The Treatment of Complex Intertrochanteric and Subtrochanteric Fractures with the Long Gamma Nail

Abstract

The surgical treatment of complex inter- and subtrochanteric fractures is difficult and a multitude of intra- and extramedullary devices are being used. Since 1992 the long gamma nail is the implant of choice at our level-1 trauma center. Over a period of seven years we treated sixty-seven consecutive patients with sixty-nine complex intertrochanteric or subtrochanteric fractures. In order to evaluate the clinical and radiological outcome we retrospectively reviewed fifty-nine of these patients with a mean follow up of twenty-four months (range: 6 to 72 months). We encountered no intra- or perioperative complication nor early or late infection. Clinical and radiological bony union was achieved at a mean of 4.3 months in all of the patients (range: 3-9 months), in 15 cases (25 %) the distal locking bolts were retrieved in order to enhance callus formation and remodelling as a planned secondary surgery. Five patients (8 %) needed no planned secondary surgery for problems related to the nailing technique. Two mechanical failures with breakage of the nail were encountered due to proximal varus malalignment, of which one was treated with exchange nailing and grafting and the other one by removal of the broken hardware, blade-plating and bone grafting. One fracture below a short long gamma nail was treated by exchange nailing and two patients with backing out of the distal interlocking bolts had them exchanged. The minimally invasive technique and simple application of the long gamma nail leads after a relatively short learning curve to a low percentage of complications in these difficult fractures. Due to its good biomechanical properties early mobilization and partial weight bearing even in patients with advanced osteoporosis is possible.

Intertrochanteric fracture - subtrochanteric fracture - long gamma nail

References

• 1 Ahlo A, Ekeland A, Grogaard B, Dokke J R. A locked hip screw-intramedullary nail (cephalomedullary nail) for the treatment of fractures of the proximal part of the femur with fractures of the femoral shaft.  J Trauma. 1996;  40 10-16
• 2 Alvarez J R, Gonzalez R C, Aranda R L, Blanco M F, Dehesa M C. Indications for use of the long gamma nail.  Clin Orthop. 1998;  350 62-66
• 3 Barquet A, Francescoli L, Rienzi D, Lopez L. Intertrochanteric-subtrochanteric fractures: Treatment with the long gamma nail.  J Orthop Trauma. 2000;  5 324-328
• 4 Baumgaertner M R, Solberg B D. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip.  J Bone Joint Surg [Br]. 1997;  79 969-971
• 5 Bergman G D, Winquist R A, Mayo K A, Hansen S T. Subtrochanteric fracture of the femur. Fixation using the Zickel nail.  J Bone Joint Surg [Am]. 1987;  69 1032-1040
• 6 Blatter G, Janssen M. Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw.  Arch Orthop Trauma Surg. 1994;  113 138-141
• 7 Brien W W, Wiss D A, Becker V J r, Lehman T. Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail.  J Orthop Trauma. 1991;  5 458-464
• 8 Bucholz R W, Brumback R J. Fractures of the shaft of the femur. In: Fractures in adults, 4th ed. By Rockwood CA, Green DP, Buchholz RW, Heckman JD. Philadelphia, Lippincott- Raven, 1996: 1827-1918
• 9 DeLee J C, Clanton T O, Rockwood CA J r. Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace.  J Bone Joint Surg [Am]. 1981;  63 773-779
• 10 Dubrana F, Poureyron Y, Tram J, Genestet M, Rizzo C, Le Nen D, Lefevre C. Long gamma nail for the treatment of subtrochanteric fracture of the femur.  Rev Chir Orthop Reparatrice Appar Mot. 2002;  88 264-270
• 11 Grosse A, Favreul E, Taglang G. The long gamma nail experience: 79 cases.  Orthopedics. 1994;  2 3-5
• 12 Hoover G K, Browner B D, Cole J D, Comstock C P, Cotler H B. Initial experience with a second generation locking femoral nail: the Russell-Taylor reconstruction nail.  Contemp Orthop. 1991;  3 199-208
• 13 Hotz T, Zellweger R, Kach K P. Minimal invasive treatment of proximal femur fractures with the long gamma nail: Indication, technique, results.  J Trauma. 1999;  47 (5) 942-945
• 14 Kang S, McAndrew M P, Johnson K D. The reconstruction locked nail for complex fractures of the proximal femur.  J Orthop Trauma. 1995;  9 453-463
• 15 Kinast C, Bolhofner B R, Mast J W, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate.  Clin Orthop. 1989;  238 285-287
• 16 Lunsjö K, Ceder L, Thorngren K G. et al . Extramedullary fixation of 569 unstable intertrochanteric fractures.  Acta Orthop Scand. 2001;  72 (2) 133-140
• 17 Mullaji A B, Thomas T L. Low-energy subtrochanteric fractures in elderly patients: results of fixation with the sliding screw plate.  J Trauma. 1993;  34 56-61
• 18 Müller M, Ganz R. Blade plate for subtrochanteric fractures.  Injury. 1998;  Suppl 3 7-15
• 19 Penschuk C E. Möglichkeiten der operativen Versorgung von per- und subtrochantären Femurfrakturen unter besonderer Berücksichtigung der DHS-Schraube.  Akt Chir. 1986;  21 72-75
• 20 Roberts C S, Nawab A, Wang M, Voor M, Seligson D. Second generation intramedullary nailing of subtrochanteric femur fractures: A biomechanical study of fracture site motion.  J Orthop Trauma. 2002;  16 231-238
• 21 Ruff M E, Lubbers L M. Treatment of subtrochanteric fractures with a sliding screw-plate device.  J Trauma. 1986;  26 75-80
• 22 Russell T A, Taylor J C. Subtrochanteric fractures of the femur. In: Skeletal Trauma, 2nd ed. Browner, Jupiter, Levine, et al., eds. PA: Saunders, Philadelphia 1992
• 23 Sanders R, Regazzoni P. Treatment of subtrochanteric femur fractures using the dynamic condylar screw.  J Orthop Trauma. 1989;  3 206-213
• 24 Seinsheimer F. Subtrochanteric fractures of the femur.  J Bone Joint Surg [Am]. 1978;  60 300-306
• 25 Singh M, Nagrath A R, Maini P S. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis.  J Bone Joint Surg [Am]. 1970;  52 457-467
• 26 Stapert J WJL, Geesing C LM, Jacobs P BD, Wit R J, Vierhort P AM. First experience and complications with the long Gamma nail.  J Trauma. 1993;  34 394-400
• 27 Tornetta P. Subtrochanteric femur fracture.  J Orthop Trauma. 2002;  16 280-283
• 28 Van den Brink W A, Janssen I MC. Failure of the gamma nail in a highly unstable proximal fracture: Report of four cases encountered in the Netherlands.  J Orthop Trauma. 1995;  9 53-56
• 29 Warwick D J, Chrichlow T PKR, Langkamer V G, Jackson M. The dynamic condylar screw in the management of subtrochanteric fractures of the femur.  Injury. 1995;  26 241-244
• 30 Wiss D A, Brien W W. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing.  Clin Orthop. 1992;  283 231-236
• 31 Zickel R E. Fractures of the adult femur excluding the femoral head and neck: a review and evaluation of current therapy.  Clin Orthop. 1980;  147 93-114
• 32 Zickel R E. An intramedullary fixation device for the proximal part of the femur: nine years’ experience.  J Bone Joint Surg [Am]. 1976;  58 866-872