Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?

Objectives To report the progression of radiographic after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early post-operative radiographs. Design Retrospective case series. Setting Urban academic Level 1 trauma center. Patients/participants 303 acute tibial shaft fractures underwent intramedullary nailing between 2006-2013, met inclusion criteria, and had at least three months of radiographic follow-up. Intervention Baseline demographic, injury, and surgical data were recorded for each patient. Each set of post-operative radiographs were scored using RUST and evaluated for implant failure. Main outcome measurements Post-operative time distribution for each RUST score, RUST score distribution for four common follow-up time points, and the presence and timing of implant failure. Results The 5th percentile and median times, respectively for reaching: any radiographic healing (RUST= 5) was 4.0 weeks and 8.4 weeks, radiographically (RUST=9) was 12.1 and 20.9 weeks, and healed and remodeled (RUST=12) was 23.5 weeks and 47.7 weeks. At six weeks, 84% of radiographs were scored as RUST≤6 (two or fewer cortices with callus). No implant failure occurred within the first eight weeks after surgery and the indication for all seven reoperations within this period was apparent on physical examination or immediate post-operative radiographs. Conclusions The median time to radiographic union (RUST=9) after tibial nailing was approximately twenty weeks and little radiographic occurred within the first eight weeks after surgery. Routine radiographs in this time period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.