Surgical Implant Generation Network Research Articles

Standard or Fin SIGN® nail? which option is better for the treatment of femoral fractures in low and middle-income countries?

PurposeFemoral fractures are common in low and middle-income countries (LMIC), predominantly caused by high-energy trauma. The surgical implant generation network (SIGN®) program offers two different intramedullary nails in LMIC which are designed to be used without image intensifier free of charge for the patients: the SIGN standard nail (SSN®) and the SIGN Fin nail (SFN®). This study aimed to compare the results of the SSN® and the SFN® for the treatment of middle and distal shaft femoral fractures through a retrograde approach.Material and MethodsThis was a retrospective, descriptive, and non-experimental study including all consecutive patients who underwent surgical management of middle or distal shaft femoral fracture between January 2017 and May 2022 in an NGO hospital located in Freetown, Sierra Leone. The duration of surgery, type of reduction, complications like screw loosening, implant migration, anterior knee pain and non-union rate at six months of follow up were evaluated.ResultsA total of 122 patients were included in the study. Group A: 60 patients were managed with SSN® and Group B: 62 patients with SFN®. The mean operative time was 104 min with SSN® and 78 with SFN® (p < 0.001). Open reduction of the fracture was necessary in ten (16.7%) patients with SSN® and 12 (19.4%) patients treated with SFN® (p = 0.69). Non-union was observed in one (1.7%) patient with SSN® and two (3.2%) patients with SFN® (p = 0.57).ConclusionsBoth options seem equally effective in treating midshaft and distal femoral shaft fractures. The SFN® reduces the surgical time, due to this fact, in polytraumatized patients, patients with bilateral femur fracture or patients with ipsilateral tibia fracture, it can be considered as the best option to be used. There was no statistical difference in the complications presented by the two groups.

Canal fitting and treatment outcomes of patients treated with sign fin nail at a Tertiary Hospital in Tanzania

Background: The Surgical Implant Generation Network (SIGN) Fin nail is a relatively newer design of intramedullary nails that eliminates the requirement for distal locking. While various factors influencing treatment outcomes with different nail designs have been extensively studied, limited research has focused on the specific implications of using the SIGN Fin nail. Objective: This study aimed to assess the relationship between Fin nail canal fitting and treatment outcomes in femur fractures treated with the SIGN Fin nail at Muhimbili Orthopaedics Institute. Methods: A cross-sectional study was conducted at a tertiary hospital in Tanzania. Patients who underwent femoral fracture fixation with SIGN Fin nails between January 2016 and December 2021 were recruited from the SIGN surgical database. Radiographic measurements were performed using radiant software, fracture union at one year was assessed using the mRUST score, and weight-bearing status at 6 weeks was obtained from patient records. Results: The mean canal diameter was 11.30±1.75 mm, and 82.2% had a canal fill of 80% or more. The reoperation rate was 5.9% (7/118). Although not statistically significant, patients with canal fill less than 80% had a higher rate of reoperation (p = 0.074). The union rate was 84.1% in this study, with a mean mRUST score of 9.4, and those patients with a canal fill of less than 80% were more likely to have nonunion at 1 year (p = 0.028). Pain on weight bearing at 6 weeks was reported by 42.9% (24/118) of participants, and this was significantly associated with canal fitting (p &lt; 0.001). Conclusion: The study found the degree of canal fitting of the Fin nail to be an important factor affecting the outcomes of femoral fractures treated with SIGN Fin nails. A higher degree of canal fill was associated with better pain outcomes and lower nonunion rates.

