Outcomes of Intramedullary Fixation of Surgical Implant Generation Network (SIGN) Nail in Fractures of Tibia at Eastern Regional Referral Hospital, Bhutan

Abstract

Background: Tibial bone fractures are the most common type of long bone fractures, primarily affecting the most productive age groups in developing countries. The SIGN nail is commonly used implant to treat these fractures. While its use among tibial fractures in other countries have shown good patient outcome or recovery, its effectiveness has not been evaluated in Bhutan. Therefore, the primary objective of this study was to assess the treatment outcome of patients with tibial fractures treated with the SIGN intramedullary nail at Eastern Regional Referral Hospital (ERRH) in Bhutan. Methods: All patients with acute tibial fractures who underwent intramedullary nailing at Eastern Regional Referral Hospital in Bhutan over a 15-year period (2009-2024) were retrospectively identified. Medical records and radiography were reviewed from the SIGN Online Surgical database. Patients were followed up with clinical examination and radio graphs at 6 weeks, 3 & 6 months, one year after surgery. The data were analyzed using SPSS version 21. Results: A total of 445 patients with tibial fractures were managed with intramedullary SIGN nailing during the study period. The mean age of the patients was 36 years (ranged: 13 to 76 years). A majority of the fracture cases occurred in males (67.9%, n=302). Road traffic accidents were the commonest mode of injury (48.3%, n=215) followed by falls (28.3%, n=126) and work related injuries (18.2%, n=81). Closed fractures accounted for 80.7% (n = 356).Within the open fracture group, Gustilo-Anderson grade 2 (6.3%) and grade 1 (5.8%) fractures were more common compared to grades 3a (3%) and 3b (4%). Fractures were almost evenly distributed between sides. The mean time to surgery was 12.8 days. Fracture union was achieved in 97% of fractures with an average time to union of 21.5weeks. Nonunion occurred in 10 [2.24%] patients. Infection occurred in 4.5% [20] patients. Open fractures had higher rate of complications than the closed fractures. In the multivariate logistic model, patients with open fracture were 4 times more likely to have complications (OR=4; p = 0.02). There were no statistically significant differences in complication rates between the closed and open reduction of fractures during intramedullary nailing. Conclusion: The SIGN intramedullary nail is an effective and reliable treatment for tibial fractures, yielding good outcomes. Its use does not require a fluoroscopic machine, making it an ideal implant for resource-limited settings.