NURD 2.0: Prediction of tibial nonunion after intramedullary nail fixation at any time within 3 months after injury

Introduction Nonunion after fixation of long bones negatively impacts outcomes and requires additional surgery. The ability to predict likelihood of nonunion after tibial shaft fracture would be helpful to clinicians and patients. The goal of this work was to combine three previous models of tibial shaft nonunion at different time points into one overall model that incorporates time as a continuous variable.Methods We conducted a retrospective review at a Level I academic trauma center. The study cohort consisted of patients with tibial shaft fractures treated with nail insertion from 2007 through 2014, excluding patients who did not have contact between bone ends, those who had planned bone grafting for acute bone defects, and those who lacked adequate follow-up. Three previous models were combined: 382 patients at time 0, 323 at 6 weeks, and 240 at 12 weeks. The primary outcome variable was surgery for nonunion. Bivariate and multivariate regression analyses determined which of 42 clinical and radiographic variables were significantly associated with nonunion. Predictive power was evaluated using area under the curve (AUC).Results The original nonunion risk determination (NURD) score was significantly improved through addition of 6- and 12-week radiographic union scores for tibial fractures, infection and complications, smoking status, and need for flaps. Overall, over the course of 12 weeks, the NURD-based model produced an AUC of 0.87 at initial time of fixation that improved to >0.9 at 6 and 12 weeks. Data were used to bin patients into five clinically important risk strata (p < 0.001). Patients in the lowest risk strata had 0% probability of nonunion (0 of 97 patients); in the second lowest risk strata, 4% (three of 73 patients); and in the highest risk strata, 48% (38 of 80 patients).Conclusions We created a NURD 2.0 score that predicts nonunion at various time points during the first 3 months after fracture. The new model is a notable improvement over previous models. A computerized version allows surgeons and patients to use the score when making treatment decisions regarding need for nonunion surgery.     

Permanent reduction plate and intramedullary nailing of open tibia fractures: Do we need to take them out?

IntroductionProvisional reduction plating has been advocated as a reduction aid for tibial shaft fractures. Concerns regarding soft tissue stripping, infection, wound complications and nonunion have been postulated. Recent studies investigating reduction plating present patient cohorts where plates are removed or left to the discretion of the surgeon. This study aims to identify a cohort of open tibial shaft fractures treated with intramedullary nailing aided by permanent reduction plating. Our hypothesis is that permanent reduction plating in conjunction with intramedullary nailing of open tibia fractures does not increase risk of nonunion, infection or time to fracture union compared to intramedullary nailing alone.MethodsAn IRB approved retrospective study was performed using trauma registry data from January 2014 to June 2018 at a Level 1 trauma center. Open AO/OTA 41A/42 A-C/43A tibial shaft fractures treated with intramedullary nail alone (IM) or intramedullary nail and permanent reduction plates (PP) were included in patients over 18 years of age with at least six month follow up or until fracture union. Patient demographics, fracture characteristics, mechanism of injury, medical comorbidities, and length of follow up were recorded along with time to union, incidence of nonunion and treatment for documented or suspected infections.ResultsDuring the study period, 389 patients underwent tibial intramedullary nailing with 162 identified as open fractures. 91 patients met inclusion criteria with 39 in the PP group and 52 in IM group. Statistical analysis revealed no difference between the two groups except more AO/OTA 42A fractures were noted in the IM group. Average follow up was 8.0 and 10.2 months for PP and IM respectively. Nonunion occurred in 2 PP group patients and 7 in the IM group (p = 0.29). Time to union was 5.5 months for PP group and 6.1 months for IM group (p = 0.39) with 4 infections in the PP group and 10 infections in IM group (p = 0.38).ConclusionDespite the small sample size, this study suggests that permanent reduction plating, in the setting of open tibia fractures, does not delay time to fracture union or increase risk of nonunion or infection.     

