ArticleEuropean journal of orthopaedic surgery & traumatology : orthopedie traumatologie2026
External validation of the FRACTING, LEG-NUI, and NURD scores for predicting non-union after tibial intramedullary nailing.
Article in European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundNon-union remains a challenging complication of tibial diaphyseal fractures treated with intramedullary nailing. Several clinical prediction scores have been developed to identify patients at increased risk of impaired fracture healing. This study aimed to externally validate the FRACTING, LEG-NUI, and NURD scores for the prediction of non-union in an independent cohort of patients with tibial diaphyseal fractures.
methodsWe retrospectively reviewed consecutive adult patients with tibial diaphyseal fractures treated with reamed intramedullary nailing at a level I trauma center between January 2015 and January 2025. FRACTING is a clinical score developed to estimate tibial fracture healing time; LEG-NUI is a clinical prediction score for non-union after fracture fixation; and NURD is a time-zero score developed to predict non-union after tibial intramedullary nailing. The primary outcome was clinically and radiographically defined non-union, while delayed union was evaluated as a secondary outcome. Discrimination was assessed using ROC analysis and AUCs with 95% confidence intervals. Pairwise comparisons used DeLong's test and exploratory thresholds were identified using the Youden index.
resultsA total of 203 patients were included, of whom 119 achieved union, 61 developed delayed union, and 23 developed non-union. NURD showed the highest numerical AUC (0.802, 95% CI 0.706-0.898), followed by FRACTING (0.742, 95% CI 0.619-0.866) and LEG-NUI (0.731, 95% CI 0.614-0.848). Pairwise comparisons showed no statistically significant differences between the three scores.
conclusionsAll three scores demonstrated discriminatory ability for non-union. NURD had the highest numerical AUC, but no score showed statistically superior discrimination. The exploratory thresholds identified in this study require further external validation before clinical application.
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