Radiographic Union Score For Tibial Fractures Research Articles

Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study.

Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity. Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis. A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively. Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions. Level III.

Comparative bone healing with induced membrane technique (IMT) versus empty defects in septic and aseptic conditions in a novel rabbit humerus model

BackgroundLong bone defects resulting from primary trauma or secondary to debridement of fracture-related infection (FRI) remain a major clinical challenge. One approach often used is the induced membrane technique (IMT). The effectiveness of the IMT in infected versus non-infected settings remains to be definitively established. In this study we present a new rabbit humerus model and compare the IMT approach between animals with prior infection and non-infected equivalents.MethodsA 5 mm defect was created in the humerus of New Zealand White rabbits (n = 53) and fixed with a 2.5 mm stainless steel plate. In the non-infected groups, the defect was either left empty (n = 6) or treated using the IMT procedure (PMMA spacer for 3 weeks, n = 6). Additionally, both approaches were applied in animals that were inoculated with Staphylococcus aureus 4 weeks prior to defect creation (n = 5 and n = 6, respectively). At the first and second revision surgeries, infected and necrotic tissues were debrided and processed for bacteriological quantification. In the IMT groups, the PMMA spacer was removed 3 weeks post implantation and replaced with a beta-tricalcium phosphate scaffold and bone healing observed for a further 10 weeks. Infected groups also received systemic antibiotic therapy. The differences in bone healing between the groups were evaluated radiographically using a modification of the radiographic union score for tibial fractures (RUST) and by semiquantitative histopathology on Giemsa-Eosin-stained sections.ResultsThe presence of S. aureus infection at revision surgery was required for inclusion to the second stage. At the second revision surgery all collected samples were culture negative confirming successful treatment. In the empty defect group, bone healing was increased in the previously infected animals compared with non-infected controls as revealed by radiography with significantly higher RUST values at 6 weeks (p = 0.0281) and at the end of the study (p = 0.0411) and by histopathology with increased cortical bridging (80% and 100% in cis and trans cortical bridging in infected animals compared to 17% and 67% in the non-infected animals). With the IMT approach, both infected and non-infected animals had positive healing assessments.ConclusionWe successfully developed an in vivo model of bone defect healing with IMT with and without infection. Bone defects can heal after an infection with even better outcomes compared to the non-infected setting, although in both cases, the IMT achieved better healing.

Delayed Reconstruction of the Perforator Pedicle Propeller Flap after the Induced Membrane Technique for Gustilo IIIB Open Distal Tibial Fracture.

This study aimed to evaluate the safety and efficacy of delayed reconstruction of the perforator pedicle propeller flap after the induced membrane technique in the treatment of Gustilo IIIB open distal tibial fracture, and to evaluate the clinical outcome and complications of two different perforator pedicle propeller flaps.Thirty-four patients with Gustilo IIIB open distal tibial fractures treated by the induced membrane technique and delayed reconstruction of two different perforator pedicle propeller flaps from May 2017 to March 2022 were retrospectively analyzed. Patients were divided into two groups according to the different kinds of perforator pedicle propeller flaps covered. The operation required two stages. The Radiographic Union Score for Tibial fractures (RUST) was used to evaluate the healing of the tibial bone defect. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to evaluate ankle function. The complications associated with the technique were recorded.The number of serial debridements, excluding those performed during emergency and final operations, was a mean of 2.28±0.83 in the PAPF group. The PAPF group had a mean bone defect length of 6.76 ± 0.69 cm, the median healing time of 13.11 ± 0.96 months, RUST score 12.68 ± 1.63, and AOFAS score of 84.12 ± 6.38. On the other hand the PTAPF group's mean bone defect length was 6.73 ± 0.95 cm, the median healing time 12.63 ± 1.46 months, RUST score 13.73 ± 1.53 and AOFAS score 82.79 ± 5.49. There were no observed significant differences the two groups in the number of serial debridements, bone defect length, bone union time, RUST score, or AOFAS score (p>0.05). Flap size ranged from 9×6cm2 to 14×7cm2 in the PAPF group and from 9×6cm2 to 13×7cm2 in the PTAPF group. There were no severe complications such as flap-related complications or amputation. The differences in complications in the two groups were not statistically significant.In cases of severe open tibial fracture, the reconstructive method is important. When delayed reconstruction is inevitable, surgeons should first perform radical debridement, followed by vacuum sealing drainage as a bridging therapy; both PAPF and PTAPF can be considered for definitive soft tissue coverage.

