Fractures of the Proximal Femur. The Gamma Nail versus Plate

Abstract

In our profession, fractures of the proximal part of the femur are increasing considerably in number, related directly to improved life expectancy [16]. Results of European studies, which are similar to those in the USA, estimate that the number of fractures of the proximal femur will multiply by a factor of two by the year 2050, and the direct costs attributed to osteoporosis will be higher than e 132 000 millions (in 2000, hospital costs directly attributed to osteoporosis were e 4 800 millions, -implying an increase of 33 % in the last 3 years). In 2001, the number of hip fractures in the EU was 480 000, an increase of 25 % over the previous 4 years. For these reasons, the need for suitable treatment of these fractures (and for the prevention of osteoporosis) in order to minimize morbidity/mortality related to all age groups, especially in the elderly, takes on great importance [22].There seems to be a consensus in the current literature and among the various authors that the primary objectives in the treatment of fractures of the proximal femur are to achieve a stable fixation of the fracture so that rapid mobilization of the patient can be initiated and to minimize the risks of implant AbstractHistorically the fractures of the proximal femur have been a challenge for the orthopaedic surgeon, because of the high number of hardware failures and the high mortality rate. The social and medical importance of these fractures is increasing and will be higher in the future because of the improved life expectancy and osteoporosis. The development of new material as well as the design of new devices have improved the results of treatment of this kind of fractures. Historically the plate was the treatment of choice for this kind of fractures, but the high incidence of hardware failures and non-unions led to the introduction of the Gamma nail which initiated a revolution in the concept of treatment of this kind of fractures. The main treatment target is to restore the functional capacity of the patient as soon as possible with the much higher mechanical guarantees of the device in order to obtain the fracture consolidation. A review of the medical literature has been done as well an evaluation of the two main concepts of treatment: plate versus endomedullary nail. Both techniques are not without risks, both have technical complications related to the technique. These complications can be resolved with an adequate learning curve. The experience of the surgeon is important to decrease these technical complications. Although it can lead to controversy about the treatment type for the stable fractures of the EPF, almost all the authors accept the endomedullary g nail (Gamma nail) as the most adequate treatment of the unstable fractures of the proximal femur extremity.

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

“…As the preference for intramedullary nailing has increased, complications associated with distal locking have emerged [1,8,11,13,16]. Stress concentrations lead to thigh pain and erosion of the femoral cortex, and the subsequent tip-effect results in femoral fractures during minimal force at the tip of the nail.…”

“…When addressing the distal locking issue, some authors have stated that distal locking is not necessary for most pertrochanteric AO 31-A1 + 2 fractures [8,[11][12][13][14][15]; they then used their samples to confirm that unlocked nailing was safe and not associated with increased complications.…”

Is distal locking with IMHN necessary in every pertrochanteric fracture?

“…Such a high frequency of these problems was not seen later in any other IMHN [7,11,13,14,16,22]. Thigh pain and especially very frequent fractures in the region of the nail tip were even considered by some authors as contraindication of GN in pertrochanteric fractures [6,18,19,25]. There were two reasons for this.…”

“…Since the introduction of the GN into clinical practice, the most frequently reported complications have been problems with distal locking [1,3,5,6,8,12,15,19,23]. Such a high frequency of these problems was not seen later in any other IMHN [7,11,13,14,16,22].…”

“…Apart from positive reports, articles also appeared pointing out problems associated with distal locking of the GN [1,3,10,12,17,19]. As a result, some authors reduced their indications for distal locking in trochanteric fractures [6,19,20,23] or they did not use it at all [3,23]. Thanks to increasing experience with intramedullary hip nails (IMHN) and the improved design of the new generation of these implants, the number of complications caused by distal locking decreased but were not completely eliminated [7,11,13,14,16,21,22].…”