Tibial shaft fractures in the adolescents: treatment outcomes and the risk factors for complications

Background: Tibial shaft fractures are common injuries in the adolescent age group. The optimal method of treatment in this age group is still controversial. It relies on several factors including patient's age, fracture pattern, fracture location, and the condition of the soft tissue envelope. The purpose of this study was to report the clinical and radiographic outcomes of adolescent tibial shaft fractures treatment at a level-I trauma center.Methods: This retrospective study reviewed consecutive patients between 10 and 18 years of age who suffered from tibial shaft fractures between 2009 and 2018 at a level-I trauma center. Outcomes of interest were the successful fracture union (primary outcome) as evaluated by the Radiographic Union Scale in Tibial fractures (RUST) and the complications (secondary outcomes).Results: Fifty-two consecutive adolescent patients treated for tibial shaft fractures using elastic stable intramedullary nails (ESIN), interlocking nails, plates and screws, external fixators, and casts were included in the study. The mean follow-up period was 27.4 months. There was no statistically significant difference in the union rate and time to fracture union between the different treatment methods. Subject weight, fracture type, and method of treatment were significant predictors for the RUST scores at 12 weeks post-operative. Adolescents with heavier bodyweight correlated with lower RUST scores (p<0.001). Open fractures were associated with significantly longer time to union (p<0.001) and lower RUST scores (p<0.001) compared to closed fractures. The patients treated with interlocking nailing showed higher RUST scores than the casting treatment group (p = 0.01). There were no statistically significant differences in complication rates between the fixation methods. Union time was significantly longer with complications than without complications (p = 0.01). Open fractures had higher complication rates compared to closed fractures. In the multivariate logistic model, patients with open fracture were 5.5 times more likely to have complications (OR=5.46; p = 0.04).Conclusion: Tibial shaft fractures in adolescents can be treated with several methods including ESIN, interlocking nail, plate and screws, external fixation, and casting. All are valid treatments for adolescent tibial shaft fractures and can achieve favorable outcomes. No single treatment method applies to all patients. Each method has advantages, disadvantages, and specific indications.     

扩髓带锁髓内钉治疗股骨、胫骨干骨折不愈合、延迟愈合

目的　总结使用扩髓带锁髓内钉治疗股骨、胫骨干骨骨折不愈合、延迟愈合的临床经验。方法　回顾自 1999年 4月～2 0 0 1年 6月使用扩髓带锁髓内钉治疗股骨干、胫骨干骨折不愈合、延迟愈合病人 2 1例 ,其中股骨 8例 ,胫骨 13例 ,钢板固定术后 ,股骨 3例 ,胫骨 6例。普通髓内针股骨 5例。外固定架胫骨 2例。石膏固定胫骨 3例 ,骨牵引股骨 2例。均采用有限切口切开复位顺行扩髓 ,静力锁定加植骨术。结果　随访半年以上 18例 ,骨折均愈合 ,临近关节功能达正常。无感染、断钉等并发症。结论　采用有限切口切开复位、扩髓、静力锁定治疗股骨、胫骨干骨折不愈合、延迟愈合 ,具有骨折稳定性可靠、有利于骨折愈合和早期关节活动的优点 ,是治疗股骨、胫骨干骨折不愈合、延迟愈合的有效方法之一。     

Small residual fracture gaps delay time to union in length stable femur fractures treated with intrameduallary fixation

