Surgical Implant Generation Network Research Articles

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.

Surgical Implant Generation Network Implant Follow-up: Assessment of Squat and Smile and Fracture Healing.

To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation. Retrospective review of the Surgical Implant Generation Network (SIGN) database. The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery. None. We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union. Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up. The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Humeral interlocking intramedullary nailing without image intensifier in a developing country

Background: Interlocking intramedullary nailing under image intensifier has been a standard approach to surgical treatment of humeral fractures. Aim: We present the outcome of humeral interlocking nailing without image intensifier in a developing country. Materials and Methods: This is a prospective study of consecutive patients with humeral shaft fractures who were treated with Surgical Implant Generation Network interlocking nailing for humeral shaft fractures using an external jig system. They were followed up for at least 6 months if there was no evidence of fracture healing and restoration of functional activities. Data collected were processed with the Statistical Package for the Social Sciences and summarised in percentages and means. Results: Forty-five patients with 46 humeral shaft fractures were studied, with a mean age and standard deviation of 46 ± 14.6 years and male-female ratio of 1.8:1. At 3 months, 44 (95.7%) of the patients have had radiographic evidence of fracture healing. Over the same period, 35 (76.1%) of them had achieved shoulder abduction >90°, 37 (80.5%) had achieved painless shoulder flexion-abduction-external rotation movement and 42 (91.3%) had achieved full activities of daily living. Conclusion: In a resource-constrained population where image intensifier is difficult to come by, humeral interlocking intramedullary nailing could still be performed using external jig system with a satisfactory outcome.

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.

Surgical Implant Generation Network (SIGN) Fin nail versus SIGN standard intramedullary nail for distal diaphyseal femur fractures treated via retrograde approach

IntroductionSurgical fixation of distal diaphyseal femur fractures remains a major challenge in developing countries given limited availability of fluoroscopy. The Surgical Implant Generation Network (SIGN) Standard Intramedullary Nail and SIGN Fin Nail are two modalities developed to address this challenge; the Fin Nail additionally avoids needing to place proximal interlocking screws. While efficacy of the Standard Nail has been established, outcomes following fixation with the Fin Nail are unknown. In this study, we compare outcomes of distal diaphyseal femur fractures treated with each implant. MethodsA prospective cohort study was conducted from 2012 to 2013 at a single tertiary-referral center in Tanzania. Skeletally mature patients with distal diaphyseal femur fractures treated with either retrograde SIGN Standard Nail or Fin Nail were included. Patients followed-up at 6, 12, 26, and 52 weeks post-operatively. The primary outcome was all-cause reoperation. Secondary outcomes included infection, non-union, malalignment, quality of life (EQ-5D score), pain (VAS score), radiographic healing (RUST score), and function (pain with weight bearing, knee range of motion, and Squat and Smile score). Results74 (85%) of 85 enrolled patients completed the minimum 1-year follow-up. There was no difference in rate of reoperation (p = 1.00), infection (p = 1.00), limb length discrepancy (p = 0.47), non-union (p = 1.00), or coronal or sagittal malalignment (p = 1.00, p = 0.55 respectively) at 1 year. There was furthermore no difference in mean EQ-5D (p = 0.82), VAS pain score (p = 0.43), RUST score (p = 0.44), maximum knee flexion (p = 0.52) and extension (p = 1.00), or Squat and Smile function (p = 1.00) between cohorts at 1 year. DiscussionOutcomes associated with the SIGN Fin Nail are comparable to those associated with the SIGN Standard Intramedullary Nail at 1 year. The SIGN Fin Nail may be useful as an alternative to Standard locked IM nails for fixation of distal diaphyseal femur fractures.

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.