The Effect of Low Magnitude High Frequency Vibration on Bone Healing by Clamp Method in Nonunion Tibial Fractures

Introduction: This study aimed to investigate the clinical effect of Low Magnitude High Frequency Vibration (LMHFV) on nonunion tibial fractures, noninvasively.
 Methods: The Experimental (n=5) and control (n=5) groups were age-matched and pooled based on the Nonunion Tibia Score System (NUSS) (p>0.05). LMHFV (0.35g, 50 Hz, 20 minutes x 4/day) was applied to the experimental group for three months by a mechanical stimulator that we developed using a ‘clamp method’. The control group was followed during three months without any application other than routine treatment. The results were evaluated using the Radiographic Union Score for Tibial Fractures (RUST) and American Orthopedics Foot and Ankle Score (AOFAS). No statistically significant difference was observed between the groups at the beginning and in the end of the 3- month application for RUST and AOFAS scores (p>0.05).
 Results: Pain and function assessment, at the beginning and end of the study, as a part of The AOFAS scorewere not statistically different (p>0.05) in the control group. However, increases in pain and function AOFAS scores were statistically significant in the experimental group at the end of the 3- month application (p

Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?

To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs. Retrospective case series. Urban academic Level 1 trauma center. Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up. Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure. Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure. The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs. The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The degree of correction in open-wedge high tibial osteotomy compromises bone healing: A consecutive review of 101 cases

BackgroundThe bone healing in open-wedge high tibial osteotomy (OWHTO) proceeds gradually by a filling of the osteotomy gap. This can comprise several risk factors. MethodsA retrospective study analysed the clinical and radiological course of 101 consecutive OWHTOs in 96 patients. The following risk factors were considered: age, body mass index, tobacco consumption, amount of tobacco consumption, severity of comorbidities, infection of the surgical area, occurrence of a lateral hinge fracture and the degree of correction. The bone healing was evaluated by using the modified Radiographic Union Score for Tibial fractures (RUST). ResultsA disturbance in bone healing was observed in 16 of the 101 osteotomies. Binary logistic regression analysis showed a correlation between the angle of the opening wedge and the development of a disturbance in bone healing (P = 0.002). The odds ratio indicated an increase in the risk of a disturbance in bone healing of 56% with each additional degree of correction. For the risk factor ‘age’ a statistical trend was recognizable (P = 0.077) with the risk of a disturbance in bone healing in higher age. ConclusionLateral hinge fractures seem not to have a detrimental effect on the filling of the osteotomy gap. An increase in the opening wedge bears the risk of a disturbance in bone healing.

Does immediate weight-bearing following intramedullary tibial nailing affect union rates? The results from a single UK trauma unit

