Utilizing the Radiographic Union Score for Hip (RUSH) to Evaluate the Healing of Subtrochanteric Fractures after Intramedullary Fixation

doi:10.21203/rs.3.rs-3241220/v1

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Research Article

Utilizing the Radiographic Union Score for Hip (RUSH) to Evaluate the Healing of Subtrochanteric Fractures after Intramedullary Fixation

https://doi.org/10.21203/rs.3.rs-3241220/v1

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published 09 Oct, 2024

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Background

Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing.

Methods

We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers reevaluated 47 randomly selected sets of radiographs. Subsequently, Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve.

Results

Based on overall impressions, the agreement level among orthopedic surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511–0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663–0.817). Regarding intraobserver reliability, there were significant differences among orthopedic surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670–0.868), 0.779 (95% CI: 0.681–0.876), and 0.771 (95% CI: 0.674–0.867), respectively.

Conclusions

Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic surgeons. We propose a cutoff value of 21 for determining fracture healing by simplifying the system to include eight cortical bone-related items.

hip fracture

intramedullary nail

fracture healing

radiological assessment

reliability

Due to the high load of the body and muscular strength, subtrochanteric fractures are more prone to mechanical complications, such as delayed fracture union and nonunion and hardware failures(1, 2). These complications result in more severe functional impairment and an increased disease burden. Hence, the assessment of fracture healing holds significant importance for orthopedic surgeons, as it directly influences critical management decisions for patients, including determining weight-bearing status, activity levels, and the necessity of revision surgery(3).

The clinical definition of fracture healing typically relies on various factors, including physical examination findings, imaging studies, and patient self-assessment(3). Plain radiographs remain the primary method for assessing fracture healing, but there is variation in the consistency of different observers(4). Given the poor agreement between orthopedic surgeons in judging tibial fracture healing, a landmark 2002 study by Whelan et al. found that by examining orthogonal radiographs and quantifying the amount of bridging cortical bone and visible cortical bone at the fracture line(5). On this basis, in 2010, Whelan et al. first proposed the Radiological Healing Score (RUST) scoring system for tibial fractures(6). Since its introduction, researchers have conducted numerous studies to assess the reliability of the RUST scoring system. A high degree of intraobserver consistency and interobserver reliability was achieved(7, 8). The results showed that both RUST and modified RUST showed statistically solid correlations with micro-CT and biomechanical parameters(9).

Based on the RUST scoring system, Bhandari et al. further developed the Radiographic Union Score for Hip fractures (RUSH) to assess femoral neck fracture healing, improving the consistency of radiographic determination of fracture healing and enhancing interobserver and intraobserver reliability(10). However, to our knowledge, there have been no reports on using this scoring system to assess the healing of subtrochanteric fractures.

Overview

The hospital ethics committee approved our research. We retrieved patient data from the medical records database from January 1, 2014, to December 31, 2021, for a total of 443 patients diagnosed with "intertrochanteric fracture of the femur," "fracture of the greater trochanter," or "subtrochanteric fracture," who underwent internal fixation surgery. We selected 94 sets of anteroposterior and lateral X-ray films of the proximal femur, independently judged by six orthopedic surgeons based on subjective impressions to determine whether the fractures healed. Then, the same imaging data were scored by the same observers using the Radiographic Union Score for Hip (RUSH). After four weeks, the research designer selected 47 imaging data sets from the 94 sets and randomly assigned them to the same observers for reevaluation based on subjective impressions and RUSH scoring. Subsequently, a consensus meeting was held by the study designer and observers to reveal the follow-up radiograph timing and series of follow-up X-ray films for the same cases, reaching a consensus on whether each group of X-ray films depicted healed fractures. Figure 1 illustrates a summary of our study method.

Observers

Our review panel comprised three orthopedic residents who had completed residency training (with an average orthopedic clinical practice experience of 3.3 years, ranging from 3 to 4 years) and three orthopedic attending physicians with expertise in the treatment of hip fractures (with an average experience of 10.0 years, ranging from 9 to 12 years). We recruited observers from two distinct seniority groups to investigate potential variations in scoring based on work experience and to evaluate the reliability of the RUSH scoring system.

Selection of Imaging Data

A follow-up imaging dataset includes an anteroposterior X-ray and a lateral X-ray of the proximal femur on the affected side of a patient. The inclusion criteria were as follows: ① Subtrochanteric fractures treated with an intramedullary nail; ② The timing for X-ray imaging was at least three weeks after surgery; ③ The time interval between the X-ray films of the same case was at least 30 days; and ④ We obtained a clinical result of fracture healing or failure. The exclusion criteria were as follows: ① other types of hip fractures; ② fixation using a plate or dynamic hip screw; and ③ incomplete preoperative or postoperative follow-up imaging data. Ultimately, the study included 38 cases and 94 follow-up imaging datasets that met the above criteria.

The selected imaging data represent various stages of recovery, with 18.0% of the images taken between 3 and 6 weeks after the initial surgery, 22.3% taken from 7 to 12 weeks, 22.3% taken from 13 to 24 weeks, 17.0% taken from 25 to 52 weeks, and 20.2% taken after 52 weeks. Personal information such as names, gender, hospital admission numbers, and time stamps were anonymized. The reviewing physicians were unaware of the follow-up times, and there were no potential markers, such as suture pins. The reviewers didn't participate in the case selection or imaging data processing.

Instruction of the RUSH Score

Bhandari et al. developed the Radiographic Union Score for Hip (RUSH) with a methodology such as the Radiographic Union Score for Tibial (RUST)(10). Its purpose is to standardize the assessment of fracture healing based on plain radiographs. This scoring system was developed by considering various definitions and criteria of fracture healing from the literature, such as bone bridging and disappearance of the fracture line(5). The RUSH score incorporates four component scores: cortical bridging, cortical fracture line disappearance, cancellous bone calcification, and cancellous bone fracture line disappearance, and the total RUSH score ranges from a minimum of 10 to a maximum of 30. Chiavaras et al. explained the indicators and scoring criteria of the RUSH scoring system in their literature (11).

Evaluation of Fracture Healing and RUSH score

The observers initially evaluated the healing status of the fracture based on their subjective impression of the set of imaging data, selecting between the options of "healed" or "not healed." While fracture healing is not a binary all-or-nothing outcome, the radiographs taken during the healing process demonstrate gradual changes. However, only orthopedic surgeons deem fully healed fractures are classified as "healed." Subsequently, each reviewer filled out the RUSH checklist for the same radiographs, which included specific inquiries regarding cortex bridging and trabecular consolidation across the fracture. Figure 2 displays X-ray images taken during two follow-up periods of the same patient and their corresponding RUSH scores.

Procedure for the Adjudication of Fracture Healing

If different surgeons evaluating the same patient arrive at similar conclusions about fracture healing, we will ensure excellent service to the patient. As a result, we made interobserver reliability our main evaluation focus while also investigating intraobserver variability. The study designer randomly uploaded the 94 digital radiograph sets to a secure, password-protected electronic adjudication platform system for online display. All reviewers received training in using the system and RUSH scoring to view and access X-ray photographs. Observers had 14 days to review these imaging data on the electronic adjudication platform and complete a fracture healing assessment for each case. Their judgments are independent, and reviewers are irrelevant to colleagues' reviews.

After four weeks, the study designer (ZTJ) selected 47 of the original 94 image files, rerandomized them, and uploaded them. We gave the reviewers an additional two weeks to reevaluate the imaging data. The questionnaires from the two assessments were gathered and summarized in a table. The study designer arranged a consensus meeting involving all reviewing doctors and disclosed the timing of follow-up and serial follow-up radiographs of the same case. Ultimately, the participants reached a consensus on whether the fractures had healed based on the provided imaging data for each group.

Data Analysis

The formula [2× (number of reviewers)²] is usually used for sample size calculation in consistency studies(12). We had six observers; the sample size requirement was 72 cases (2×6²). According to the above sample size requirements, the sample size of 94 sets of image data is sufficient to achieve good statistical accuracy. We used the Fleiss-kappa (κ) coefficient to evaluate the consistency of multiple reviewers' subjective judgments on fracture healing. As the RUSH score is a continuous variable ranging from 10 to 30, the intraclass correlation coefficient (ICC) was employed to assess the consistency among observers. Both kappa (κ) and ICC values range from − 1.00 (indicating absolute disagreement) to 1.00 (indicating total agreement). According to the guidelines proposed by Landis and Koch, kappa values between 0.00 and 0.20 are categorized as poor agreement, 0.21 to 0.40 as fair agreement, 0.41 to 0.60 as moderate agreement, 0.61 to 0.80 as substantial agreement, and 0.81 to 1.00 as almost perfect agreement(13). Finally, we conducted regression analysis and ROC analysis to explore the possibility of optimizing the RUSH scoring criteria, specifically the overall score, the overall score for cortical bone items, and the overall score for cancellous bone items.

