Local production of skeletal traction pins to improve access to skeletal traction

Introduction

Midshaft femoral fractures represent a significant orthopaedic injury, with the potential for considerable handicap if non-union or mal-union should occur. In the developed world closed reduction and locked intramedullary nailing is now recognised as the ‘gold standard’ of treatment for such fractures. However, in the less developed world, barriers exist to intramedullary nailing; these include cost of the fixation device, lack of surgical skill, lack of operating theatre capacity and the absence of intraoperative fluoroscopy, widely regarded as a prerequisite in obtaining distal locking of an intramedullary device. As a consequence, in many resource-limited nations, traction remains the mainstay of treatment for midshaft femoral fractures.

Traction refers to the application of force to pull a part of the body along the longitudinal axis. This can be used to pull the margins of fractured long bones into the anatomical alignment and holding them until union has occurred. Two main methods of traction exist: skin traction and skeletal traction.

Skin traction refers to the application of traction force over a large area of skin, using adhesive and non-adhesive techniques. Subsequently, the force applied is transmitted from skin to bone via the fascial layers and intermuscular septae. This method is widely used in the developing world to manage fractured femora. ¹ Although skin traction is cheap, readily available and less invasive than skeletal traction, many complications may arise such as skin damage and allergic reactions to the adhesive strapping.

Skeletal traction involves the insertion of metal pins, such as a ‘Steinmann’ pin, through a bony landmark distal to the fracture. Incremental weights then applied to the traction pin can bring the limb ‘out to length’, inferring close proximity of the fracture margins and thereby facilitating bony union if the traction is maintained over the subsequent weeks and months. Insertion of skeletal traction pins does not need to take place in theatre, nor is specialised orthopaedic skill required; they can safely be inserted on the ward under local anaesthesia.

A Steinmann pin refers to a stainless steel nail with a circular or triangular shank measuring 2–4 mm in diameter and up to 200 mm in length (Figure 1). Although skeletal traction using Steinmann pins may lead to complications such as pin-tract infections, mal-union and thromboembolic disease, it remains the preferred treatment for femoral fractures permitting a greater weight (11–18 kg) to be applied, when compared to skin traction (maximum 5 kg), leading to an improved reduction of the fracture and a decrease in skin-related complications.^2,3 OPEN IN VIEWER

In resource-limited countries, use of skeletal traction remains limited in part by the cost and availability of traction pins. These pins are usually procured from developed world orthopaedic equipment companies at a typical cost of $5–44 per pin, depending on the manufacturer and product quality. This price does not include shipping or freight fees, which is usually in the range of $160–320. We hypothesise that metal traction pins can be produced locally in less developed countries using cut down stainless steel rods of the appropriate diameter. Such rods are widely and cheaply available throughout Africa for use in the construction industry. Provision of traction pins should enable more skeletal traction-based treatment for femoral fractures to be performed, improving the reduction and reducing the time needed for union, overall length of hospitalisation and total treatment cost.

Methods

The overall costs for traction pins were first obtained from UK-based companies, which are a key exporter of pins to resource-limited countries. In order to achieve this, an email was sent out to a random selection of five orthopaedic supplies companies obtained by an online directory. This email contained the specifications of the traction pins, including their composition (grade 316 stainless steel), size (200 mm in length and 4 mm in width) and necessity for a unilateral sharpened end. An image of the traction pins, with the specific dimensions was also attached to the email, as seen in Figure 1. A minimum order of 100 pins was requested, a typical quantity for hospitals when purchasing pins. If these companies did not respond within 2 weeks of sending the email, we contacted them using their online enquiry forms or telephone numbers. The quotations received also included estimated freight and shipping costs to Africa. Afterwards, the same email was sent out to a random selection of five orthopaedic supplies companies in the Indian subcontinent, obtained through the official online database of trade companies in this region. The Indian subcontinent, namely India and Pakistan, are important suppliers of traction pins to much of the resource-limited world. The quotations obtained were also for 100 pins with an estimate for freight and shipping costs. Finally, costs of locally produced traction pins of the same specification were obtained by local contacts from five metal fabrication shops in Malawi, Kenya and Tanzania. The costs of the locally produced pins and those obtained from the Indian subcontinent or UK-based companies (with freight and shipping costs included) were then compared by means of an unpaired t-test using Prism software. Statistical significance was inferred at P < 0.05.

Results

Quotations for 100 Steinmann pins were obtained from five suppliers in the UK, the Indian subcontinent, Malawi, Tanzania and Kenya. The mean price in dollars for 100 pins from the UK was $3757. In the Indian subcontinent, the mean price was $428. In comparison, the mean price of locally produced Steinmann pins was $96 in Malawi, $105 in Kenya and $244 in Tanzania (Table 1).

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Table 1.

Mean prices of 100 pins from UK-based, Indian subcontinent-based, Malawian, Kenyan and Tanzanian suppliers or manufacturers.

	UK-based orthopaedic suppliers	Indian subcontinent-based orthopaedic manufacturers	Local manufacturers in Malawi	Local manufacturers in Kenya	Local manufacturers in Tanzania
Mean price for 100 Steinmann pins (SEM)	$3757 (±1276)	$428 (±14)	$96 (±9)	$105 (±12)	$244 (±9)

The Indian subcontinent, namely India and Pakistan, are the principal suppliers of orthopaedic equipment to the resource-limited world. Much of the equipment available in countries such as Malawi, Kenya and Tanzania are imported from this region. Using an unpaired t-test, the mean price of locally produced pins in resource-limited countries was compared to the price of importing the same product from the Indian subcontinent. On average, locally produced pins in Malawi were $332 cheaper than purchasing from the Indian subcontinent, as seen in Figure 2 (P < 0.001; 95% confidence interval [CI], 294–371). Locally producing the same pins in Kenya was $323 cheaper than importing from India or Pakistan, as seen in Figure 2 (P < 0.001; 95% CI, 281–365). Finally, local production of pins in Tanzania was $184 cheaper than purchasing the pins from the Indian subcontinent, as seen in Figure 2 (P < 0.001; 95% CI, 146–222). OPEN IN VIEWER

Conclusions

Our results illustrate that Steinmann pins may be produced at a significantly cheaper price locally from cut down stainless steel rods in resource-limited countries, rather than obtaining the pins from developed countries or the Indian subcontinent. In practice, by procuring these pins at a much lower price, access and availability to skeletal traction should improve significantly. In turn, by increasing the provision of skeletal traction in resource-limited countries, the management of femoral fractures will improve, mainly due to improved reduction and union of femoral fractures. This may lead to a reduction in the length of hospitalisation, thereby reducing the overall costs of treatment. Interestingly, investing in local metal fabrication shops in these resource-limited countries may also help to boost the local economy and improve quality of life.

This study has been able to show a clear benefit of locally producing Steinmann pins in order to treat fractured femora. However, some limitations do exist. For example, orthopaedic suppliers from developed countries usually utilise ‘surgical grade’ stainless steel when producing surgical instruments. ⁴ Surgical grade stainless steel contains a greater percentage of chromium, reducing its reactivity, corrosion and improving overall efficacy. ⁴ Although the results from this study provided clear evidence of the cost-effective nature of locally producing Steinmann pins, further research is required in more resource-limited countries to generate a more representative picture of costs and methods of implementation of local production.