Skip to main content
SpringerLink
Log in

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

  • Review Article
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Eighty per 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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Ameratunga S, Hijar M, Norton R (2006) Road-traffic injuries: confronting disparities to address a global-health problem. Lancet 367(9521):1533–1540

    Article  PubMed  Google Scholar 

  2. Beveridge M, Howard A (2004) The burden of orthopaedic disease in developing countries. J Bone Joint Surg Am 86:1819–1822

    PubMed  Google Scholar 

  3. Bickler SW, Sanno-Duanda B (2000) Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Organ 78:1330–1336

    PubMed  CAS  Google Scholar 

  4. Brooks PM (2006) The burden of musculoskeletal disease—a global perspective. Clin Rheumatol 25:778–781

    Article  PubMed  Google Scholar 

  5. Calafi LA, Antkowiak T, Curtiss S, Neu CP, Moehring DA (2010) A biomechanical comparison of the Surgical Implant Generation Network (SIGN) tibial nail with the standard hollow nail. Injury 41(7):753–757

    Article  PubMed  CAS  Google Scholar 

  6. Carr CR, Wingo CH (1973) Fractures of the femoral diaphysis. A retrospective study of the results and costs of treatment by intramedullary nailing and by traction and a spica cast. J Bone Joint Surg Am 55(4):690–700

    PubMed  CAS  Google Scholar 

  7. Clough M, Zirkle LG, Schmitt RJ (2010) The role of SIGN in the development of a global orthopaedic trauma database. Clin Orthop Relat Res 468(10):2592–2597

    Article  PubMed  Google Scholar 

  8. Dormans JP, Fisher RC, Pill SG (2001) Orthopaedics in the developing world: present and future concerns. J Am Acad Orthop Surg 9:289–296

    PubMed  CAS  Google Scholar 

  9. Downing ND, Griffin DR, Davis TR (1997) A comparison of the relative costs of cast treatment and intramedullary nailing for tibial diaphyseal fractures in the UK. Injury 28:373–375

    Article  PubMed  CAS  Google Scholar 

  10. Eriksen HM, Chugulu S, Kondo S, Lingaas E (2003) Surgical-site infections at Kilimanjaro Christian Medical Center. J Hosp Infect 55(1):14–20

    Article  PubMed  CAS  Google Scholar 

  11. Fakhry SM, Rutledge R, Dahners LE, Kessler D (1994) Incidence, management, and outcome of femoral shaft fracture: a statewide population-based analysis of 2805 adult patients in a rural state. J Trauma 37(2):255–260

    Article  PubMed  CAS  Google Scholar 

  12. Gendin O, Schultz R (2009) SIGN nailing of humeral fractures and nonunions. Tech Orthop 24(4):253–257

    Article  Google Scholar 

  13. Gillquist J, Liliedahl SO, Rieger A (1971) Fracture of the femur diaphysis. Traction or nailing? Acta Chir Scand 137(6):515–520

    PubMed  CAS  Google Scholar 

  14. Gosselin RA, Heitto M, Zirkle LG (2009) Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia. Int Orthop 33(5):1445–1448

    Article  PubMed  Google Scholar 

  15. Gosselin RA, Lavaly DJ (2007) Perkins traction for adult femoral shaft fractures: a report on 53 patients in Sierra Leone. Int Orthop 31(5):697–702

    Article  PubMed  Google Scholar 

  16. Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG (2009) Injuries: the neglected burden in developing countries. Bull World Health Organ 87(4):246–246a

    Article  PubMed  Google Scholar 

  17. Hooper GJ, Keddell RG, Penny ID (1991) Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial. J Bone Joint Surg Br 73(1):83–85

    PubMed  CAS  Google Scholar 

  18. Ikem IC, Ogunlusi JD, Ine HR (2007) Achieving interlocking nails without using an image intensifier. Int Orthop 31(4):487–490

    Article  PubMed  Google Scholar 

  19. Johnson KD, Johnston DW, Parker B (1984) Comminuted femoral shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail. J Bone Joint Surg Am 66(8):1222–1235

    PubMed  CAS  Google Scholar 

  20. Krug EG, Sharma GK, Lozano R (2000) The global burden of injuries. Am J Public Health 90:523–526

    Article  PubMed  CAS  Google Scholar 

  21. Lefaivre KA, Guy P, Chan H, Blachut PA (2008) Long-term follow-up of tibial shaft fractures treated with intramedullary nailing. J Orthop Trauma 22(8):525–529

    Article  PubMed  Google Scholar 

  22. Lopez AD, Begg S, Bos E (2006) Demographic and epidemiological characteristics of major regions, 1990–2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. The International Bank for Reconstruction and Development/The World Bank, Washington, DC; Oxford University Press, New York, 1:17–44

