Assessment of Radiographic Fracture Healing in Patients With Operatively Treated Femoral Neck Fractures

Bhandari, Mohit; Chiavaras, Mary M.; Ayeni, Olufemi R.; Chakraverrty, Rajesh; Parasu, Naveen; Choudur, Hema; Bains, Simrit; Sprague, Sheila; Petrisor, Brad

doi:10.1097/bot.0b013e318282e692

Cited by 48 publications

(27 citation statements)

References 18 publications

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“…In the initial study completed assessing the RUSH checklist, reviewers were provided with a single radiograph for each case, and were unaware of when it was obtained with regard to surgery [11]. In the previous study, overall impression of fracture healing resulted in only fair agreement for both femoral neck (ICC = 0.22, 95% CI: 0.01-0.41) and intertrochanteric fractures (ICC = 0.34, 95% CI: 0.11-0.52).…”

Section: Resultsmentioning

confidence: 99%

“…This checklist was developed analogous to the Radiographic Union Score for Tibial fractures (RUST) checklist [12], and was piloted among surgeons and radiologists to ensure early face and content validity. The RUSH checklist was first used in an earlier study we conducted that assessed hip fracture healing agreement using a single radiograph; reviewers were unaware of the time from surgery for each radiograph [11]. It was developed in an effort to standardize hip fracture healing assessment and incorporated several definitions of fracture healing found in the literature, including cortical and trabecular bridging and fracture line disappearance.…”

Section: Methodsmentioning

confidence: 99%

“…Results from the overall impression of fracture healing and the score from the RUSH checklist were then compared to the above mentioned study that was completed previously to determine if agreement in the present study was improved [11]. …”

Section: Methodsmentioning

confidence: 99%

“…The objectives in this study were therefore to: 1) evaluate inter-observer hip fracture healing agreement between surgeons and radiologists, 2) evaluate the performance of a previously developed checklist the Radiographic Union Score for Hip (RUSH) for fracture healing by examining its effect on inter-observer agreement, and 3) determine if agreement improved when using sequential radiographs in comparison to a previous study in which single radiographs with an unknown time from surgery were assessed [11]. We hypothesized improved agreement between surgeons and radiologists when compared to our previous study and improved agreement with the use of the RUSH checklist.…”

Section: Introductionmentioning

confidence: 99%

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Radiographic union score for hip substantially improves agreement between surgeons and radiologists

Bhandari

Chiavaras

Parasu

et al. 2013

BMC Musculoskelet Disord

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BackgroundDespite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.MethodsA panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.ResultsThe agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.ConclusionsAgreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Radiographic union score for hip substantially improves agreement between surgeons and radiologists

Bhandari

Chiavaras

Parasu

et al. 2013

BMC Musculoskelet Disord

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“…The Radiographic Union Score for Hip (RUSH) is a previously validated tool that improves fracture healing agreement between radiologists and orthopaedic surgeons by using a checklist-based scoring approach [1,2,5]. Using this tool to grade the healing of femoral neck fractures leads to better agreement with respect to radiographic healing and improved intra-and interobserver reliability [5].…”

Section: Introductionmentioning

confidence: 99%

The Radiographic Union Score for Hip (RUSH) Identifies Radiographic Nonunion of Femoral Neck Fractures

Frank

Osterhoff

Sprague

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background The Radiographic Union Score for Hip (RUSH) is a previously validated outcome instrument designed to improve intra-and interobserver reliability when describing the radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining nonunion in clinical trials and predicting patients who will likely require additional surgery to promote fracture healing. We sought to investigate the utility of the RUSH score to define femoral neck fracture nonunion. Questions/purposes (1) What RUSH score threshold yields at least 98% specificity to diagnose nonunion at 6 months postinjury? (2) Using the threshold identified, are patients below this threshold at greater risk of reoperation for nonunion and for other indications? Methods A representative sample of 250 out of a cohort of 725 patients with adequate 6-month hip radiographs was analyzed from a multinational elderly hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the 6-month postinjury radiographs and interrater reliability was assessed with the interclass correlation coefficient (ICC). There was substantial reliability between the reviewers assigning the RUSH scores (ICC, 0.81; 95% confidence interval [CI], 0.76-0.85). The RUSH score is a checklist-based system that quantifies four measures of healing: cortical bridging, cortical fracture disappearance, trabecular consolidation, and trabecular fracture disappearance.. Fracture healing was determined by two independent methods: (1) concurrently by the treating surgeon using both clinical and radiographic assessments as per routine clinical care; and (2) retrospectively by a Central Adjudication Committee using complete obliteration of the fracture line on radiographs alone. Receiver operating characteristic tables were used to 123Clin Orthop Relat Res (2016) 474:1396-1404 DOI 10.1007 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons® define a RUSH threshold score that was [ 98% specific for fracture nonunion. Results A threshold score of \ 18 was associated with a 100% specificity (95% CI, 97%-100%) and a positive predictive value of 100% (95% CI, 73%-100%) for radiographic nonunion. In contrast, using the fracture healing assessments of the treating surgeons failed to identify a useful discriminatory nonunion threshold and the highest positive predictive value was 43%. With respect to complications, patients with RUSH scores below 18 had greater risk of undergoing reoperation for nonunion ( Conclusions The 6-month RUSH score is a reliable method for assessing radiographic healing. Our results highlight the discordance between radiographic determinations and clinician assessments of fracture healing and stress the need for clinical data to be incorporated in research studies evaluating fracture healing. Level of Evidence Le...

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Short and long‐term outcomes of three‐dimensional printed surgical guides and virtual surgical planning versus conventional methods for fibula free flap reconstruction of the mandible: Decreased nonunion and complication rates

et al. 2021

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BackgroundTo determine whether virtual surgical planning and three‐dimensional printed cutting guides (3D/VSP) improved radiographic bone union compared to conventional methods (CM) in fibula free flap (FFF) reconstruction of the mandibles.MethodsRetrospective study from the years 2000–2018 at a tertiary hospital. Osseous union was evaluated by a radiologist blinded to each patient's treatment.ResultsTwo hundred sixty patients who underwent FFF tissue transfer, 28 with VSP and 3D cutting guides. Bony union was not achieved in 46 (20%) patients who underwent CM compared to 1 (4%) of patients with VSP and guides (p = 0.036). FFF complication was significantly higher in CM with 87 patients (38%) compared to three patients (11%) in 3D/VSP (p = 0.005). Median time to bony union for patients who underwent CM was 1.4 years compared to 0.8 years in 3D/VSP.Conclusions3D/VSP reduced the rate of radiographic nonunion and flap‐related complications in FFF reconstruction for mandibular defects.

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Assessment of Radiographic Fracture Healing in Patients With Operatively Treated Femoral Neck Fractures

Cited by 48 publications

References 18 publications

Radiographic union score for hip substantially improves agreement between surgeons and radiologists

Radiographic union score for hip substantially improves agreement between surgeons and radiologists

The Radiographic Union Score for Hip (RUSH) Identifies Radiographic Nonunion of Femoral Neck Fractures

Short and long‐term outcomes of three‐dimensional printed surgical guides and virtual surgical planning versus conventional methods for fibula free flap reconstruction of the mandible: Decreased nonunion and complication rates

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