Complications and technical problems with the gamma nail

Salvage of cephalomedullary nail cutout with the variable angle proximal femoral plate

INTRODUCTION

Excellent results have been published in the treatment of the trochanteric fractures in the elderly with cephalomedullary nails or compression hip screws but not free of complications. The perforation of the lag screw through the superior cortex of femoral neck or head followed by rotation and varus collapse of the head-neck fragment, also known as cut-out, is one of them. Probably total hip arthroplasty is the most common solution, but there is no systematic technique for treatment. The objective of this study is to evaluate the results obtained in the treatment of this complication using a variable angle femoral plate.

MATERIAL AND METHODS

This retrospective study concerns patients over 65 years with peritrochanteric fractures treated with cephalomedullary nail with cut-out failure solved by re-osteosyntesis with variable angle femoral plate between 1st January 2000 and 31 st December 2017. The series includes 29 patients, 26 women and 3 men with average age 87,3. Patients were followed up clinically and radiologically at regular intervals until fracture consolidation at least 9 months.

RESULTS

No patients died at the first 9 months after surgery. Fracture mean consolidation has occurred in all patients in 14th weeks (6-20). Operative time was 93,2 minutes (62-129) including removal of nail. No intraoperative complications were observed. Five patients experienced medical complications and two had a superficial wound infection. The mean tip-apex distance (TAD) was 5mm (2-7mm). The neck-shaft angle was 127 degrees. The mean valgization achieved was 32 degrees (15-40). Only one patient needed a second revision surgery due to aseptic hip joint subluxation after 8 weeks of the surgery solved with total hip arthroplasty.

CONCLUSIONS

The use of variable angle femoral plate in the cut-out treatment is an attractive option which allows the valgization of the fracture to virtually physiological limits and the placement of the cephalic screw in the most sutiable position with good outcomes and few complications.

Distal Locked versus Unlocked Intramedullary Nailing in Intertrochanteric Fracture; A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Trials

Objective:

To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials.

Methods:

Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis.

Results:

The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08).

Conclusion:

The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.

A simple reproducible technique for the retrieval of broken proximal femoral blades, a technical note and review of literature

Despite advances in metallurgy, fatigue failure of hardware in orthopaedics is common especially when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware. Several different methods are usually used to successfully remove the intact or broken hardware. The proximal blade fracture is rare and under-reported in the literature. In our tertiary non-union and limb reconstruction unit, we have developed a technique for an easy and quick removal of a broken proximal femoral blades.

Short Versus Long Cephalomedullary Nails for Fixation of Stable Versus Unstable Intertrochanteric Femur Fractures at a Level 1 Trauma Center

The purpose of this study was to compare failure and complication rates associated with short cephalomedullary nail vs long cephalomedullary nail fixation for stable vs unstable intertrochanteric femur fractures. This study included 201 adult patients with nonpathologic intertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1.1-3, 31-A2.1-3, 31-A3.1-3) who were treated with a short cephalomedullary nail (n=70) or a long cephalomedullary nail (n=131) and had at least 6 months of follow-up. Treatment groups were similar in terms of age, sex, and comorbidities. In the stable fracture group (N=81), there was no difference in total complications (adjusted P=.73), failure (adjusted P=.78), or mortality (adjusted P=.62) between short cephalomedullary nails and long cephalomedullary nails. Unstable fracture patterns were more likely to be treated with a long cephalomedullary nail than a short cephalomedullary nail (P=.01). In the unstable fracture group (N=120), there was no difference in total complications (adjusted P=.32) or failure (adjusted P=.31) between short cephalomedullary nails and long cephalomedullary nails. A cumulative mortality curve showed a trend toward increasing mortality in unstable fractures treated with short cephalomedullary nails. Traumatologists did not display a statistically significant preference between short cephalomedullary nails and long cephalomedullary nails when compared with nontraumatologists. [Orthopedics. 2019; 42(2):e202-e209.].

[Surgical revision for complications after gamma3-nailing osteosynthesis of proximal humeral fractures : Follow-up series of 1500 patients]

BACKGROUND

The γ‑nailing system is a widespread intramedullary therapeutic option that has been used for intertrochanteric and subtrochanteric fractures since the late 1980s; however, some reports from the 1990s describing femoral shaft fractures questioned the indications for this system in simple fracture types. Due to increasing numbers of patients treated with this system, the complication rate is continuously falling as confirmed by many recent studies.

OBJECTIVE

Between 2008 and 2013 a total of 1500 operations using the γ‑nailing system were performed at this traumatology department. The standard 200 mm nail was used in 1290 cases and the extended system available from 340 to 440 mm in 210 cases. The aim of this study was to record the excellent results using the standard γ‑nailing system and to confirm the indications of the long intramedullary nailing system (Gamma3®) also for use in complex intertrochanteric and subtrochanteric fractures.

MATERIAL AND METHODS

All 1500 patients were retrospectively analyzed. Information on epidemiological data, intraoperative and postoperative complications and patient outcome was retrieved from the digital patient medical history. All available radiographs were assessed by a single traumatologist.

RESULTS

The results showed a low complication rate of 5% for surgical complications, mainly caused by cutting out in 34.66%, followed by hematomas in 21.33% and fractures of the nail in 16%. A comparison of the standard and long nailing systems could be carried out, showing a complication rate of 3.64% for the standard system compared to 13.33% for the long γ‑nail system.

CONCLUSION

The γ‑nailing system is a safe treatment option for trochanteric femoral fractures and failure of the implant is associated with high biomechanical forces in unstable fractures. A low complication rate is linked to a thorough surgical technique under consideration of a correct positioning of the implant.

Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures

Pertrochanteric femur fractures are considered amongst the most commonly encountered fractures in the geriatric age group. We evaluated radiographic and functional outcomes of patients with unstable pertrochanteric fractures treated with the proximal femur nail antirotation (PFNA). Between March 2013 and December 2015, fifty patients (28 male and 22 females with a mean age of 72.8 years (range, 20-94)) with unstable pertrochanteric fractures (AO 31.A2 and 31.A3) were fixed with the PFNA at our institution, and they were retrospectively evaluated. Forty one patients were treated with short PFNA and nine with long PFNA. Operative time ranged between 30 and 150 (average 73.60) min, blood loss ranged between 50 and 250 (average 80) milliliter and hospital stay ranged between 3 and 18 (6.86) days. The mean follow-up period was 18 months (range, 11-31). At final follow-up, solid union of all fractures had been achieved without any implant-related complications, the mean Harris Hip Score (HHS) was 79.34 ± 9.10 points and the mean neck-shaft angle was 127.2° ± 5.07°. No significant differences were encountered between the functional and radiographic outcomes of the PFNA with regards to the AO fracture classification and the implant version. PFNA is a recommended option for the treatment of unstable pertrochanteric fractures owing to its easy insertion, reduced blood loss, stable fixation and satisfactory functional and radiological outcomes.

Implant-Related Complications and Mortality After Use of Short or Long Gamma Nail for Intertrochanteric and Subtrochanteric Fractures: A Prospective Study with Minimum 13-Year Follow-up

Background:

The purpose of this study was to evaluate the rates of implant-related complications and mortality after treatment of an intertrochanteric or subtrochanteric fracture with a short or long Gamma nail.

Methods:

Between September 1998 and August 2003, 644 patients at 2 centers treated with a long or short Gamma nail for a hip fracture were prospectively enrolled in this study. These patients were followed until they reached 1 of the study end points, which included death, a reoperation directly related to the Gamma nail, or the end date of the study.

Results:

The average age (and standard deviation) of the patients included in the study was 81.3 ± 8.6 years at the time of the operation, and 28.3% of the patients were male. The rate of implant-related complications was 9.9%. The most common complications included peri-implant fracture (4.2%), proximal lateral thigh discomfort requiring extraction of the implant (2.0%), and lag-screw cutout (1.1%). Interestingly, more than half (56%) of the 27 peri-implant fractures occurred >1.5 years after the index operation. The median time from the operation to death was 2.9 years (range, 0 to 17.1 years). The 30-day mortality rate after treatment was 9.5%. Patients with American Society of Anesthesiologists (ASA) class-3 or 4 physical status had a significantly higher risk of mortality than ASA class-1 patients.

Conclusions:

Gamma nails are effective in the treatment of intertrochanteric and subtrochanteric fractures. However, 9.8% of patients had complications requiring additional surgery. The most common serious complications include peri-implant fracture and lag-screw cutout. Several peri-implant fractures occurred long after the index procedure. Patients had a high rate of mortality (27%) after 1 year, and higher preoperative ASA class was found to be a predictor of increased risk of mortality. Therefore, clinicians must carefully consider patients’ preoperative comorbidities when counselling patients on the risks of surgery.

Level of Evidence:

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

How evolution of the nailing system improves results and reduces orthopedic complications: more than 2000 cases of trochanteric fractures treated with the Gamma Nail System

PURPOSE

The incidence of trochanteric fractures has increased significantly during the last few decades, especially in elderly patients with osteoporosis. The dynamic/sliding hip screw and the cephalomedullary nail are the most commonly used fixation methods to treat trochanteric fractures. The improvements in the Gamma Nail System (GNS) associated with a correct surgical technique reduced the postoperative orthopedic complications. The purpose of this study was to compare the results of the different Gamma Nails.

METHODS

The present study is a retrospective analysis of 2144 patients treated with GNS between January 1997 and December 2011 for trochanteric fractures, classified according to AO classification method. The patients were divided into three groups according to the nailing system: 525 were treated with Standard Gamma Nail (SGN), 422 with Trochanteric Gamma Nail (TGN) and 1197 with Gamma3 Nail.

RESULTS

The overall incidence of intra-operative complications was 1.21 %; the incidence of intra-operative complications for each group was 1.71 % for SGN group, 0.47 % for TGN group and 1.25 % for Gamma3 Nail group. The overall incidence of postoperative complications was 5.48 %, and the incidence for each group was 10.73 % for SGN group, 9.92 % for TGN group and 2.92 % for Gamma3 Nail group.

CONCLUSION

The GNS is a safe device with a low rate of intra-operative complications. The evolution of this nail system reduces postoperative complications, thus improving the results at follow-up and confirming that the Gamma3 Nail is a safe and predictable device to fix trochanteric fracture.

InterTan nail versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures

BACKGROUND

Trochanteric fractures (TF) have become a major source of morbidity and mortality in elderly. We conducted this study to compare the outcomes of unstable trochanteric fractures treated with the InterTan nail and Gamma3 nail.

METHODS

Between January 2008 and May 2013, patients aged 60 years or older with a diagnosis of unstable TF treated with InterTan nail or Gamma3 nail were included. Patients treated with InterTan nail were pair-matched to patients treated with Gamma3 nail in a 1:2 ratio. Radiographs were obtained at 1, 3, 6, and 12 months follow-up, and all implant position changes, complications, fixation failures and functional scores were recorded.

