title: Predictors of Reoperation for Adult Femoral Shaft Fractures Managed Operatively in a Sub-Saharan Country.
abstract: BACKGROUND
  The optimal treatment for femoral shaft fractures in low-resource settings has yet to be established, in part, because of a lack of data supporting operative treatment modalities. We aimed to determine the reoperation rate among femoral fractures managed operatively and to identify risk factors for reoperation at a hospital in a Sub-Saharan country.
  
  
  METHODS
  We conducted a prospective clinical study at a single tertiary care center in Tanzania, enrolling all skeletally mature patients with diaphyseal femoral fractures managed operatively from July 2012 to July 2013. Patients were followed at regular intervals for 1 year postoperatively. The primary outcome was a complication requiring reoperation for any reason. Secondary outcomes were scores on the EuroQol (EQ)-5D, radiographic union score for tibial fractures (RUST), and squat-and-smile test.
  
  
  RESULTS
  There were a total of 331 femoral fractures (329 patients) enrolled in the study, with a follow-up rate at 1 year of 82.2% (272 of 331). Among the patients with complete follow-up, 4 injuries were managed with plate fixation and 268 were managed with use of an intramedullary nail. The reoperation rate for plate fixation was 25% (1 of 4) compared with 5.2% (14 of 268) for intramedullary nailing (p = 0.204). As found in a multivariate logistic regression, a small nail diameter, a Winquist type-3 fracture pattern, and varus malalignment of proximal fractures were associated with reoperation. The mean EQ-5D score at 1 year was 0.95 for patients who did not require reoperation compared with 0.83 for patients who required reoperation (p = 0.0002).
  
  
  CONCLUSIONS
  Intramedullary nailing for femoral shaft fractures was associated with low risk of reoperation and a nearly full return to baseline health-related quality of life at 1 year of follow-up. There are potentially modifiable risk factors for reoperation that can be identified and addressed through education and dissemination of these findings.
  
  
  METHODS
  Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: 1Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania 2Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, San Francisco General Hospital, San Francisco, California 3Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.
authors.forename: Edmund N
authors.initials: EN
authors.lastname: Eliezer
authors.forename: Billy T
authors.initials: BT
authors.lastname: Haonga
authors.forename: Saam
authors.initials: S
authors.lastname: Morshed
authors.forename: David W
authors.initials: DW
authors.lastname: Shearer
mesh_terms: D000328:Adult; D001860:Bone Plates; D003906:Developing Countries; D005260:Female; D005264:Femoral Fractures / Q000453:epidemiology* / Q000601:surgery*; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal; D005594:Fracture Fixation, Intramedullary; D006801:Humans; D008297:Male; D011203:Poverty; D011379:Prognosis; D011446:Prospective Studies; D011788:Quality of Life; D020127:Recovery of Function; D012086:Reoperation; D012307:Risk Factors; D013636:Tanzania / Q000453:epidemiology; D055815:Young Adult