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Femoral Fracture Fixation in Developing Countries: An Evaluation of the Surgical Implant Generation Network (SIGN) Intramedullary Nail
Patrick Sekimpi, MD1; Kanu Okike, MD, MPH2; Lewis Zirkle, MD3; Andrew Jawa, MD4
1 Department of Orthopaedics, Mulago Hospital, P.O. Box 7051, Kampala, Uganda
2 Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
3 Surgical Implant Generation Network, 451 Hills Street, Suite B, Richland, WA 99354
4 Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Dowling Building, 2 North, 850 Harrison Avenue, Boston, MA 02118
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at Mulago National Hospital, Kampala, Uganda

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Oct 05;93(19):1811-1818. doi: 10.2106/JBJS.J.01322
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The Surgical Implant Generation Network (SIGN) intramedullary nailing system was designed to treat femoral fractures in developing countries where real-time imaging, power equipment, and fracture tables are often not available. We performed a retrospective analysis of prospectively collected data on femoral shaft fractures treated with the SIGN intramedullary nailing system.


Seventy consecutive patients with a closed diaphyseal femoral fracture were treated with the SIGN intramedullary nail at Mulago National Hospital in Uganda between February 2007 and March 2008, and fifty of these patients (the study cohort) were followed for at least six months or until fracture-healing.


The mean time to surgery was 13.2 days (range, zero to thirty-three days). All fractures healed, although two required dynamization for treatment of delayed union. No hardware failures occurred. An interlocking screw missed the nail in two patients, but both fractures healed without complications. One superficial and one deep infection developed; the latter required nail removal after fracture union. Including these patients, complications requiring further treatment occurred in 14% (seven) of the fifty patients.


The SIGN intramedullary nailing system promotes predictable healing of femoral fractures in settings with limited resources including lack of real-time imaging, lack of power reaming, and delayed presentation to the operating room.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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