Outcomes of intramedullary nailing for traumatic adult femoral shaft fractures in low-and-middle-income countries; a systematic review

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Objective: This review reports on the radiologic and functional outcomes and complications of managing adult traumatic femur shaft fractures (FSFs) with intramedullary nailing (IMN) in Low-and-Middle-Income Countries (LMICs) and evaluates the quality of existing evidence. Methodology: A thorough literature search was conducted across several databases, including reference lists of selected articles. Screening was done per the PRISMA guidelines. Peer-reviewed articles published in English between January 2011 and December 2022 that reported radiologic or functional outcomes in adults with isolated traumatic FSFs managed with IMN in LMICs were included for review. The quality and level of evidence were assessed using modified Critical Appraisal Skills Program checklists and the modified Oxford Centre for Evidence-Based Medicine criteria. Findings: Forty studies from 13 LMICs were included in this review. The mean time to union was 15.4 weeks, with a mean union rate of 88.1%. Functional outcomes scores showed >70% excellent outcomes. The Radiographic Union Scale in Tibia score and Thoresen criteria were the most used assessment tools. Mean infection rates were 4.8%, and limb shortening (of varying amounts) occurred in 3.5% of patients. The findings revealed variability in measuring and reporting IMN outcomes in FSFs, but overall, the existing evidence was of satisfactory quality. Conclusion: Despite the data limitations, methodological differences, and outcome discrepancies, this review demonstrates a trend favoring IMN for FSFs, with low failure rates in low-resources settings. However, more robust studies using standardized radiographic and functional outcomes measures in LMICs are needed.

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