RESULTS

Eighty-seven patients were included in the InterTan nail group, and 174 pair-matched patients were included in the Gamma3 nail group. Preoperative scores were similar between the 2 groups. There are significant improvements postoperatively in both groups. The incidence of cut-out and femoral shaft fracture were significantly higher in the Gamma3 nail group than the InterTan nail group (P=0.024 and P=0.044, respectively). Patients treated with the InterTan nail experienced longer fluoroscopy and operative times.

CONCLUSIONS

The InterTan nail may have a tendency in better outcomes for patients with unstable TF. However, the limited period of follow-up and inherent defects of nonrandomized trials indicate that better-designed randomized controlled trials will be required.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_191.

[Randomized prospective study on the influence distal block and Gamma 3 nail on the treatment of intertrochanteric fractures of femur]

OBJECTIVE

The purpose of this study is to assess the need to lock the Gamma 3 nail (Stryker, Mahwah New Jersey USA) distally for intertrochanteric fractures of femur 31-A1 and 31-A2 of the AO.

MATERIAL AND METHODS

Details were recorded on a sample of 177 patients with intertrochanteric femoral fractures treated in our hospital by a standard Gamma nail between June 2011 and January 2013. A prospective study was conducted by randomizing patients by year of birth, even numbers with, or odd number without, distal locking, forming two groups of 90 and 87 fractures, respectively.

RESULTS

The patients treated with a distal locking nail had an increased incidence of medical complications, a lower incidence of biomechanical complications, and an increase in the fracture collapse compared with the control group, with statistical significance (p < 0.05). It is also observed in the group with distal locking increased transfusion requirement and a higher death rate, with statistically significant differences (p < 0.05), but this significance disappears when adjusting for other patient-related characteristics.

CONCLUSIONS

Based on the results found in this work, the use of distal locking screw in the Gamma 3 nails should be restricted to unstable trochanteric fractures after reduction where additional stability to the intramedullary nail is required, and may decrease the risk of complications from use.

Complications following Treatment of Trochanteric Fractures with the Gamma3 Nail: Is the Latest Version of Gamma Nail Superior to Its Predecessor?

Gamma nail is a cephalomedullary implant that was developed for the treatment of pertrochanteric hip fractures and has been successfully used for over 20 years. During this period, modifications of design and instrumentation have occurred to combat the intra- and postoperative complications that were associated with the use of early designs. The purpose of this study was to compare the complications observed with the use of the Gamma3 nail (G3N) with those seen following use of the previous trochanteric gamma nail (TGN). This study prospectively recorded the intra- and postoperative complications of 175 patients treated with the Gamma3 nail and compared them with those of a historical cohort of 192 patients treated with the trochanteric gamma nail. We encountered less intra- and postoperative complications with the use of Gamma3 nail. Femoral fractures and lag screw cutout were significantly lower. The reoperation rate was significantly higher in the TGN group. Gamma3 nail has proved to be a safe and efficient implant for the treatment of pertrochanteric fractures. The improvement of the biomechanical characteristics has led to a significant decrease in complication rates, demonstrating superiority over its predecessor.

In vitro comparison of resistance to implant failure in unstable trochanteric fractures fixed with intramedullary single screw versus double screw device

BACKGROUND

The purpose of this study was to compare the resistance of intramedullary single screw device (Gamma nail) and double screw device proximal femoral nail (PFN) in unstable trochanteric fractures in terms of the number of cycles sustained, subsidence and implant failure in an axial loading test in cadaveric femora.

MATERIALS AND METHODS

The study was conducted on 18 dry cadaveric femoral specimens, 9 of these were implanted with a Gamma nail and 9 with PFN. There was no significant difference found in average dual energy X-ray absorptiometry value between both groups. The construct was made unstable (AO type 31A3.3) by removing a standard sized posteromedial wedge. These were tested on a cyclic physiological loading machine at 1 cycle/s with a load of 200 kg. The test was observed for 50,000 loading cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine construct stiffness and gap micromotion in axial loading.

RESULT

It was observed that there was statistically significant difference in terms of displacement at the fracture gap and overall construct stiffness of specimens of both groups. PFN construct group showed a mean subsidence of 1.02 mm and Gamma nail construct group showed mean subsidence of 2.36 mm after cycling. The average stiffness of Gamma nail group was 62.8 ± 8.4 N/mm which was significantly lower than average stiffness of the PFN group (80.4 ± 5.9 N/mm) (P = 0.03). In fatigue testing, 1 out of 9 PFN bone construct failed, while 5 of 9 Gamma nail bone construct failed.

CONCLUSION

When considering micromotion (subsidence) and incidence of implant/screw failure, double screw device (PFN) had statistically significant lower micromotion across the fracture gap with axial compression and lower incidence of implant failure. Hence, double screw device (PFN) construct had higher stability compared to single screw device (GN) in an unstable trochanteric fracture femur model.

InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures

The goal of this study was to compare the outcomes of unstable trochanteric fractures treated with the InterTan nail (Smith & Nephew, Memphis, Tennessee) and the Proximal Femoral Nail Antirotation (PFNA-II) (Synthes, Solothurn, Switzerland). A total of 132 consecutive patients with unstable trochanteric fractures of the femur were enrolled in the study. The only intervention was InterTan nail or PFNA-II fixation of the unstable trochanteric fractures. Follow-up occurred at 1, 3, 6, and 12 months postoperatively and yearly thereafter. Radiographs were obtained at each follow-up, and all implant position changes, complications, and fixation failures were recorded. A total of 113 patients meeting the criteria were evaluated at a mean last follow-up of 18.36 months (range, 12-30 months). Intraoperative complications and length of hospital stay were comparable between the groups. Patients treated with the PFNA-II experienced shorter fluoroscopy and operative times, less intraoperative blood loss, and less femoral neck shortening. The incidence of thigh pain was significantly higher in the PFNA-II group (30.4%) than in the InterTan group (10.3%) (P=.001). No statistically significant differences existed in general complications, local complications, walking ability, Harris Hip Scores, or hip range of motion at final follow-up.

