We review the results of the Gamma nail fixation to elucidate its effectiveness in the treatment of peritro-chanteric and subtrochanteric fractures of the neck of femur. We report the result of 718 cases of Gamma nail fixation in all such cases presenting at our institution since 1988. 573 cases of peritrochanteric and 145 cases of sub-trochanteric fractures were treated by means of standard and long Gamma nail. Age groups of the patients are from 33 to 99 years. No distal locking screw was used in cases of standard nails. All grades of surgeons were involved. Full weight bearing was allowed on the first post operative day. Cases were followed up for one year. No intraoperative iatrogenic fracture was encountered. Minimal post operative pain was experienced and mobility was regained early. All fractures healed satisfactorily except the following: 51 cases developed coxa vera deformity; 37 cases of undisplaced fractures of base of greater trochanter were noticed at 6 weeks follow up - all healed spontaneously; 1 case of external rotational deformity occurred in a long nail where no distal locking screw was used. 2 cases of deep infection were treated successfully by removal of nail and antibiotic treatment; 4 cases of fracture at the level of the distal end of the prosthesis, presented at 6 weeks to 2 year period following a subsequent trauma, were treated with exchange of device with long nail. Upward penetration of hip screw 22. No case of metal failure observed. Gamma nail provides a stable fixation in both simple and complex fractures of proximal femur with a much less invasive tehcnique which allows minimal disturbance of fracture haematoma, less incidence of wound infection and less amount of postoperative pain. Early mobility is regained with immediate and unrestricted weight bearing. Biomechanically also Gamma nail produces a better means of osteosynthesis

Introduction. The gamma nail is a cephalomedullary implant used in proximal femoral fracture management. Short gamma nails are technically less demanding, but there is concern over potentially higher complication rate. Objectives. To determine differences in implant related complications between the short and long gamma nail. Methods. 54 patients were identified who had either short or long gamma nail for a proximal femoral fracture. Case notes and radiographs were reviewed retrospectively to determine the complication rate due to implant failure. Fisher's exact test was used for testing the significance. Results. Out of 54 patients, 20 patients had short gamma and 34 patients had long gamma nail. 4 (20%) patients with short gamma nail had implant related complications whereas none in the long gamma nail group (P<.05). 2 (10%) patients had fracture of the nail at the level of proximal screw, 1 (5%) patient had cut out of the screw from the femoral head and 1 (5%) patient had fracture below the tip of the nail. Conclusions. Our study suggests short gamma nails are associated with higher rate of implant related complications and we now routinely use long gamma nails whenever indicated

The gamma interlocking nail, designed combining the advantages of the sliding hip screw with the intramedullary nail, was initially introduced for the management of unstable proximal femoral fractures. However the unacceptably high incidence of lateral femoral shaft fractures led to the development of the long gamma nail. This is the result of a prospective study of the use of the long gamma nail in 35 patients over a 7 year period till March 2000. The mean age of the patients was 69.9 years. There were 13 men and 22 women. All but two of the fractures had a subtrochanteric component. Ten were pathological fractures. An identical size of nail was used in all cases. Elderly patients were permitted to mobilise without restriction, whereas partial weight bearing was imposed on the younger patients till some signs of radiological healing. Patients were reviewed at a hip fracture clinic. Mean clinical follow up was 381 days and radiological follow up was 244 days. Mean hospital stay 22 days. The post operative mortality at 30 days was 20%, rising to 45% at one year. General complications that occurred were pneumonia – 3, fat embolism – 1, myocardial infarction – 1, and GI bleed – 1. Four cases had superficial wound infection, which resolved with oral antibiotics. Fracture related complications occurred in 4 cases. These were intra-operative femoral shaft fracture – 1, fracture at tip of nail – 1, nail breakage – 2. All went on to heal after exchange nailing. The long gamma nail does not appear to have reduce the post-operative incidence of femoral fractures, which is most likely related to the large size of the distal locking screws and stress concentration at the tip of the nail. The two cases of nail breakage appear to reflect metal fatigue failure in the setting of delayed union in younger patients

