Purpose: The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail. Methods: The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures. Results: The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P < .001) and knee ROM >90° (30% vs 91%, P < .001). There was no significant difference in mean DFAA between united and nonunited fractures in the coronal (2.1° vs 3.8°, P = .298) or sagittal (2.5° vs 3.5°, P = .528) planes. Conclusion: The SIGN Fin nail achieves satisfactory radiographic alignment and clinical outcomes at minimum 6 month follow-up...

Purpose: In developing countries, long bone fractures following trauma are a significant contributor to morbidity, and operating room resources are often limited in these settings. The Surgical Implant Generation Network (SIGN) Fin nail may reduce the challenges of retrograde intramedullary nailing of femoral fractures without fluoroscopy. In contrast to the traditional SIGN nail placed in a retrograde fashion, the Fin nail does not require proximal interlocking screws. Instead, the nail achieves stability through an interference fit within the proximal femoral canal. The purpose of this study is to compare postoperative alignment in femoral shaft fractures treated with either a retrograde SIGN Fin nail or a standard retrograde SIGN nail. Method: Using the SIGN online surgical database, we identified all femoral shaft fractures treated with a retrograde SIGN Fin nail at 2 African hospitals. Two examiners independently classified fracture patterns using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system. Using an on-screen protractor tool, postoperative coronal and sagittal plane alignment were measured and recorded as deviation from anatomic alignment (DFAA), with units in degrees. Available patient demographics and surgical details were also recorded. Fin nail cases were matched in a 1:1 ratio to retrograde standard SIGN nail cases based on AO/OTA fracture type. Results: Twenty-eight retrograde Fin nail cases were identified, and 28 matched retrograde SIGN nail cases were selected. The Fin nail and retrograde SIGN nail groups were well matched in terms of demographics, AO/OTA fracture type, and surgical characteristics. There was no significant difference in postoperative coronal or sagittal plane alignment between the groups. There were no cases in either group of average postoperative malalignment >5° in any plane. Conclusion: The SIGN Fin nail appears to achieve satisfactory radiographic alignment without the need for proximal interlocking screws, making it an attractive implant for retrograde femoral shaft fracture fixation in resource-limited settings. Further research is required to validate these findings and determine long-term Fin nail clinical outcomes.

Objectives: To identify the methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among surgical patients on an orthopaedic trauma service and to determine whether screening is an effective tool for reducing postoperative MRSA infection in this population. Design: Prospective. Setting: Level 1 trauma center. Patients/Participants: Two hundred forty-eight patients with operatively managed orthopaedic trauma conditions during the study period. Two hundred three patients (82%) had acute orthopaedic trauma injuries. Forty-five patients (18%) underwent surgery for a nonacute orthopaedic trauma condition, including 36 elective procedures and 9 procedures to address infection. Intervention: MRSA screening protocol, preoperative antibiotics per protocol. Main Outcome Measurements: MRSA carrier rate, overall infection rate, MRSA infection rate. Results: Our screening captured 71% (175/248) of operatively treated orthopaedic trauma patients during the study period. The overall MRSA carrier rate was 3.4% (6/175). When separated by group, the acute orthopaedic trauma cohort had an MRSA carrier rate of 1.4% (2/143), and neither MRSA-positive patient developed a surgical site infection. Only one MRSA infection occurred in the acute orthopaedic trauma cohort. The nonacute group had a significantly higher MRSA carrier rate of 12.5% (4/32, P = 0.01), and the elective group had the highest MRSA carrier rate of 15.4% (4/26, P < 0.01). The odds ratio of MRSA colonization was 10.1 in the nonacute group (95% confidence interval, 1.87–75.2) and 12.8 for true elective group (95% confidence interval, 2.36–96.5) when compared with the acute orthopaedic trauma cohort. Conclusions: There was a low MRSA colonization rate (1.4%) among patients presenting to our institution for acute fracture care. Patients undergoing elective surgery for fracture-related conditions such as nonunion, malunion, revision surgery, or implant removal have a significantly higher MRSA carrier rate (15.4%) and therefore may benefit from MRSA screening. Our results do not support routine vancomycin administration for orthopaedic trauma patients whose MRSA status is not known at the time of surgery. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives:(1) The purpose of this study was to investigate immediate postoperative weight-bearing status and other potential risk factors for nonunion after locked plating of distal femur fractures and (2) to compare clinical and radiographic union using the previously validated Radiographic Union Scale for Tibia (RUST) and modified RUST scores.Design:This is a retrospective cohort analysis.Setting:Academic Level-1 trauma center.Patients/Participants:Ninety patients with distal femur fractures (OTA/AO 33-A, including periprosthetic) treated with lateral locked plating over a 10-year period.Intervention:Distal femur fracture fixation with lateral locked plating; surgical intervention to facilitate bone healing in cases of nonunion.Main Outcome Measurements:Nonunion rate, construct rigidity scores, RUST, and modified RUST scores.Results:Seventy-eight of 90 patients (87%) achieved clinical union (13% nonunion rate). Rigidity score was significantly associated with risk of nonunion (P = 0.003). No significant association was detected between nonunion and postoperative weight-bearing status (P = 0.77) or other previously identified risk factors. Patients who achieved fracture union had significantly higher mean (SD) RUST (10.67 [1.37] vs. 6.53 [1.48], P < 0.001) and modified RUST (13.47 [2.20] vs. 6.94 [1.79], P < 0.001) scores than patients who developed nonunion. Sensitivity (Sn) analyses identified a RUST score threshold of 9 for diagnosing clinical union (Sn 93.6% and specificity [Sp] 91.7%) and a modified RUST score threshold of 8 (Sn 93.6%, Sp 91.7%).Conclusions:Immediate postoperative weight-bearing status does not seem to affect nonunion rates. We observed a statistically significant association between rigidity score and nonunion. This study supports the utility of the RUST and modified RUST scores in distal femur metaphyseal fractures.Level of Evidence:Therapeutic Level IV.