The stability score of the intramedullary nailed intertrochanteric fractures: stability of nailed fracture and postoperative patient mobilization

Background

Intertrochanteric fractures of the femur are the most common type of fracture, and are an increasing occurrence due to the aging of the population. The objectives of our study are to predict the fate of intertrochanteric fractures treated with intramedullary hip nails by assessing the postoperative fracture stability utilizing the newly developed scoring system, and to help rehabilitate these patients.

Methods

Eighty-two patients with intertrochanteric fractures that were treated with intramedullary hip nails between December, 2004 and January, 2011 were subjected to this study. The patients who could be followed for a minimum of one year postoperatively were enrolled. The immediate postoperative conditions were determined by radiograms: reduction status (3 parameters/4 points: contact accuracy of posteromedial cortex, severity of angulation, and distraction), fixation status (3 parameters/3 points: tip-apex distance, location of tip of the lag screw, entry point of the intramedullary nail), and fracture type (1 parameter/1 point: stable or unstable type by the Kyle's classification). Postoperative reduction loss and fixation failure were checked by radiograms taken at a minimum 3 months postoperative.

Results

Reduction loss and fixation failure were observed in 14 consecutive patients (17%). The fixation failure rate was 100% (2 patients) in score 1, 60% (3 out of the 5 patients) in score 2, 39% (3 out of the 8 patients) in score 3, and 50% (4 out of the 8 patients) in score 4 groups. There were fixation failures only in 1 out of 13 patients with score 5, and in 1 out of 18 patients with score 6. There was no fixation failure in 17 patients with score 7 and 11 patients with score 8.

Conclusions

Maintenance of the fracture reduction by the stable fixation in the patient scores over 5 could be predicted by the postoperative radiograms.

Using three-dimensional computational modeling to compare the geometrical fitness of two kinds of proximal femoral intramedullary nail for Chinese femur

Objective. The aim of this study was to use three-dimensional (3D) computational modeling to compare the geometric fitness of these two kinds of proximal femoral intramedullary nails in the Chinese femurs. Computed tomography (CT) scans of a total of 120 normal adult Chinese cadaveric femurs were collected for analysis. With the three-dimensional (3D) computational technology, the anatomical fitness between the nail and bone was quantified according to the impingement incidence, maximum thicknesses and lengths by which the nail was protruding into the cortex in the virtual bone model, respectively, at the proximal, middle, and distal portions of the implant in the femur. The results showed that PFNA-II may fit better for the Chinese proximal femurs than InterTan, and the distal portion of InterTan may perform better than that of PFNA-II; the anatomic fitness of both nails for Chinese patients may not be very satisfactory. As a result, both implants need further modifications to meet the needs of the Chinese population.

Comparison between bipolar hemiarthroplasty and total hip arthroplasty for unstable intertrochanteric fractures in elderly osteoporotic patients

The present study was conducted to compare bipolar hemiarthroplasty (BA) with total hip arthroplasty (THA) in treatment of unstable intertrochanteric fractures in elderly osteoporotic patients. The THA group included 14 males and 26 females with a mean age of 73.4 years, and the BA group included 27 males and 45 females with a mean age of 76.5 years. Significant difference existed between the two groups in operation time, blood loss, transfusion volume and cost of hospitalization, while no remarkable difference was identified in hospitalization period, general complications, joint function, pain, rate of revision and mortality. No dislocation was observed in BA group while 3 occurred in THA group. The results indicated that for unstable intertrochanteric fractures in elderly osteoporotic patients, BA seems to be a better or more reasonable choice compared with THA for the reason of less blood loss, shorter operation time, lower cost and no dislocation.

Salvage procedures for trochanteric femoral fractures after internal fixation failure: Biomechanical comparison of a plate fixator and the dynamic condylar screw

The aim of this study was the biomechanical evaluation of the reversed less invasive stabilization system (LISS) internal fixation as a joint-preserving salvage procedure for trochanteric fractures. Five LISS plates and five dynamic condylar screws (DCS) were tested using synthetic femora (Sawbones®) with an osteotomy model similar to a type-A2.3 pertrochanteric fracture. The constructs were subjected to axial loading up to 1000 N for five cycles. Then, the force was continuously increased until fixation failure. For the evaluation of the biomechanical behaviour, the stiffness levels were recorded and the osteotomy gap displacement was mapped three-dimensionally. The average stiffness for the constructs with LISS plates was 412 N/mm (with a standard deviation (SD) of 103N/mm) and 572 N/mm (SD of 116 N/mm) for the DCS constructs ( p = 0.051). Local displacement at the osteotomy gap did not yield any significant differences. The LISS constructs failed at a mean axial compression of 2103 N (SD of 519 N) and the DCS constructs at a mean of 2572 N (SD of 372 N) ( p = 0.14). It is concluded that the LISS plate offers a reliable fixation alternative for salvage procedures.

Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA)

BACKGROUND

Controversy persists concerning the preferred treatment of peritrochanteric femoral fractures. The purpose of the present study was to evaluate the mid-term outcomes of the newly developed implants - proximal femoral nail antirotation (PFNA) for the stabilisation of this type of fracture.

