Low infection rates after 34,361 intramedullary nail operations in 55 low- and middle-income countries: Validation of the Surgical Implant Generation Network (SIGN) Online Surgical Database

Background: The Surgical Implant Generation Network (SIGN) supplies intramedullary (IM) nails for the treatment of long bone fractures free of charge to hospitals in low- and middle-income countries (LMICs). Most operations are reported to the SIGN Online Surgical Database (SOSD). Follow-up has been reported to be low, however. We wanted to examine the pattern of follow-up and to assess whether infection rates could be trusted. Patients and methods: The SOSD contained 36,454 IM nail surgeries in 55 LMICs. We excluded humerus and hip fractures, and fractures without a registered surgical approach. This left 34,361 IM nails for analysis. A generalized additive regression model (gam) was used to explore the association between follow-up rates and infection rates. Results: The overall follow-up rate in the SOSD was 18.1% (95% CI: 17.7–18.5) and national follow-up rates ranged from 0% to 74.2%. The overall infection rate was 0.7% (CI: 0.6–0.8) for femoral fractures and 1.2% (CI: 1.0–1.4) for tibial fractures. If only nails with a registered follow-up visit were included (n = 6,224), infection rates were 3.5% (CI: 3.0–4.1) for femoral fractures and 7.3% (CI: 6.2–8.4) for tibial fractures. We found an increase in infection rates with increasing follow-up rates up to a level of 5%. Follow-up above 5% did not result in increased infection rates. Interpretation: Reported infection rates after IM nailing in the SOSD appear to be reliable and could be used for further research. The low infection rates suggest that IM nailing is a safe procedure also in low- and middle-income countries.publishedVersio

Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries

Background: The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data. Methods: The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis. Results: The overall follow-up rate was 23.1 %. The overall infection ratewas 1.0 %, 0.7 %for humerus, 0.8 %for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country. Conclusions: The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC

Antimicrobial particulate silver coatings on stainless steel implants for fracture management

We have used particulate silver coating on stainless steel to prevent in vivo bacterial infection. Stainless steel is commonly used as an implant material for fracture management. The antimicrobial use of silver has been well documented and studied, therefore the novelty of this research is the use of a particulate coating as well as facing the real world challenges of a fracture repair implant. The variable parameters for applying the coating were time of deposition, silver solution concentration, voltage applied, heat treatment temperature between 400 and 500°C and time. The resultant coating is shown to be non-toxic to human osteoblasts using an MTT assay for proliferation and SEM images for morphology. In vitro silver release studies of various treatments were done using simulated body fluid. The bactericidal effects were tested by challenging the coatings with Pseudomonas aeruginosa in a bioreactor and compared against uncoated stainless steel. A 13-fold reduction in bacteria was observed at 24h and proved to be statistically significant. ► Processing of particulate silver coating that are strongly adherent on SS surface. ► Optimized the amount of silver that is sufficient to reduce bacterial colonization but non-toxic to human bone tissue. ► The adhesion strength of silver was sufficient to survive industrial sterilization steps used for fracture management devices

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

OBJECTIVES: To evaluate the effectiveness of the Surgical Implant Generation Network (SIGN) intramedullary (IM) nail in distal tibial metaphyseal fractures. DESIGN: Retrospective Case Series. SETTING: Three Level I trauma centers in 3 different developing countries from 2009 to 2013. PATIENT/PARTICIPANTS: One hundred sixty patients with 162 distal tibial metaphyseal fractures (AO/OTA 43-A). INTERVENTION: SIGN IM nailing was performed using hand reaming and without the use of an image intensifier. MAIN OUTCOME MEASUREMENTS: 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. RESULTS: 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 (deformity) was found in 134 fractures (83%). Infection occurred in 14 patients (8.6%). Revision surgery was required in 10 fractures (6.2%). CONCLUSIONS: 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. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

Outcome of tibial shaft fractures treated with the SIGN FIN nail at Addis Ababa Emergency, Burn, and Trauma Hospital (AaEBT) Addis Ababa, Ethiopia

Abstract. Objectives:. To determine the outcome of tibial fractures treated with the SIGN FIN nail. Study Design:. Retrospective case series study. Study Setting:. Trauma center. Methods and Materials:. We included 14 patients aged 18–51 years with 16 tibial fractures in this study. Patients were followed clinically and radiographically, and the minimum time followed was 6 months. Johner and Wruhs criteria with modification were used to assess the outcome. Result:. There were 11 male (78.6%) and three female (21.4%) patients. The mean age was 32.44 ± 8.98 (range 18–51) years. The right-sided tibia was injured in six as compared with the left side in four, and four patients had bilateral injuries. Eight (50%) fractures were closed fractures, whereas the rest eight (50%) were open types of fractures. Among the latter, half (n = 4; 50%) fractures were Gustilo type II fractures, while three (37.5%) fractures were Gustilo type III fractures, and one (12.5%) patient had a Gustilo type I fracture. All patients had radiologic union. There were no infections or secondary surgery for any reason. Excellent, good, and fair results were achieved in 62.5%, 25%, and 12.5%, respectively. All patients were able to return to their preinjury activity except two patients. Conclusion:. SIGN FIN nail is an option for treating tibial shaft fractures with good outcomes and few complications in selected fractures. Level of evidence:. Level I