Focus on interlocking intramedullary nailing without fluoroscopy in resource-limited settings: strategies, outcomes, and outlook

Abstract

Introduction: Closed static interlocking nailing with c-arm guidance is the standard procedure for the treatment of closed diaphyseal fractures. In low-income settings, it is still very difficult to carry out such procedures because of few or absent image intensifiers (c-arm) despite the necessity. Authors provide a review of the literature on interlocking intramedullary nailing without fluoroscopy in resource-limited settings, followed by strategies, outcomes, and outlook.

Materials and method: A comprehensive search of the PubMed, Web of Science, Embase, and Cochrane Library databases was performed with the help of a biomedical information specialist. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Results: We identified 15 series of interlocking intramedullary nailing without fluoroscopy in resource-limited settings. All papers focused on the care for long bones (humerus, femur, tibia). All studies discussed the quality of the nailing operative procedure. The entry point was described in five series; the nail insertion in the proximal and distal medullary canal was good in all studies. The distal locking was missed between 0 and 27%.

Discussion: Intraoperative strategies depend on the type of bone affected, the opening of the fracture site, the fracture line, and the availability of a functional orthopaedic table. Three techniques to insert the nail in the proximal and distal fracture fragment with reduction of the fracture site are described. Insertion of distal screws is possible by using ancillary devices. Outcomes are comparable to those of the series using c-arm guidance. In low-income countries, it can been proposed as an alternative to the gold standard in resources constraints settings. In high-income setting this technique can help to reduce exposure of X-ray.

Conclusion: There is a need to improve equipment in low-income countries hospitals to make trauma surgery with c-arm a gold standard with a minimal exposure to radiation.

Keywords: Fluoroscopy; Fractures; Interlocking intramedullary nailing; Low-income countries.