Overall Impression of Fracture Healing

Overall, the consistency of orthopedic doctors in their subjective judgments of fracture healing was moderate (kappa = 0.564, 95% CI: 0.511–0.616). When analyzed by subgroup, the consistency among resident doctors (kappa = 0.658, 95% CI: 0.542–0.775) was slightly higher than that among senior attending doctors (kappa = 0.486, 95% CI: 0.370–0.603). However, after four weeks, the consistency among orthopedic doctors in their overall impression-based judgments of fracture healing decreased to a fair level (kappa = 0.324, 95% CI: 0.250–0.398). Among the senior attending doctors, the consistency (kappa = 0.450, 95% CI: 0.294–0.624) was higher than that among the resident doctors (kappa = 0.133, 95% CI: 0.032–0.298). There is substantial variation in the intraobserver reliability among orthopedic doctors in their subjective judgments of fracture healing after a 4-week interval. Specifically, one observer shows almost perfect agreement, one demonstrates a high level of consistency, three exhibit moderate, and one shows poor. Table 1 illustrates the specific kappa values for intraobserver reliability among different observers.

Table 1

Intraobserver reliability of fracture healing assessment based on orthopedic surgeons' subjective impressions.
Residents			Attendings
Number	Kappa	Significance(P)	Number	Kappa	Significance(P)
Reviewer1	0.823	0.000	Reviewer 3	0.782	0.000
Reviewer2	0.081	0.480	Reviewer 4	0.496	0.001
Reviewer6	0.443	0.001	Reviewer 5	0.394	0.003

Subjective Assessment and Consensus on Fracture Healing

The initial evaluation revealed a moderate-level correlation, as indicated by the Kendall tau-b correlation coefficient, between each observer's subjective assessment of fracture healing and the final consensus. Table 2 presents detailed correlation coefficients.

Table 2

༎The correlation between subjective impressions-based judgments and the consensus on fracture healing(First round).
Residents			Attendings
Number	Kendall tau-b	95%CI	Number	Kendall tau-b	95%CI
Reviewer1	0.462	0.348–0.563	Reviewer 3	0.564	0.464–0.650
Reviewer2	0.658	0.574–0.729	Reviewer 4	0.666	0.583–0.736
Reviewer6	0.577	0.479–0.661	Reviewer 5	0.508	0.399–0.602
Note: 95%CI*(95% confidence intervals).

In the second evaluation, the Kendall tau-b correlation coefficients between the observers' subjective assessments of fracture healing and the final consensus on union varied significantly, ranging from low to high correlation. Table 3 displays these specific coefficients.

Table 3

The correlation between subjective impressions-based judgments and the consensus on fracture healing(Second round).
Residents			Attendings
Number	Kendall tau-b	95%CI	Number	Kendall tau-b	95%CI
Reviewer1	0.282	0.092–0.452	Reviewer 3	0.498	0.336–0.632
Reviewer2	0.393	0.215–0.547	Reviewer 4	0.207	0.012–0.386
Reviewer6	0.440	0.268–0.585	Reviewer 5	0.737	0.633–0.815
Note: 95%CI*(95% confidence intervals).

Interobserver and intraobserver agreement of the RUSH score

Among the 94 cases of imaging data in the initial evaluation, there was a high level of agreement among all orthopedic surgeons in the total score obtained using the RUSH scale (ICC = 0.748, 95% CI: 0.663–0.817). The ICC was 0.787 (95% CI: 0.706–0.849) when using the cortical-only total score, which includes cortical bridging and the cortical fracture line. The cancellous-only total score, which considers trabecular calcification and the cancellous fracture line, had an ICC of 0.668 (95% CI: 0.589–0.744). When analyzing the data by grouping, senior attendings showed higher consistency in RUSH total scores compared to residents (senior attendings: ICC = 0.780, 95% CI: 0.643–0.862; residents: ICC = 0.674, 95% CI: 0.527–0.779). The analysis of individual items of the RUSH score revealed moderate to high agreement among the scores for each element. Table 4 displays the specific ICC values for each item.

Table 4

Interobserver agreement for the first assessment of RUSH component scores
Item	ICC	95%CI	Index	ICC	95%CI
Cortex Bridging-A*	0.543	0.441–0.642	Cortex Fracture Line-A*	0.583	0.499–0.669
Cortex Bridging-P*	0.544	0.442–0.642	Cortex Fracture Line-P*	0.587	0.497–0.675
Cortex Bridging-M*	0.482	0.375–0.588	Cortex Fracture Line-M*	0.633	0.551–0.713
Cortex Bridging-L*	0.557	0.454–0.655	Cortex Fracture Line-L*	0.642	0.563–0.720
Trabecular Consolidation	0.522	0.417–0.624	Trabecular Fracture Line	0.557	0.457–0.654
Note: A: anterior; P: posterior; M: medial; L: lateral. ICC* (intraclass correlation coefficient), 95%CI*(95% confidence intervals).

