Basic Operative Techniques with Short Nails: Operative Technique for Short Gamma Nails

Abstract

The Gamma nail is a commonly used implant for proximal femoral fractures (AO classification 31 A1-3). 31 A3 fractures should be treated with a long Gamma nail. The Gamma nail consists of a nail, a lag screw and a distal locking screw. After positioning the patient on a fracture table, the fracture is then reduced. The surgeon can choose a Gamma nail of 125, 130 or 135 degrees, depending on the femoral neck angle. There are several possibilities for opening the femoral canal to introduce the nail. The lag screw is placed via a targeting device. The optimal position is still a subject of discussion. Distal locking is also done via a targeting device. Complications of this procedure are femoral fractures, cut-out of the lag screw, fatigue fractures of the locking bolts and infection.

Gamma nail - operative technique - proximal femoral fracture

References

• 1 Adams C I, Robinson C M, Court-Brown C M, McQueen M M. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur.  J Orthop Trauma. 2001;  15 394-400
• 2 Bannister G C, Gibson A G, Ackroyd C E, Newman J H. The closed reduction of trochanteric fractures.  J Bone Joint Surg [Br]. 1990;  72 317
• 3 Bellabarba C, Herscovici D, Ricci W M. Percutaneous treatment of peritrochanteric fractures using the Gamma nail.  Clin Orthop. 2000;  375 30-42
• 4 Bodoky A, Neff U, Heberer M, Harder F. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip.  J Bone Joint Surg [Am]. 1993;  75 61-65
• 5 Boriani S, De lure F, Campanacci L, Specchia L, Bungaro P, Regnoli R, Triscari C, Giacomelli M, Dorigotti P, Costa P, Carretti P, Carfagni A, Giacomi R. A technical report reviewing the use of the 11 mm Gamma nail: intraoperative femur fracture incidence.  Orthopedics. 1996;  19 597-600
• 6 Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.  Lancet. 1996;  347 1133-1137
• 7 Boyd R J, Burke J F, Colton T. A double-blind clinical trial of prophylactic antibiotics in hip fractures.  J Bone Joint Surg [Am]. 1973;  55 1251-1258
• 8 Britton J R, Dunkerley D R. Closed nailing of a femoral fracture followed by sciatic nerve palsy.  J Bone Joint Surg [Br]. 1990;  72 318
• 9 Brumback R J, Ellison T S, Molligan H, Molligan D J, Mahaffey S, Schmidhauser C. Pudendal nerve palsy complicating intramedullary nailing of the femur.  J Bone Joint Surg [Am]. 1992;  74 1450-1455
• 10 Burnett J W, Gustilo R B, Williams D N, Kind A C. Prophylactic antibiotics in hip fractures, a double-blind, prospective study.  J Bone Joint Surg [Am]. 1980;  62 457-462
• 11 Chen C M, Chiu F Y, Lo W H. Avascular necrosis of femoral head after Gamma-nailing for unstable intertrochanteric fractures.  Arch Orthop Trauma Surg. 2001;  121 505-507
• 12 Davis T R, Sher J L, Horsman A, Simpson M, Porter B B, Checketts R G. Intertrochanteric femoral fractures. Mechanical failure after internal fixation.  J Bone Joint Surg [Br]. 1990;  72 26-31
• 13 Docquier P L, Manche E, Autrique J C, Geulette B. Complications associated with gamma nailing. A review of 439 cases.  Acta Orthop Belg. 2002;  68 251-257
• 14 France M P, Aurori B F. Pudendal nerve palsy following fracture table distraction.  Clin Orthop. 1996;  276 272-276
• 15 Gaebler C, Stanzl-Tschegg S, Tschegg E K, Kukla C, Menth-Chiari W A, Wozasek G E, Heinz T. Implant failure of the gamma nail.  Injury. 1999;  30 91-99
• 16 Hartog B D den, Bartal E, Cooke F. Treatment of the unstable intertrochanteric fracture. Effect of the placement of the screw, its angle of insertion, and osteotomy.  J Bone Joint Surg [Am]. 1991;  73 726-733
• 17 Haynes R C, Poll R G, Miles A W, Weston R B. Failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the Gamma locking nail and AO dynamic hip screw.  Injury. 1997;  28 337-341
• 18 Haynes R C, Poll R G, Miles A W, Weston R B. An experimental study of the failure modes of the Gamma locking nail and AO dynamic hip screw under static loading: a cadaveric study.  Med Eng Phys. 1997;  19 446-453
