title: Management of Distal Tibial Metaphyseal Fractures With the SIGN Intramedullary Nail in 3 Developing Countries.
abstract: OBJECTIVE
  To evaluate the effectiveness of the Surgical Implant Generation Network (SIGN) intramedullary (IM) nail in distal tibial metaphyseal fractures.
  
  
  METHODS
  Retrospective Case Series.
  
  
  METHODS
  Three Level I trauma centers in 3 different developing countries from 2009 to 2013.
  
  
  METHODS
  One hundred sixty patients with 162 distal tibial metaphyseal fractures (AO/OTA 43-A).
  
  
  METHODS
  SIGN IM nailing was performed using hand reaming and without the use of an image intensifier.
  
  
  METHODS
  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 (<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%).
  
  
  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.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Henry Ford Macomb Hospital Clinton Township, MI; †Rehman Medical Institute, Peshawar, Pakistan; ‡Tenwek Hospital, Bomet, Kenya; §Soddo Christian Hospital, Soddo, Ethiopia; ‖Department of Orthopaedics and Traumatology, Lady Reading Hospital, Peshawar, Pakistan; ¶Department of Orthopaedics and Rehabiliation University of Wisconsin, Madison, WI; **Resurgens Orthopaedics, Marietta, GA; and ††SIGN Fracture Care International.
authors.forename: Kyle R
authors.initials: KR
authors.lastname: Stephens
authors.forename: Faseeh
authors.initials: F
authors.lastname: Shahab
authors.forename: Daniel
authors.initials: D
authors.lastname: Galat
authors.forename: Duane
authors.initials: D
authors.lastname: Anderson
authors.lastname: Shahabuddin
authors.forename: Paul S
authors.initials: PS
authors.lastname: Whiting
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Lundy
authors.forename: Lewis G
authors.initials: LG
authors.lastname: Zirkle
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails / Q000706:statistics & numerical data*; D003906:Developing Countries / Q000706:statistics & numerical data*; D019544:Equipment Failure Analysis; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000295:instrumentation* / Q000379:methods / Q000706:statistics & numerical data*; D017102:Fracture Healing; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010154:Pakistan / Q000453:epidemiology; D015995:Prevalence; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D013978:Tibial Fractures / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult