Professional Documents
Culture Documents
We madea randomised prospective comparison of the the screw from the femoral head, a complication which
Dynamic Hip Screw and the Gamma locking nail for the has been related to inaccurate screw placement, severe
internal fixation of 200 pertrochanteric femoral fractures osteoporosis and fracture comminution. Failure of fixa-
in elderly patients. There was less intraoperative blood loss tion of the plate is much less frequent.
and a lower rate of wound complications in the patients The Gamma locking nail was introduced after the
treated by the Gamma nail. They had, however, a high success of closed intramedullary nailing of femoral shaft
incidence of femoral shaft fracture which we relate in part fractures. The theoretical advantage of using a femoral
to implant design. We do not recommend the use of the nail instead of a plate is that the nail is nearer to the axis
Gamma nail for these fractures. of weight-bearing through the femoral head and the
leverage is, therefore, reduced. The closed technique of
JBoneJoint Surg[Br] 1993; 75-B :789-93.
insertion may also be expected to be associated with less
Received 20 January 1993; Accepted 16 March 1993
blood loss and fewer wound complications.
The initial trials of the Gamma nail by Halder
Internal fixation of extracapsular fractures of the proxi- (1992) and Leung et a! (1992) were encouraging but the
ma! femur was a significant advance when popularised first of these was not a controlled trial and the second was
by Jewett (1941) and others. It allowed early mobilisation in Asiatic patients whose femoral anatomy, the authors
of the patient and reduced deformity due to malunion. concluded, was sufficiently different for a special ‘Asiatic’
Fixation of comminuted fractures, however, by the Gamma nail to be required. There have been several
original single-piece implants often failed due to collapse reports of complications of the use of the Gamma nail
at the fracture site and nail penetration of the head including fractures ofthe femoral shaft (Bridle et a! 1991;
(Dimon 1973 ; Bannister and Gibson 1983) and for this Leung et al 1992; Williams and Parker 1992). In an
reason the sliding nail-plate was introduced by Pugh in editorial Calvert (1992) commented that prospective
1955. randomised studies were required to “define more
There is biomechanical evidence that the fixation of precisely the best design and the indications for use of
a screw in the femoral head is better than that of a nail this new device”. We now report the results of such a
(Brodetti 1961) and a sliding screw-plate implant, such study, comparing the Gamma nail with the Dynamic
as the AO Dynamic Hip Screw, has become the standard Hip Screw (DHS).
treatment for such fractures in elderly patients. The
results have been inconsistent. In the hands of experi-
PATIENTS AND METHODS
enced surgeons mechanical failure rates as low as 1%
have been reported (Mulholland and Gunn 1972), but in All patients aged 60 years or over with fractures were
routine practice serious complications including fixation eligible for inclusion and 200 patients were randomly
failure have occurred in up to 20% of cases (Wolfgang, assigned to have fracture fixation by either a DHS
Bryant and O’Neill 1982; Simpson, Varty and Dodd (Stratec Medical Ltd, Welwyn Garden City, UK) or a
1989). The commonest mode of failure is cutting out of Gamma nail (Howmedica (UK) Ltd, London, UK).
Preoperatively, we recorded age, sex, haemoglobin
level, concurrent medical problems, mental state using
P. J. Radford, MA, FRCS, FRCS(Orth), Senior Orthopaedic Registrar
M. Needoff, FRCS, Orthopaedic Registrar
the Mini-Mental State Examination (MMSE) (Cockrell
J. K. Webb, FRCS, Consultant Orthopaedic Surgeon and Folstein 1988), and prefracture housing and walking
DepartmentofFracture and Orthopaedic Surgery, University Hospital,
Queen’s Medical Centre, Clifton Boulevard, Nottingham NG7 2UH,
status, using simple five-point scoring systems. The
UK. fracture patterns were categorised as stable or unstable
Correspondence should be sent to Mr P. J. Radford. as described by Evans (1949).
