Outcomes and complications of subtrochanteric femur fractures treated using the SIGN nail with and without plate augmentation in resource-limited settings

In low- and middle-income countries, the SIGN intramedullary nail has been successfully used to treat femoral fractures, but subtrochanteric fractures remain a treatment dilemma with high rates of nonunion and implant failure. Plate augmentation has been proposed as a technique to improve proximal fixation and reduce the risk of implant failure. In this retrospective descriptive study, we compare the infection rate and x-ray healing for subtrochanteric fractures treated using the SIGN Nail with and without plate augmentation. We performed a retrospective cohort study using the SIGN Surgical Database. We included adult patients with subtrochanteric femur fractures treated from 2017-2023 with a SIGN intramedullary nail that had a minimum of 3 months follow-up. Infection rates, X-ray healing, painless weight bearing, knee flexion, and nonunion rates were compared between SIGN nails with and without plate augmentation. Cox regression was used to assess time to infection between plated and non-plated nails. We identified a total of 381 patients in our cohort. The overall infection rate for patients who received plate augmentation was 3.3%, compared to 2.4% for those who did not (p=0.661). The rate of x-ray healing was 96.7% with plate augmentation and 91.0% without (p=0.071). There was no significant difference in time to infection between plated and non-plated nails (HR: 1.43 95% CI: 0.36-5.71, p=0.612). No statistically significant differences were observed for any outcome. In plate augmentation cases overall, rates of radiographic healing were high (96.7%), and rates of infection were low (3.3%). While this technique shows promise as an alternative when cephallomedullary implants are not available, higher quality prospective studies are needed given the low follow-up rates in the SIGN database and unmeasured confounders such as fracture complexity.