Surgical Implant Generation Network Nail Research Articles

Locked intramedullary nailing of open fractures in resource-poor settings: a prospective observational study of challenges and functional outcomes in 101 fractures at Ogbomoso, Nigeria

BackgroundTrauma is now one of the fastest growing epidemics globally but low and middle-income countries (LMICs) are more severely affected in terms of cost, disability and death. The high-energy trauma of road traffic accidents and violence often produces open fractures which can be difficult to manage in resource-poor settings. Adequate stabilization, such as provided by locked nails, has been found to ensure better outcome for open fractures. There is dearth of published studies on the use of locked intramedullary nail in the treatment of open fractures in Nigeria.MethodsThis is a prospective observational study of all the 101 open fractures of the humerus, femur and tibia treated over a period of 92 months with Surgical Implant Generation Network (SIGN) nail. Fracture severity was classified according to the modified Gustilo-Anderson system. The intervals between fracture and antibiotics administration, débridement and definitive fixation, as well as surgery duration and method of fracture reduction were noted. Outcomes measured at follow-up included infection, ongoing radiographic healing, knee flexion/shoulder abduction beyond ninety degrees (KF/SA > 900), full weight bearing (FWB), painless squatting (PS&S)/shoulder abduction-external rotation (SAER).ResultsMost of the patients fall between ages 20 and 49 years; 75.5% of them were males. There were more Gustilo-Anderson type IIIA fractures than other types but nine type IIIB tibia fractures were also nailed. The overall infection rate was 15%, contributed mostly by the type IIIB fractures. By the 12th post-operative week, at least 79% had ongoing radiographic healing and had achieved all of KF/SA > 900, FWB, and PS&S/SAER.ConclusionThe SIGN nail’s solid construct reduces the risk of infection and allows earlier use of the limb, making it particularly suitable in LIMCs where socioeconomic functioning often requires an unhindered use of the limbs.

Prevalence and associated factors of infection after intramedullary nailing of long bone fractures among patients attending St. Paul's Hospital Millennium Medical College, AaBET Hospital, Addis Ababa, Ethiopia.

The intramedullary nailing of long bone fractures is a major challenge for orthopedic surgeons, with increased risk of infection in third-world countries. Research gaps remain in Ethiopia, determining the magnitude of the problem. This study aimed to determine the prevalence and associated factors of infection after intramedullary nailing of long bone fractures in Ethiopia. This was a descriptive, cross-sectional, retrospective design study with a total census of 227 cases of long bone fractures treated with intramedullary Surgical Implant Generation Network nails at Addis Ababa Burn Emergency and Trauma Hospital from August 2015 to April 2017. Data were collected from 227 patients and descriptive analyses were done to summarize the study variables. Binary and multivariable logistic regression analyses were performed at a p value of 0.05 with a 95% confidence interval and adjusted odds ratio. The mean age of patients was 32.9 years, with a male-to-female ratio of 3.5:1. Only 22 (9.3%) of the 227 patients with long bone fractures treated with intramedullary nails developed a surgical site infection, and 8 (3.4%) were developed deep (implant) infections requiring debridement. Road traffic injuries were the leading cause of trauma (60.9%), followed by falls from a height (22.7%). Debridement was done within 24 h for 52 (61.9%) and within 72 h for 69 (82.1%) patients with open fractures. Only 19 (22.4%) and 55 (64.7%) patients with open fractures and tibial long bone fractures received antibiotics within 3 h. Open fractures and tibial fractures had higher percentages of infection, 18.6% and 12.1%, respectively. Previous use of an external fixator (44.4%) and prolonged surgery (12.5%) were associated with higher proportions of infection. This study found that the prevalence of infections after intramedullary nailing of long bone fractures in Ethiopia was 44.4% after external fixation, compared to 6.4% after intramedullary nail was inserted directly. Proper control measures are needed to reduce morbidity and complications related to long fracture treatment, such as open fractures, tibial fractures, the use of an external fixator, delayed debridement and skin closure, and prolonged surgery developed surgical site infection rate.