Introduction Extra-articular diaphyseal tibial fractures are a common injury and are often treated with intramedullary nailing (IMN). Weight-bearing (WB) of simple tibial fractures treated with an IMN immediately as pain allows is now standard practice. Our aim was to assess the impact of varied WB on fracture union following IMN of diaphyseal tibia fractures. Methods We conducted a retrospective cohort study of tibial fractures treated with IMN in our department between 2012-2017. WB status was recorded in the post-operative note and subsequently reviewed in the patients’ follow-up appointments. Patients were divided in three groups; Group I: immediate full-WB, Group II: non-WB for 6 weeks and Group III: 2 weeks non-WB, 4 weeks increasing partial-WB and full-WB at 6 weeks. Radiographic union score for tibial fractures (RUST) of ≥10 at a painless fracture site was considered as evidence of fracture union. Results 92 patients with comparable pre-operative demographics [mean age 40 y (16-88)] were included. The median union time in weeks for each group was: Group I 17.3, Group II 21.7 and Group III 19.5 (F 1.09, p 0.34). Survival analysis and log rank test did not show any difference in union times between the three groups (x2 1.1, p 0.57). 12 delayed unions were identified across all groups. Multiple logistic regression identified three factors that could increase the rate of delayed union – non-WB, smoking and IMN size 11/12 mm - however the results were not statistically significant. Conclusion Immediate post-operative WB does not adversely affect union time in statically locked IMNs. In fact, although our data show no statistically significant difference in fracture healing between the three groups, full WB seems to decrease overall time to union. In conclusion, we could suggest that full WB after IMN in patients with AO 42-A/B type fractures is safe practice.

Radiographic evaluations: Which are most effective to follow fracture healing?

The assessment of fracture healing is an imperative and fundamental clinical aspect within orthopaedics. Despite that, there have historically been non-reliable methods utilized to assess for fracture union and nonunion. In recent years, a number of radiographic assessment tools such as the Radiographic Union Score for Tibial fractures (RUST) and Radiographic Union Score for Hip fracture (RUSH) have been developed in order to improve the reliability of fracture assessment for union. These scores have not only increased the reliability of assessments but have also provided thresholds to aid in predicting nonunion as well as union. The nonunion risk determination (NURD) Score was also created to prognosticate these clinical presentations. With the large burdens of cost, lower quality of life and morbidity associated with fracture nonunion, these evaluation methods have provided orthopaedic surgeons with an improved ability to predict nonunion and assist in the management of patients. This review outlines the development, reliability testing as well as biomechanical validity testing associated with these scoring systems.

Evaluation of Fracture and Osteotomy Union in the Setting of Osteogenesis Imperfecta: Reliability of the Modified Radiographic Union Score for Tibial Fractures (RUST).

Evaluation of the union of osteotomies and fractures in patients with osteogenesis imperfecta (OI) is a critical component of patient care. Studies of the OI patient population have so far used varied criteria to evaluate bony union. The radiographic union score for tibial fractures (RUST), which was subsequently revised to the modified RUST, is an objective standardized method of evaluating fracture healing. We sought to evaluate the reliability of the modified RUST in the setting of the tibias of patients with OI. Tibial radiographs of 30 patients with OI fractures, or osteotomies were scored by 3 observers on 2 separate occasions. Each of the 4 cortices was given a score (1=no callus, 2=callus present, 3=bridging callus, and 4=remodeled, fracture not visible) and the modified RUST is the sum of these scores (range, 4 to 16). The interobserver and intraobserver reliabilities were evaluated using intraclass coefficients (ICC) with 95% confidence intervals. The ICC representing the interobserver reliability for the first iteration of scores was 0.926 (0.864 to 0.962) and for the second series was 0.915 (0.845 to 0.957). The ICCs representing the intraobserver reliability for each of the 3 reviewers for the measurements in series 1 and 2 were 0.860 (0.707 to 0.934), 0.994 (0.986 to 0.997), and 0.974 (0.946 to 0.988). The modified RUST has excellent interobserver and intraobserver reliability in the setting of OI despite challenges related to the poor quality of the bone and its dysplastic nature. The application and routine use of the modified RUST in the OI population will help standardize our evaluation of osteotomy and fracture healing. Level III-retrospective study of nonconsecutive patients.

Perbandingan Tingkat Penyembuhan Tulang Antara Isolated Tibial Diaphyseal Fracture, Both Tibial dan Fibula Diaphyseal Fracture Setelah Terapi Interlocking Intramedullary Solid Nail

ABSTRACTOne of the fixation method is interlocking intramedullary solid nail that can enhance the callus formation in tibial diaphyseal fracture through the secondary healing. The research aimed to compare the rate of bone healing between isolated tibial diaphyseal fracture and both diaphyseal tibial and fibular fracture after therapy solid interlocking intramedullary nail. This research was conducted by comparing the results of the cure rate among patients with isolated fractures of the tibia and fracture of the tibia with fractures of the fibula during November 2007 to December 2015. The first group, comprising 29 patients and the second group comprised 47 patients. All patients had solid action intramedullary nail. The evaluation was done 30 weeks post-surgery, to assess the Union Rate using Radiographic Union Score for tibial Fractures (RUST). Data were analyzed using non-parametric test of Mann-Whitney test for comparing the union rate between the two groups. The results showed that 27 of 29 patients with isolated tibial fractures had RUST score > 7 and 2 patients with RUST score < 7. Meanwhile, 44 patients out of 47 patients with both diaphyseal tibial and fibular fracture, having RUST score > 7 and 3 patients with a score < 7. Keywords: Interlocking intramedullary solid nail, Isolated Tibial Diaphyseal Fracture Radiographic Union Score, Unionrate

Evaluation of a Critical Sized Bone Defect in a Porcine Tibial Model

Background/Hypothesis:
 Few large animal bone injury models exist. We present a porcine tibial model of metacritical and critical sized bone defects for the simulation of traumatic bone injuries.
 Project Methods:
 16 pigs were used in this study. The pigs were divided into 3 groups (n=4-8/group). In 12 pigs, a 25 mm osteotomy was created in the tibia and the space was filled with a 25 mm scaffold. 8 of the 25 mm scaffolds were secured with an intramedullary (IM) nail and 4 of the scaffolds were secured with plates. In 4 pigs a 40 mm osteotomy was created, filled with a 40 mm scaffold, and secured with plates. Fracture healing was assessed 3 months post-operatively using the Radiographic Union Score for Tibial Fractures (RUST) criteria.
 Results:
 For the 25 mm IM group, none of the 8 pigs achieved cortical bone union at 3 months post-op. In contrast, cortical union was observed in all of the 25 mm defects secured with plates. None of the 40 mm defects secured with plates achieved cortical union.
 Conclusion/Potential Impact:
 The failure of the 25 mm defect secured with an IM nail and the 40 mm defect secured with plates demonstrates that these are critical sized defect models. However, because the 25 mm defect secured with bridge plates did heal, we have termed this a metacritical sized defect. Identification of a defect size that can heal or not heal based on the fixation technique is a powerful translational model for testing therapies.

Experimental Validation of the Radiographic Union Score for Tibial Fractures (RUST) Using Micro-Computed Tomography Scanning and Biomechanical Testing in an in-Vivo Rat Model

