Outcomes following lower limb long bone intramedullary nail fixation in South Africa : a prospective cohort study of 495 patients.

AIMS: Musculoskeletal injuries are more common in sub-Saharan Africa than anywhere else in the world, yet there is limited evidence to guide the management of these injuries in low- and middle-income countries. We aimed to evaluate the outcomes of lower limb intramedullary nailing (IMN) for long bone fractures in South Africa and identify predictors of these outcomes. METHODS: Adults who sustained tibia and femur shaft fractures, and were treated with IMN at two tertiary hospitals in South Africa from September 2017 to December 2018, were followed for at least 12 months. We compared fracture characteristics and outcomes between open and closed fractures. We employed multivariable logistic regression models to investigate the associations between union status at six months, infection, and quality of life (EuroQol five-dimension five-level questionnaire) in open and closed fractures. RESULTS: In total, 495 patients with tibia and femur fractures underwent IMN. Of these, 240 patients had open fractures, and 255 patients presented with closed fractures. Gunshot wound fractures comprised 52% (124/240) of the open fractures. The overall delayed and nonunion rate reported in our study was 18% (85/479) and 5.8% (28/479), respectively, across the study population. The rate of deep surgical site infection, superficial site infection, and late infection in the study population was 6%, 2%, and 2%, respectively. Open fractures had a higher odd of delayed union (adjusted odds ratio (aOR) 1.97 (95% CI 1.03 to 3.75)), nonunion (aOR 3.01 (95% CI 1.20 to 7.53)), and early surgical site infections (aOR 3.46 (95% CI 1.39 to 8.62)) when compared to closed injuries. The overall health-related quality of life outcomes were comparable between open and closed fractures at the nine-month follow-up. CONCLUSION: Our study demonstrates comparable outcomes of infection and fracture healing rates in patients who undergo internal fixation for lower limb fractures in a resource-limited setting, when compared to study populations in a high-income country.