ObjectivesThe purpose of this study was to investigate whether residual fracture gapping and translation at time of intramedullary nail (IMN) fixation for diaphyseal femur fractures were associated with delayed healing or nonunion.DesignRetrospective cohort studySettingLevel 1 trauma hospital, quaternary referral centerPatients/Participants/InterventionLength stable Winquist type 1 and 2 diaphyseal femur fractures treated with IMN at a single Level I trauma center were retrospectively reviewed.Main Outcome MeasureThe largest fracture gap and translation were evaluated on immediate anteroposterior (AP) and lateral postoperative radiographs. Radiographic healing was assessed using Radiographic Union Score in Femur (RUSF) scores at each follow-up. Radiographic union was defined as a RUSF score ≥8 and consolidation of at least 3 cortices. ANOVA and student's t-tests were used to evaluate the influence of fracture gap parameters on time to union (TTU) and nonunion rate. Patients were stratified to measured average gap and translation distances <1mm, 1-3mm and >3mm for portions of the analysis.ResultsSixty-six patients who underwent IMN with adequate follow-up were identified. A total of 93.9% of patients achieved union at an average of 2.8 months. Fractures with average AP/lateral gaps of <1mm, 1-2.9 mm, and >3mm had an average TTU of 70.1, 91.7, and 111.9 days respectively; fractures with larger residual gap sizes had a significantly longer TTU (p=0.009). Fractures with an average gap of 1-2.9mm and >3 mm had a significantly higher nonunion rate (1.5% and 4.5% respectively) compared to 0% nonunion in the <1 mm group (p=0.003).ConclusionResidual gapping following intramedullary fixation of length stable diaphyseal femur fractures is associated with a significant increase in likelihood of nonunion.SummaryResidual displacement of length stable femoral shaft fractures following intramedullary nailing can have a significantly negative impact on fracture healing. An average 3 mm AP/lateral residual fracture gap or a total of 6 mm of the AP + lateral fracture gap appeared to be a critical gap size with increased rates of nonunion and time to union. Therefore, we suggest minimizing the sum of the residual AP and lateral fracture gap to less than a total of 6 mm.     

Suprapatellar versus infrapatellar nailing for tibial shaft fractures: A comparison of surgical and clinical outcomes between two approaches

BackgroundTibial shaft fractures are a relatively common injury and contemporary treatment includes on-axis fixation with a locked intramedullary nail in the majority of cases. The conventional technique is via an infrapatellar approach but currently there is a trend towards the use of a suprapatellar approach. We compared key variables including operative time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nailing in our unit versus our previous experience of infrapatellar tibial nailing.MethodTwenty-eight consecutive patients with tibial fracture underwent tibial nailing via the suprapatellar (SPN) approach. Six patients in the study group were excluded due polytrauma and need for dual orthopaedic and plastic surgery management. We compared outcomes with our most recent 20 consecutive patients who had undergone tibial nailing via an infrapatellar (IPN) approach. Primary surgical outcomes were: operative time, radiation exposure and accuracy of entry point of the nail on both anteroposterior and lateral radiographs. Clinical outcomes included time to weightbearing, time to radiographic union and patient-reported outcome score (Lysholm score).ResultsForty-eight consecutive patients underwent intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study (22 SPN vs 20 IPN). There were no significant differences in patient demographics or injury patterns between the two groups. Operative time and radiation exposure were significantly lower in the SPN group when compared to the IPN group (115 min vs 139 min ± 12.5) (36 cGY/cm² vs 76.33 cGY/cm² +/- 20.1). Furthermore, patients in the SPN group reported superior outcome scores at a mean follow up of 3 months (8–24 weeks) There were no observed differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months.ConclusionOur study shows that adoption of the SPN approach requires minimal learning curve, and has the potential benefits of reduced operative time, radiation exposure and superior patient reported outcomes when compared to the conventional infrapatellar approach.     