A Retrospective Cohort Study on Using Fully Threaded, Cortical Screws in Locking SIGN Intramedullary Nails

The Surgical Implant Generation Network (SIGN) produces solid and straight intramedullary nails used for femoral or tibial fractures. These utilize interlocking screws with proximal and distal threads to purchase at the cortices. When SIGN interlocking screws are unavailable, 4.5 mm, fully threaded, stainless steel, cortical screws are sometimes used to lock the nails. This study compared the alignment, fracture healing, and screw failure rates between cases which solely used SIGN interlocking screws and those which incorporated fully threaded, cortical screws. The SIGN census from January 2018 to August 2021 was reviewed. 79 cases were included in this study. 59 solely used SIGN interlocking screws and 20 incorporated fully threaded, cortical screws. The former group had acceptable alignment in 91.5%, 3-4 bridging cortices by the 12th week in 81.4%, and no screw failure in 96.8%. The latter group had acceptable alignment in 90.0%, 3-4 bridging cortices by the 12th week in 80.0%, and no screw failure in 95.0% of cases. The chi-square test showed no significant difference in outcomes between the two groups with p= .836 for fracture alignment, p= .894 for fracture healing, p= .745 for screw failure. This study concluded that 4.5 mm, fully threaded, stainless steel, cortical screws may be incorporated to lock SIGN nails when SIGN interlocking screws are unavailable.

Fixation of intertrochanteric femur fractures using the SIGN intramedullary nail augmented by a lateral plate in a resource-limited setting without intraoperative fluoroscopy: assessment of functional outcomes at one-year follow-up at Juba Teaching Hospital.

Objectives:The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate.Design:Prospective case seriesSetting:Juba Teaching Hospital, Tertiary Referral Hospital for South SudanParticipants:Adult patients with intertrochanteric hip fracturesIntervention:SIGN nail augmented by a lateral plateMain Outcome Measurements:Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery.Results:Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations.Conclusions:The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.

Radiographic outcomes of femur fractures following SIGN Fin nailing in low- and middle-income countries.

Objective:To measure the effectiveness of the Surgical Implant Generation Network (SIGN) Fin nail for achieving satisfactory postoperative radiographic alignment following femoral shaft fractures.Methods:Femoral shaft fractures stabilized with the SIGN Fin nail were identified using the SIGN Online Surgical Database. A random number generator was used to identify 500 femur fractures fixed within 6 weeks of injury for which postoperative radiographs were available. Fractures were classified using OTA/AO and Winquist-Hansen classification systems. Deviation from anatomic alignment was measured on anterior-posterior and lateral radiographs using an on-screen protractor tool. Other clinical variables recorded in the SIGN Online Surgical Database were also analyzed. Simple logistic regression was used to assess for associations between subject and surgical characteristics and misalignment status. Intra- and inter-rater agreement was assessed with intraclass correlation coefficient (ICC).Results:The overall rate of malalignment >5° was 9.4%. Factors associated with increased incidence of malalignment include older age, increased time to surgery, distal diaphyseal location, closed (vs open) reduction, degree of comminution, and fracture classification. Intra-rater ICC was 0.70 (0.52, 0.82) in the coronal plane and 0.55 (0.32, 0.72) in the sagittal plane. Inter-rater ICC was 0.37 (0.08, 0.60) and 0.32 (0.05, 0.54), respectively.Conclusion:The SIGN Fin nail is an effective implant for fixation of femoral shaft fractures in resource-limited regions, achieving rates of satisfactory postoperative alignment comparable to that of the standard SIGN nail as well as femoral shaft fractures treated in North American Trauma Centers. Further research is required to investigate rotational alignment and long-term clinical outcomes for the SIGN Fin nail.Level of evidence:IV.

Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail

Le développement économique des pays à faibles revenus a pour corollaire une augmentation considérable des véhicules motorisés, et en particulier des motocyclettes. Les accidents de la circulation augmentent ainsi que les fractures qui y sont associées. Le traitement des fractures des os longs repose dans la majorité des cas sur l´enclouage centro-médullaire verrouillé, procédé rarement disponible en situation sanitaire dégradée. Pour apporter à ces pays un traitement optimal, le clou SIGN (Surgical Implant Generation Network) a été développé en 1999 par Lewis Zirkle. Il est actuellement utilisé gratuitement dans 53 pays. En contrepartie une base de données internationale doit être remplie afin de l´évaluer et de le faire évoluer. A la lumière de nos expériences en Haïti et au Burundi et d´une revue de la littérature, nous décrivons ici ses particularités conceptuelles et techniques, dont l´implantation dans les pays francophones reste limitée.