The aim of the present study was to compare the amount of blood loss between Gamma nail and DHS operative procedures in treating fractures N.O.F. Material and Method: thirty patients 81 years of age (average), suffering from N.O.F. fracture were divided in two groups, depending on sex, age, weight and type of fracture, in such way that for every patient operated using one procedure there was a similar one treated with the other one (pairing). The admission and discharge Ht, the blood unites needed for the whole patients hospitalization time were compared. Statistically T-test, Pearson chi square – Fisher exact test were used. Results: The average age for the Gamma nail group and DHS group were 82 yrs (sd=11,5) and 81,3 (sd=10,6), the admission Ht 36,9% (sd=4,0) and 36,72% (3,27) and the discharge Ht. was 33,2% (sd=2) and 34,9% (sd=2.9) respectively. For the first group (Gamma nail) 2.3 (sd=1.1) units of blood were used, compared to 2.4 (sd=0.7) for the second one (DHS). There was no statistical difference concerning the age and the population sample, the admission and discharge Ht, and the blood units needed between these two groups. Conclusion: There is no difference concerning blood loss between Gamma nail and DHS in treating fractures N.O.F

The aim of the study is to review the results of prophylactic reconstruction of subtrochanteric metastatic bone disease of femur using a Long Gamma Nail. Metastasis in the subtrochanteric region of femur can be challenging to treat not only due to peculiarities in biomechanics and anatomy, but also due to weak and deficient bone stock due to metastasis. Between 1996 and 2002, 28 subtrochanteric metastatic lesions of femur in 25 patients (3 bilateral) were treated with Long Gamma Nail. The outcome measures used in this study were pain relief, postoperative mobilization, and medical and implant related complications rate. There were 16 female and 9 male patients with an average age of 64 years. All patients reported marked pain relief. All but one regained pre-operative mobilization status. There were no intra-operative deaths including 3 bilateral nailings. Significant surgical and implant related complications were seen in 3(12%) patients. Postoperative medical complications were seen in 3 (12%) patients. There were no implant failures and reoperations. At the time of study 14 patients died with an average survival of 9 months and 11 patients were alive with an average survival of 16.5 months. Long Gamma Nail is valuable reconstruction device for the prophylactic treatment of subtrochanteric metastatic bone disease of femur. It is strong, versatile and biomechanically superior to extramedullary devises and compares favourably with other intramedullary devices. In our experience Long Gamma Nail allows immediate unrestricted mobilization with marked pain relief

We report the results of the use of the Long Gamma Nail in the treatment of complex proximal femoral fractures in our hospital. All patients at one hospital treated with the Long Gamma Nail were reviewed. Information collected included the age, sex, type of injury, fracture classification, intra-operative complications, post-operative complications, and survival of the implant and patient. One hundred nails were reviewed which were inserted in 97 patients. 70 patients were followed up for 1 month or more and their mean follow up was 8 months (range 3 months to 6 years). The mean age was 74 (range 16–98). Twenty were inserted into femurs with metastatic malignancy and four patients were victims of poly-trauma. The average length of the operation was 2 hours 22 minutes. Blood transfusion was required in 74% and on average was 2.5 units. There were 7 significant complications. Five patients underwent revision, 2 to Total Hip Arthroplasty after proximal screw migration and 2 patients required exchange nailing. There was one broken nail and two peri-prosthetic fractures at the tip of the nail. Success was defined as achievement of stability of fracture until union or death; this was achieved in 15% of cases. The mortality was 7% at 30 days and 17% at one year. One death was directly related to the nail and the rest due to medical co-morbidities. Complication rate fell with increasing experience in the unit. The training of surgeons had no detrimental effect on outcome. Complex proximal femoral fractures including pathological lesions, subtrochanteric fractures and pertrochanteric fractures with subtrochanteric extensions are difficult to treat, with all implants having high failure rates. The long gamma nail allows early weight bearing and seems effective in treating these difficult fractures. Furthermore the majority of these unstable fractures tend to occur in the very elderly with osteoporosis and other medical co-morbidity. Care should be taken to avoid malpositioning of the implant, as this was the major cause of failure and revision. The length of time surgery may take and the anticipated blood loss should not be underestimated especially when dealing with challenging fractures in frail and elderly patients or those with medical co-morbidity

