gms | German Medical Science

Objectives: Union as reported by the physician based on x-ray was the conventional goal of fracture repair. However, the growing concern nowadays is the patient reported outcome(s); true more so in the part of the world where squatting, cross-leg sitting and kneeling have become the basic functional needs of the daily activities of the patients for social, cultural and religious reasons. The "Squat and Smile" photograph is easy to acquire and assess by the physician including on virtual platform using smartphone for assessment of fracture healing. This shall save time and effort of patient/physician, avoid cost of x-ray/OPD visit and radiation exposure. It's more useful in current locked down, Corona virus pandemic etc. We studied to find out whether assessment of "Squat and Smile" function on clinical photograph is a reliable proxy tool to predict the healing of lower limb fractures after SIGN (Surgical Implant Generation Network) solid intramedullary interlocking nail fixation.

Methods: Prospectively collected data of 56 adults (mean age: 32.13±15.42), whose either tibia (42A, 42B and 42C, n=32) or femur (32A, 32B and 32C, n=24) fracture was fixed, having minimum eighteen months follow up x-rays and whose corresponding "Squat and Smile" photographs were available at the SIGN online surgical database from www.signsurgery.com were retrospectively reviewed. A group of two independent blinded observers scored the x-rays of the patients for healing while other group of two independent blinded observers scored the "squat and smile" clinical photographs for quality of squatting. Same group of observers repeated the same assignment for the second time after a period of one month.

Results and Conclusion: The inter-observer and intra-observer correlation for x-ray scoring were 0.635 to 0.757 (very good) and 0.774 to 0.825 (very good) respectively while they were 0.476 to 0.650 (moderate to good) and 0.688 to 0.785 (good) respectively for "Squat and Smile" scoring. The overall sensitivity and specificity of "Squat and Smile" score in predicting the healing of fracture was 82.22% and 63.64% respectively considering the radiological union score for tibia (RUST) as the gold standard.

"Squat and Smile" assessment is a reliable proxy tool for assessment of fracture healing of tibia and femur fixed with an intramedullary interlocking nailing.