Reamed intramedullary nailing of diaphyseal multifragmentary femur fractures (AO/OTA 32-C) without fluoroscopy guidance: prospective analysis of methods and short-term outcomes in a low-resource setting.

PURPOSE: To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table. METHODS: The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months. RESULTS: DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm. CONCLUSION: The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.

Retrograde intramedullary nailing with supplemental plate and lag screws allows early weight bearing following distal end-segment femur fractures (AO/OTA 33) in a low-resource setting.

PURPOSE: To underline the feasibility of achieving early weight bearing in patients with distal end-segment femur fractures (AO/OTA 33) treated with retrograde intramedullary nailing and supplemental plate or lag screws in the absence of C-arm. METHODS: 41 distal end-segment femur fractures (DFFs) included in the study were treated with SIGN nails with or without a side plate in a center that lacked intraoperative fluoroscopy and fracture table. A medial or lateral para-patellar incision was used for fracture reduction, nail insertion and side plate placement. Follow-ups were done at six weeks, 12 weeks, and six months post-operatively. RESULTS: Distal end-segment fractures constituted 13.2% of all femur fractures treated. The patients' mean age and range were 49.6 and 23-83 years respectively. They were mostly injured in road traffic accidents. 27 were daily-income earners. By the 12th week post-operatively, 82.1% of them could flex their knee beyond 90°, all of them could bear weight fully, and 71.8% could squat & smile. CONCLUSION: The study highlighted the procedure for retrograde nailing of DFFs in a setting without the requisite facilities for minimally-invasive surgeries. The findings demonstrated the feasibility of achieving an expedited weight bearing for the predominantly daily-income-earning victims to ensure early return to work and poverty reduction. While the small sample size is a limitation, the study does provide information that could serve as a basis for future randomized controlled trials in low-resource settings.

Follow-up non-attendance after long-bone fractures in a low-resource setting: a prospective study of predictors and interventions to increase attendance rates.

BACKGROUND: While the majority of traumatic injuries occur in low- and middle-income countries, the published literature comes chiefly from high-income countries due to poor follow-up. Clinical and radiographic post-surgical trauma follow-up is essential to high-quality research and objective monitoring for healing and/or complications. This study aimed to identify the predictors of follow-up non-attendance in a low-resource setting and investigate the extent to which interventional efforts based on mobile phone technology (MPT) and home visits improved the follow-up rates for fractures treated with SIGN nails. METHODS: This was a prospective study of 594 patients with long-bone fractures. Socio-demographic (e.g. age, gender, marital status, education level, etc.) and clinical (e.g. fracture type, concomitant injuries, comorbidity, etc.) data were collected on each patient. Before discharge, the importance of follow-up was explained to patients and their relations. They were encouraged to attend even if they felt well. Their residential addresses and telephone numbers were validated and securely stored. Patients who missed their appointments were contacted by phone. Those who failed to honour 2 or 3 rescheduled appointments were visited in their home. The patients were divided into those who returned for the primarily scheduled follow-up without prompting (volition group) and those who did not come (non-attenders). Univariate analyses and binary logistic regression were conducted to determine the significant predictors of non-attendance. RESULTS: The proportion of patients in the volition group reduced from 96.1% at 6 weeks to 53.0% at 12 weeks and 39.2% at 6 months. However, interventional efforts increased these values to 98.5%, 92.5%, and 72.4% respectively. Walking unaided before the primarily scheduled 12-week appointment was the major reason for not attending the follow-up. Education, occupation, post-operative length of hospital stay (PLOS) and infection were significantly associated with non-attendance but younger age, long distances from the hospital, being separated or divorced, difficulty paying the in-patient care bill, closed fracture, having no (or a non-limb) concomitant injury, achieving painless weight bearing ≤ 6 weeks post-operatively and needing no additional surgery were independent predictors of non-attendance. CONCLUSIONS: Our study sheds light on the predictors of follow-up non-attendance and demonstrates how interventional efforts improved attendance rates in a low-resource setting. In addition, efforts that better the socio-economic status of people such as more-encompassing health insurance coverage and greater work flexibility can improve the follow-up attendance rates.

Foot-at-risk among adult outpatients with diabetes mellitus in Bowen University Teaching Hospital, Ogbomoso, Nigeria.

Introduction: the rising prevalence of diabetes mellitus (DM) around the world has dramatically increased the number of people bearing the complications of this potentially incapacitating disease. One of these complications is foot ulcers that may result in amputation. This study sets out to determine the profiles of the "foot-at-risk" for ulceration and the associated socio-medical factors in DM patients. Methods: this study was conducted at Bowen University Teaching Hospital, Ogbomoso, Southwest, Nigeria. This was a descriptive cross-sectional study comprising 299 outpatient adults aged 18 years and above with diabetes mellitus of at least 6 months in duration. Comprehensive Foot Examination and Risk Assessment tool was used to identify the foot-at-risk categories of the participants. Data analysis was done using Statistical Package for Social Sciences (SPSS) version 20. Results: the prevalence of foot-at-risk among the participants was 64.9% (194). Among the 194 participants with foot-at-risk, 35.1% (105) belonged to the foot-at-risk categories 0, 37.8% (113) in category 1, 16.1% (48) in category 2, and 11.0% (33) in category 3. Other factors that had a statistically significant association with foot-at-risk included; age, religion, level of education, duration of diabetes, history of smoking, and glycemic control. Conclusion: foot-at-risk was found to have an alarming prevalence among the participants. In addition, the level of glycemic control in this group was unacceptably poor. Clinicians need to intensify preventive measures like foot screening and health education to prevent foot ulcerations, which may result in limb amputation in DM patients.

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria.

Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients' population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table.

PURPOSE: Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. METHODS: A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. RESULTS: Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005). CONCLUSION: With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.

Radiation-free interlocking intramedullary nailing of three-hundred and seventy long bone fractures in Ogbomoso, Nigeria.

Long bone fracture care in developing countries remains largely different from that of the developed world where closed reduction and internal fixation with locked intramedullary nail is the standard treatment. This study in a developing country presents the pattern and outcome of treatment of 370 long bone fractures using the SIGN nail over a five-year period in order to underline the wide array of patients and fractures treatable with the nail. Using a prospective descriptive approach, all the 342 patients with 370 fractures of the humerus, femur and tibia treated from July 2014 to June 2019 were studied. The fractures were reduced without image intensifier or fracture table and fixed with the SIGN nail. Post-discharge, the patients were followed up at the out-patient clinic. The mean age of the patients was 43.45 years with a range of 10-99 years. Sixty-six percent were males who were mostly injured in motorcycle accidents. Femur, tibia and humerus fractures accounted for 59.7%, 28.4% and 11.9% respectively. Eighty-six percent were diaphyseal fractures, 73% were fresh and the main previous treatment was traditional bone setting. Deep infection occurred in 4.9%, 66.0% achieved knee flexion > 90° by sixth week, the majority achieved full weight bearing and could squat and smile by 12th week. The SIGN nail is versatile, useful for treating a wide range of fractures in most age groups particularly in developing countries where orthopaedic fractures are prevalent but the more sophisticated facilities are lacking or poorly maintained.