Introduction: The Radiological healing score for tibia is a useful instrument to quantify fracture healing in tibial fractures. It is a validated score showing strong to almost perfect agreement between observers. The present study tends to evaluate the results of the score when applied on open tibial fractures stabilized with an intramedullary device.

Material and Methods: 60 cases of open tibial fractures that underwent intramedullary nailing were evaluated for fracture healing using the RUST score. 40 prospective cases and 20 retrospective cases were evaluated radiographically using standardized radiographs. Four observers, two of whom were orthopedic surgeons and two were radiologists, independently evaluated the radiographs to determine a score. Interobserver reliability and Intraobserver reliability was statistically calculated using the interclass correlation co-efficient (ICC).

Results: This was a longitudinal cohort study involving 60 patients who were treated for open tibial fractures. At 6 months the median RUST scores for all 60 patients were 9.5. At 6 months the interobserver agreement was excellent and statistically significant (ICC 0.911).

For the prospective cases, The Inter-rater agreement amongst observers for RUST score was found to be good and statistically significant at 6 weeks (ICC 0.872) that improved to excellent at 6 months (ICC 0.962).

Discussion: Radiological assessment of fracture healing is accepted universally due to its availability and low costs. However, it is still a subjective interpretation of data and can be misleading. The RUST score tends to address these shortcomings by applying a numerical value to various parameters visible on radiographs. To avoid the pitfall of subjectivity, the score has been subsequently validated in studies applying inter and intra observer reliability when independently observed by number of evaluators. This study tends to confirm that there is an almost perfect agreement amongst observers across various specialties when the RUST score is applied for open tibial fractures treated with intramedullary nailing. 

Keywords- Tibial fractures, RUST score, Intramedullary nailing, Interobserver reliability.

1. Bhandari M, Guyatt G, Swiontkowski M, schemitsch E. treatment of open fractures of the shft of the tibia. J Bone Joint Surg 2001;83(1): 62-68
2. Panjabi M, Walter S, Karuda M, white A, Lawson J. Correlations of radiographic analysis of healing fractures with strength: A statistical analysis of experimental osteotomies. J Orthop Res 1985; 3 (2): 212-218
3. Corrales L, Morshed S, Bhandari M, Miclau T. variability in the assessment of fracture healing in orthopedic trauma studies. J Bone joint Surg 2008; 90 (9): 1862-1868
4. Hammer R, Hammerby S, Lindholm B. Accuracy of radiologic assessment of tibial shaft fracture union in humans. Clin Orthop Relat Res 1985; 199: 233-238
5. Lane J, Sandhu H. Current approaches to experimental bone grafting. Orthop Clin North Am 1987; 18: 213-225
6. Whelan D, Bhandari M, Mckee M, Guyatt G, Kreder H, Stephan D et al. Inter-observer and Intra-observer variation in the assessment of healing of tibial; fractures after intramedullary fixation. J Bone Joint Surg 2002; 84 (1): 15-18
7. Bhandari M, Guyatt G, Swiontkowski M, Tornetta P, Sprague S, Schemitsch E. A lack of consensus in the assessment of fracture healing amongst orthopedic surgeons. J Orthop Trauma 2002; 16 (8): 562-566
8. Whelan D, Bhandari M, Stephan D, Kreder H, Mckee M, Zdero R et al. Development of the radiographic union Score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma Injury Infect Crit Care 2010; 68 (3): 629-632
9. Krestan CR, Noske H, Vasilevska V, Weber M, Scheuller G, Imhof H, Czerny C.MDCT Versus Digital radiography in the evaluation of bone healing in Orthopedic patients. Am J Radiol 2006; 186:1754-1760
10. Smith MA, Jones EA, Strachan RK, Nicoll JJ, Tothill P, Hughes SPF. Prediction of fracyure healing in the tibia by quantitative radionuclide imaging. J Bone Joint Surg1987; 69 (3): 441-447
11. Claes LE, Cunningham JL. Monitoring the mechanical properties of healing bone. Clin Orthop Relat Res 2009; 467 (8): 1964-1971
12. Cekic E, Alici E, Yesil M. Reliability of radiographic union score for tibial fractures. Acta Orthop Traumatol Turc 2014; 46 (4): 746-750
13. Kooistra BW, Dijkamn BG, Busse JW, Sprague S, Schemitsch EH, Bhandari M. The radiographic union score in tibial fractures: Relaibility and Validity. J Orthop Trauma 2010; 24 Suppl. 3: S81-86
14. Leow J, Clement N, Tawonsawatruk T, Simpson C, Simpson A. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an imndependant center. Bone Joint Res 2016; 5(4): 116-121
15. Azevedo FF, Cotias R, Azi M, Teixiera A. Reliability of the radiographic union scale in tibial fractures (RUST). Revista Brasil-eira de Orthopedia 2017; 52 (1): 35-39
16. Mohit B, Bauke W, Jason B, Stephan W, Paul T, Emil S. Radiographic union scale for tibial (RUST) fracture healing assessment: preliminary validation. J Bone Joint Surg 2011; 93 Suppl. IV: 575
17. Tawonsawatruk T, Hamilton DF, Simpson HRW. Validation of the use of Radiographic fracture-healing score in a small animal model. J Orthop Res 2014: 1117-1119
18. Steiner M, Claes L, Ignatius A, Simon U Wehner T. Optimization of intramedullary nailing by numerical simulation of fracture healing. J Orthop Res 2012; 30(4): 569-573
19. Chehade MJ, Vakaci IA, Callary SA, Findlay DM, Solomon LB. Differentially loaded Radiostereometric Analysis in Torsion adds essential informationin Diaphyseal bone healing: the example of a tibial osteotomy. J Bioengineer & Biomedical Sci 2011 S1: 004.

Vineet Aggarwal

Professor, Department of Orthopedics

Indira Gandhi Medical College, Shimla, India