©l993 British Editorial Society of Bone and Joint Surgery Only surgeons of registrar grade and above in our
0301-620X/93/S633 $2.00 department took part in the trial. They were already
experienced in the use of the DHS and in intramedullary surgeons : four senior registrars, two registrars and one
femoral nailing, and they were personally instructed in consultant. There was no significant difference in the
the operative technique for the Gamma nail by one of seniority level of the surgeons who performed the
the authors (PJR). The first two Gamma nail operations operations in each group or in the operating time. The
performed by each surgeon were not included in the trial. measured operative blood loss was significantly less
The operations were performed using image inten- (p < 0.05) in the Gamma-nail group (120 ml) than in the
sification. Closed reduction was achieved, if possible, on DHS group (250 ml).
the traction table. Ifthis was not possible, open reduction There was no significant difference between the two
was performed during the procedure. For both implants groups in the rate of postoperative mobilisation. Despite
we aimed to have a central position of the screw in the the difference in peroperative blood loss, the haemoglobin
femoral head on both anteroposterior and lateral views, levels and the requirements for blood transfusion were
with its tip S to 10 mm from the subchondral bone. The similar in the two groups. There was no significant
DHS used was the four-hole, 135#{176}
plate with a screw of difference in the hospital stay of those who were
appropriate length. For the Gamma nail a preoperative discharged between the two groups, and similar numbers
radiograph of the other hip was compared with implant in each group were transferred to long-term care.
templates to decide the angle of the chosen nail. At the three-month and one-year follow-up, there
For Gamma nailing, the tip ofthe greater trochanter were no significant differences between the groups, after
was opened with an awl, hand reamers were passed into excluding from analysis those patients who had developed
the medullary cavity and used to measure its diameter the complications discussed below.
and to enlarge it to at least 2 mm greater than the Complications. The main difference between the two
diameter of the intended nail. The proximal femur and groups of patients was in the frequency of postoperative
entry point were reamed to at least 17 mm in all cases. complications.
Power was used only when reaming could not be Death. At three months, 12 patients in the Gamma nail
satisfactorily performed by hand. Distal locking of the group and 10 in the DHS group had died. In none of
nail in the femoral shaft was performed only when these was death directly related to a complication of the
indicated for longitudinal instability (due to poor reduc- fracture fixation.
tion, fracture comminution or subtrochanteric exten- Wound healing. Eight patients in the DHS group and
sion), or for rotational instability due to a poor interface three in the Gamma-nail group had delayed wound
between nail and femur. Suction drains were used in all healing or persistent discharge sufficient to create the
cases. Perioperative antibiotic prophylaxis was with suspicion ofinfection and for another course of antibiotics
cephradine. to be given. None of these developed a proven infection.
The operating time was recorded, perioperative Infection. By three months there had been four bacterio-
bloodloss measured, and any specific technical difficulties logically proven wound infections in the DHS group and
were noted along with a rating of the overall level of none in the Gamma-nail group. By nine months one
difficulty. patient in the Gamma nail-group had developed a deep
Postoperatively, patients were mobilised from the infection due to Streptococcus pneumoniae, shortly after
second postoperative day after removal of the drains. being treated for pneumonia.
The haemoglobin level, any postoperative complications, Thromboembolism. Six patients in the DHS group and
the length of hospital stay and the housing status at eight in the Gamma-nail group developed proven deep-
discharge were recorded. The postoperative radiographs vein thrombosis during their stay in hospital.
were examined to determine the position of the screw in Nonunion. No case of fracture nonunion was encountered
the femoral head and the quality of fracture reduction. in this study.
The patients were reviewed at three months and at Fixationfailure. There were three cases in the DHS group
one year.
Table I. Preoperative data of the 200 patients with pertrochanteric
femoral fractures
RESULTS
Dynamic hip screw Gamma nail
There were 100 patients in each group, which were (n=100) (n=100)
similar in terms of age, sex, mental status, intercurrent Average age (years; range) 18 (60 to 90) 83 (60 to 91)
medical conditions, prefracture mobility and housing
Male:female 16:24 79:21
scores (Table I).
