Postoperative radiographs showing the first surgery performed in Syria using the SIGN intramedullary nail fixation system.
Courtesy of Lewis Zirkle, MD


Published 3/1/2014
Samer Attar, MD, FACS

Bringing SIGN to Syria

Most of the medical work on the ground in northern Syria is being provided by local Syrian doctors and nurses. Many are supported by humanitarian organizations such as the Syrian American Medical Society (SAMS), the group that facilitated my trip.

While in Syria, I had noticed that several patients were being treated with definitive external fixation due to a sparse supply of intramedullary nail systems. Moreover, many of the makeshift hospitals in Syria have no C-arms. I thought that the Surgical Implant Generation Network (SIGN) nail could help patients in this environment.

SIGN is a system that permits intramedullary nail fixation without the need for intraoperative imaging. From an underground operating room in Aleppo, I emailed Lewis G. Zirkle Jr, MD, the founder of SIGN Fracture Care International. He responded immediately, and we agreed to discuss logistics after I returned to the United States. In mid-August, Dr. Zirkle and I planned to incorporate SIGN into an upcoming SAMS conference in Gaziantep, Turkey, near the Syrian border.

The SAMS conferences are regularly held for Syrian field medics. It gives them an opportunity to refresh their skills and also recharge mentally. For these medics, being able to sleep in a quiet hotel for 4 days and listen to lectures without the threat of bullets and bombs is a short respite from the zones of conflict where they normally reside. The Gaziantep conference was funded and staffed by SAMS and the International Rescue Committee.

About 50 Syrian field medics attended the course to learn about resuscitation, intensive care, and advanced techniques in field medicine. Even though violence in Syria had closed the Turkish border, they all managed to make it across.

About 10 orthopaedic surgeons came to learn about SIGN and spent 2 days in lectures and workshops. Dr. Zirkle then personally donated two SIGN nail sets that he had used to teach the course, and they were taken into Syria.

Seeking a solution
When asked to describe his experience, Dr. Zirkle wrote the following:

“The conference program included treatment of patients who had inhaled sarin-like gas, as well as treatment of civilians with severe fractures using the SIGN technique. The operating rooms throughout Syria are located in improvised areas such as basements. The building above the basement affords some protection because hospitals and schools are targeted by bombs and other missiles. Surgeons have become accustomed to the tremors and noise of bombs dropping around them. These hospitals do not have adequate surgical equipment to care for the many injuries.

“These surgeons elected to remain in Syria to treat the numerous injuries from snipers, bombs, and missile attacks. As I listened to their stories, their facial expressions, especially their eyes, portrayed the despair and helplessness of the situation as well as the determination to treat their patients.

Postoperative radiographs showing the first surgery performed in Syria using the SIGN intramedullary nail fixation system.
Courtesy of Lewis Zirkle, MD
A field hospital in Aleppo, Syria, destroyed by an airstrike in February 2014.
Courtesy of Samer Attar, MD

“One doctor from Damascus was exposed to sarin gas from the clothes of patients he treated. He fainted and was revived by atropine injections. He was blind temporarily and continues to be tired. He walked for days from Damascus to the conference to learn more about treating victims of gas poisoning. One of his walking companions stepped on a mine and was killed instantly.

“The Syrian surgeons are too psychologically traumatized to offer solutions to the conflict. They hope other governments and individuals throughout the world will help solve this problem by negotiating a diplomatic and peaceful solution. These surgeons are like ducks on water—calm on top yet paddling furiously below the surface.

“We discussed and demonstrated how to use the SIGN implants to treat fractures. They realized that the patients can walk with crutches the day after surgery and thereby leave the hospital. Two SIGN systems, which the course teachers had carried in their luggage, were distributed. I felt inadequate because many surgeons wanted SIGN for their hospitals. I therefore committed to send at least three more SIGN systems. I also felt guilty leaving these fellow surgeons to return to the security of living here in Richland, Wash.

“One of the books I read on the way home was Justice: What’s the right thing to do? by Michael J. Sandel. He uses Immanuel Kant as a reference. Kant states that all people have an absolute value as opposed to a relative value. This value is not dependent on family relationships, nationality, distance from us, or any other factor except being human. If we accept the premise that all people have absolute value, the conflict in Syria is our problem as well as theirs. Although no one person or government has the solution to the conflict, we hope the solution will be a multinational effort including the Syrian factions. In the meantime, we must support the treatment of civilian injuries.”

Six SIGN nail sets have so far been delivered into Syria. Of note, the first SIGN nail surgery in Syria was performed at the hospital in Aleppo where I had volunteered. This hospital was predominantly funded and supplied by American donations through SAMS, and it was one of the main trauma hospitals in Aleppo. It was destroyed by an airstrike on Feb.7, 2014.

For more information about SAMS, visit

For more information about SIGN Fracture Care International, visit

Samer Attar, MD, FACS, is an assistant professor in orthopaedic surgery at Northwestern University’s Feinberg School of Medicine.

Editor’s Note: The October 2013 issue of AAOS Now included a report by Samer Attar, MD, on his 2-week surgical mission to a field hospital in northern Syria (“Crisis in Syria: An Orthopaedic Surgeon’s Perspective).