Outcomes of femoral shaft fractures in Sub-Saharan Africa: A systematic review.

PURPOSE: Femoral shaft fractures are significant injuries and if not managed appropriately can result in high complication rates and long-term disability. These complex injuries occur at a higher rate across low and middle income countries and sub-Saharan Africa is thought to have a higher incidence than other regions across the world. This study aims to summarise the most up to date evidence surrounding the treatment and associated outcomes of adult femoral shaft fractures in sub-Saharan Africa - giving a clear understanding of current practices and highlighting potential areas for further research. METHODS: PubMed, Google Scholar, Africa Journals Online, Cochrane, Clinicaltrial.gov were searched using Boolean search strategies. Data collected included demographics, fracture classification, interventions, union rates, time to union, patient-reported outcomes / functional outcome scores, and secondary outcomes (orthopaedic and medical complications, malunion / non-union, length of admission). RESULTS: Twenty-three studies reporting 2,180 patients were included-73% (1592/2180) of patients were male, with a mean age of 35 years. Overall, 59% of patients were treated with intramedullary nailing (IMN), 23% with skeletal traction, and 14% with open reduction internal fixation (ORIF). There was a heterogeneity in practice in different regions, with the highest reported rates of IMN in Tanzania (99%), and lowest in Malawi (29.4%). Union rates were highest in IMN (82.4-100%) versus traction (48 - 100%) and ORIF (83.3-87%). Intramedullary nailing demonstrated a super complication profile, with better functional outcomes, shorter hospital stays and time to mobilisation. CONCLUSION: Intramedullary nailing demonstrated superior clinical and functional outcomes compared to other modalities for the treatment of femur shaft fractures across sub-Saharan Africa. However, there is significant sparsity of research and variable management approaches across the region. Focused research to determine the burden of injury, current healthcare resources and cost-effective and appropriate interventions to improve outcomes are now a public health priority.