INTRODUCTION: Non-union can be defined as the lack of consolidation of a fracture, after the definitive treatment, within the time usually needed for that specific skeletal part. The burden of disease on the patient is remarkable, as well as the costs for the National Healthcare System, considering the incidence rate of non-union. Being able to predict which fractures are more likely to incur in this complication is fundamental, for both the orthopaedical surgeon and the patient. The former could undertake early interventions to make sure the disease does not occur, whilst the latter would better tolerate a long healing period and the need for further surgical treatments, where required, given his awareness of the gravity and the poor prognosis of his lesion. We’ve fortunately been having, for some years, many risk scores, whose purpose is to predict non-union; about lower limb fractures, we now have FRACTING SCORE, LEG-NUI and NURD SCORE. We aim to compare them in order to establish which one is the most accurate and reliable in predicting tibial non-unions in adults. MATERIALS AND METHODS: We enrolled 110 adult patients suffering from tibial shaft fracture (AO classification 41-A e -B, 42-A, -B, -C, e 43-A), who underwent intramedullary nailing as definitive treatment. Patients were treated at the Orthopaedical Clinic in “A.O.U Ospedali Riuniti di Ancona”, at “A.O. Marche Nord” and at “Carlo Urbani” hospital in Jesi. For each of them we retrospectively calculated FRACTING score, LEG-NUI and NURD, and radiographically evaluated the healing of the fracture at a time of 6 months since the nailing. Those who didn’t fulfill the consolidation criteria at that time where considered as non-unions. Thanks to logistic regression we developed a model to predict union or non-union for each patient, basing on the class of each score, age and sex. In this way we were able to compare the accuracy, the AUC (Area Under the Curve) and the statistical confidence values reached for each score. RESULTS: The highest accuracy was reached by FRACTING (75.83%) vs LEG-NUI (70.83%) and NURD (70.83%); the largest AUC belongs to FRACTING as well (0.780), while both LEG-NUI and NURD record 0.688. The highest value for statistical confidence was reached by FRACTING (0.953), against LEG-NUI (0.801) and NURD (0.534) CONCLUSIONS: Our predictive model shows the superiority of FRACTING on both LEG-NUI and NURD as regards accuracy and reliability. LEG-NUI shows the same accuracy of NURD, but a better reliability. We suggest the use of FRACTING in daily clinical decision-making, in order to obtain the greatest benefit for the patient.
INTRODUZIONE: La pseudoartrosi (o non-union) è definibile come la mancata consolidazione di una frattura scheletrica entro i tempi previsti, per sede e tipologia, successivamente al trattamento definitivo. Complicanza tutt’altro che infrequente, grava in maniera importante sullo stato di salute psicofisico di chi ne è affetto e sui costi del Sistema Sanitario Nazionale. Conoscere in anticipo quali fratture possano andare incontro a tale destino è fondamentale, sia per il chirurgo ortopedico, che per il paziente. Per il primo, tale informazione consente di attuare precocemente interventi terapeutici specifici (sia invasivi che non), volti a favorire la guarigione della lesione e scongiurare l’insorgenza della malattia. Per il secondo, la consapevolezza di aver subito una lesione di grave entità e scarsa prognosi significa (almeno in teoria) una migliore accettazione di lunghi tempi di trattamento (ed eventuali reinterventi) e dell’eventualità di una mancata consolidazione, nonostante tutto. Fortunatamente, già da qualche anno esistono in letteratura medica alcuni scores di rischio, che consentono di effettuare una previsione circa lo sviluppo di pseudoartrosi. In questa opera, dopo aver esaminato l’aspetto diagnostico, classificativo, eziologico e terapeutico della pseudoartrosi, tramite uno studio retrospettivo sarà messa a confronto l’accuratezza e l’affidabilità di tre di questi scores (FRACTING, LEG-NUI e NURD), relativi alle fratture di tibia dell’adulto, trattate con chiodo endomidollare. MATERIALI E METODI: Abbiamo reclutato 110 pazienti maggiorenni con fratture della diafisi tibiale (tipologia AO 41-A e -B, 42-A, -B, -C, e 43-A) trattati con chiodo endomidollare. I pazienti coinvolti erano stati trattati presso la Clinica Ortopedica degli ospedali riuniti di