The Radiographic Union Score for Tibial fractures (RUST) and the modified version of the system, mRUST, are popular standards for assessing fracture-healing progress with use of radiographs. To our knowledge, this is the first study to experimentally validate the ability of RUST and mRUST to accurately assess bone-healing progression with use of both micro-computed tomography (micro-CT) scanning and biomechanical testing. Adult male rats (n = 29) underwent osteotomy with a midshaft fracture gap repaired with use of a polyetheretherketone plate. Anteroposterior and lateral radiographs were made of the repaired femora prior to rat death at end points of 5, 6, 7, 8, 9, and 17 weeks, and 2 fellowship-trained orthopaedic trauma surgeons independently assigned RUST and mRUST scores to repaired femora. The repaired and intact contralateral femora were then dissected. Bones underwent dissection, micro-CT scanning, and biomechanical torsion testing at the end points. RUST scores ranged from 5 to 12 and mRUST scores ranged from 5 to 16. Intraclass correlation coefficients (ICCs) were 0.89 (95% confidence interval [CI]: 0.78 to 0.94) for RUST and 0.86 (95% CI: 0.74 to 0.93) for mRUST, which fall within the "almost perfect agreement" category for ICCs. Spearman rank correlation coefficients (RS) showed correlation of RUST (RS range, 0.456 to 0.818) and mRUST (RS range, 0.519 to 0.862) with micro-CT measurements of mineralized callus volume (BV), total callus volume (TV), and BV/TV ratio, but less so with bone mineral density (BMD). Additionally, RUST (RS range, 0.524 to 0.863) and mRUST (RS range, 0.434 to 0.850) were correlated with some biomechanical properties. A RUST score of 10 or an mRUST score of 15 may be considered the threshold above which a plated bone is "healed" because, at these scores, 120% or 140% of failure torque, respectively, was achieved by the repaired femora as compared with the intact contralateral femora. RUST and mRUST both show strong statistical correlations with micro-CT and biomechanical parameters. RUST and mRUST scoring systems provide clinicians with validated, reliable, and available tools to assess the progress of fracture-healing.

Prediction of tibial nonunion at the 6-week time point

IntroductionIntramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST). MethodsA retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study. ResultsInfection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratio > or < 1.0; p < 0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6–9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST <6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion. ConclusionThree variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients.

Predictors of Reoperation for Adult Femoral Shaft Fractures Managed Operatively in a Sub-Saharan Country.

The optimal treatment for femoral shaft fractures in low-resource settings has yet to be established, in part, because of a lack of data supporting operative treatment modalities. We aimed to determine the reoperation rate among femoral fractures managed operatively and to identify risk factors for reoperation at a hospital in a Sub-Saharan country. We conducted a prospective clinical study at a single tertiary care center in Tanzania, enrolling all skeletally mature patients with diaphyseal femoral fractures managed operatively from July 2012 to July 2013. Patients were followed at regular intervals for 1 year postoperatively. The primary outcome was a complication requiring reoperation for any reason. Secondary outcomes were scores on the EuroQol (EQ)-5D, radiographic union score for tibial fractures (RUST), and squat-and-smile test. There were a total of 331 femoral fractures (329 patients) enrolled in the study, with a follow-up rate at 1 year of 82.2% (272 of 331). Among the patients with complete follow-up, 4 injuries were managed with plate fixation and 268 were managed with use of an intramedullary nail. The reoperation rate for plate fixation was 25% (1 of 4) compared with 5.2% (14 of 268) for intramedullary nailing (p = 0.204). As found in a multivariate logistic regression, a small nail diameter, a Winquist type-3 fracture pattern, and varus malalignment of proximal fractures were associated with reoperation. The mean EQ-5D score at 1 year was 0.95 for patients who did not require reoperation compared with 0.83 for patients who required reoperation (p = 0.0002). Intramedullary nailing for femoral shaft fractures was associated with low risk of reoperation and a nearly full return to baseline health-related quality of life at 1 year of follow-up. There are potentially modifiable risk factors for reoperation that can be identified and addressed through education and dissemination of these findings. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Medial Open Wedge High Tibial Osteotomy: Can Delayed or Nonunion Be Predicted?

