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VOLUME 19 , ISSUE 2 ( May-August, 2024 ) > List of Articles

ORIGINAL RESEARCH

Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications

Anne Kummer, Luan Nieuwoudt, Leonard Charles Marais

Keywords : Bone transport, Critical bone defect, Distraction osteogenesis, Docking site, Docking site complication, Frame removal, Ilizarov frame, Modified RUST score, Segmental bone loss

Citation Information : Kummer A, Nieuwoudt L, Marais LC. Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications. 2024; 19 (2):73-81.

DOI: 10.5005/jp-journals-10080-1621

License: CC BY-NC 4.0

Published Online: 14-08-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Abstract

Aim: Reconstruction of segmental bone defects with bone transport is a well-established treatment. Mechanical complications at the docking site after frame removal are common. These complications include malunion, non-union, axial deviation and refracture. A simple tool to assess the healing of the docking site is currently lacking. The aim of this study is to evaluate the use of the modified RUST (mRUST) score in the setting of bone transport and to identify factors associated with an increased risk of docking site complications. Methods: This retrospective study was conducted at a single tertiary centre in South Africa, included 24 patients with a tibial bone defect treated with bone transport and a circular frame between 2014 and 2023. Demographic data, clinical and bone transport characteristics were recorded. Mechanical complications, such as fracture, non-union, any angulation >5°, shortening >5 mm, or any other complication requiring reoperation, were recorded. The mRUST was adapted as a ratio for the purpose of this study to overcome the common occurrence of cortices being obscured by the frame. The mRUST ratio was applied before and after frame removal for each patient by three appraisers. Comparison between the groups with and without complications was performed regarding bone transport characteristics, docking site configuration and mRUST ratio. The correlation of the score between radiographs before and after frame removal was assessed. The inter-rater reliability of the mRUST was analysed using Fleiss Kappa statistics for each cortex individually and the intraclass correlation coefficient (ICC) for the mRUST ratio. Results: In this study, 20 men and 4 women with a median age of 26 years were included. The overall rate of mechanical complications after frame removal was 21.7%. Complications were all related to the docking site, with two angulations, two fractures and one non-union. Demographics, bone transport characteristics and mRUST ratio before and after frame removal were similar between the two groups. Regarding the configuration of the docking site, an angle of 45° or more between the bone surfaces was associated with the occurrence of mechanical complications (p < 0.001). The correlation of the mean mRUST ratio before and after frame removal showed a moderate relationship, with a Spearman correlation coefficient of 0.50 (p-value 0.13). The inter-rater reliability of the mRUST was “fair” (kappa 0.21–0.40) for the scoring of individual cortices, except for one score which was “slight” (kappa 0.00–0.20). The ICC of the mRUST ratio was 0.662 on radiographs with the frame, and 0.759 after frame removal. Conclusion: This study did not find the mRUST or mRUST ratio useful in assessing the healing of the docking site to decide on the best time to remove the frame. However, a notable finding was that the shape and orientation of the bone ends meeting at the docking site might well be relevant to decrease complication rates. If the angle between the bony surfaces is 45° or more, it may be associated with an increased risk of complications. It may be worthwhile considering reshaping these bone ends at the time of debridement or formal docking procedure to be more collinear, in order to reduce the potential for mechanical complications such as non-union, axial deviation or refracture at the docking site.