METHODS

Between April 2006 and March 2008, 169 patients with peritrochanteric femoral fractures were treated with PFNA. As many as 26 patients were excluded from the study. According to the Orthopaedic Trauma Association (OTA) classification system, the remaining 143 fractures were classified as 19 cases of AO/OTA 31A1 fractures, 83 cases of 31A2 fractures, 28 cases of 31A3 fractures and 13 cases of 31A combined with proximal 32 fracture or separate proximal 32 fracture. The mean age of these patients was 67 years (range, 20-93 years). The operative time, the overall fluoroscopy time, the duration of hospitalisation and the surgical complications were noted. Patients were followed up for a mean of 21 months (range, 12-36 months). Functional outcomes were assessed according to the Harris hip scoring system.

RESULTS

Fifteen patients (10%) required open reduction. The mean duration of surgery (from the beginning of close reduction to wound closure) was 72 min with a range between 45 and 170 min. The mean fluoroscopy time was 164 s with a range between 92 and 396 s. The mean time of hospital stay was 15 days. Postoperative X-rays showed a good or acceptable reduction in 134 cases (94%), and an ideal implant position in 131 cases (92%). There were 12 (8%) postoperative complications. All patients except one healed their fractures without any implant-specific complication (bending, breaking of the implant, cut out of the PFNA blade, femoral head penetration of the blade or ipsilateral fractures of the femoral shaft at the tip of the implant). The average time to bone healing was 16 weeks (range, 12-25 weeks). At the time of the latest follow-up, 106 patients (74%) were restored to their preoperative mobility. The mean Harris hip score was 84 points (range, 46-100 points). A total of 106 patients (74%) had an excellent or good outcome. According to the patients and/or their caregivers, outcome was described as satisfactory in 120(84%) of the 143 patients, and 36(90%) of the 40 patients, who were more than 80 years old.

CONCLUSION

The results suggest that PFNA is a very effective and safe method in the treatment of different patterns of peritrochanteric femoral fractures. The fixation is adequate to maintain reduction over time even in osteoporotic bones.

3066 consecutive Gamma Nails. 12 years experience at a single centre

Background

Fixation of trochanteric hip fractures using the Gamma Nail has been performed since 1988 and is today well established and wide-spread. However, a number of reports have raised serious concerns about the implant's complication rate. The main focus has been the increased risk of a subsequent femoral shaft fracture and some authors have argued against its use despite other obvious advantages, when this implant is employed.

Through access to a uniquely large patient data base available, which is available for analysis of trochanteric fractures; we have been able to evaluate the performance of the Gamma Nail over a twelve year period.

Methods

3066 consecutive patients were treated for trochanteric fractures using Gamma Nails between 1990 and 2002 at the Centre de Traumatologie et de l'Orthopedie (CTO), Strasbourg, France. These patients were retrospectively analysed. Information on epidemiological data, intra- and postoperative complications and patients' outcome was retrieved from patient notes. All available radiographs were assessed by a single reviewer (AJB).

Results

The results showed a low complication rate with the use of the Gamma Nail. There were 137 (4.5%) intraoperative fracture-related complications. Moreover 189 (6.2%) complications were detected postoperatively and during follow-up. Cut-out of the lag screw from the femoral head was the most frequent mechanical complication (57 patients, 1.85%), whereas a postoperative femoral shaft fracture occurred in 19 patients (0.6%). Other complications, such as infection, delayed healing/non-union, avascular femoral head necrosis and distal locking problems occurred in 113 patients (3.7%).

Conclusions

The use of the Gamma Nail in trochanteric hip fractures is a safe method with a low complication rate. In particular, a low rate of femoral shaft fractures was reported. The low complication rate reported in this series can probably be explained by strict adherence to a proper surgical technique.

Short proximal femoral nail fixation for trochanteric fractures

PURPOSE

To review outcomes of 100 patients who underwent short proximal femoral nailing for stable and unstable intertrochanteric fractures.

METHODS

Records of 62 men and 38 women aged 56 to 83 (mean, 67) years who underwent short proximal femoral nailing for stable peritrochanteric A1 (n=36), unstable peritrochanteric A2 (n=40), and unstable intertrochanteric A3 (n=24) fractures were reviewed.

RESULTS

80 patients achieved anatomic reduction. At the one-year follow-up, 90% of the patients had good or excellent outcomes, and 50% had returned to their pre-injury functional level. One patient with avascular necrosis noted at 20 months and another patient with non-union/pseudarthrosis underwent a revision bipolar arthroplasty. Two patients had a Z effect and one a reverse Z effect. Six patients with osteoporosis had superior migration of the nail with varus collapse. Two patients had cutting out of the screw, but the fractures eventually healed. Ten patients had shortening of <2 cm. Seven patients had lateral thigh discomfort attributed to irritation of the protruding screws against the tensor fascia lata, and 5 of them underwent screw removal. None had fractures of the femoral shaft or trochanter or experienced nail breakage.

CONCLUSION

The short proximal femoral nail is a superior implant for stable and unstable intertrochanteric fractures in terms of operating time, surgical exposure, blood loss, and complications, especially for patients with relatively small femora.