Retrospective cohort study analyzing outcomes of the SIGN Fin Nail in adult femoral fractures using the retrograde approach

PurposeThere is high burden of long bone fractures in low- and middle-income countries (LMICs). Given a limited availability of fluoroscopy in LMICs, the Surgical Implant Generation Network (SIGN) developed two types of intramedullary nails: the SIGN standard nail and the SIGN Fin Nail. A limited number of studies have analyzed healing outcomes with the SIGN Fin Nail and the current study is the largest one to date. The purpose of this study is to compare outcomes between the SIGN standard nail and SIGN Fin Nails in adult femoral shaft fractures treated with a retrograde approach. MethodA retrospective cohort study of adults with femoral shaft fractures was performed using the Sign Online Surgical Database (SOSD). The primary outcome was achieving full painless weight bearing and the secondary outcomes assessed were radiographic healing and infection. A propensity-score adjustment was performed for potential confounders and effect modification due to fracture location was tested using a Mantel-Haenszel test for heterogeneity. ResultsOf 19,928 adults with femoral shaft fractures, 2,912 (14.7%) had the required 6-month follow-up to be included. The overall propensity score weighted relative risk between the Fin and Standard Nail for achieving painless weight-bearing was 0.99, 95% CI [0.96–1.03] and for radiographical healing was 0.99, 95%CI [0.97–1.02]. The propensity score weighted relative risk for infection was 1.30, 95% [0.85–1.97]. Use of the Fin nail was also significantly associated with shorter surgery times (p < 0.005, effect size = 24 min). Sub-group analysis based on fracture location and injury cause demonstrated no change in relative risk. ConclusionThe Fin nail showed no change in relative risk in terms of achieving full painless weightbearing or radiographic healing compared to the standard nail for retrograde nailing of femoral shaft fractures in adults. The heterogeneous nature of the cohort and large sample size allow for generalizability and add to a growing base of literature supporting use of the Fin Nail for retrograde femoral nailing. However, there are limitations as we could not correct for comminution at the fracture site or measure radiographic alignment or shortening.

Delays in Debridement of Open Femoral and Tibial Fractures Increase Risk of Infection.

Infection remains a costly, devastating complication following the treatment of open fractures. The appropriate timing of debridement is controversial, and available evidence has been conflicting. This study is a retrospective analysis of the SIGN (Surgical Implant Generation Network) Surgical Database (SSDB), a prospective registry of fracture cases in predominantly low-resource settings. Skeletally mature patients (≥16 years of age) who returned for follow-up at any time point after intramedullary nailing of an open femoral or tibial fracture were included. Patients were excluded if they had delays in debridement exceeding 7 days after the injury. Utilizing a model adjusting for potential confounders, including patient demographic characteristics, injury characteristics, country income level, and hospital type and resources, local logistic regression analysis was performed to evaluate the probability of infection with increasing time to debridement in 6-hour increments. In this study, 27.3% of patients met the eligibility criteria and returned for follow-up, with a total of 10,651 fractures from 61 countries included. Overall, the probability of infection increased by 0.17% for every 6-hour delay in debridement. On subgroup analysis, the probability of infection increased by 0.23% every 6 hours for Gustilo-Anderson type-III injuries compared with 0.13% for Gustilo-Anderson type-I or II injuries. The infection risk increased every 6 hours by 0.18% for tibial fractures compared with 0.13% for femoral fractures. There was a linear and cumulative increased risk of infection with delays in debridement for open femoral and tibial fractures. Such injuries should be debrided promptly and expeditiously. The size and international nature of this cohort make these findings uniquely generalizable to nearly all environments where such injuries are treated. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries.

Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings. We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon. Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up. Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries. Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Knee Pain After Retrograde Intramedullary Nailing with Surgical Implant Generation Network of Femur Shaft Fractures at Public Hospitals in Bahir Dar City, Ethiopia: Analysis of 6-Months Follow-Up Results.

