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Fig. 1 Squat and smile picture compared with radiograph taken at the same time. The patient went on to complete healing.
Courtesy of Sign Fracture Care International


Published 8/1/2012
Lewis G. Zirkle Jr, MD

Diversity Drives Design

Many of the things people use daily owe their efficiency to the cumulative efforts of a variety of people. As Scott Page—author of The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies—reminds us, diversity trumps ability.

In orthopaedics, the efforts of engineers, scientists, surgeons, and others have contributed to advances in patient care. Similarly, the success of SIGN Fracture Care International (SIGN), which aims to create equality of fracture care by bringing orthopaedic training and instrumentation to developing countries, is the result of collaboration between orthopaedic surgeons from diverse backgrounds.

In developing countries, fracture treatment depends on available implants, operating room availability, and the time between when the injury occurred and the patient is seen at the hospital. Innovation arises from necessity, therefore, and is an opportunity for orthopaedic surgeons to learn from each other.

For example, even though the SIGN intramedullary nail was originally designed as a fixation for tibial fractures, shortly after it was introduced in Vietnam in 1999, orthopaedic surgeons there began using it to treat femur fractures, using a retrograde approach. The SIGN program manager, Han Khoi Quang, MD, used the SIGN nail for femur fractures using an antegrade approach.

“I thought we would have to redesign the nail,” he said, “but we thought that the proximal interlocking could be done anterior-posterior or lateral-medial with equal stability. This has proven to be true.”

“When the SIGN nail was first used in Bangladesh, we found that patients had harder bone than Vietnamese patients,” added Faraque Quasem, MD, assistant professor of orthopaedics and SIGN program manager at Sir Salimullah Medical College, in Bangladesh. “We did not have power drills and therefore the drill bits skived off the bone during the process of placing the distal interlocking screws. We hung up a reamer in this hard femoral canal as we hurried through the last surgery before catching the plane to travel home. We later realized that we could use the configuration of the reamer at the end of the SIGN nail and use it for interlocking purposes.”

Distal tibia fractures and pilon fractures are difficult to reduce and stabilize. Dr. Quang first used the SIGN nail to stabilize a distal, open, comminuted tibia fracture by implanting it from the tibia into the talus. After the fracture was stabilized, the patient was sent to Ho Chi Minh City for treatment of soft tissue by Dr. Tuan.

In Myanmar, Thit Lwin, MD, professor of orthopaedics at Yangon General Hospital, used a SIGN nail with the retrograde ankle approach to fuse a Charcot ankle joint. Professor Shahab from Pakistan used the retrograde ankle approach for a comminuted tibia fracture with bone loss and transported bone over this nail.

Professor Shahab has also used the solid SIGN nail to successfully treat blast injuries and infected bone. He and his son are studying the use of a “squat and smile” picture as a way to determine fracture healing without radiographs (Fig. 1).

The SIGN conference
Bringing together 150 surgeons from around the world, the annual SIGN conference is a beehive of activity and orthopaedic discussions. The 2012 SIGN conference will be held Sept. 19–22, 2012, in Richland, Wash. Attendance is limited due to its popularity. For more information, please contact

Lewis G. Zirkle Jr, MD, is the founder of SIGN. He can be reached at lewis.zirkle@signfracturecare.org