The pre- and postoperative radiographs showed no MMSE (per cent < 23/30) 21 24
significant differences between the two groups in the Number with diabetes 4 6
numbers of fractures graded as stable or unstable (Evans
Average prefracture mobility score 3.7 3.9
1949). In the DHS group, 43% were unstable, and in the
Gamma-nail group, 38%. Average prefracture housing score 4. 1 4.3
The operations had been performed by seven S Mini-Mental State Examination (Cockrell and Folstein 1988)
Peroperative Postoperative
Number 6 5
No treatment required 3 0
Traction treatment 2 2
Revision operation 1 3
United 6 5
concerns about screw-holes in the cortex of the femoral Browner BJ, Mast G, Mendes M. Principles of internal fixation. In:
Browner B, Jupiter J, Levine A, Trafton P0, eds. Skeletal trauma.
isthmus. Since the distal part ofthe nail already produces
London, etc: WB Saunders, 1992 :257.
a concentration of stress at that site, weakening of the
Calvert PT. The Gamma nail : a significant advance or a passing
bone by the presence of screws should be avoided fashion? J Bone Joint Surg [Br] 1992; 74-B :329-31.
whenever possible. Cockrell JR, Folsteln MF. Mini-mental state examination (MMSE).
Physchopharmaco/ But! 1988 ; 24 :689-92.
Despite the reductions in peroperative blood loss
Dimon JH. The unstable intertrochantenc fracture. C/in Orthop 1973;
and wound complications that we have documented, we
92:100-7.
no longer use the Gamma nail in the management of Evans EM. The treatment of trochanteric fractures of the femur. J Bone
femoral fractures. We believe that the frequency of JointSurg[Br] 1949; 3l-B:l90-203.
femoral fractures after Gamma-nailing more than out- Halder SC. The Gamma nail for peritrochanteric fractures. J Bone Joint
Surg[Br] 1992; 74-B :340-4.
weighs the benefits.
Jewett EL. One-piece angle nail plate for trochanteric fractures. J Bone
No benefits in any form have been received or will be received from a Joint Surg 1941 ; 23:803-10.
commercial party related directly or indirectly to the subject of this
Leung KS, So WS, Shen WY, Hid PQ. Gamma nails and dynamic hip
article.
screws for peritrochanteric fractures : a randomised prospective
study in elderly patients. J Bone Joint Surg [Br] 1992; 74-B:
345-51.
Mulbolland RC, Gunn DR. Sliding screw fixation of intertrochanteric
REFERENCES
femoral fractures. J Trauma 1972; 12:581-91.
Bannister GC, GibsOn AGF. Jewett nail plate or AO dynamic hip screw
Pugh WL. A self-adjusting nail-plate for fractures about the hip joint.
for trochanteric fractures? : a randomised prospective controlled
trial. J BoneJoint Surg[Br] 1983; 65-B :218.
J Bone Joint Surg [Am] 1955 ; 37-A :108S-93.
Simpson AHRW, Varty K, Dodd CAF. Sliding hip screws : modes of
Bridle SH, Patel AD, Bircher M, Calvert PT Fixation of intertrochan-
failure. Injury 1989; 20 :227-31.
teric fractures of the femur : a randomised prospective comparison
of the Gamma nail and the dynamic hip screw. J Bone Joint Surg Williams WW, Parker BC. Complications associated with the use of
[Br] 1991 ; 73-B :330-4. the Gamma nail. Injury 1992; 23 :291-2.
Brodetti A. An experimental study on the use of nails and bolt screws Wolfgang GL, Bryant MH, O’Neill JP. Treatment of intertrochanteric
in the fixation of fractures of the femoral neck. Acta Orthop Scand fracture ofthe femur using sliding screw plate fixation. C/in Orthop
1961 ; 31 :247-71. 1982; 163:148-58.