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  1. Ferreira N, Tanwar YS. Systematic approach to the management of post-traumatic segmental diaphyseal long bone defects: Treatment algorithm and comprehensive classification system. Strateg Trauma Limb Reconstr 2020;15(2):106–116. DOI: 10.5005/jp-journals-10080-1466.
  2. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop 1992;(280):143–152. PMID: 1611734.
  3. Lavini F, Dall'Oca C, Bartolozzi P. Bone transport and compression-distraction in the treatment of bone loss of the lower limbs. Injury 2010;41(11):1191–1195. DOI: 10.1016/j.injury.2010.09.030. Epub 2010 Oct 12.
  4. Aktuglu K, Erol K, Vahabi A. Ilizarov bone transport and treatment of critical-sized tibial bone defects: A narrative review. J Orthop Traumatol Off J Ital Soc Orthop Traumatol 2019;20(1):22. DOI: 10.1186/s10195-019-0527-1.
  5. Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: Effectiveness, complications and clinical results; A systematic review and meta-analysis. Bone Joint J 2013;95-B(12):1673–1680. DOI: 10.1302/0301-620X.95B12.32385.
  6. Yin P, Ji Q, Li T, et al. A systematic review and meta-analysis of Ilizarov methods in the treatment of infected nonunion of tibia and femur. PloS One 2015;10(11):e0141973. DOI: 10.1371/journal.pone.0141973.
  7. Catagni MA, Azzam W, Guerreschi F, et al. Trifocal versus bifocal bone transport in treatment of long segmental tibial bone defects. Bone Joint J 2019;101-B(2):162–169. DOI: 10.1302/0301-620X.101B2.BJJ-2018-0340.R2.
  8. Feng D, Zhang Y, Wu W, et al. Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects. J Orthop Surg 2023;18(1):889. DOI: 10.1186/s13018-023-04356-6.
  9. Thakeb MF, Kozman MA, ElGebeily MA, et al. Bone transport through induced membrane versus conventional bone transport in management of infected long-bone defects of lower limbs: A randomized controlled trial. J Orthop Trauma 2023;37(9):462–468. DOI: 10.1097/BOT.0000000000002613.
  10. Shyam AK, Singh SU, Modi HN, et al. Leg lengthening by distraction osteogenesis using the Ilizarov apparatus: A novel concept of tibia callus subsidence and its influencing factors. Int Orthop 2009;33(6):1753–1759. DOI: 10.1007/s00264-008-0660-6.
  11. Tirawanish P, Eamsobhana P. Prediction of callus subsidence in distraction osteogenesis using callus formation scoring system: Preliminary study. Orthop Surg 2018;10(2):121–127. DOI: 10.1111/os.12374.
  12. Ferreira N, Sabharwal S, Hosny GA, et al. Limb reconstruction in a resource-limited environment. SICOT-J 2021;7:66. DOI: 10.1051/sicotj/2021066.
  13. Iobst CA, Mohammed W, Colley R. Determining when it is safe to remove the external fixator: Results from a survey of the limb lengthening and reconstruction society. Orthopedics 2017;40(5):e876–879. DOI: 10.3928/01477447-20170810-06.
  14. Li R, Saleh M, Yang L, Coulton L. Radiographic classification of osteogenesis during bone distraction. J Orthop Res Off Publ Orthop Res Soc 2006;24(3):339–347. DOI: 10.1002/jor.20026.
  15. Hazra S, Song H-R, Biswal S, et al. Quantitative assessment of mineralization in distraction osteogenesis. Skeletal Radiol 2008;37(9):843–847. DOI: 10.1007/s00256-008-0495-7.
  16. Saran N, Hamdy RC. DEXA as a predictor of fixator removal in distraction osteogenesis. Clin Orthop 2008;466(12):2955–2961. DOI: 10.1007/s11999-008-0514-y.
  17. Song S-H, Agashe M, Kim T-Y, et al. Serial bone mineral density ratio measurement for fixator removal in tibia distraction osteogenesis and need of a supportive method using the pixel value ratio. J Pediatr Orthop Part B 2012;21(2):137–145. DOI: 10.1097/BPB.0b013e32834f04f3.
  18. Zhao L, Fan Q, Venkatesh KP, Park MS, Song HR. Objective guidelines for removing an external fixator after tibial lengthening using pixel value ratio: A pilot study. Clin Orthop 2009;467(12):3321–3326. DOI: 10.1007/s11999-009-1011-7.
  19. Whelan DB, Bhandari M, Stephen D, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 2010;68(3):629–632. DOI: 10.1097/TA.0b013e3181a7c16d.
  20. Litrenta J, Tornetta P, Mehta S, et al. Determination of radiographic healing: An assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma 2015;29(11):516–520. DOI: 10.1097/BOT.0000000000000390. DOI: 10.1002/jor.23710.
  21. Cooke ME, Hussein AI, Lybrand KE, et al. Correlation between RUST assessments of fracture healing to structural and biomechanical properties. J Orthop Res Off Publ Orthop Res Soc 2018;36(3):945–953. DOI: 10.1002/jor.23710.
  22. Fiset S, Godbout C, Crookshank MC, et al Experimental validation of the radiographic union score for tibial fractures (RUST) using micro-computed tomography scanning and biomechanical testing in an in-vivo rat model. J Bone Joint Surg Am 2018;100(21):1871–1878. DOI: 10.2106/JBJS.18.00035.
  23. Litrenta J, Tornetta P, Ricci W, et al. In vivo correlation of radiographic scoring (radiographic union scale for tibia fractures) and biomechanical data in a sheep osteotomy model: Can we define union radiographically? J Orthop Trauma 2017;31(3):127–130. DOI: 10.1097/BOT.0000000000000753.