The functional results of tibial shaft fractures treated with intramedullary nail compressed by proximal tube

Nailing of tibial shaft fractures is considered the gold standard surgical method by many surgeons. The aim of this retrospective study was to investigate and compare the clinical outcome of tibial shaft fractures treated with intramedullary nails compressed by proximal tube and conventional intramedullary interlocking nails. Fifty-seven patients with tibial shaft fractures, treated with intramedullary nails compressed by proximal tube (n = 32) and the conventional interlocking nails (n = 25), were reviewed. All fractures except for one were united without any additional surgical intervention in the proximal compression tube nail group, whereas in the conventional interlocking nail group, six patients needed dynamization surgery (p = 0.005) and three cases of nonunion were recorded. In the proximal compression tube nail group, faster union occurred in 20 ± 2 (16–24) weeks (mean ± SD; range) without failure of locking screws and proximal nail migration, whereas in the conventional interlocking nail group, union occurred in 22 ± 2.5 (17–27) weeks (p = 0.001) with two failures of locking screws and two proximal nail migration. The proximal compression tube nail system is safer than the conventional nailing methods for the treatment for transverse and oblique tibial shaft fractures with a less rate of nonunion, proximal locking screw failure and proximal nail migration.     

交锁髓内钉治疗胫腓骨骨折

目的 观察交锁髓内钉治疗胫腓骨骨折的疗效及并发症防治。方法 用交锁髓内钉治疗胫腓骨骨折46例,均采用扩髓及静力型固定。结果 46例均得到随访,平均20个月（6个月-3年）,愈合时间为3-12个月,平均4个月,感染4例均为开放性骨折,肢体短缩1例,成角畸形2例,延迟愈合7例,无不愈合。根据Johner-Wruh评分标准,优36例,良7例,中2例,差1例。结论 交锁髓内钉治疗胫腓骨骨折是一种很好的方法。但仍有一些并发症,在应用中必须引起重视;开放性骨折以不扩髓为宜。     

Association of hyperglycemia with increased mortality after severe burn injury

OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures. METHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al. RESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion. CONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.     

Ipsilateral fractures of the femoral neck and shaft.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.     

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail

ObjectivesTo identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population.MethodsA retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract.ResultsDeep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%–6% with <10 points to high risk (58%–69%) with >40 points.ConclusionsThis risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.     

应用扩髓交锁髓内钉治疗胫骨不稳定性骨折

目的 探讨扩髓交锁髓内钉治疗胫骨不稳定性骨折的治疗效果。方法 对42例胫骨不稳定性骨折患行扩髓交锁髓内钉固定，闭合性骨折22例，开放性骨折20例，均应用静力性固定。结果 平均随访时间12个月，采用Johner—Wruh评分标准，治疗结果：优32例，良8例，一般2例。骨折平均愈合时间：闭合性骨折15周，开放性骨折19周，3例延迟愈合，无深部感染、骨髓炎、畸形愈合及骨不连发生。结论 扩髓交锁髓内钉是治疗胫骨不稳定性骨折较理想的方法，可促进骨折愈合，并发症少。     

加压交锁髓内钉固定加植骨治疗胫骨骨不连的临床研究

目的:探讨加压交锁髓内钉内固定加交锁髓内钉开口处取骨植骨治疗胫骨骨不连的临床疗效。方法:回顾性分析自2008年2月至2010年10月采用加压交锁髓内定内固定加髓内针开口处取骨植骨治疗18例胫骨骨干骨不连,男12例,女6例;年龄31～67岁,平均42岁。受伤至手术时间6～18个月,平均8个月。骨折不愈合11例,延迟愈合7例。术后根据HSS评分系统评价膝功能,采用Tenny和Wiss评分系统评估疗效。结果:术后随访12～36个月,平均18个月,患者切口愈合良好,无感染,无皮肤坏死。全部患者未见骨不愈合、感染、畸形及再骨折发生。骨性愈合时间4～8个月,平均6个月。患者术后1年膝关节功能HSS评分平均(89.97±3.21)分。术后根据Tenny和Wiss评分系统评估疗效,优16例,良2例。结论:采用加压交锁髓内钉内固定加交锁髓内钉开口处取骨植骨治疗胫骨骨折不愈合及延迟愈合,能提高骨折愈合率,避免髂骨取骨带来的并发症,减少患者医疗费用。     

Butterfly fragments in diaphyseal tibial fractures heal unpredictably: Should we be adopting other strategies for these high risk fractures?

