Use of intramedullary nailing in poor sanitary conditions: French Military Medical Service experience.

INTRODUCTION: Intramedullary (IM) nailing is the gold standard for treating long bone fractures in developed countries because of its minimally-invasive application and good biomechanical properties. In precarious conditions, external fixation or open plate fixation are often performed because surgeons do not have the means to carry out IM nailing. However, these procedures can lead to infection-related complications and mechanical failures. The aim of our study was to describe the outcomes and postoperative complications of IM nailing of closed, long bone fractures in patients operated in a French front-line combat surgical unit (role 2+). Our hypothesis was that IM nailing is a reliable technique with low morbidity for the initial treatment of long bone fractures, even in precarious situations.

MATERIAL AND METHODS: This was a prospective, single-center, descriptive study of patients operated on between April 2016 and November 2017. All the patients with a closed femur or tibia fracture who were treated by IM nailing were eligible, no matter their time to surgery. The minimum follow-up was 6 months. The primary endpoint was the absence of infection-related complications and the secondary endpoint was fracture union.

RESULTS: Fifty-eight patients were reviewed after an average follow-up of 4.7 months (range, 3-15 months). The mean patient age was 35.2 years (15-85 years) and the majority of patients were men (52 of 58). The fracture was in the femur in 74.1% (n=43) of cases and in the tibia in 25.9% (n=15) of cases. The time to surgery averaged 122.3 days (7-720 days) with a median of 60 days. In 74% of cases (n=43), fracture realignment required an open surgical approach. The postoperative course was considered normal in 96.6% of cases (n=51). No infections were reported as of the last follow-up visit. Union occurred in an average of 4 months in 70.7% of cases (n=41). There were three cases of nonunion after 6 months.

DISCUSSION: Even in precarious situations, IM nailing is an effective, reliable method with a low complication risk and high union rate for the treatment of neglected long bone fractures. This surgical treatment is well suited to the poor sanitary conditions on the African continent.

LEVEL OF EVIDENCE: II, low-powered prospective study.