Session X - Pelvis/Geriatrics
Trochanteric Gamma Nail: A Prospective Clinical Study on the Treatment of Peritrochanteric Femoral Fractures
Thomas K. Hotz, MD; Stefan Breitenstein, MD; Marco Di Lazzaro, MD; Kurt P. Kaech, MD, Kantonsspital Winterthur, Winterthur, Switzerland
Purpose: We evaluated the clinical use of the trochanteric gamma nail (TGN) for peritrochanteric femoral fractures at an academic teaching hospital.
Methods: We prospectively collected the pre-, peri- and postoperative data concerning 140 consecutive peritrochanteric fractures treated with the TGN during a 2-year period. The patients were evaluated clinically as well as radiologically in a standardized manner shortly after mobilization as well as, at the earliest, 4 months postoperatively. The radiological parameters assessed were bone consolidation, implant position, and leg shortening. The TGN is a shorter version of the standard gamma nail (180 mm compared with 200 mm); however, the working distance between the hip screw and the interlocking screw is identical. The TGN has a lesser curvature (4o compared with 10o). Consequently, a better alignment with the anatomy of the proximal femur is achieved, and in most of the procedures reaming of the femoral cavity is not necessary.
Results: The 140 TGN implantations were performed on 137 patients (109 women, 28 men) with a median age of 80 years (range, 21 to 101 years) at the time of operation. Eighteen percent of the cases had two-part-fractures, 24% three-part-fractures, and 58% four-part-fractures. According to the AO/ASIF classification, there were 28 type 31-A1, 104 type 31-A2, and 8 type 31-A3 fractures. The TGN implantations were performed in a median skin-to-skin operation time of 50 minutes (range, 20 to 195). We allowed the patients full weight bearing after the second postoperative day. Two patients (1.5%) developed hematomas and one patient (0.7%) a superficial wound infection. All three patients were treated with evacuation and drainage with no further problems. There was no occurrence of deep infection or femoral shaft fracture. The clinical and radiological follow-up was performed after an average of 7 months. During this time 23 patients (17%) had died of causes unrelated to the osteosynthesis. Clinical follow-up was achieved in all of the other 117 cases (100%). The radiological follow-up was possible in 111 cases (95%). Primary healing occurred in all but three fractures (97%). One case healed after bone grafting without any further problems, and one patient was successfully treated with a hip-screw replacement. The third patient, with a cutout of the hip screw from the femoral head, walks with pain but has not agreed to any further treatment.
At the clinical follow-up, Harris Hip scores reached 76 points on the fractured side compared with 90 points on the contralateral side. D'Aubigné Postel scores were 14 points compared with 17 points on the unfractured side. On the Barthel Index, the patients reached 80 points compared with 87 points prior to injury. The radiological follow-up examination revealed that shortening of the femoral length measured on average 5.8 mm, and the dynamic sliding of the hip screw in the nail showed an average of 2 mm. There were no implant failures except for one broken distal locking bolt.
Conclusion: The TGN allowed us to treat patients with peritrochanteric two-, three- and four-fragment fractures with a safe and succesful minimally invasive technique. We believe that it is reliable, causes little trauma to the soft tissues, has few complications, and allows immediate mobilization with full weight bearing. The TGN therefore fulfills all requirements of modern fracture treatment of the proximal femur, especially for geriatric patients.