After four weeks, the orthopedic surgeon reassessed the RUSH scores for the 47 imaging data sets. The interobserver agreement for the total RUSH score decreased (ICC = 0.574, 95% CI: 0.397–0.721). However, the senior attending physician group (0.698, 95% CI: 0.550–0.810) still exhibited higher consistency than the resident physician group (ICC = 0.554, 95% CI: 0.246–0.748).

Statistical analysis of internal consistency among the observers revealed that after four weeks, two observers from the senior attending group demonstrated nearly perfect intraobserver agreement, while one observer achieved a high degree of consistency, with respective ICC values of 0.859, 0.642, and 0.825. Among the resident physicians, the intraobserver agreement after four weeks was almost perfect, moderate, and high, with ICC values of 0.828, 0.523, and 0.642, respectively (Table 5).

Table 5

Intraobserver consistency of the RUSH score
Residents			Attendings
Number	ICC*	95%CI*	Number	ICC*	95%CI*
Reviewer1	0.828	0.711-0.900	Reviewer 3	0.859	0.717–0.926
Reviewer2	0.523	-0.062-0.794	Reviewer 4	0.642	0.438–0.784
Reviewer6	0.642	0.391–0.795	Reviewer 5	0.825	0.700–0.900
Note: ICC* (intraclass correlation coefficient), 95%CI*(95% confidence intervals).
ROC Analysis of the RUSH Score

We performed regression analysis on the average total RUSH score, average cortical bone item score, and average cancellous bone item score and plotted ROC curves (Fig. 3) accordingly. The results showed a strong correlation between all three indicators and fracture healing consensus, with respective AUC values of 0.769 (95% CI: 0.670–0.868), 0.779 (95% CI: 0.681–0.876), and 0.771 (95% CI: 0.674–0.867). The optimal cutoff values determined by the Youden index are 25.917, 21.415, and 4.915, respectively. The AUC for the cortical bone score item was the highest. In practical scoring, one can select a cortical bone item score greater than 21 as the criterion for determining fracture healing, corresponding to a sensitivity of 0.660 and a specificity of 0.864.

Subtrochanteric fractures generally refer to fractures in which the center of the fracture is located 5 cm below the lower edge of the lesser trochanter(14). Fractures in this region primarily affect the cortical bone, with the fracture line extending into the cancellous bone within the trochanteric region. Therefore, using the RUSH score is highly suitable for determining the healing status of subtrochanteric fractures.

Our findings indicate that the consistency of subjective overall impression by orthopedic surgeons in assessing the healing of subtrochanteric fractures reached only a moderate level of agreement (Kappa = 0.564, 95% CI: 0.511–0.616). This level of consistency is higher than that reported by Chiavaras et al. for overall impression-based fracture healing assessment by radiologists and orthopedic surgeons regarding intertrochanteric fractures (ICC = 0.34, 95% CI: 0.11–0.52)(11), as well as the level of consensus achieved by Bhandari et al. between surgeons and radiologists in assessing the healing of intertrochanteric fractures (ICC = 0.50, 95% CI: 0.33–0.62)(15).

By utilizing the RUSH scoring system, we achieved a high level of consistency among the six observers (ICC = 0.748, 95% CI: 0.663–0.817). Our ICC value falls in between the values reported by Chiavaras (0.66)(11) and Bhandari (0.88)(15). Upon grouping, the senior attendings in our center demonstrated higher consistency in overall RUSH scores compared to the orthopedic residents. However, upon conducting a second round of RUSH scoring four weeks later, the general agreement among our observers slightly decreased (ICC = 0.574, 95% CI: 0.397–0.721), although the consistency in the group of senior attendings (0.698, 95% CI: 0.550–0.810) remained higher than that in the group of residents.

Analysis of intraobserver agreement revealed that after four weeks, two observers among the senior residents reached an almost perfect agreement, while one got a high level of consistency. On the other hand, the orthopedic residents demonstrated almost perfect, moderate, and high levels of internal consistency. These data indicate that the intraobserver agreement of our orthopedic surgeons in utilizing the RUSH scoring system for subtrochanteric fractures is not as strong as the findings of the other two studies. However, the extensive experience of the senior orthopedic surgeons in interpreting X-ray images contributes to their higher consistency in scoring.