The opening wedge approach to high tibial osteotomy (HTO) is perceived to have some advantages relative to the closing wedge approach but it may be associated with delayed and nonunions. Because nonunions evolve over months, it would be advantageous to be able to identify risk factors for and early predictors of nonunion after medial opening wedge HTO. We sought to determine whether (1) preoperatively identifiable patient factors, including tobacco use, body mass index > 30 kg/m(2), and degree of correction, are associated with nonunion, and (2) a modified Radiographic Union Score for Tibial Fractures (RUST) score, taken at 6 weeks and 3 months, would be predictive for delayed or nonunion after medial opening wedge HTO. The medical records and radiographs of 185 patients, 21 bilateral cases, treated with a medial open wedge HTO using the TomoFix(®) device were retrospectively evaluated. For all patients, demographic data regarding risk factors were collected from their records. Diagnosis for delayed or nonunion was already done earlier for standard medical care by the orthopaedic surgeon based on clinical and radiographic grounds. For the retrospective radiographic evaluation, a modified RUST score was used in which each tibial cortex is scored by one observer. Logistic regression analysis was used to identify preoperative and postoperative predictive factors for developing delayed or nonunion. In the series, a total of 19 patients (9.2%) developed clinically delayed/nonunion of whom 10 patients (4.9%) developed a nonunion. Smoking was identified as a risk factor for developing delayed/nonunion (19% for smokers versus 5.4% for nonsmokers; p = 0.005; odds ratio, 4.1; 95% confidence interval, 1.5-10.7). By contrast, body mass index, lateral cortical hinge fracture, age, infection, and degree of correction were not risk factors. Patients with delayed/nonunion had lower RUST scores at all time points when a radiograph was taken compared with the total study group. The RUST score at 6 weeks and 3 months after surgery and the use of tobacco were identified as predictive factors for development of delayed union and nonunion after open wedge HTO. Based on these results, we now actively try to stop patients from smoking and these data are helpful in doing that. The RUST score may be of use to identify which patients are at risk for developing a delayed union so that interventions may be offered earlier in the course of care. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

F1.4 Verification of the reliability of the Radiographic Union Score for Tibial Fractures in the follow-up of patients with tibia corpus fractures operated via the intramedullary nailing technique using the patients' clinical condition

Introduction: The aim of this study was to clinically verify the hypothesis of ‘Radiographic Union Score for Tibial Fractures (RUST)’ introduced in 2010. Materials and Methods: Forty-one patients with tibia corpus fractures that had undergone intramedullary nailing at the Dokuz Eylul University Medical Faculty Orthopedics and Traumatology Department between 2005 and 2010, were included in the study. The Karlstrom-Olerud physical function scale evaluation was performed dduring the follow-up examinations. VAS at rest and during activity, and SF-36 physical function and pain scores were obtained according to this scale. Results: The patients were then radiographically evaluated and scored according to the RUST scoring system. The data were then compared to each other. As a result, the Radiographic Union Score for Tibial Fractures scoring system was found to be significant in terms of the p value when compared to the physical functions and pain scores of the patients. In other terms, when the union findings of the patients were physically good, the RUST scores were generally high. Furthermore, therewas significance in the comparisons of other parameters with each other. Conclusion: In the light of this information, the Radiographic Union Score for Tibial Fractures scoring system may be used in the future subsequent to wider studies, or at least it may be used as a source for further scoring systems

Development of the Radiographic Union Score for Tibial Fractures for the Assessment of Tibial Fracture Healing After Intramedullary Fixation

: The objective was to evaluate the newly developed Radiographic Union Score for Tibial fractures (RUST). Because there is no "gold standard," it was hypothesized that the RUST score would provide substantial improvements compared with previous scores presented in the literature. : Forty-five sets of X-rays of tibial shaft fractures treated with intramedullary fixation were selected. Seven orthopedic reviewers independently scored bony union using RUST. Radiographs were reassessed at 9 weeks. Intraclass correlation coefficients (ICC) with 95% confidence intervals (CI) measured agreement. : Overall agreement was substantial (ICC, 0.86; 95% CI, 0.79-0.91). There was improved reliability among traumatologists compared with others (ICC = 0.86, 0.81, and 0.83, respectively). Overall intraobserver reliability was also substantial (ICC, 0.88; 95% CI, 0.80-0.96). : The RUST score exhibits substantial improvements in reliability from previously published scores and produces equally reproducible results among a variety of orthopedic specialties and experience levels. Because no "gold standards" currently exist against which RUST can be compared, this study provides only the initial step in the score's full validation for use in a clinical context.