Department of Orthopedic Surgery, Shenzhen Key Laboratory of Musculoskeletal Tissue Reconstruction and Function Restoration, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, 518020, P.R. China.
The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, 510405, P.R. China.
BMC Musculoskelet Disord. 2024 Oct 9;25(1):798. doi: 10.1186/s12891-024-07902-3.
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.
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 trauma 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 re-evaluated 47 randomly selected sets of radiographs. 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.
Based on overall impressions, the agreement level among orthopedic trauma 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 trauma 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.
Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.
及时识别骨折愈合对于医疗决策和临床研究至关重要。本研究旨在评估髋关节放射评分（RUSH）在转子下骨折中的有效性，并确定骨折愈合的最佳评分阈值。
我们从 35 例接受髓内钉固定治疗转子下骨折的患者的术后随访中获得了 94 套 X 射线片。6 名创伤骨科医生根据主观判断评估影像学数据并确定骨折愈合情况。然后，他们使用 RUSH 表格对 X 射线图像进行评分。四周后，同一观察者重新评估了 47 套随机选择的 X 射线片。随后，观察者和研究设计师进行了共识会议，就骨折是否愈合达成一致。我们使用 Fleiss kappa 评估观察者基于主观印象的一致性，并使用组内相关系数评估 RUSH 评分的一致性。回归分析使用受试者工作特征（ROC）曲线研究评分与骨折愈合共识之间的关系。
根据整体印象，创伤骨科医生判断转子下骨折愈合状态的一致性水平为中度（Kappa=0.564，95%CI：0.511-0.616）。然而，使用 RUSH 评分系统可以提高一致性，达到实质性的一致水平（ICC=0.748，95%CI：0.663-0.817）。关于观察者内可靠性，创伤骨科医生在根据整体印象判断骨折愈合方面存在显著差异。然而，使用 RUSH 评分表格，主治医生组的观察者内一致性优于住院医生组。回归分析和 ROC 曲线分析表明，RUSH 总分、皮质骨评分、松质骨评分与骨折愈合共识之间存在很强的相关性。AUC 值分别为 0.769（95%CI：0.670-0.868）、0.779（95%CI：0.681-0.876）和 0.771（95%CI：0.674-0.867）。
本研究强调了 RUSH 评分系统在提高创伤骨科医生评估转子下骨折愈合的观察者间一致性和观察者内一致性方面的有效性。我们建议将 21 分作为简化 RUSH 评分系统判断骨折愈合的阈值。该系统仅包括与皮质骨相关的 8 项内容，总分为 24 分。
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