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Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?

HYPOTHESIS: The aim of this study was to investigate the reproducibility, reliability, and accuracy of Mirels’ score in upper limb bony metastatic disease and validate its use in predicting pathologic fractures. METHODS: Forty-five patients with upper limb bony metastases met the inclusion criteria...

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Autores principales: Hoban, Katie A., Downie, Samantha, Adamson, Douglas J.A., MacLean, James G., Cool, Paul, Jariwala, Arpit C.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Elsevier 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264023/
https://www.ncbi.nlm.nih.gov/pubmed/35813136
http://dx.doi.org/10.1016/j.jseint.2022.03.006
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author Hoban, Katie A.
Downie, Samantha
Adamson, Douglas J.A.
MacLean, James G.
Cool, Paul
Jariwala, Arpit C.
author_facet Hoban, Katie A.
Downie, Samantha
Adamson, Douglas J.A.
MacLean, James G.
Cool, Paul
Jariwala, Arpit C.
author_sort Hoban, Katie A.
collection PubMed
description HYPOTHESIS: The aim of this study was to investigate the reproducibility, reliability, and accuracy of Mirels’ score in upper limb bony metastatic disease and validate its use in predicting pathologic fractures. METHODS: Forty-five patients with upper limb bony metastases met the inclusion criteria (62% male 28/45). The mean age was 69 years (SD 9.5), and the most common primaries were lung (29%, 13/45), followed by prostate and hematological (each 20%, 9/45). The most commonly affected bone was the humerus (76%, 35/45), followed by the ulna (6.5%, 3/45). Mirels’ score was calculated in 32 patients; with plain radiographs at index presentation scored using Mirels’ system by 6 raters. The radiological aspects (lesion size and appearance) were scored twice by each rater (2 weeks apart). Intraobserver and interobserver reliability were calculated using Fleiss’ kappa test. Bland-Altman plots compared the variances of both individual components and the total Mirels’ score. RESULTS: The overall fracture rate of upper limb metastatic lesions was 76% (35/46) with a mean follow-up of 3.6 years (range 11 months-6.8 years). Where time from diagnosis to fracture was known (n = 20), fractures occurred at a median 19 days (interquartile range 60-10), and 80% (16/20) occurred within 3 months of diagnosis. Mirels’ score of ≥9 did not accurately predict lesions that fractured (fracture rate 11%, 5/46, for Mirels’ ≥ 9 vs. 65%, 30/46, for Mirels’ ≤ 8, P < .001). Sensitivity was 14%, and specificity was 73%. When Mirels’ cutoff was lowered to ≥7, patients were more likely to fracture than not (48%, 22/46, vs. 28%, 13/46, P = .045); sensitivity rose to 63%, but specificity fell to 55%. Kappa values for interobserver variability were κ = 0.358 (fair, 95% confidence interval [CI] 0.288-0.429) for lesion size, κ = 0.107 (poor, 95% CI 0.02-0.193) for radiological appearance, and κ = 0.274 (fair, 95% CI 0.229-0.318) for total Mirels’ score. Values for intraobserver variability were κ = 0.716 (good, 95% CI 0.432-0.999) for lesion size, κ = 0.427 (moderate, 95% CI 0.195-0.768) for radiological appearance, and κ = 0.580 (moderate, 95% CI 0.395-0.765) for total Mirels’ score. CONCLUSIONS: This study demonstrates moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. However, Mirels’ score had a poor sensitivity and specificity in predicting upper extremity fractures. Until a more valid scoring system has been developed, based on our study, we recommend a Mirels’ threshold of ≥7/12 for considering prophylactic fixation of impending upper limb pathologic fractures. This contrasts with the current ≥9/12 cutoff, which is recommended for lower limb pathologic fractures.
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spelling pubmed-92640232022-07-09 Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation? Hoban, Katie A. Downie, Samantha Adamson, Douglas J.A. MacLean, James G. Cool, Paul Jariwala, Arpit C. JSES Int Shoulder HYPOTHESIS: The aim of this study was to investigate the reproducibility, reliability, and accuracy of Mirels’ score in upper limb bony metastatic disease and validate its use in predicting pathologic fractures. METHODS: Forty-five patients with upper limb bony metastases met the inclusion criteria (62% male 28/45). The mean age was 69 years (SD 9.5), and the most common primaries were lung (29%, 13/45), followed by prostate and hematological (each 20%, 9/45). The most commonly affected bone was the humerus (76%, 35/45), followed by the ulna (6.5%, 3/45). Mirels’ score was calculated in 32 patients; with plain radiographs at index presentation scored using Mirels’ system by 6 raters. The radiological aspects (lesion size and appearance) were scored twice by each rater (2 weeks apart). Intraobserver and interobserver reliability were calculated using Fleiss’ kappa test. Bland-Altman plots compared the variances of both individual components and the total Mirels’ score. RESULTS: The overall fracture rate of upper limb metastatic lesions was 76% (35/46) with a mean follow-up of 3.6 years (range 11 months-6.8 years). Where time from diagnosis to fracture was known (n = 20), fractures occurred at a median 19 days (interquartile range 60-10), and 80% (16/20) occurred within 3 months of diagnosis. Mirels’ score of ≥9 did not accurately predict lesions that fractured (fracture rate 11%, 5/46, for Mirels’ ≥ 9 vs. 65%, 30/46, for Mirels’ ≤ 8, P < .001). Sensitivity was 14%, and specificity was 73%. When Mirels’ cutoff was lowered to ≥7, patients were more likely to fracture than not (48%, 22/46, vs. 28%, 13/46, P = .045); sensitivity rose to 63%, but specificity fell to 55%. Kappa values for interobserver variability were κ = 0.358 (fair, 95% confidence interval [CI] 0.288-0.429) for lesion size, κ = 0.107 (poor, 95% CI 0.02-0.193) for radiological appearance, and κ = 0.274 (fair, 95% CI 0.229-0.318) for total Mirels’ score. Values for intraobserver variability were κ = 0.716 (good, 95% CI 0.432-0.999) for lesion size, κ = 0.427 (moderate, 95% CI 0.195-0.768) for radiological appearance, and κ = 0.580 (moderate, 95% CI 0.395-0.765) for total Mirels’ score. CONCLUSIONS: This study demonstrates moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. However, Mirels’ score had a poor sensitivity and specificity in predicting upper extremity fractures. Until a more valid scoring system has been developed, based on our study, we recommend a Mirels’ threshold of ≥7/12 for considering prophylactic fixation of impending upper limb pathologic fractures. This contrasts with the current ≥9/12 cutoff, which is recommended for lower limb pathologic fractures. Elsevier 2022-04-25 /pmc/articles/PMC9264023/ /pubmed/35813136 http://dx.doi.org/10.1016/j.jseint.2022.03.006 Text en © 2022 Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
spellingShingle Shoulder
Hoban, Katie A.
Downie, Samantha
Adamson, Douglas J.A.
MacLean, James G.
Cool, Paul
Jariwala, Arpit C.
Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title_full Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title_fullStr Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title_full_unstemmed Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title_short Mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
title_sort mirels’ score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?
topic Shoulder
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264023/
https://www.ncbi.nlm.nih.gov/pubmed/35813136
http://dx.doi.org/10.1016/j.jseint.2022.03.006
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