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

AIM: Assess the effect of delay in treatment greater than 24 hours on the development of infection for open tibia fractures. MATERIALS & METHODS: A retrospective review of all patients was conducted to identify skeletally mature patients with an open tibia fracture treated with the Surgical Implant Generation Network (SIGN) intramedullary nail from February 2006 and June 2015. Descriptive data, time to treatment, fracture characteristics, and presence of infection were collected and analyzed. RESULTS: Infection occurred in 19 (11%) patients (Gustilo I 1/44, 2%; Gustilo II 6/39, 15%, Gustilo IIIa 9/44, 21%; Gustillo IIIb 3/44, 7%). One hundred forty-four patients were treated within 24 hours from injury (mean, 8.2 hours) and 28 were treated after 24 hours (mean, 41.1 hours). There was no significant difference in the rates of infection for fractures before or after six hours from the time of injury (15% vs. 11%, P = 0.6207). Infection rate was similar in patients treated within 24 hours and beyond 24 hours (10% vs. 14%, P = 0.518). The average time to treatment of patients with and without infectious outcome were not significantly different (15.6 vs 13.4 hours, P = 0.700). There was an association between more severe Gustilo types and infection, yet this did not reach significance (P = 0.402) CONCLUSION: Our results show that initial treatment beyond 24 hours did not lead to a significant increase in the rate of infection. While not significant, a greater proportion of infections occurred in higher Gustilo types. Our results suggest that fracture type rather than time to treatment may be a more important predictor of infection.

Development of Squat-and-Smile Test as Proxy for Femoral Shaft Fracture-Healing in Patients in Dar es Salaam, Tanzania.

There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test. The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed. Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78). The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S. The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.

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.

Locked intramedullary nailing using the sign nailing device.

Locked intramedullary nailing is the treatment of choice not only in diaphyseal fractures of long bone but also in most metaphyseal and periarticular fractures. In this study, we set out to present our experience with the Surgical Implant Generation Network (SIGN)] technique of locked intramedullary nailing in long bones that do not require the use of image intensifier, fracture table, and power reamers. This was a hospital-based prospective descriptive study involving 54 consecutive patients seen over a 2-year period. All closed fractures of the femur and tibia/fibula seen within the period under review were included in the study. The patients were followed up for a minimum of 12 months. Fracture union was recorded when there was absence of pain at fracture site and X-ray shows presence of bridging callus in two orthogonal views. Fifty seven fractures in 54 patients were managed in the period of the study. There were 46 [81%] femoral and 11 [19%] tibia/fibula fractures recorded in 47 [87%] males and 7 [13%] females with a male to female ratio of 6.7:1. Majority of the patients were within the 31--40 years age bracket (n = 25, 46%). All the fractures were as a result of motor vehicle accident. Thirty six (78%) of the femoral fractures were operated through the antegrade approach, whereas the rest (22%) were through the retrograde approach. Both proximal and distal locking were achieved in all cases. Fracture union was recorded in all but one case [98%]. Complications were observed in 8 cases, which included 5 cases of superficial infection, one case each of osteomyelitis, delayed union and nonunion. Locked intramedullary nailing using external jigs for screw placement as in the SIGN technique gives a good result and is recommended for use in the developing countries where image intensifiers are not readily available.

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

AIM: Assess the effect of delay in treatment greater than 24 hours on the development of infection for open tibia fractures. MATERIALS &amp; METHODS: A retrospective review of all patients was conducted to identify skeletally mature patients with an open tibia fracture treated with the Surgical Implant Generation Network (SIGN) intramedullary nail from February 2006 and June 2015. Descriptive data, time to treatment, fracture characteristics, and presence of infection were collected and analyzed. RESULTS: Infection occurred in 19 (11%) patients (Gustilo I 1/44, 2%; Gustilo II 6/39, 15%, Gustilo IIIa 9/44, 21%; Gustillo IIIb 3/44, 7%). One hundred forty-four patients were treated within 24 hours from injury (mean, 8.2 hours) and 28 were treated after 24 hours (mean, 41.1 hours). There was no significant difference in the rates of infection for fractures before or after six hours from the time of injury (15% vs. 11%, P = 0.6207). Infection rate was similar in patients treated within 24 hours and beyond 24 hours (10% vs. 14%, P = 0.518). The average time to treatment of patients with and without infectious outcome were not significantly different (15.6 vs 13.4 hours, P = 0.700). There was an association between more severe Gustilo types and infection, yet this did not reach significance (P = 0.402) CONCLUSION: Our results show that initial treatment beyond 24 hours did not lead to a significant increase in the rate of infection. While not significant, a greater proportion of infections occurred in higher Gustilo types. Our results suggest that fracture type rather than time to treatment may be a more important predictor of infection.