  23. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL (2006) Measuring the global burden of disease and risk factors, 1990–2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. The International Bank for Reconstruction and Development/The World Bank, Washington, DC; Oxford University Press, New York, 1:1–14

  24. Lwin T (2009) Tibio-talo-calcaneal fusion using SIGN IM nail. Tech Orthop 24(4):277–278

    Article  Google Scholar 

  25. Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3:e442

    Article  PubMed  Google Scholar 

  26. Mathers CD, Lopez AD, Murray CJL (2006) The burden of disease and mortality by condition: data, methods, and results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. The International Bank for Reconstruction and Development/The World Bank, Washington, DC; Oxford University Press, New York, 1:45–240

  27. Miller CW, Anderson L, Grossman J, Grant G (1978) Comparison of three treatments for fractures of the diaphysis of the femur. Surg Gynecol Obstet 146(4):572–576

    PubMed  CAS  Google Scholar 

  28. Mock CN, Adzotor KE, Conklin E, Denno DM, Jurkovich GJ (1993) Trauma outcomes in the rural developing world: comparison with an urban level I trauma center. J Trauma 35:518–523

    Article  PubMed  CAS  Google Scholar 

  29. Mock CN, Boland E, Acheampong F, Adjei S (2003) Long-term injury related disability in Ghana. Disabil Rehabil 25:732–741

    Article  PubMed  Google Scholar 

  30. Mock C, Cherian MN (2008) The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res 466:2306–2316

    Article  PubMed  Google Scholar 

  31. Nantulya VM, Reich MR (2002) The neglected epidemic: road traffic injuries in developing countries. BMJ 324:1139–1141

    Article  PubMed  Google Scholar 

  32. Ogunlosi JD, St. Rose RS, Davids T (2010) Interlocking nailing without imaging: the challenges of locating distal slots and how to overcome them in SIGN intramedullary nailing. Int Orthop 34(6):891–895

    Article  Google Scholar 

  33. Peden M, McGee K, Sharma G (2002) The injury chart book: a graphical overview of the global burden of injuries. World Health Organization, Geneva

    Google Scholar 

  34. Reggiori A, Ravera M, Cocozza E, Andreata M, Mukasa F (1996) Randomized study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa. Br J Surg 83(3):356–359

    Article  PubMed  CAS  Google Scholar 

  35. Sekimpi P, Okike K, Zirkle L, Jawa A (2011) Femoral fracture fixation in developing countries: an evaluation of the Surgical Implant Generation Network (SIGN) intramedullary nail. J Bone Joint Surg Am 93(19):1811–1818

    Article  PubMed  Google Scholar 

  36. Subak LL, Caughey AB (2000) Measuring cost-effectiveness of surgical procedures. Clin Obstet Gynecol 43(3):551–560

    Article  PubMed  CAS  Google Scholar 

  37. Thomas TL, Meggitt BF (1981) A comparative study of methods for treating fractures of the distal half of the femur. J Bone Joint Surg Br 63-B:3–6

    PubMed  CAS  Google Scholar 

  38. Toivanen JA, Hirvonen M, Auvinen O et al (2000) Cast treatment and intramedullary locking nail for simple and spiral wedge tibial shaft fractures—a cost-benefit analysis. Ann Chir Gynaecol 89(2):138–142

    PubMed  CAS  Google Scholar 

  39. Webb LX, Gristina AG, Fowler HL (1988) Unstable femoral shaft fractures: a comparison of interlocking nailing versus traction and casting methods. J Orthop Trauma 2(1):10–12

    Article  PubMed  CAS  Google Scholar 

  40. World Health Organization (2010) World Health Statistics. Available via: http://www.who.int/whosia/whostat/EN_WHS10_Full.pdf. Accessed 28 Apr 2012

  41. World Health Organization (2004) World report on road traffic injury prevention. World Health Organization, Geneva

    Google Scholar 

  42. Young S, Lie SA, Hallan G, Zirkle LG, Engesaeter LB, Havelin LI (2011) 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. Acta Orthop 82(6):737–743

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, San Francisco General Hospital, 2550 23rd Street, Bldg. 9, 2nd Floor, San Francisco, CA, 94110, USA

    Jonathan Phillips & Richard A. Gosselin

  2. SIGN Fracture Care International, 451 Hills St., Suite B, Richland, WA, 99354, USA

    Lewis G. Zirkle

Authors
  1. Jonathan Phillips
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lewis G. Zirkle
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richard A. Gosselin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jonathan Phillips.

Additional information

Dr. Zirkle is the founder and current president of SIGN Fracture Care International.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Phillips, J., Zirkle, L.G. & Gosselin, R.A. Achieving locked intramedullary fixation of long bone fractures: technology for the developing world. International Orthopaedics (SICOT) 36, 2007–2013 (2012). https://doi.org/10.1007/s00264-012-1625-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-012-1625-3

Keywords

Search

Navigation