  24. Franzone JM, Finkelstein MS, Rogers KJ, et al. Evaluation of fracture and osteotomy union in the setting of osteogenesis imperfecta: Reliability of the modified radiographic union score for tibial fractures (RUST). J Pediatr Orthop 2020;40(1):48–52. DOI: 10.1097/BPO.0000000000001068.
  25. Kizkapan TB, Misir A, Oguzkaya S, et al. Reliability of radiographic union scale in tibial fractures and modified radiographic union scale in tibial fractures scores in the evaluation of pediatric forearm fracture union. Jt Dis Relat Surg 2021;32(1):185–191. DOI: 10.5606/ehc.2021.78465.
  26. Plumarom Y, Wilkinson BG, Willey MC, et al. Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard. Bone Jt Open 2021;2(10):796–805. DOI: 10.1302/2633-1462.210.BJO-2021-0071.R1.
  27. Urva M, Challa ST, Haonga BT, et al. Reliability of modified radiographic union score for tibia scores in the evaluation of femoral shaft fractures in a low-resource setting. J Am Acad Orthop Surg Glob Res Rev 2022;6(5):e21.00211. DOI: 10.5435/JAAOSGlobal- D-21-00211.
  28. Mitchell SL, Obremskey WT, Luly J, et al. Inter-rater reliability of the modified radiographic union score for diaphyseal tibial fractures with bone defects. J Orthop Trauma 2019;33(6):301–307. DOI: 10.1097/BOT.0000000000001445.
  29. De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop 1987;7(2):129–134. DOI: 10.1097/01241398-198703000-00002.
  30. Schober P, Boer C, Schwarte LA. Correlation coefficients: Appropriate use and interpretation. Anesth Analg 2018;126(5):1763–1768. DOI: 10.1213/ANE.0000000000002864.
  31. Ranganathan P, Pramesh CS, Aggarwal R. Common pitfalls in statistical analysis: Measures of agreement. Perspect Clin Res 2017;8(4):187–191. DOI: 10.4103/picr.PICR_123_17.
  32. Zapf A, Castell S, Morawietz L, Karch A. Measuring inter-rater reliability for nominal data - which coefficients and confidence intervals are appropriate? BMC Med Res Methodol 2016;16:93. DOI: 10.1186/s12874-016-0200-9.
  33. Leow JM, Clement ND, Simpson AHWR. Application of the radiographic union scale for tibial fractures (RUST): Assessment of healing rate and time of tibial fractures managed with intramedullary nailing. Orthop Traumatol Surg Res OTSR 2020;106(1):89–93. DOI: 10.1016/j.otsr.2019.10.010.
  34. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159–174. PMID: 843571.
  35. Giotakis N, Narayan B, Nayagam S. Distraction osteogenesis and nonunion of the docking site: Is there an ideal treatment option? Injury 2007;38 (Suppl 1):S100–107. DOI: 10.1016/j.injury.2007.02.015
  36. Tetsworth K, Paley D, Sen C, et al. Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects. Injury 2017;48(10):2276–2284. DOI: 10.1016/j.injury.2017.07.018.
  37. Liodakis E, Giannoudis VP, Harwood PJ, et al. Docking site interventions following bone transport using external fixation: A systematic review of the literature. Int Orthop 2024;48(2):365–388. DOI: 10.1007/s00264-023-06062-8.
  38. Spiegl U, Pätzold R, Friederichs J, et al. Clinical course, complication rate and outcome of segmental resection and distraction osteogenesis after chronic tibial osteitis. Injury 2013;44(8):1049–1056. DOI: 10.1016/j.injury.2013.05.003.
  39. Liu Y, Yushan M, Liu Z, et al. Complications of bone transport technique using the Ilizarov method in the lower extremity: A retrospective analysis of 282 consecutive cases over 10 years. BMC Musculoskelet Disord 2020;21(1):354. DOI: 10.1186/s12891-020-03335-w.
  40. Garcia FL, Picado CHF, Garcia SB. Histology of the regenerate and docking site in bone transport. Arch Orthop Trauma Surg 2009;129(4):549–558. DOI: 10.1007/s00402-008-0587-9.
  41. Hohmann E, Birkholtz F, Glatt V, Tetsworth K. The “Road to Union” protocol for the reconstruction of isolated complex high-energy tibial trauma. Injury 2017;48(6):1211–1216. DOI: 10.1016/j.injury.2017.03.018.
  42. Lovisetti G, Sala F. Clinical strategies at the docking site of distraction osteogenesis: Are open procedures superior to the simple compression of Ilizarov? Injury 2013;44 (Suppl 1):S58–62. DOI: 10.1016/S0020-1383(13)70014-7.
  43. Magadum MP, Basavaraj Yadav CM, Phaneesha MS, et al. Acute compression and lengthening by the Ilizarov technique for infected nonunion of the tibia with large bone defects. J Orthop Surg Hong Kong 2006;14(3):273–279. DOI: 10.1177/230949900601400308.
  44. Sala F, Thabet AM, Castelli F, et al. Bone transport for postinfectious segmental tibial bone defects with a combined Ilizarov/Taylor spatial frame technique. J Orthop Trauma 2011;25(3):162. DOI: 10.1097/BOT.0b013e3181e5e160.
  45. Elbatrawy Y, Abuomira IEA, Sala F, et al. Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame. Strateg Trauma Limb Reconstr 2016;11(3):153–159. DOI: 10.1007/s11751-016-0264-4.
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