Outcome of Surgical Implant Generation Network Intramedullary Nail in Diaphyseal Femur Fractures at a Tertiary Care Center in Nepal

Outcome of Surgical Implant Generation Network Intramedullary Nail in Diaphyseal Femur Fractures at a Tertiary Care Center in Nepal

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.

Management of Distal Tibial Metaphyseal Fractures With the SIGN Intramedullary Nail in 3 Developing Countries.

To evaluate the effectiveness of the Surgical Implant Generation Network (SIGN) intramedullary (IM) nail in distal tibial metaphyseal fractures. Retrospective Case Series. Three Level I trauma centers in 3 different developing countries from 2009 to 2013. One hundred sixty patients with 162 distal tibial metaphyseal fractures (AO/OTA 43-A). SIGN IM nailing was performed using hand reaming and without the use of an image intensifier. The primary outcome measures were the rate of union and complications. The secondary outcome measures were the effect of open fractures on outcomes, effectiveness and safety of open reduction of closed fractures, and risk factors for the development of malalignment and possible solutions. The average age of patients was 35.3 years. Seventy-nine percent were male. Sixty percent of the fractures were closed. The mean time to surgery was 4.1 days. Fracture union occurred in 97.3% of fractures with an average time to union of 105 days. Open reduction of closed fractures was performed in 51 fractures. Nonunion occurred in 3 patients (1.8%). Acceptable alignment (<5 degrees deformity) was found in 134 fractures (83%). Infection occurred in 14 patients (8.6%). Revision surgery was required in 10 fractures (6.2%). In developing settings, distal metaphyseal tibial fractures can be managed successfully with the SIGN IM nail. There is an increased risk for complications (P = 0.001) and infection (P = 0.0004) in open fractures. Open reduction of closed distal tibia fractures is safe and effective. Malalignment can be improved with fibula stabilization but indications remain unclear. For surgeons interested in international mission work, the SIGN IM nail is an effective tool in managing distal tibial fractures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

Clinical outcomes of patients with isolated femoral shaft fractures treated with S.I.G.N interlock nails versus Cannulated Interlock Intramedullary nails

ObjectiveThe S.I.G.N (Surgical Implant Generation Network Inc.) solid intramedullary nail is originally designed for tibial shaft fractures and is currently being used for femoral shaft fractures as an extended use. The nail is used in developing nations such as the Philippines, as an alternative for those who could not afford the commercially available nails. The main objective of the study is to determine whether there is a difference in clinical outcomes of patients with isolated femoral shaft fractures in Philippine General Hospital, treated with S.I.G.N intramedullary nails versus Cannulated intramedullary nails, from year 2007 to 2012. PopulationA total of 175 patients fulfilled the inclusion criteria based from reviews of censuses, in-patient and OPD charts of the trauma section of the Department of Orthopedics, Philippine General Hospital. The Surgical Implant Generation Network (S.I.G.N) Fracture Care On-line Database was also screened for patients to be included in the study. A total of 68 patients were able to follow-up, with 48 patients in the S.I.G.N group and 20 patients for the Cannulated group. Main outcome measuresThe dependent variables of the study are radiographic and clinical union, knee range of motion, weight bearing status, and complications. ResultsThe subjects were divided into patients operated with S.I.G.N nails and with Cannulated Interlock Intramedullary nails. For the S.I.G.N group, the mean age is 32.1 years and mean follow-up is 40.75 weeks post-op. The Cannulated group has a mean age of 27.9 years and mean follow-up of 35.85 weeks post-op. Radiographic union rate for the S.I.G.N group is 68.8% while for the Cannulated group is 80%. Clinical union and full weight bearing status of patients are 100% in both groups. There is no significant difference with the number of patients with full range of motion in both groups: (S.I.G.N: 85%; Cannulated: 90%). Complication rates are also non-significant (S.I.G.N: 12.5%; Cannulated: 5%). ConclusionsThere is no significant difference between patients with isolated femoral shaft fractures treated with S.I.G.N. Interlock Intramedullary nail versus Cannulated Interlock Intramedullary nail in terms of Clinical and radiographic union, weight bearing, knee range of motion and complication rate.