Retrograde Intramedullary Nailing of Pediatric Femoral Shaft Fractures Does Not Result in Growth Arrest at the Distal Femoral Physis-A Retrospective Cases Series.

To evaluate femoral growth after placement of retrograde intramedullary nails in the treatment of pediatric femoral shaft fractures. Retrospective case series. Large urban trauma center in Mongolia. Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture were included in the study. Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin Surgical Implant Generation Network nail across an open distal femoral physis. The main outcome measure was the distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up. The mean age of patients was 10.7 years (range: 7-14 years). Follow-up occurred at a mean of 292 days (range: 53-714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (P < 0.001) and 0.84 (P < 0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, whereas age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found. This is the first study, to our knowledge, to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral intramedullary nails does not seem to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Use of the SIGN IM nail system to stabilize tibiotalocalcaneal arthrodesis in two African hospital settings.

Objectives:To determine the effectiveness and describe the technique of using the Surgical Implant Generation Network (SIGN) nail to augment tibiotalocalcaneal (TTC) arthrodesis in the developing world.Design:Retrospective review of the SIGN database and description of surgical technique.Setting:Two centers in rural Kenya, East Africa.Patients:Fifty-seven patients with ankle/hindfoot arthritis or severe trauma. We were able to follow 17 through complete arthrodesis.Invention:TTC arthrodesis stabilized with SIGN nail.Main outcome measure:Radiographic arthrodesis and return to function.Result:Of the patients with significant follow-up, arthrodesis occurred in an average of 19.3 ± 7.5 weeks from the date of surgery.Conclusions:Recognizing the obstacles to follow-up, the SIGN nail placed with the Herzog curve apex posterior is shown to be an effective device to stabilize a TTC arthrodesis in a limited subgroup of patients with full follow-up.

Short-Term Outcomes of Treatment of Open Fracture of Long Bone Using Surgical Implant Generation Network Nail at Kumi Orthopaedic Center, Uganda

Short-Term Outcomes of Treatment of Open Fracture of Long Bone Using Surgical Implant Generation Network Nail at Kumi Orthopaedic Center, Uganda

Clinical and radiographic outcomes following retrograde SIGN fin nailing for femoral shaft fractures.

Purpose:The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail.Methods:The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures.Results:The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P < .001) and knee ROM >90° (30% vs 91%, P < .001). There was no significant difference in mean DFAA between united and nonunited fractures in the coronal (2.1° vs 3.8°, P = .298) or sagittal (2.5° vs 3.5°, P = .528) planes.Conclusion:The SIGN Fin nail achieves satisfactory radiographic alignment and clinical outcomes at minimum 6 month follow-up. The overall union rate is comparable to that achieved with the standard SIGN nail. Ease of implantation makes the Fin nail an attractive option in resource-limited settings.

Functional outcome of patients of tibial fracture treated with solid nail (SIGN nail) versus conventional hollow nail – A randomized trial