A comparative study of screw and helical proximal femoral nails for the treatment of intertrochanteric fractures

The goal of this study was to compare treatment outcomes of screw proximal femoral nails and helical proximal femoral nails and to investigate the effectiveness of helical proximal femoral nails for the treatment of intertrochanteric fractures. Forty patients with intertrochanteric fractures were treated at our institution between January 2005 and January 2007, with a minimum follow-up of 1.5 years. Seventeen patients were treated with screw proximal femoral nails (mean patient age, 67 years; age range, 45-89 years; men:women ratio, 3:14), and 23 were treated with helical proximal femoral nails (mean patient age, 74 years; age range, 64-91 years; men:women ratio, 6:17). We evaluated mean operation time, amount of bleeding, time to ambulation, average union period, changes in neck shaft angle, and complications, and performed radiographic reviews, telephone interviews, and direct contact interviews at an outpatient clinic. We evaluated postoperative function and mobility using social function scores and mobility scores.Helical proximal femoral nails produced better results in terms of social function scores, mobility scores, and complication rates with statistical significance. No significant differences were found between the 2 nails in terms of mean operation time, amount of bleeding, average union period, time to ambulation, or neck shaft angle changes. Screw proximal femoral nails and helical proximal femoral nails are suitable implants for intertrochanteric fractures, but helical proximal femoral nails are better in terms of functional aspects and complication rates.

The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures

INTRODUCTION

PFNA design compacts the cancellous bone to provide increased stability and has been bio-mechanically proven to retard rotation and varus collapse.

METHODS

Between 2006 and 2007, 62 consecutive patients with unstable proximal femoral fractures were treated with the PFNA.

RESULTS

Twenty males and 42 females with a mean age of 78 years (44-94) were reviewed. In 48 patients, the fracture resulted from a low energy injury. The majority of the fractures belonged to AO/ASIF types 31A2.3 (22) and 31A3.2 (29). Twelve patients required open reduction. The PFNA blade position was central in 52 patients with a mean tip-apex distance (TAD) of 12 mm (range 4-34 mm). Post-operatively, five patients died within 3 months and two patients were lost to follow-up. Forty-nine fractures united between 3 and 4 months. Four patients had delayed union. The PFNA blade cut out rate was 3.6%.

CONCLUSIONS

Unstable proximal femoral fractures were treated successfully with the PFNA. The PFNA blade appears to provide additional anchoring in osteoporotic bone. No results have been published on this new design.

A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

One and two femoral neck screws with intramedullary nails for unstable trochanteric fractures of femur in the elderly--randomised clinical trial

Intramedullary nailing has been the gold standard in the management of lower limb fractures by virtue of advantage of early joint mobilisation and weight bearing. They are being increasingly used in the peri-trochanteric fractures of femur. Biomechanical studies have proved the supremacy of single femoral neck screw construct over two femoral neck screws along with the intramedullary nails in osteoporotic bones due to lower incidence of complications. This randomised clinical trial was conducted to study the clinico-radiological outcome of single and two-femoral neck screw construct in the management of unstable trochanteric fractures in the elderly osteoporotic bones. Although there was no significant difference in the clinical outcome in the two groups, less sliding of the femoral neck screws was noted with two-femoral neck screw configuration. The tip-apex distance was also significantly lower in the two-screw construct compared to that of the single screw construct. This study to our knowledge is the first randomised control clinical trial evaluating the effectiveness of one and two femoral neck screw configuration of intra-medullary nails in the management of unstable trochanteric fractures.

Experience in the use of the long Gamma nail for 16 femoral shaft fracture that have occurred following initial Asian Pacific Gamma nail fixation for pertrochanteric fractures

From January 1993 to September 2002, 931 patients suffered from intertrochanteric fracture and subrochanteric fracture received open reduction and internal fixation with APGN in our institute. Among these patients, 16 patients (1.7%) developed a femoral shaft fracture after the initial fixation with APGN. Removal of the APGN, closed reduction and fixation with long Gamma nail (LGN) was performed in all the 16 patients. The patients were followed for 12-60 months (average, 39.8 months). The union time of fracture was 12-24 weeks (average, 18.5 weeks) for femoral shaft fractures and 12-20 weeks (average, 16 weeks) for peritrochanteric fractures. Two early complications were noted, including one superficial (6%) infection and one deep (6%) infection. Two malunions (12.5%) developed with no definite functional impairment. The functional results using the Harris hip score were good to excellent. In conclusion, closed reduction and internal fixation with a LGN is very effective in the management of a femoral shaft fracture, a complication of a previous APGN that had been initially used for stabilisation of a pertrochanteric fracture.

The Trochanteric Nail versus the Sliding Hip Screw for Intertrochanteric Hip Fractures: A Review of 93 Cases

BACKGROUND

The trochanteric nail, a redesigned short gamma nail, (Howmedica, Rutherford, NJ) was introduced in the United States during 1998 for the treatment of intertrochanteric fractures.

METHODS

We retrospectively reviewed 93 patients who were treated for an intertrochanteric fracture with either a sliding hip screw (SHS) or the short trochanteric nail (TN).

RESULTS

In all, 94% of the patients in the sliding hip screw group healed without complication. There was one case of femoral head necrosis, one lag screw cutout, and one hardware removal for pain. Eighty-nine percent of the patients in the trochanteric nail group healed without complication. There was one late fracture at the tip of the nail, three cases of lag screw cutout, and one nonunion.

CONCLUSIONS

This study suggests that the trochanteric nail is a reasonable alternative to the sliding hip screw when used for intertrochanteric fractures, although it may be associated with higher complication rates.

Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures?

We reviewed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications. Results were stratified according to fracture type and surgeon experience to determine which problems occurred in these groups. One year postoperative followup was available for 129 of 132 surviving patients (98%). Failure of fixation occurred in three patients (2%), and a femoral shaft fracture occurred in one patient (0.7%). Fixation failures included one cutout, one delayed fracture healing, and one lateral displacement of the antirotation screw. The total reoperation rate was high (12%) mainly because of hardware removals, which occurred in 13 patients (8.6%). Stratification of results showed that hematomas and iliotibial tract irritation occurred more commonly with lesser surgical experience. General complications and intraoperative problems were seen more often with subtrochanteric fractures. Because the high reoperation rate with the proximal femoral nail is a concern, extramedullary devices continue to be the preferred implants for treatment of stable trochanteric fractures. The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures.

Treatment of intertrochanteric fractures in geriatric patients with a modified external fixator

Forty-two geriatric patients who had an intertrochanteric fracture were treated with a semicircular modification of the Ilizarov frame designed by Cattaneo and Catagni between January 1997 and September 2001. Twenty-five of the patients were female, 17 male. The average age of the patients was 77.5 years (range, 63-99). No intraoperative complication occurred. Deep pin-track infection was found in four patients and varus deformity was observed in two patients and shortening of less than 2 cm in 10 patients. Fixator removal was achieved in a mean time of 12 weeks (range, 10-18). No implant failure, refracture or stiffness of knee and hip joint movements was recorded. We concluded that the treatment of intertrochanteric fractures of the elderly patients with our modification provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time.

Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail

OBJECTIVES

To compare the results between a new intramedullary Gamma nail and a compression hip screw in the treatment of trochanteric fractures.

DESIGN

Prospective randomized.

SETTING

Level 1 trauma center.

PATIENTS

Two hundred ten consecutive patients older than 65 years with trochanteric femoral fractures.

INTERVENTIONS

Treatment with a compression hip screw or a new design of the Trochanteric Gamma nail (180 mm in length with a mediolateral angle of 4 degrees and available only with a proximal diameter of 17 mm and distal diameter of 11 mm).

MAIN OUTCOME MEASUREMENTS

Operative and fluoroscopy times, blood loss, functional outcome, complication rate, and failure of fixation.

RESULTS

The Trochanteric Gamma nail was used in 104 patients and the compression hip screw in 106. The 2 groups were similar in terms of their preoperative data, with a median follow-up of 13.6 months (range 12-30). The results show no difference in operating time (P = 0.21), but the Trochanteric Gamma nail group had a significantly shorter fluoroscopy time (P = 0.006), and the number of patients transfused and the mean of units of blood transfused were significantly less in the Trochanteric Gamma nail group (P = 0.013, 0.046, respectively). Mortality within 12 months was similar in both groups (P = 0.83). All fractures were radiographically healed at the last visit. There was no difference in intraoperative and postoperative complications or rate of fixation failure between the 2 groups, and no case of secondary shaft fracture of the femur was encountered in this study. In the entire series, there was no difference in the functional outcome (P = 0.74), but the postoperative walking ability was better in those patients with unstable fractures who were treated with the Trochanteric Gamma nail (P = 0.017).

CONCLUSIONS

The new Trochanteric Gamma nail is an effective method for the treatment of trochanteric femoral fractures in elderly patients. The indication for either Trochanteric Gamma nail or compression hip screw is similar in stable fractures, but we recommend the use of the Trochanteric Gamma nail for unstable trochanteric fractures.

Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature

For operative treatment of unstable trochanteric fractures two options exist: extramedullary or intramedullary stabilisation. A review of 18 international papers that compared two different treatment methods for trochanteric fractures, in prospective randomised clinical trials, is presented. In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. For these fractures one of the sliding hip screw systems provides a safe and simple alternative. For unstable fractures intramedullary implants are (biomechanically) superior. The review shows that clinical advantages of both treatment methods are suggested and advocated, but still remain to be demonstrated on evidence base.

Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail

We report our initial experience with a new reconstruction nail, the long proximal femoral nail (L.PFN), in the treatment of subtrochanteric femoral fractures and metastases. We performed 52 L.PFN in 49 patients over a period of 18 months with an average follow-up period of 47.7 weeks. Group I consisted of 24 patients, who had L.PFN for traumatic subtrochanteric femoral fractures. Group II consisted of 25 patients, who had L.PFN for femoral metastases and pathological fractures. (Three bilateral.) In nine patients in group I, the fracture was extending to the intertrochnateric region with involvement of the piriformis fossa. Eight patients in group I had open reduction and cerclage cabling of the fracture prior to L.PFN. All the traumatic fractures in group I had united with an average time to union of 19.4 weeks. In eight operations there were technical difficulties with the insertion of proximal locking screws. Five patients in our series had complications but we had no mechanical failures of the implant. L.PFN is a reliable implant for subtrochanteric femoral fractures and metastases. We also showed that open reduction and cerclage cabling of unstable subtrochanteric fractures prior to nailing was not detrimental to fracture healing in our series.

The proximal femoral nail (PFN)--a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months

In 1996, the AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary device for the treatment of unstable per-, intra- and subtrochanteric femoral fractures. In a prospective study, we treated 55 patients having proximal femoral fractures with the PFN from 1997 to 2000. In 34 patients, we achieved what was close to anatomic reduction of the main fracture fragments. Immediate full weight bearing was permitted in 49 patients. During the follow-up period of 15 months, complications occurred in 12 patients. 2 patients had a cut-out of the implant because we used too short proximal gliding screws. In 5 patients, closed fracture reduction could not be done and open fracture reduction with use of cerclage became necessary. Careful surgical technique and modification of the PFN can reduce the high complication rate. In conclusion, the PFN is a good minimal invasive implant of unstable proximal femoral fractures, if closed reduction is possible. If open reduction of the fracture becomes necessary and several fragments are found (especially of the greater trochanter), we prefer to use a dynamic hip screw (DHS) with the trochanter stablizing plate.

