Schwartz Michael H, Georgiadis Andrew G
Orthopedic Surgery, University of Minnesota - Twin Cities, Minneapolis, United States of America.
Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, United States of America.
PLoS One. 2025 Jul 29;20(7):e0328036. doi: 10.1371/journal.pone.0328036. eCollection 2025.
Clinical gait analysis (CGA) has historically relied on clinician experience and judgment, leading to modest, stagnant, and unpredictable outcomes. This paper introduces Evidence-Based Gait Analysis Interpretation Tools (EB-GAIT), a novel framework leveraging machine learning to support treatment decisions. The core of EB-GAIT consists of two key components: (1) treatment recommendation models, which are models that estimate the probability of specific surgeries based on historical standard-of-practice (SOP), and (2) treatment outcome models, which predict changes in patient characteristics following treatment or natural history. Using Bayesian Additive Regression Trees (BART), we developed and validated treatment recommendation models for 12 common surgeries that account for more than 95% of the surgery recorded in our CGA center's database. These models demonstrated high balanced accuracy, sensitivity, and specificity. We used Shapley values for the models to enhances interpretability and allow clinicians and patients to understand the factors driving treatment recommendations. We also developed treatment outcome models for over 20 common outcome measures. These models were found to be unbiased, with reliable prediction intervals and accuracy comparable to experimental measurement error. We illustrated the application of EB-GAIT through a case study, showcasing its utility in providing treatment recommendations and outcome predictions. We then use simulations to show that combining recommendation and outcome models offers the possibility to improve outcomes for treated limbs, maintain outcomes for untreated limbs, and reduce the number of surgeries performed. For example, under the counterfactual situation where femoral derotation osteotomies are administered only when they align with historical standard of practice (> 50% probability of surgery) and are predicted to improve the Gait Deviation Index (change > 7.5 points), the model predicts a 11 percentage point reduction in surgeries (26% limbs currently, 15% limbs simulated), a 6 point improvement in Gait Deviation Index among treated limbs (6 currently, 12 simulated), and no change in Gait Deviation Index for untreated limbs (2 currently, 2 simulated). EB-GAIT represents a significant step toward precision medicine in CGA, offering a promising tool to enhance treatment outcomes and patient care. The EB-GAIT approach addresses the limitations of the conventional CGA interpretation method, offering a more structured and data-driven decision-making process. EB-GAIT is not intended to replace clinical judgment but to supplement it, providing clinicians with a second opinion grounded in historical data and predictive analytics. While the models perform well, their effectiveness is constrained by historical variability in treatment decisions and the inherent complexity of patient outcomes. Future efforts should focus on refining model inputs, incorporating surgical details, and pooling data from multiple centers to improve generalizability.
临床步态分析(CGA)历来依赖临床医生的经验和判断,导致结果有限、停滞不前且不可预测。本文介绍了基于证据的步态分析解释工具(EB-GAIT),这是一个利用机器学习来支持治疗决策的新颖框架。EB-GAIT的核心由两个关键组件组成:(1)治疗推荐模型,即基于历史实践标准(SOP)估计特定手术概率的模型;(2)治疗结果模型,预测治疗后或自然病程中患者特征的变化。使用贝叶斯加法回归树(BART),我们开发并验证了针对12种常见手术的治疗推荐模型,这些手术占我们CGA中心数据库中记录手术的95%以上。这些模型显示出高平衡准确率、敏感性和特异性。我们使用模型的沙普利值来增强可解释性,并让临床医生和患者了解推动治疗推荐的因素。我们还为20多种常见结果指标开发了治疗结果模型。发现这些模型无偏差,具有可靠的预测区间,准确率与实验测量误差相当。我们通过一个案例研究说明了EB-GAIT的应用,展示了其在提供治疗推荐和结果预测方面的效用。然后,我们通过模拟表明,结合推荐模型和结果模型有可能改善治疗肢体的结果,维持未治疗肢体的结果,并减少手术数量。例如,在反事实情况下,仅当股骨旋转截骨术符合历史实践标准(手术概率>50%)且预计会改善步态偏差指数(变化>7.5分)时才进行该手术,模型预测手术减少11个百分点(当前26%的肢体,模拟15%的肢体),治疗肢体的步态偏差指数提高6分(当前6分,请模拟12分),未治疗肢体的步态偏差指数无变化(当前2分,模拟2分)。EB-GAIT代表了CGA向精准医学迈出了重要一步,提供了一个有望改善治疗结果和患者护理的工具。EB-GAIT方法解决了传统CGA解释方法的局限性,提供了一个更结构化和数据驱动的决策过程。EB-GAIT并非旨在取代临床判断,而是对其进行补充,为临床医生提供基于历史数据和预测分析的第二种意见。虽然模型表现良好,但其有效性受到治疗决策中的历史变异性和患者结果固有复杂性的限制。未来的工作应集中在完善模型输入、纳入手术细节以及汇集多个中心的数据以提高通用性。