Single-stage intramedullary nailing for patients with multiple concurrent long-bone fractures in a low-resource setting: what factors contribute to prolonged operative duration?

Purpose: To investigate the factors that prolonged the operative duration (OD) in patients who underwent single-stage locked intramedullary nailing of their multiple concurrent long-bone fractures (LBFs) using Surgical Implant Generation Network (SIGN) nails.

Methods: Forty-nine patients who fulfilled the inclusion criteria were enrolled prospectively over 8½ years. Data collected included age, sex, injury mechanism and severity, fracture characteristics, nail types and diameter, OD, fracture-to-fixation time, length of hospital stay (LOS), functional outcomes and complications. Factors associated with prolonged OD were identified using Pearson's chi-square test.

Results: The mean age was 40.6 years. There were 101 fractures of the humerus (8), femur (41) and tibia (52). The median ISS was 14. The mean OD per fracture was 55.8 min. The average LOS was 11 days. A prolonged OD was significantly associated with fracture-to-fixation time > 5 days, fractures with end-segment involvement, fixation with SIGN standard and thinner nails, open reduction, supplemental plating, and antegrade femoral nailing. Radiographic and functional outcomes were satisfactory. Ten patients developed post-operative breathing difficulty warranting oxygen administration. Four fractures were infected. No mortality within the first post-operative year.

Conclusion: The study identified fracture fixation beyond five days, end-segment involvement, open reduction, use of standard and thinner nails, supplemental plating, and antegrade femoral nailing as factors that can prolong the OD during single-stage fixation of multiple concurrent LBFs in settings without modern fracture-care equipment. While some of these factors are unmodifiable on certain occasions, bearing them in mind can improve pre-operative planning and intra-operative efficiency to reduce OD.