oncologist based on plain radiographs and then underwent CT scans of both femurs with a phantom of known density. The CTRA was then performed. Between 2004 and 2008, six study centers performed CTRA on 125 patients. The general indications for this test were femoral metastatic lesions potentially at risk of fracture. The enrolling physician was allowed the choice of prophylactic stabilization or nonsurgical treatment, and the local treating oncology team along with the patient made this decision. Of those 125 patients, 78 (62%) did not undergo prophylactic stabilization and had followup sufficient for inclusion, which was fracture through the lesion within 12 months of CTRA, death within 12 months of CTRA, or 12-month survival after CTRA without fracture, whereas 15 (12%) were lost to followup and could not be studied here. The mean patient age was 61 years (SD, 14 years). There were 46 women. Sixtyfour of the lesions were located in the proximal femur, 13 Clin Orthop Relat Res (2016) 474:643-651 DOI 10.1007/s11999-015-4453-0 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons®were in the diaphysis, and four were distal. Osteolytic lesions prevailed (48 lesions) over mixed (31 lesions) and osteoblastic (15 lesions). The most common primary cancers were breast (25 lesions), lung (14 lesions), and myeloma (11 lesions). CTRA was compared with Mirels based on sensitivity/specificity analysis, ROC, and fracture prediction by multivariate analysis. For the CTRA, reduction greater than 35% in axial, bending, or torsional rigidities at the lesion was considered at risk for fracture, whereas a Mirels score of 9 or above, as suggested in the original manuscript, was used as the definition of impending fracture. Results CTRA provided higher sensitivity (100% versus 66.7%), specificity (60.6% versus 47.9%), positive predictive value (17.6% versus 9.8%), and negative predictive value (100% versus 94.4%) compared with the classic Mirels definition of impending fracture (C 9), although there was considerable overlap in the confidence intervals. ...

show abstract

Section: Methodsmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions

Damron

Nazarian

Entezari

et al. 2016

Clinical Orthopaedics &Amp; Related Research

View full text Add to dashboard Cite

show abstract

“…However, there is little consensus regarding the most appropriate method to assess risk of fracture in this patient population and treatment planning is subject to high variability between medical specialties [4]. The Mirels' score is the most popular method to determine risk of fracture in metastatic bone disease.…”

Section: Discussionmentioning

confidence: 99%

Does CT-based Rigidity Analysis Influence Clinical Decision-making in Simulations of Metastatic Bone Disease?

Nazarian

Entezari

Villa-Camacho

et al. 2016

Clinical Orthopaedics &Amp; Related Research

View full text Add to dashboard Cite

Background There is a need to improve the prediction of fracture risk for patients with metastatic bone disease. CTbased rigidity analysis (CTRA) is a sensitive and specific method, yet its influence on clinical decision-making has never been quantified. Questions/purposes What is the influence of CTRA on providers' perceived risk of fracture? (2) What is the influence of CTRA on providers' treatment recommendations in simulated clinical scenarios of metastatic bone disease of the femur? (3) Does CTRA improve interobserver agreement regarding treatment recommendations? Methods We conducted a survey among 80 academic physicians (orthopaedic oncologists, musculoskeletal radiologists, and radiation oncologists) using simulated vignettes of femoral lesions presented as three separate scenarios: (1) no CTRA input (baseline); (2) CTRA input suggesting increased risk of fracture (CTRA+); and (3) CTRA input suggesting decreased risk of fracture (CTRAÀ). Participants were asked to rate the patient's risk of fracture on a scale of 0% to 100% and to provide a treatment recommendation. Overall response rate was 62.5% (50 of 80). Results When CTRA suggested an increased risk of fracture, physicians perceived the fracture risk to be slightly greater (37% ± 3% versus 42% ± 3%, p \ 0.001; mean difference [95% confidence interval {CI}] = 5% [4.7%-5.2%]) and were more prone to recommend surgical stabilization (46% ± 9% versus 54% ± 9%, p \ 0. suggested a decreased risk of fracture, physicians perceived the risk to be slightly decreased (37% ± 25% versus 35% ± 25%, p = 0.04; mean difference [95% CI] = 2% [2.74%-2.26%]) and were less prone to recommend surgical stabilization (46% ± 9% versus 42% ± 9%, p \ 0.03; mean difference [95% CI] = 4% [3.9-5.1]). The effect size of the influence of CTRA on physicians' perception of fracture risk and treatment planning varied with lesion severity and specialty of the responders. CTRA did not increase interobserver agreement regarding treatment recommendations when compared with the baseline scenario (j = 0.41 versus j = 0.43, respectively). Conclusions Based on this survey study, CTRA had a small influence on perceived fracture risk and treatment recommendations and did not increase interobserver agreement. Further work is required to properly introduce this technique to physicians involved in the care of patients with metastatic lesions. Given the number of preclinical and clinical studies outlining the efficacy of this technique, better education through presentations at seminars/webinars and symposia will be the first step. This should be followed by clinical trials to establish CTRA-based clinical guidelines based on evidence-based medicine. Increased exposure of clinicians to CTRA, including its underlying methodology to study bone structural characteristics, may establish CTRA as a uniform guideline to assess fracture risk. Level of Evidence Level III, economic and decision analyses.

show abstract

“…As an alternative to existing methods, Van der Linden et al proposed an approach based on axial cortical involvement, the accuracy of which was further demonstrated in a randomized trial [13]. There are also conflicting data on reproducibility and reliability of the results obtained from different specialties [14] and anatomical sites [15], further emphasizing the need for a more accurate clinical tool to assess fracture risk in the presence of metastatic lesions.…”

Section: Introductionmentioning

confidence: 99%

Finite element analysis and CT-based structural rigidity analysis to assess failure load in bones with simulated lytic defects

Anez‐Bustillos¹,

Derikx²,

Calderon³

et al. 2014

Bone

View full text Add to dashboard Cite

There is an urgent need to improve the prediction of fracture risk for cancer patients with bone metastases. Pathological fractures that result from these tumors frequently occur in the femur. It is extremely difficult to determine the fracture risk even for experienced physicians. Although evolving, fracture risk assessment is still based on inaccurate predictors estimated from previous retrospective studies. As a result, many patients are surgically over-treated, whereas other patients may fracture their bones against expectations. We mechanically tested ten pairs of human cadaveric femurs to failure, where one of each pair had an artificial defect simulating typical metastatic lesions. Prior to testing, finite element (FE) models were generated and computed tomography rigidity analysis (CTRA) was performed to obtain axial and bending rigidity measurements. We compared the two techniques on their capacity to assess femoral failure load by using linear regression techniques, Student's t tests, the Bland-Altman methodology and Kendall rank correlation coefficients. The simulated FE failure loads and CTRA predictions showed good correlation with values obtained from the experimental mechanical testing. Kendall rank correlation coefficients between the FE rankings and the CTRA rankings showed moderate to good correlations. No significant differences in prediction accuracy were found between the two methods. Non-invasive fracture risk assessment techniques currently developed both correlated well with actual failure loads in mechanical testing suggesting that both methods could be further developed into a tool that can be used in clinical practice. The results in this study showed slight differences between the methods, yet validation in prospective patient studies should confirm these preliminary findings.

show abstract

Inter- and intra-observer variation in classification systems for impending fractures of bone metastases

Cited by 26 publications

References 11 publications

CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions

CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions

Does CT-based Rigidity Analysis Influence Clinical Decision-making in Simulations of Metastatic Bone Disease?

Finite element analysis and CT-based structural rigidity analysis to assess failure load in bones with simulated lytic defects

Contact Info

Product

Resources

About