IntroductionThe natural history of diaphyseal tibial butterfly fragments is poorly documented. Numerous studies have analyzed risk factors for nonunions in the tibial shaft with known factors including Gustilo classification, ASA class, and cortical contact. However, the healing potential and ideal management of nonsegmental butterfly fragments in this setting remains unknown. The aim of this study was to determine the nonunion rate of diaphyseal tibial fractures with a butterfly fragment.MethodsA performed a retrospective review of patients at a single academic Level 1 Trauma Center from 2000-2020 who underwent intramedullary nailing of tibial shaft fractures. Those with non-segmental butterfly fragments (OTA/AO: 42-B) and minimum 12 month follow up were included. Morphologic measurements of butterfly fragments were performed to measure location, size, and displacement, and mRust scores at final follow up were calculated. Outcome measures were surgery to promote union, and mRust scores.ResultsA total of 99 patients were included with 21 patients requiring revision surgery to promote union. Thirty six patients had open fractures and 77% of patients were male with a mean age of 34 (range: 12-80). Average follow up was 19 months (3 months – 12 years). The most common location of the butterfly fragment was the anterior cortex (42%), with a mean length of 7.8cm (SD: 3.3) and width of 1.8cm (SD: 0.5cm). At final follow-up 37% of fractures had persistent lucency without callus at the site of the butterfly while only 31% of fractures had remodeled cortex. Average time to complete healing was 13.3 months. Open fractures with butterfly fragments were more likely to go on to nonunion than closed (44% vs 9.2%, p=<0.001). The length of the butterfly fragment was not different between the union and nonunion groups (7.7 vs 7.5, P=0.42).ConclusionsOpen tibial shaft fractures with a butterfly fragment have a high risk of nonunion. Further research may seek to determine if adjunct treatment of butterfly fragments (ie inter-fragmentary compression) in the acute setting could improve healing rates.     

Treatment of high‐energy tibial shaft fractures with internal fixation and early prophylactic NovaBone grafting

Objective: To evaluate the safety and efficacy of early NovaBone grafting in accelerating healing of high‐energy tibial shaft fractures. Methods: In a prospective, randomized, controlled study 78 patients with open or closed tibial shaft fractures were treated with reamed interlocking nails, combined with NovaBone grafting. Forty patients were randomly assigned to the experimental group (with NovaBone grafting at fracture site), and 38 to the control group (without NovaBone grafting). Results: All patients were followed up for an average of 8 months (range 6–18 months). The average fracture healing time was 12 weeks (range 8–16 weeks) in the experimental group, and 19 weeks (range 12–36 weeks) in the control group (P < 0.01). No delayed union or nonunion was found in the experimental group, but four cases (10.5%) in the control group were found to heal spontaneously between 7 and 8 months. When the data were analyzed at week 12 and week 26 according to the criteria of Johner and Wruhs, 88% and 100% of the cases in the experimental group were rated as excellent and good respectively, but in the control group, 50% and 89% were rated as excellent and good respectively, these being significant differences (P < 0.05). Conclusion: Internal fixation supplemented with early prophylactic NovaBone grafting of high‐energy tibial shaft fractures is a safe and effective treatment which accelerates fracture healing.     

Distal tibial nonunion using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach: A retrospective case series