BackgroundTrauma related disabilities disproportionately affects low and middle income countries due to lack of resources, skills and optimal implants. Despite adequate animal studies, biomechanical studies, cohort studies and comparison studies we are not aware of any randomized trial to compare the functional outcome of SIGN (Surgical Implant Generation Network, US) solid nailing with a hollow nailing for tibial shaft fracture. MethodsSixty patients (≥16 years) of closed and Gustilo grade I traumatic fractures of the leg were randomized into SIGN solid nailing or hollow nailing group. Cases with compromised soft tissue and grossly deformed medullary canal were excluded. Functional outcome and need for resurgery were the primary outcomes while the secondary outcomes were duration of surgery, intraoperative blood loss, overall pain (VAS), radiological union (RUST), surgery related complications (infection, malalignment, shortening, nonunion) and pain/range of motion (ROM) of knee/ankle. All SIGN surgery related data were entered and retrieved online from www.signsurgery.org. ResultThe demographical parameters were symmetrically distributed between the groups (p > 0.05). 2 cases in SIGN nailing and 4 cases in hollow nailing needed open reduction. The functional outcome, as assessed by blinded physiotherapist using Johner and Wruh criteria, was excellent in 18 (62.06%), good in 6 (20.68%), fair in 3 (10.34%) and poor in 2 (6.89%) for SIGN nail whereas it was 16 (57.14%), 8 (28.57%), 3 (10.71%) and 1 (3.57%) respectively for hollow nail. There was 1 case of implant failure and 1 case of infection. Intraoperative blood loss (397 ± 94.47 ml versus 350 ± 75.43 ml, p = 0.037) and duration of surgery (94.8 ± 14.57 min versus 82.0 ± 12.36 min, p = 0.001) were significantly more in hollow nailing group. At final follow up, overall pain on weight bearing (VAS score) and radiological union (RUST score) were 2.1 and 11.7 for SIGN nailing while they were 2.7 and 11.3 respectively for hollow nailing.(p = 0.41 and 0.45 respectively) The malrotation (p = 1.000), shortening (p = 1.000), varus-valgus angulation (p = 0.511), AP angulation (p = 0.706), ROM ankle (p = 0.239) and ROM knee (p = 0.086) were similar. ConclusionSolid SIGN nailing gives comparable functional outcome as conventional hollow nailing for tibia shaft fracture. For developing world with limited resources, SIGN nail is useful which is supplied freely and is designed to be used without image intensifier and fracture table.

Outcome of tibial diaphyseal fracture fixation with Surgical Implant Generation Network (SIGN) nail

Introductions: Fractures of diaphyseal region of the tibial bone are amongst the most commonly seen extremity injuries in the developing countries. The surgical implant generation network (SIGN) intramedullary (IM) nail was designed for the treatment of long bone fractures in the developing nations. &#x0D; Methods: From March 2008 to December 2018, a total of 104 patients with 104 tibial diaphyseal fractures were treated with SIGN IM nail. The follow-up visits were arranged at 6, 12, 24 weeks and one-year post operatively. During follow-up visits, the signs of fracture union clinically as well as radiologically and the presence of complications any were recorded and analyzed. &#x0D; Results: The mean age of the patients was 32.81 (16 – 65) years, male 74 (71.2%) and female 30 (28.8%). Majority of the patients 70 (67.3%) had fractures after road traffic accidents. The mean time of surgery was 13.58 (1 – 463) days. Six (5.8%) patients had delayed union and no non-union was detected. We had 10 cases (9.6%) of mal-alignment but were on acceptable range. &#x0D; Conclusions: In the developing country like Nepal, the SIGN nail is an effective surgical implant for the management of the tibial diaphyseal fractures with good result of fracture union and low rates of nonunion, mal-alignment and manageable complications.

Satisfactory postoperative alignment following retrograde SIGN Fin nailing for femoral shaft fractures

Purpose:In developing countries, long bone fractures following trauma are a significant contributor to morbidity, and operating room resources are often limited in these settings. The Surgical Implant Generation Network (SIGN) Fin nail may reduce the challenges of retrograde intramedullary nailing of femoral fractures without fluoroscopy. In contrast to the traditional SIGN nail placed in a retrograde fashion, the Fin nail does not require proximal interlocking screws. Instead, the nail achieves stability through an interference fit within the proximal femoral canal. The purpose of this study is to compare postoperative alignment in femoral shaft fractures treated with either a retrograde SIGN Fin nail or a standard retrograde SIGN nail.Method:Using the SIGN online surgical database, we identified all femoral shaft fractures treated with a retrograde SIGN Fin nail at 2 African hospitals. Two examiners independently classified fracture patterns using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system. Using an on-screen protractor tool, postoperative coronal and sagittal plane alignment were measured and recorded as deviation from anatomic alignment (DFAA), with units in degrees. Available patient demographics and surgical details were also recorded. Fin nail cases were matched in a 1:1 ratio to retrograde standard SIGN nail cases based on AO/OTA fracture type.Results:Twenty-eight retrograde Fin nail cases were identified, and 28 matched retrograde SIGN nail cases were selected. The Fin nail and retrograde SIGN nail groups were well matched in terms of demographics, AO/OTA fracture type, and surgical characteristics. There was no significant difference in postoperative coronal or sagittal plane alignment between the groups. There were no cases in either group of average postoperative malalignment >5° in any plane.Conclusion:The SIGN Fin nail appears to achieve satisfactory radiographic alignment without the need for proximal interlocking screws, making it an attractive implant for retrograde femoral shaft fracture fixation in resource-limited settings. Further research is required to validate these findings and determine long-term Fin nail clinical outcomes.

Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries.

(1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. Prospective cohort study using an international online database. Multiple hospitals in LMICs worldwide. A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis.

This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up. We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the "remove one" sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval. There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%-6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%). Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

State of Pelvic and Acetabular Surgery in the Developing World: A Global Survey of Orthopaedic Surgeons at Surgical Implant Generation Network (SIGN) Hospitals.

To document the current state of pelvic and acetabular surgery in the developing world and to identify critical areas for improvement in the treatment of these complex injuries. A 50-question online survey. International, multicenter. One hundred eighty-one orthopaedic surgeons at Surgical Implant Generation Network (SIGN) hospitals, which represent a cross-section of institutions in low- and middle-income countries that treat high-energy musculoskeletal trauma. Administration and analysis of 50-question survey. Surgeon training and experience; hospital resources; volume and patterns of pelvic/acetabular fracture management; postoperative protocols and resources for rehabilitation; financial responsibilities for patients with pelvic/acetabular fractures. Complete surveys were returned by 75 institutions, representing 61.8% of the global SIGN nail volume. Although 96% of respondents were trained in orthopaedic surgery, 53.3% have no formal training in pelvic or acetabular surgery. Emergency access to the operating room is available at all responding sites, but computed tomography scanners are available at only 60% of sites, and a mere 21% of sites have access to angiography for pelvic embolization. Cannulated screws (53.3%) and pelvic reconstruction plates (56%) are available at just over half of the sites, and 68% of sites do not have pelvic reduction clamps and retractors. 21.3% of sites do not have access to intraoperative fluoroscopy. Responding hospitals see an average of 38.8 pelvic ring injuries annually, with 24% of sites treating them all nonoperatively. Sites treated an average of 22.5 acetabular fractures annually, with 34.7% of institutions treating them all nonoperatively. Patients travel up to 1000 km or 20 hours for pelvic/acetabular treatment at some sites. Although 78.7% of sites have inpatient physical or occupational therapy services, only 17% report access to home physical therapy, and only 9% report availability of nursing or rehabilitation facilities postdischarge. At over 80% of hospitals, patients and their families are at least partially responsible for payment of surgical, implant, hospital, and outpatient fees. Government aid is available for inpatient fees at over 40% of sites, but outpatient services are subsidized at only 28% of sites. We report the current state of pelvic and acetabular surgery in low- and middle-income countries. Our results identify significant needs in surgeon training, hospital resources, availability of instruments and implants, and access to appropriate postoperative rehabilitation services for pelvic and acetabular surgery in the developing world. Targeted programs designed to overcome these barriers are required to advance the care of pelvic and acetabular fractures in the developing world.

A Retrospective Case Series of Surgical Implant Generation Network (SIGN) Placement at the Afghan National Police Hospital, Kabul, Afghanistan.

In Afghanistan, adequate and cost-effective medical care for even routine conditions is lacking; especially for complex injuries like long-bone fractures. The Surgical Implant Generation Network (SIGN) intramedullary nail is used for treatment of long-bone fractures from blunt injuries and does not require imaging. We are reporting for the first time results of the SIGN intramedullary nail at the Afghan National Police Hospital, a tertiary care facility in Kabul. 71 records from the SIGN Online Surgical Database were reviewed for gender, age, date of injury, implant date, patient's home of record, and type/ mechanism of injury. Mean age was 26.7 years, all but one being male; time from injury to implant ranged 1 to 401 days, with mean of 40.6 days. Long-bone fractures from motor vehicle accidents remained constant, and war injuries peaked in summer. Follow-up is limited because of security and financial burdens of travel. However, personal communication with Afghan National Police Hospital surgeons suggests that patients included in the current study have not experienced any adverse outcomes. While it remains to be seen if the SIGN Online Surgical Database will facilitate more comprehensive outcome studies, our results provide support for the efficacy of SIGN nails in treating long-bone fractures from war injuries.