Ancona, presso il reparto di Ortopedia dell’ospedale Marche Nord e dell’ospedale Carlo Urbani di Jesi. Per ciascuno, abbiamo retrospettivamente calcolato gli score FRACTING, LEG-NUI e NURD e valutato radiograficamente, sempre in maniera retrospettiva, la consolidazione della frattura o la presenza di pseudoartrosi a 6 mesi dall’osteosintesi definitiva. Tramite la metodica della regressione logistica abbiamo sviluppato un esempio di predizione per la comparsa di pseudoartrosi per ogni paziente. I parametri considerati erano la classe (per ciascuno score), il sesso e l’età. In tal modo è stato possibile confrontare l’accuratezza, l’area sotto le curve ROC ed il grado di confidence probabilistica raggiunto, per ciascuno score. RISULTATI: L’accuratezza maggiore è stata raggiunta con FRACTING (75.83%), al secondo posto a pari merito LEG-NUI e NURD (70.83%); la maggior AUC (area sotto la curva ROC) appartiene a FRACTING (0.780), mentre LEG-NUI e NURD fanno registrare entrambi il valore di 0.688. Il massimo valore di confidence probabilistica è stato raggiunto con FRACTING (0.953), mentre il massimo valore registrato per LEG-NUI è 0.801, mentre per NURD 0.534. CONCLUSIONI: Nel nostro modello predittivo FRACTING score ha mostrato la maggiore accuratezza, nonché la maggiore affidabilità prognostica. LEG-NUI e NURD si equivalgono per accuratezza, ma LEG-NUI presenta maggiori valori di confidence. E’ auspicabile che lo score FRACTING venga utilizzato routinariamente nel decision-making clinico per ottenere il massimo beneficio, per il chirurgo ortopedico e per il paziente.
Confronto tra scores predittivi per pseudoartrosi nelle fratture di tibia: uno studio retrospettivo multicentrico
MONTANARI, ALESSANDRO
2020/2021
Abstract
INTRODUCTION: Non-union can be defined as the lack of consolidation of a fracture, after the definitive treatment, within the time usually needed for that specific skeletal part. The burden of disease on the patient is remarkable, as well as the costs for the National Healthcare System, considering the incidence rate of non-union. Being able to predict which fractures are more likely to incur in this complication is fundamental, for both the orthopaedical surgeon and the patient. The former could undertake early interventions to make sure the disease does not occur, whilst the latter would better tolerate a long healing period and the need for further surgical treatments, where required, given his awareness of the gravity and the poor prognosis of his lesion. We’ve fortunately been having, for some years, many risk scores, whose purpose is to predict non-union; about lower limb fractures, we now have FRACTING SCORE, LEG-NUI and NURD SCORE. We aim to compare them in order to establish which one is the most accurate and reliable in predicting tibial non-unions in adults. MATERIALS AND METHODS: We enrolled 110 adult patients suffering from tibial shaft fracture (AO classification 41-A e -B, 42-A, -B, -C, e 43-A), who underwent intramedullary nailing as definitive treatment. Patients were treated at the Orthopaedical Clinic in “A.O.U Ospedali Riuniti di Ancona”, at “A.O. Marche Nord” and at “Carlo Urbani” hospital in Jesi. For each of them we retrospectively calculated FRACTING score, LEG-NUI and NURD, and radiographically evaluated the healing of the fracture at a time of 6 months since the nailing. Those who didn’t fulfill the consolidation criteria at that time where considered as non-unions. Thanks to logistic regression we developed a model to predict union or non-union for each patient, basing on the class of each score, age and sex. In this way we were able to compare the accuracy, the AUC (Area Under the Curve) and the statistical confidence values reached for each score. RESULTS: The highest accuracy was reached by FRACTING (75.83%) vs LEG-NUI (70.83%) and NURD (70.83%); the largest AUC belongs to FRACTING as well (0.780), while both LEG-NUI and NURD record 0.688. The highest value for statistical confidence was reached by FRACTING (0.953), against LEG-NUI (0.801) and NURD (0.534) CONCLUSIONS: Our predictive model shows the superiority of FRACTING on both LEG-NUI and NURD as regards accuracy and reliability. LEG-NUI shows the same accuracy of NURD, but a better reliability. We suggest the use of FRACTING in daily clinical decision-making, in order to obtain the greatest benefit for the patient.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/8368