A randomized study of the compression hip screw and Gamma nail in 426 fractures

A prospective, randomized study comparing the compression hip screw with the Gamma nail in the treatment of 426 intertrochanteric fractures is reported. The median patient age was 80 years, and 71% were women The compression hip screw operation took less time except in Evans Type 5 fractures. Blood loss generally was less in the compression hip screw group except in patients with Type 5 fractures. The most frequent surgical problem for patients in the Gamma group was problems with distal locking. Cephalic position of the femoral head screw and cut-out were seen more often in the Gamma nail group. The Gamma nail more frequently preserved the fracture position obtained perioperatively. Whether there was distal locking of the Gamma nail in unstable fractures did not seem to affect the healing rate. Additional fissures or fractures in the proximal femur occurred during five Gamma nail operations and two compression hip screw operations. Postoperative walking ability did not differ between the groups. At 6 months 88% of the fractures were healed. In less comminuted fractures, the compression hip screw method is the preferred method of treatment whereas the Gamma nail is an alternative treatment for more comminuted Evans Type 5 fractures.

Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results

OBJECTIVES

This study aimed at comparing the results obtained with a sliding screw plate and an experimental device including a small-diameter nail that can be placed with a mini-invasive approach and provides a stable fixation.

DESIGN

Randomized prospective study.

SETTING

University hospital.

PATIENTS

The study included two groups with thirty fractures of the trochanteric area.

INTERVENTIONS

In both groups, the surgical procedure was carried out on patients placed on a traction table in a supine position, under an x-ray amplifier. Sliding screw plates (THS) were set in place according to the usual open technique. Nails were placed through a twenty-millimeter supratrochanteric cutaneous incision. This experimental system comprised a locked intramedullary nail with two nonparallel seven-millimeter cervicocephalic screws.

MAIN OUTCOME MEASURES

The comparison between the two groups was based on the surgical procedure (time, duration of x-ray irradiation, and total blood loss); the initial postoperative period (complications, duration of hospital stay, and the time before returning home); the time before full weight bearing became effective; the functional and social recovery; mortality; and the quality of immediate and final anatomic restitution and healing.

RESULTS

Operating time (p < 0.001) and blood loss (p < 0.001) were lower in the nail group, and no blood transfusion was required. Postoperative pain (p < 0.01), time necessary to support full weight bearing (p < 0.02), and time before returning home (p < 0.05) were reduced in the nail group. All fractures healed in the same amount of time, with good anatomic results in the nail group, whereas ten impactions beyond ten millimeters occurred in the plate group. No difference was found between the two groups in walking ability and autonomy recovery, but hip function (p < 0.05) was better in the nail group.

CONCLUSION

This preliminary clinical study has shown the advantages of this mini-invasive technique. It could not evaluate all the possible disadvantages inherent in the method. These points will be evaluated in a multicenter study justified by these preliminary results.

Intramedullary femoral nails: one or two lag screws? A preliminary study

Failures of proximal femoral nails that treat unstable femoral fractures have been reported. In this communication, a finite element model to include a proximal femoral nail within a fractured femur was used to carry out preliminary investigations into configurations of single or double lag screws. The effects of the different types of fracture were investigated. The results show that in order to share the load evenly between two lag screws, a good configuration seems to be to have a slightly larger screw above the lower screw. This also ameliorates stresses in the nail at the lag screw insertion holes. However, using two screws in this way can lead to large stresses in the cancellous bone in the femoral head, and these stresses may be significant in the initiation of cut-out.

Percutaneous treatment of peritrochanteric fractures using the Gamma nail

The goal of the current study was to analyze patients treated with the Gamma nail, and to describe techniques that prevent commonly reported complications. One hundred patients with closed peritrochanteric femur fractures were treated by one surgeon using the Gamma nail. Ninety patients met the minimum 6 month followup requirement. Eighty-eight of the 90 fractures (98%) healed after the index procedure. There were nine (10%) complications (nine patients) with four patients (4%) requiring surgical intervention. One patient required total hip arthroplasty because of nonunion, and one patient required cerclage wiring of a postoperative femoral fracture. The third patient had an infection develop which resolved after debridement and a course of antibiotics. The fourth patient complained of thigh pain, which resulted in hardware removal. In the five remaining patients with complications, one patient had multi-infarct dementia and the family refused additional treatment, two patients with intraoperative femur fractures did not require treatment and two patients with thigh pain did not require additional treatment. Surgical time averaged 53 minutes and blood loss averaged 104 cc. Percutaneous fixation using the Gamma nail is effective in treating patients with peritrochanteric fractures. Surgical time and blood loss were minimized, early weightbearing was initiated, and previously reported complications were decreased.

The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures

Currently available intramedullary devices for the treatment of unstable pertrochanteric femoral fractures are technically demanding and show a considerable failure rate due to their massiveness and the persistent rotational instability of the head-neck fragment. The Arbeitsgemeinschaft für Osteosynthesefragen (AO/ASIF) therefore designed a new intramedullary device, the proximal femoral nail (PFN), which during a handling study was tested in 4 European clinics. Within one year 191 proximal femoral fractures were treated with the PFN. After a follow up period of at least 4 months technical failures (poor reduction, malrotation or wrong choice of screws) were seen in just 4.6% of the cases. One patient showed a cut-out of the implant but there were no mechanical failures (bending, breaking of the implant) or ipsilateral fractures of the femoral shaft at the tip of the implant. It is therefore concluded that the results of this new implant compare favourably to the currently available implants for the treatment of the unstable pertrochanteric femoral fracture.