• 19 Kawaguchi S, Sawada K, Nabeta Y. Cutting-out of the lag screw after internal fixation with the Asiatic Gamma nail.  Injury. 1998;  29 47-53
• 20 Kukla C, Pichl W, Prokesch R, Jacyniak W, Heinze G, Gatterer R, Heinz T. Femoral neck fracture after removal of the standard gamma interlocking nail: a cadaveric study to determine factors influencing the biomechanical properties of the proximal femur.  J Biomech. 2001;  34 1519-1526
• 21 Kukla C, Heinz T, Gaebler C, Heinze G, Vécsei V. The standard Gamma nail: a critical analysis of 1,000 cases.  J Trauma. 2001;  51 77-83
• 22 Kyle R F, Wright T M, Burstein A H. Biomechanical analysis of the sliding characteristics of compression hip screws.  J Bone Joint Surg [Am]. 1980;  62 1308-1314
• 23 Lacroix H, Arwert H, Snijders C J, Fontijne W P. Prevention of fracture at the distal locking site of the gamma nail. A biomechanical study.  J Bone Joint Surg [Br]. 1995;  77 274-276
• 24 Leung K S, Chen C M, So W S, Sato K, Lai C H, Machaisavariya B, Suntharalingam S. Multicenter trial of modified Gamma nail in East Asia.  Clin Orthop. 1996;  323 146-154
• 25 Leunig M, Meyer M, Beck M, Triller J, Stupnicki A, Zimmermann H. Fatal retroperitoneal hemorrhage caused by perforation of a guide wire pin for proximal femur fixation.  Arch Orthop Trauma Surg. 2002;  122 61-63
• 26 Lyddon D W. The prevention of complications with the Gamma locking nail.  Am J Orthop. 1996;  25 357-363
• 27 Madsen J E, Naess L, Aune A K, Alho A, Ekeland A, Stromsoe K. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw.  J Orthop Trauma. 1998;  12 241-248
• 28 McConnell T, Tornetta P, Benson E, Manuel J. Gluteus medius tendon injury during reaming for Gamma nail insertion.  Clin Orthop. 2003;  407 199-202
• 29 Mousavi M, David R, Ehteshami J, Pajenda G, Vécsei V. Pressure changes during reaming with different parameters and reamer designs.  Clin Orthop. 2000;  373 295-303
• 30 Muller C, McIff T, Rahn B A, Pfister U, Weller S. Intramedullary pressure, strain on the diaphysis and increase in cortical temperature when reaming the femoral medullary cavity during reaming. A comparison between blunt and sharp reamers.  Injury. 1993;  24 (Suppl 3) 22-30
• 31 Muller C, Frigg R, Pfister U. Effect of flexible drive diameter and reamer design on the increase of pressure in the medullary cavity during reaming.  Injury. 1993;  24 40-47
• 32 Muller C, Rahn B A, Pfister U, Weller S. Extent of bluntness and damage to reamers from hospitals.  Injury. 1993;  24 (Suppl 3) 31-35
• 33 Park S R, Kang J S, Kim H S, Lee W H, Kim Y H. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw - a randomised prospective trial.  Int Orthop. 1998;  22 157
• 34 Parker M J. Cutting out of the dynamic hip screw related to its position.  J Bone Joint Surg [Br]. 1992;  74 625
• 35 Parker M J, Handoll H H. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev 2002; (4): CD000093
• 36 Rantanen J, Aro H T. Intramedullary fixation of high subtrochanteric femoral fractures: a study comparing two implant designs, the Gamma nail and the intramedullary hip screw.  J Orthop Trauma. 1998;  12 249-252
• 37 Sim E, Freimuller W, Reiter T J. Finite element analysis of the stress distributions in the proximal end of the femur after stabilization of a pertrochanteric model fracture: a comparison of two implants.  Injury. 1995;  26 445-449
• 38 Tait G R, Dalton M. Contralateral sciatic nerve palsy following femoral nailing.  J Bone Joint Surg [Br]. 1991;  73 689-690
• 39 Valverde J A, Alonso M G, Porro J G, Rueda D, Larrauri P M, Soler J J. Use of the Gamma nail in the treatment of fractures of the proximal femur.  Clin Orthop. 1998;  350 56-61
• 40 Wang C J, Yettram A L, Yao M S, Procter P. Finite element analysis of a Gamma nail within a fractured femur.  Med Eng Phys. 1998;  20 677-683
• 41 Yang K H, Byun Y S, Park H W, Park S J. Failure on attempted removal of a Gamma nail in two young patients.  J Orthop Trauma. 2003;  17 379-382