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Prognostic nomogram did not determine surgical management for posterior wall fractures
Positive predictive value was not clinically useful for THA or the overall unsatisfactory clinical result.
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Acetabular fracture prognostic nomogram did not provide sufficient information to predict outcomes after open reduction and internal fixation or determine appropriate surgical management for posterior wall fractures, according to a study.
“You cannot rely exclusively on this nomogram to determine the treatment for posterior wall fractures,” Berton R. Moed, MD, chairman of the Department of Orthopedic Surgery at St. Louis University School of Medicine, told Orthopedics Today. “The indicators used in this nomogram make sense, but when you turn it around and try to actually use it to give an indication of what is going to happen to the hip joint with open reduction and internal fixation, based on this nomogram, it is no better than chance.”
Acetabular fracture nomogram
Moed and his colleagues calculated a percent risk of requiring reconstructive hip surgery within 2 years of open reduction and internal fixation (ORIF) for 103 patients with consecutive acute posterior wall fractures using an acetabular fracture nomogram with data obtained from the original injury radiographs and intraoperative findings. Main outcome measures included comparison of the percent risk to the actual clinical outcome within 2 years after ORIF measured by total hip arthroplasty (THA) performed and overall unsatisfactory hip function, as determined by the modified Merle d’Aubigné score.
According to the receiver operating characteristic curve analysis, the optimal predictor of either THA within 2 years or an overall unsatisfactory clinical result was a low cut-point risk score of 16%. Researchers found 16 patients who matched or exceeded this score. Of these, four underwent THA within 2 years while seven had an unsatisfactory clinical result. Although researchers noted a sensitivity of 0.78 and a specificity of 0.90 for undergoing THA within 2 years and unsatisfactory clinical results, the positive predictive value was not clinically useful at 0.25 for THA and 0.44 for the overall unsatisfactory clinical result with chance being 0.50.
“If you thought using this [nomogram] as a prognostic tool was going to be able to dictate your treatment, it does not, so you should not rely on it,” Moed said. “I think this information is important clinically, especially now when [there] is a general feeling that total joint arthroplasty could be the better way to go for these patients, as it would save a treatment step.”
Experience, expertise
Moed said he was not surprised the nomogram did not help determine the appropriate treatment for posterior wall fractures.
He added, “I did [this study] because I was concerned that propagation of the nomogram could result in more emphasis on a knee-jerk reaction to the treatment of these fractures rather than careful analysis to determine treatment. [I] think [this study] is a restatement of what we already know, that these [posterior wall fractures] are bad fractures and you need experience and expertise in order to get the best result.” – by Casey Tingle
- Reference:
- Moed BR, et al. J Orthop Trauma. 2016;doi:10.1097/BOT.0000000000000480.
- For more information:
- Berton R. Moed, MD, can be reached at the Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Ave., 7th Fl. Desloge Towers, St. Louis, MO 63110; email: moedbr@slu.edu.
Disclosure: Moed reports no relevant financial disclosures.