Functional assessment of long bone fracture healing in Samburu County Referral Hospital (Kenya): the squat and smile challenge

Abstract

Background: The burden of musculoskeletal trauma is increasing in low- and middle-income countries. Due to the low clinical follow-up rates in these regions, the Squat-and-Smile test (S&S) has previously been proposed as a proxy to assess bone healing (BH) capacity after surgery involving bone fractures. This study deals with various aspects of using S&S and bone radiography examination to obtain information about an individual's ability to recover after a trauma. In summary, we performed the S&S test to assess the possibility of recovering biomechanical function in lower limbs in a remote area of Kenya (Samburu County). Methods: Eighty-nine patients (17.9% F; 31.7 ± 18.9 yrs) who underwent intramedullary nail treatment for femur or tibia fractures were enrolled in this study. Both S&S [evaluated by a goal attainment scale (GAS)] and x-ray (evaluated by REBORNE, Bone Healing Score) were performed at 6 and 24 weeks, postoperatively. An acceptable margin for satisfactory S&S GAS scores was determined by assessing its validity, reliability, and sensitivity. Results: S&S GAS scores increased over time: 80.2% of patients performed a satisfactory S&S at the 24-weeks follow-up with a complete BH. A high correlation between S&S GAS and REBORNE at the 6- and 24- weeks’ timepoint was found. Facial expression correlated partially with BH. The S&S proved to be accurate at correctly depicting the BH process (75% area fell under the Receiver Operator Curve). Conclusion: The S&S provides a possible substitution for bone x-ray during BH assessment. The potential to remotely follow up the BH is certainly appealing in low- and middle-income countries, but also in high-income countries; as was recently observed with the Covid-19 pandemic when access to a hospital is not conceivable.

Predictors of nonunion for transverse femoral shaft fractures treated with intramedullary nailing: a SIGN database study

“… 24 Functional healing has been assessed using the S&S test, the patient's ability to perform an unassisted active knee range-of-motion squat, which we have shown to indicate earlier healing compared with radiographic evaluation, but its utility as a measure of healing is controversial. 17 , 20 , 25 , 26 Of the 84 patients in our cohort who had an S&S test, 83.3% of them were considered functionally healed which is similar to Scuito et al 17 who found 80.2% of their 89 patient cohort with femoral fractures were able to pass the S&S test at 24 weeks. Our findings comparing S&S with radiographic healing showed a significant correlation between the 2 tests which may add validity to the S&S examination.…”

“…While nonunion can be assessed for radiographic, clinical, or functional healing, this study focused primarily on radiographic and functional healing. 14,17,18 Radiographic union and nonunion have been reliably assessed using the mRUST score. [13][14][15]19 This study found the union rate for transverse femur fractures to be 61.0% based on mRUST score at a minimum of 9-month follow-up.…”

“…Images of patients in an active knee range-of-motion squat (Squat and Smile or S&S) has been previously established as an effective method in determining bone healing and clinical weight-bearing in patients undergoing IMN of the femur. 17 We assessed S&S images of patients at the same follow-up appointment in which mRUST was measured and scored each patient's ability to squat below their knee line. Scoring of active knee range-of-motion images was performed by 2 independent reviewers (B.C., B.J.).…”