The Transformative Impact and Persisting Challenges of Intramedullary Nailing in Low- and Middle-Income Countries

Commentary More femoral shaft fractures occur annually than new cases of HIV (human immunodeficiency virus) infection, yet the skills and tools to manage this neglected epidemic remain inaccessible for most patients worldwide1. Consider a patient with a femoral fracture who I met at a rural district hospital in Malawi. She was facing weeks immobilized in skeletal traction, risking pin tract infections, nonunion, knee stiffness, indignity, and relentless pain. Her life was crumbling around her, as immobility and loss of income shifted her from breadwinner to dependent, plunging her family into poverty2. For American orthopaedic surgeons trained after 1970, it is hard to imagine a time before intramedullary nailing. However, this now-indispensable treatment only recently became available in many low- and middle-income countries (LMICs). The nonprofit organization SIGN (Surgical Implant Generation Network) Fracture Care International has made impressive strides in improving orthopaedic care globally by introducing intramedullary nailing that is accessible in resource-limited settings. With hand reamers and a long target arm, SIGN intramedullary nails (IMNs) can be placed without electricity and fluoroscopy. This has been a remarkable breakthrough for surgeons in LMICs, who receive the IMNs for free if they report their cases in the SIGN database. This database provides a rare and essential insight into orthopaedic surgical care in LMICs. It has revealed infection rates comparable with those in high-income countries, showing that intramedullary nailing can be performed safely in resource-limited environments3. In Malawi, intramedullary nailing of femoral fractures leads to better outcomes and is even cost-saving when compared with skeletal traction4. Patients themselves understand this; those who receive surgery can walk out of the hospital, while the less-fortunate patients remain trapped in traction2. Overwhelmed hospitals, outdated infrastructure, and few skilled surgeons leave many patients waiting weeks for surgery. In their article, Subramanian et al. retrospectively analyzed nearly 10,000 patients treated with SIGN IMNs in LMICs. The mean time to surgery was 10.5 days. Unsurprisingly, longer delays were associated with longer surgery duration, higher rates of open reduction, and more infections. Operating on a 5-week-old neglected femoral fracture is an unenviable task, but it is a reality for many surgeons. Picture a rural district hospital and a 35-year-old farmer with a femoral fracture who arrives on the back of a motorcycle 3 days after injury. He joins a long waiting list for surgery, behind open fractures and emergencies that take precedence every morning, while he lies in a hospital bed for weeks. The operating room is basic: a bare lightbulb illuminates the surgical field, worn-out cloth drapes the patient, and a thin screen separates him from cesarean sections that are being performed nearby. An open reduction is necessary, taking precious time, while the surgeon worries about complications that may land the patient back on the same long case list. The SIGN system undoubtedly offers a lifeline, but we must do better than this. While Subramanian et al. report low infection rates (3.1%), nearly half of the patients were lost to follow-up. This remains a major challenge in resource-limited settings. Even after surgery, patients face the same barriers that delayed their initial care. Loss of finances and family support can follow both injury and infection, with complications further eroding faith in hospitals. Moreover, many hospitals have few antibiotic options and cannot perform antibiotic sensitivity testing, contributing to a global rise in multidrug-resistant infections5. SIGN IMNs have revolutionized fracture care in resource-limited settings, but systemic challenges remain. Access to timely surgery, safe operating conditions, and affordable implants is essential, yet remains out of reach for many. It is a daunting problem that calls for greater global collaboration. Surgeons in resource-rich settings can play a critical role by training, mentoring, and advocating for their colleagues abroad. By amplifying their voices, we can help our colleagues push hospitals, governments, and donors to implement policies and investments that enhance trauma care. Donations are vital for the most marginalized, but we must prioritize making safe implants affordable and sustainably accessible to surgeons worldwide. The article by Subramanian et al. reminds us why timely surgery is essential. The ascent toward better infrastructure, trained surgeons, and accessible implants is steep, but many countries have made or are already making that climb. Greater collaboration and innovation are crucial to help break the cycle of pain and multigenerational poverty for millions of patients.