The incidence of femur fractures in young and elderly people has increased, particularly in countries with limited resources like Ethiopia. Intra-medullary nailing (IM) has been an effective and cost-effective method of treating long bone shaft fractures, but it can lead to complications such as knee pain. This study aimed to evaluate knee pain and its associated factors following retrograde intramedullary nailing for femur fractures. The study followed 110 patients diagnosed with femur fractures and treated with retrograde SIGN Standard Nail or Fin Nail from January 2020 to December 2022 at two hospitals in Ethiopia. The patients were followed up for at least 6 months, and data were collected from medical charts, patient interviews, and phone calls to patients who did not attend the follow-up appointment. Binary logistic regression analysis was used to identify factors associated with knee pain. The study showed that 40 patients reported knee pain at 6-months follow-up, making a prevalence of 36.4%. Factors significantly associated with knee pain were a time of injury to nailing (AOR=4.23, 95% CI: 1.28-13.92), use of a screw to the medial cortex (AOR=9.30, 95% CI: 2.90-12.74), and fracture site (AOR= 2.67, 95% CI: 14.01-7.03). Specifically, the longer the time from injury to nailing, the higher the risk of knee pain. The use of a longer screw to the medial cortex and a fracture site were also positively associated with knee pain. This study concludes that although retrograde intramedullary nail fixation is an effective method for femur fractures, it often results in knee pain. Approximately 4 of 10 patients suffered from knee pain in this study. Avoiding delayed surgical management and minimizing the use of prominent metalwork may reduce knee pain.

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.

Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting.

Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration () and definitive fracture fixation (); definitive wound closure (), fracture-reduction methods (), and surgery duration (). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.

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.

Infection after surgical implant generation network (SIGN) nailing in treatment of long bone shaft fractures in Ethiopia: analysis of a 4-year results

BackgroundOne of the challenge to manage long bone fracture is the risk of infection. Intramedullary nailing is the standard treatment of long bone shaft fractures. Infection from the surgical site during orthopedic management is posing postoperative burdens in different perspectives like patient perspectives and healthcare facilities. However, there is limited information on the magnitude of infection in Ethiopia after surgical implant generation network (SIGN) nailing in the treatment of long bone shaft fractures. Therefore, the current study aimed to assess the prevalence of infection in patients with long bone shaft fractures treated with surgical implant generation network (SIGN) nailing.ObjectiveTo assess prevalence of infection in patients with long bone shaft fractures treated with SIGN nailing at Felege Hiwot Referral Hospital from January 1, 2015, to December 31, 2018, Bahir Dar, Northwest, Ethiopia.MethodsThis was a retrospective study over a period of 4 years. SIGN surgical-related data, presence or absence of infection from the documented information were collected from the chart/the source. The types of infection were also collected with the standard classification as superficial, deep and deep with osteomyelitis. Age, sex, fracture pattern, nature of fracture, mechanism of injury, prophylaxis antibiotics, nail type, follow-up in weeks and other factors were also extracted from the patients’ charts with structured checklist. Data were analyzed with statistical package for social sciences (SPSS) version 23. The analyzed data were presented with texts, tables and a graph.ResultsThree hundred and eighty-two long bone fractures were treated by locked SIGN intramedullary nailing during the study period. After screening the inclusion criteria, a total of 311 cases were included in this study. A total of 13 (4.2%) patients who treated with SIGN intramedullary nailing developed infection.ConclusionsWe conclude that the overall prevalence of infection with SIGN intramedullary nailing is almost similar with the surgeries done in the developed countries.

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.

Factors Affecting Time to Healing in Humeral Shaft Fractures Treated with SIGN Intramedullary Nailing

There is a tendency to treat humeral fractures with the use of splintage in resource poor countries due to a perceived high rate of complications with operative fixation. The Surgical Implant Generation Network (SIGN) intra medullary nail has provided an alternative in the management of humeral shaft fractures. Due to the paucity of research work in this area, our study evaluated factors that influence the time to fracture union in humeral shaft fractures. Fifty-eight humeral Diaphysial fractures were treated over six years. It is a retrospective study. Case notes and the database were analysed. The statistical analysis was done using the SPSS 24 software. The time to fracture healing was the primary outcome variable and how it was influenced by patient and implant variables was studied. The mean time to fracture healing was 17.38 weeks. All 58 fractures united. The mean time to fracture healing in the 20 - 29 years was 16.00 weeks which was lower than in older age groups. Fractures in males healed at 16.33 weeks and in females at 18.76 weeks. Patients with Diabetes Mellitus had a mean healing time of 29.00 weeks, while third proximal fractures healed in a mean time of 15.25 weeks. Age and sex had no significant influence on the time to fracture healing while Diabetes Mellitus, longer duration of antibiotic use, open fractures, and presence of fracture gap post fixation and third middle fractures had increased time to fracture healing.