Retrospective Study Comparing Outcomes of Open Antegrade and Open Retrograde Femoral Nailing Using the SIGN Nail in Philippine General Hospital Patients

Objectives: To compare the outcomes of open antegrade and retrograde intramedullary nailing of the femur using the Surgical Implant Generation Network (SIGN) nail in adult PGH patients. Methods: This is a retrospective review of adult patients with closed femoral shaft fractures who were treated using an interlocked intramedullary nail (SIGN nail). Fourty-two patients were treated by open antegrade nailing and 16 patients were treated by open retrograde nailing. The two groups were compared using the following outcomes: duration of surgery, amount of blood loss, length of hospital stay, infection rate, weight bearing time, union rate, malunion, knee and hip pain, neurovascular deficits, peri-implant fracture incidence and length of post-op hospital stay. Results: There was a statistically significant difference in the duration of surgery between the antegrade nailing group compared to the retrograde nailing group. All the other outcome parameters were not statistically different between the two groups. Conclusion: Outcomes of femoral shaft fractures in adults treated by open antegrade nailing and open retrograde nailing using the SIGN nail are similar except for a slightly longer operative time for the retrograde nail group. Key words: open intramedullary nailing femur; retrograde nailing femur; SIGN nail

Outcome of intramedullary interlocking SIGN nail in tibial diaphyseal fracture.

To determine the outcome of intramedullary interlocking surgical implant generation network (SIGN) nail in diaphyseal tibial fractures in terms of union and failure of implant (breakage of nail or interlocking screws). Case series. Orthopaedics and Spinal Surgery, Ghurki Trust Teaching Hospital, Lahore Medical and Dental College, Lahore, from September 2008 to August 2009. Fifty patients aged 14 - 60 years, of either gender were included, who had closed and Gustilo type I and II open fractures reported in 2 weeks, whose closed reduction was not possible or was unsatisfactory and fracture was located 7 cm below knee joint to 7 cm above ankle joint. Fractures previously treated with external fixator, infected fractures and unfit patients were excluded. All fractures were fixed with intramedullary interlocking SIGN nail and were followed clinically and radiographically for union and for any implant failure. Forty one (88%) patients had united fracture within 6 months, 5 (10%) patients had delayed union while 4 (8%) patients had non-union. Mean duration for achieving union was 163 + 30.6 days. Interlocking screws were broken in 2 patients while no nail was broken in any patient. Intramedullary interlocking nailing is an effective measure in treating closed and grade I and II open tibial fractures. It provides a high rate of union less complications and early return to function.

Achieving locked intramedullary fixation of long bone fractures: technology for the developing world

Eightyper cent of severe fractures occur in developing countries. Long bone fractures are treated by conservative methods if proper implants, intraoperative imaging and consistent electricity are lacking. These conservative treatments often result in lifelong disability. Locked intramedullary nailing is the standard of care for long bone fractures in the developed world. The Surgical Implant Generation Network (SIGN) has developed technology that allows all orthopaedic surgeons to treat fracture patients with locked intramedullary nailing without the need for image intensifiers, fracture tables or power reaming. Introduced in 1999, SIGN nails have been used to treat more than 100,000 patients in over 55 developing world countries. SIGN instruments and implants are donated to hospitals with the stipulation that they will be used to treat the poor at no cost. Studies have shown that patients return to function more rapidly, hospital stays are reduced, infection rates are low and clinical outcomes excellent. Cost-effectiveness analysis has confirmed that the system not only provides better outcomes, but does so at a reduced cost. SIGN continues to develop new technologies, in an effort to transform lives and bring equality in fracture care to the poorest of regions.