BackgroundDistal tibial nonunion is usually due to severe open distal tibial fractures with high energy injury. The best surgical treatment is not well established because of the poor soft tissue condition. We retrospectively analyzed a series of patients with distal tibial nonunion after severe open distal tibial fractures; our purpose was to introduce a treatment using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach with Iliac crest bone graft and evaluate the outcomes of patients.MethodsAll patients with distal tibial nonunion who received a contralateral anterior L-shaped locking compression plate fixation through the posterior-lateral approach with Iliac crest bone graft by a single surgeon from 2014 to 2016 were reviewed. 9 patients met the criteria. Five of nine patients had varus deformities (range, 9–40°) and 4 patients had valgus deformities (range, 5–30°). Postoperative radiographs, Postoperative complications, limb alignment and limb functional outcome information of AOFAS ankle-hindfoot score were recorded.ResultsAll patients were followed up for at least 8 months (range, 8–16 months). Union was achieved in all patients after the index surgery without postoperative wound complications while one patient came up with checkrein deformity. Average time to radiographic union was 16 weeks (range, 12–24 weeks). All patients had correction to neutral alignment in both coronal and sagittal planes. The average AOFAS ankle-hindfoot score was 90 (range, 77–100) at the last follow-up of patients.ConclusionsUsing a contralateral anterior L-shaped locking compression plate fixation through a posterior-lateral approach with Iliac crest bone graft to reconstruct the distal tibial nonunion is a safe and reliable method that can successfully treat patients with poor soft tissue condition of anterior portion of leg because of its adequate exposure, both tibia and fibula rigid fixation and plenty of bone graft. We believe the application of this method resulting in a high union and low complication rate.     

扩髓交锁髓内钉治疗胫骨萎缩性骨不连

[目的] 探讨胫骨萎缩性骨不连的原因及扩髓交锁髓内钉治疗胫骨萎缩性骨不连的效果。[方法] 对26例胫骨萎缩性骨不连的病例采用扩大髓腔的交锁髓内钉内固定。[结果] 经6个月～2年的随访，骨折全部愈合，关节功能明显改善。[结论] 扩大 髓腔的交锁髓内钉内固定是治疗胫骨萎缩性骨不连的理想方法。     

Squat and smile assessment in predicting healing of lower limb fractures fixed with a SIGN nail

BackgroundIrrespective of the treatment method, union is the ultimate goal of any fracture treatment. However, nowadays, rather than the physician-based clinico-radiological methods, the patient-reported outcome measurements assessing their quality of life and function are gaining much popularity. This is specifically true in the part of the world where the patient needs almost complete degree of hip/knee flexion – for social, cultural, religious or occupational reason(s). The ability to squat can assess the mobility and stability of joints and thus the quality of squatting is a proxy reflection of the functional outcome after fixation of lower limb fracture. Thus, we studied to determine the inter-observer and intra-observer reliability of Radiographic Union Score for Tibia (RUST) and Squat and Smile (S & S) test in clinical photograph. We further calculated the sensitivity and specificity of S & S test in predicting healing of lower limb fracture fixed by intramedullary interlocking nail considering RUST as the gold standard.MethodsThis was a retrospective study of prospectively collected data of solid Surgical Implant Generation Network (SIGN) intramedullary interlocking nailing from a single, university-based, high volume tertiary center where 56 consecutive adults with either tibial or femoral shaft fractures fixed with a SIGN nail within one year and not requiring any surgery till minimum of eighteen-month follow-up were included. Cases without either Anterior-Posterior (AP) view and/or Lateral (Lat.) view follow-up x-ray(s) or proper S & S clinical photograph (at least 1.5-year post fixation) were excluded. The x-rays (RUST criteria) and clinical photograph (S & S grading) were scored by two independent and blinded observers each and repeated after 1 month.ResultsThe overall intra-observer reliability was from 0.773 to 0.825 and inter-observer reliability from 0.635 to 0.757 for RUST scoring which was from 0.687 to 0.785 and from 0.301 to 0.650 respectively for S & S scoring. The sensitivity and specificity of S & S in predicting fracture healing were up to 82.22% and 63.64% respectively.ConclusionThe S & S test is reliable to predict the healing of lower limb fracture fixed with an intramedullary nail. The test is more useful to determine healed fractures than to determine non-healed ones. (sensitivity being higher than specificity)     

Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion

BackgroundThe purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion.Materials and methodsPatients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment.ResultsSixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745).ConclusionsRUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.