Rust score-An adequate rehabilitation guide for diaphyseal femur fractures managed by TENS

Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing

OBJECTIVES

To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail.

OUTCOME MEASURES AND COMPARISONS

PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair.

RESULTS

A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011).

CONCLUSIONS

Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures

Objective

To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.

Design

Retrospective 1:1 matched cohort study.

Setting

Single-level 1 trauma center.

Participants

One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.

Intervention

Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.

Main Outcome Measurement

Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.

Results

Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.

Conclusions

Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series

Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.

Reliability of RUST and modified RUST scores for evaluation of union in pediatric and adult femoral shaft fractures

OBJECTIVE

This study aimed to determine the reliability levels of the radiographic union scale for tibial fractures (RUST) and the modified version of the system, mRUST, for femoral shaft fractures in pediatric and adult patients and to evaluate the value of the scores for total and each cortex in the decision making on fracture union.

METHODS

A total of 15 orthopedic surgeons scored the radiographs of 24 pediatric and 24 adult patients with femoral shaft fractures that were obtained at 0, 4, 8, 12, and 16 postoperative weeks treated with elastic stable intramedullary nail in pediatric patients and locked intramedullary nail in adult patients using the RUST and mRUST scores. Intra-class correlation coefficient (ICC) was used in the evaluation of reliability of the RUST and mRUST scores. The Fleiss kappa (k) coefficient was used in the agreement between evaluators regarding union decision (united or non-united). The thresholds for RUST and mRUST for radiographic union decision were determined. Receiver operating curves were created to evaluate the contribution of total and individual cortical scores in the decision of united or non-united.

RESULTS

Intra- and inter-rater reliabilities of mRUST (ICC: 0.92 and 0.86, respectively) were slightly higher than those of RUST (ICC: 0.81 and 0.77, respectively) with perfect intra- and inter-rater reliabilities for RUST (ICC: 0.92 and 0.90, respectively) and mRUST (ICC: 0.88 and 0.83, respectively) in pediatric patients and substantial intra- and inter-rater reliabilities in adult patients (ICC: 0.80 and 0.76, respectively, for mRUST, and 0.76 and 0.71, respectively, for RUST). At each time point, the mean mRUST and RUST scores were higher for pediatric fractures (p<0.001). The Fleiss k coefficient for union decision was perfect for pediatric fractures (0.88) and substantial for adult fractures (0.79). The total mRUST score had a higher predictive value of union than the total RUST score (area under the curve: 0.984 vs. 0.922 in adult fractures and 0.990 vs. 0.943 in pediatric fractures). A RUST score of ≥10 and mRUST score of ≥12 were excellent predictors of fracture union.

CONCLUSION

Fracture union of simple two-part pediatric and adult femoral shaft fractures treated with intramedullary fixation can be reliably assessed using the RUST and mRUST scores. The diagnostic value of the mRUST score is more evident in adult fractures.

LEVEL OF EVIDENCE

Level II, Diagnostic Study.