We performed separate analyses on cortical bone-related items and cancellous bone-related items. The ICC for cortical bone-related items was 0.787 (95% CI: 0.706–0.849) in the initial evaluation of 94 imaging data sets, whereas the ICC for cancellous bone-related items was 0.668 (95% CI: 0.589–0.744). Our findings demonstrate that orthopedic surgeons indicate a higher level of consistency in assessing "cortical bridging formation" and "disappearance of cortical fracture lines." On the contrary, accurately distinguishing the disappearance of fracture lines and evaluating the degree of trabecular calcification in the cancellous bone region of subtrochanteric fractures poses more significant challenges for orthopedic surgeons. In the RUSH scoring system, Chiavaras et al. conducted separate statistical analyses for the components of fracture line disappearance, including four cortical areas and one cancellous area, as well as the items related to calcification, which included cortical bridging and cancellous trabecular consolidation. The ICC values for consistency in these two items were 0.68 (95% CI: 0.56–0.77) and 0.57 (95% CI: 0.43–0.69), respectively (11). The reliability of this method of splitting was lower than that of our analysis.

By conducting regression analysis and plotting ROC curves, we discovered strong correlations between the average total RUSH score, average cortical bone item score, average cancellous bone item score, and consensus on fracture healing. The optimal cutoff thresholds were 25.917, 21.415, and 4.915. For practical convenience, we selected a cutoff value of 21 points for the total score of cortical bone-related items, resulting in improved sensitivity (0.660) and specificity (0.864) for determining fracture healing. This threshold indicates that our central orthopedic surgeon has adopted stricter criteria for judging the healing of subtrochanteric fractures, allowing only minimal visibility of cortical bone fracture lines or no presence of callus in one direction. However, Frank et al. evaluated postoperative X-rays of 250 cases of hip fractures treated with cancellous bone screws or sliding hip screws using the RUSH score at six months. Their study involved only two observers and achieved high interobserver consistency (ICC = 0.81, 95% CI: 0.76–0.85). Additionally, the ROC analysis found that a threshold of RUSH < 18 was associated with 100% specificity and 100% positive predictive value for radiographic nonunion(12).

Our study has some limitations as well. For instance, our orthopedic surgeons were all new to using the RUSH scoring system. Despite receiving training before scoring, there may be differences in their understanding and interpretation. Additionally, due to the low occurrence rate of subtrochanteric fractures, we had to select multiple sets of X-ray images from some patients at different follow-up times. Although we randomized the order of these images twice, there is still a possibility of some bias remaining. Furthermore, during the X-ray imaging process, operator habits and patient cooperation variations sometimes prevented us from obtaining ideal orthogonal views for both the frontal and lateral images. Some images were oblique views, which could have adverse effects on scoring. However, this reflects the real-world clinical situation and enhances the generalizability of our findings.

To summarize, our study demonstrates that utilizing the RUSH scale enhances the consistency of evaluating subtrochanteric fracture healing among orthopedic surgeons, regardless of their experience level. A simplified RUSH scoring system, focusing on eight cortical bone-related items, can be utilized in subtrochanteric fractures. It is essential to acknowledge that the ideal method for assessing fracture healing should incorporate clinical and radiographic assessments. Future investigations should explore the impact of integrating clinically relevant information into this scale to enhance its reliability further.

Ethics approval and consent to participate：

The Medical Ethics Committee of Shenzhen People's Hospital approved the study, with the committee's reference number LL-KY-2021070. We confirm that appropriate informed consent was obtained from all subjects and/or their legal guardian(s). Our study did not involve any participants who were minors or illiterates.

Consent for publication

We obtained consent from all enrolled patients or authorized representatives the participating patients to anonymize their imaging data for publication purposes.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Science, Technology and Innovation Commission of Shenzhen Municipality funded this research under Grant Nos. JCYJ20200109144229150, JCYJ20190806152205452, and ZDSYS20200811143752005.

Authors' contributions

ZTJ conceived the study and was involved in its design, coordination, and manuscript drafting. RJK, ZX, LWX, YP, LJW, and ZT conducted the assessments and scoring of the radiographs and participated in consensus meetings. ZTJ performed the statistical analysis. JS and XZS contributed to assisting with the statistical analysis and manuscript editing. All authors have read and approved the final manuscript.

Acknowledgments

We want to thank Professor Yu Long Sun, Dr. Zi Hao Liu, and Dr. Qiang Lian for their assistance while writing this paper.

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No competing interests reported.

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Utilizing the Radiographic Union Score for Hip (RUSH) to Evaluate the Healing of Subtrochanteric Fractures after Intramedullary Fixation

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