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.

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.

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.

Complications and functional, psychological outcomes of bilateral tibial lengthening over intramedullary nail: evidence from Vietnam.

The purpose of this study was to assess the functional, psychological outcomes and complications of bilateral tibial lengthening over intramedullary nail. The intramedullary nail in this study was the Surgical Implant Generation Network (SIGN) nail. We enrolled patients desiring stature lengthening at the 108 MilitaryCentral Hospital (Hanoi, Vietnam) from October 2011 to January 2019. A total of 104 people have been enrolled in the study and underwent the bilateral tibial lengthening procedure. Average tibial lengthening was 7.1 ± 0.8cm in men and 6.5 ± 0.6cm in women. Percentage of tibial lengthening as compared with tibia length at the time of pre-operation was 23.9 ± 3.5% for male patients and 21.5 ± 3.7% for female patients. The outcome was excellent in 85 patients (81.7%) and good in 19 (18.3%). All patients experienced improved self-esteem and enhanced quality of life. Our study suggests that bilateral tibial lengthening over nail was safe and effective provided complications are looked for and kept in check. Equinus contracture, pin tract infection, and valgus deviation were the most common complications. Valgus deviation occurs during distraction period. In patient who had neutral or valgus alignment, we recommend to use a blocking screw at the proximal segment post-operatively and use a blocking screw at the valgus distal segment at the end of distraction period to maintain the mechanical axis of both tibias. Bilateral tibial lengthening over nail should be widely employed in low-income countries.

Squat and smile assessment in predicting healing of lower limb fractures fixed with a SIGN nail

BackgroundIrrespective of the treatment method, union is the ultimate goal of any fracture treatment. However, nowadays, rather than the physician-based clinico-radiological methods, the patient-reported outcome measurements assessing their quality of life and function are gaining much popularity. This is specifically true in the part of the world where the patient needs almost complete degree of hip/knee flexion – for social, cultural, religious or occupational reason(s). The ability to squat can assess the mobility and stability of joints and thus the quality of squatting is a proxy reflection of the functional outcome after fixation of lower limb fracture. Thus, we studied to determine the inter-observer and intra-observer reliability of Radiographic Union Score for Tibia (RUST) and Squat and Smile (S & S) test in clinical photograph. We further calculated the sensitivity and specificity of S & S test in predicting healing of lower limb fracture fixed by intramedullary interlocking nail considering RUST as the gold standard. MethodsThis was a retrospective study of prospectively collected data of solid Surgical Implant Generation Network (SIGN) intramedullary interlocking nailing from a single, university-based, high volume tertiary center where 56 consecutive adults with either tibial or femoral shaft fractures fixed with a SIGN nail within one year and not requiring any surgery till minimum of eighteen-month follow-up were included. Cases without either Anterior-Posterior (AP) view and/or Lateral (Lat.) view follow-up x-ray(s) or proper S & S clinical photograph (at least 1.5-year post fixation) were excluded. The x-rays (RUST criteria) and clinical photograph (S & S grading) were scored by two independent and blinded observers each and repeated after 1 month. ResultsThe overall intra-observer reliability was from 0.773 to 0.825 and inter-observer reliability from 0.635 to 0.757 for RUST scoring which was from 0.687 to 0.785 and from 0.301 to 0.650 respectively for S & S scoring. The sensitivity and specificity of S & S in predicting fracture healing were up to 82.22% and 63.64% respectively. ConclusionThe S & S test is reliable to predict the healing of lower limb fracture fixed with an intramedullary nail. The test is more useful to determine healed fractures than to determine non-healed ones. (sensitivity being higher than specificity)

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