Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low‐ and Middle‐income Countries

Abstract

BackgroundThe fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.MethodsThe SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.ResultsThe overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.ConclusionsThe overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.

Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment

“…One likely factor in the impressively low frequency of malalignment in SIGN surgeries is that although the surgery can be performed without fluoroscopic imaging, the majority of the surgeries are performed using some measure of open reduction. Despite the use of adjunctive open reduction, infection rates in SIGN surgeries are within the acceptable norm and are more influenced by fracture characteristics and the use of preoperative antibiotics [19,20].…”

Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data

“…3 IMN fixation especially has become standard treatment of femoral and tibial shaft fractures resulting in a high rate of union; however, past studies have shown an increased risk of infection for IMN of open fractures when compared to any orthopaedic trauma surgery. [10][11][12][13][14] On the contrary, a study by Avilucea et al found that plating leads to higher rates of nonunion and increases the odds of postoperative complications compared with IMN of open tibial shaft fractures. 15 Im and colleagues similarly found that the plating group was associated with a 23% infection rate compared to a rate of 3% for IMN patients.…”

Complications of Intramedullary Nailing

“…Rates in the femur are reported at slightly lower rates (1.5-3.2 %) largely because of the more generous soft tissue envelope and decreased risk of open fracture [ 18 , 19 , 40 , 41 ]. The rate of infection following intramedullary nailing of humerus fractures is similarly low [ 40 ]. There are several well accepted risk factors for infection following intramedullary nailing.…”

“…Single or serial thorough debridements are of utmost importance for prevention of deep infection. Delay or lack of peri-operative prophylactic antibiotics also increases the risk of postoperative infection by up to 29 % [ 40 ]. Other risk factors for infection following intramedullary fi xation include lower socioeconomic status [ 40 ], delay in soft tissue coverage/wound closure [ 43 ] and duration of the surgical procedure [ 18 , 42 ].…”

“…Delay or lack of peri-operative prophylactic antibiotics also increases the risk of postoperative infection by up to 29 % [ 40 ]. Other risk factors for infection following intramedullary fi xation include lower socioeconomic status [ 40 ], delay in soft tissue coverage/wound closure [ 43 ] and duration of the surgical procedure [ 18 , 42 ]. Prior stabilization with external fi xation has also been shown to increase the risk of postoperative infection after defi nitive intramedullary nailing [ 18 , 44 , 45 ].…”