Aims: Review the results of Long Gamma nail in the treatment of a select group subtrochanteric meta-static lesions of femur. Methods: From 1996 to 2002, 34 patients with subtrochanteric metastatic lesions of femur treated with Long Gamma Nail were included in this retrospective study. Hospital records and x-rays were reviewed for collecting the data. Results: 37 met-astatic femoral subtrochanteric lesions (3 bilateral) in 34 patients, 17 male and 19 female, with an average age of 65 yrs, had reconstruction with Long Gamma Nail. Right femur was affected in 15 and left in 22. Most common primary cancer was breast in 15, prostrate in 5, lung in 5, and others in 9 cases. Prophylactic nailing was preformed in 28 femurs (75%) and nailing of actual fracture in 9 femurs (25%). All femurs had distal locking bolts except in 2. Postoperatively pain relief was achieved and pre-op mobility was regained in all patients. 5 patients (13.5%) had medical complications including a death due to chest infection. 4 patients (10%) had implant related complications but none required any further surgery. There were no implant failures. From the time of surgery 20 patients (60%) died with a mean survival of 9 months, and 13 patients (40%) are alive, pain free and independent with a mean survival of 18 months. The overall patient survival rates after operation are 73% at 6 months, 56% at one year and 40% at 4 years. Conclusion: Reconstruction of met-astatic subtrochanteric femoral lesions with long gamma nail is highly effective in achieving local pain control, restoring limb function and better quality of remaining life with acceptable rate of complications

A number of techniques have been developed to improve the immediate mechanical anchorage of implants for enhancing implant longevity. This issue becomes even more relevant in patients with osteoporosis who have fragile bone. We have previously shown that a dynamic hip screw (DHS) can be augmented with a calcium sulphate/hydroxyapatite (CaS/HA) based injectable biomaterial to increase the immediate mechanical anchorage of the DHS system to saw bones with a 400% increase in peak extraction force compared to un-augmented DHS. The results were also at par with bone cement (PMMA). The aim of this study was to investigate the effect of CaS/HA augmentation on the integration of a different fracture fixation device (gamma nail lag-screw) with osteoporotic saw bones. Osteoporotic saw bones (bone volume fraction = 15%) were instrumented with a gamma nail without augmentation (n=8) or augmented (n=8) with a CaS/HA biomaterial (Cerament BVF, Bonesupport AB, Sweden) using a newly developed augmentation method described earlier. The lag-screws from both groups were then pulled out at a displacement rate of 0.5 mm/s until failure. Peak extraction force was recorded for each specimen along with photographs of the screws post-extraction. A non-parametric t-test was used to compare the two groups. CaS/HA augmentation of the lag-screw led to a 650% increase in the peak extraction force compared with the controls (p<0.01). Photographs of the augmented samples shows failure of the saw-bones further away from the implant-bone interface indicating a protective effect of the CaS/HA material. We present a novel method to enhance the immediate mechanical anchorage of a lag-screw to osteoporotic bone and it is also envisaged that CaS/HA augmentation combined with systemic bisphosphonate treatment can lead to new bone formation and aid in the reduction of implant failures and re-operations

Aim of the study : The purpose of this work was to study the short term results of the surgical treatment of subtrochanteric femoral fractures with the use of long gamma nail. Material – method : Fifteen consecutive patients suffering from subtrochanteric fracture of their femur, were treated by means of long gamma nail in our clinic during the last two years. The type of fracture concluded comminuted subtrochanteric fractures, unstable spiral fractures and fractures on previous operated on peritrochanteric fractures. Results : The patient’s age averaged the 76 years. There were 4 men and 11 women. The follow-up period was from 5 months to 2 years. The blood transfusion averaged the 2 units. All patients ambulated the second postoperative day and the fracture healing observed two months later. We have no infection, pseudarthrosis or hardware failure at this series. Conclusion : Long gamma nail is a method of choice in the treatment of subtrochanteric femoral fractures. We can achieve stable osteosynthesis, without soft tissue damage and immediate ambulating of the patient

Purpose: Osteosynthesis of complex subtrochanteric fractures is a difficult task. Complications are frequent and results are uncertain. Cemented fixation of pathological metastatic fractures requires a major intervention. The functional prognosis remains uncertain. Our objective was to evaluate the contribution of the long gamma nail (50 nails) in this type of situation and to determine its advantages and disadvantages. Material and methods: The 50 long gamma nails were inserted in 23 women and 26 men who were followed eight months (4–16). We implanted 39 long gamma nails for complex subtrochanteric fractures (AO classification) in patients aged 59 years on average (19–93) and eleven nails for metastatic femur fractures in patients aged 59 years on average (19–93) with a trochanterodiaphyseal localisation. For the non-metastatic fractures, closed nailing was used in 28 patients and minimum opening for eleven. For the metastatic fractures, the primary tumour was known in eleven cases. The nailing was a preventive measure in six and performed after fracture in five. Three patients had plurifocal fractures. We analysed 43 parameters (position of the cervical screw in the four quadrants of the femoral neck and clinical and radiological features). Results: For the 39 fractures, reduction was anatomic in 24 and with a gap in 15. The position of the cervical nail was correct in 34 cases. It was in the anterosuperior quadrant in three, the posterosuperior quadrant in one and the posteroinferior quadrant in one. Weight bearing was resumed at 1.5 months on average. Healing with total weight bearing was achieved at four months on average (maximum 8 months). Mechanical complications were: migration of the cephalic screw (n=4), rupture of the locking wings (n=9), nail fracture (n=1), non-union (n=2). Total pain relief was achieved for the eleven pathological fractures (maximum follow-up 16 months). Weight-bearing with crutches was possible in seven patients and not possible in four. There was no dismounting. Outcome was comparable with cemented osteosyntheses. Discussion: For pathological fractures, this less aggressive osteosynthesis provides very effective pain relief. For other complex subtrochanteric fractures, complete closed nailing was not always possible

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Introduction: While recent guidelines for the treatment of such fractures do not recommend load-bearing devices, there is little evidence actually condemning them, and there is still a lack of literature on the reconstruction nails now generally used. Aim: To evaluate the clinical outcome of pathological (metastatic) proximal femoral fractures treated by either a long Gamma nail, an AO nail with a spiral blade plate (AO-SBP), or a dynamic hip screw (DHS). Method: Eighty-six operations in 80 patients with average age 63.9 years were followed for 18 months or until death. Thirty-one procedures were prophylactic. Results: Thirty Gamma nails (three bilateral), 28 AO SBP rods (three bilateral) and 28 DHS were implanted. The DHS had complications in 10 cases (35%), all occurred in less than 14 months; three implants fractured, four cut out, and three failed to relieve symptoms. The Gamma nail group had two (7%) complications, both after 20 months; one nail fractured and the other lost fixation. The AO-SBP group had two (7%) complications, with one SBP misplacement, and one postoperative death after bilateral nailing. Pain relief and function were greatly improved by the nailing procedures in 57 out of 58 cases. Survival averaged 5.5 months, and was related to primary disease, and presence of visceral metastases. Conclusion: Both the long Gamma and AO- SBP nails reliably treated metastatic proximal femoral fractures, but loss of fixation occurred with long-term survival. The DHS had a high complication rate when used in these cases, and we do not recommend its use

Purpose: To describe a technique that allows “closed” reduction and “percutaneous” fixation of intertrochanteric fractures that were unable to be reduced preoperatively, with the use of the Trochanteric Gamma Nail. Materials-methods: From October 2001 until March 2003 we treated 11 patients with intertrochanteric fractures that were unable to be reduced with preoperative manipulation. To achieve “closed”, intaoperative reduction of fractures, the Trochanteric Gamma Nail was used as a lever. The operation was performed through a 2–3 cm long skin incision (“percutaneous technique”). Results: There were no particular difficulties with this method. Stable fixation was achieved in all cases and mobilization, full-weight bearing, was allowed from the first day postoperatively. No intraoperative or postoperative complications occurred. Intraoperative blood loss averaged 150 cc. Conclusion: Use of the TGN in the treatment of pre-operatively unreducible fractures can help to avoid an “open” reduction. Furthermore, placement of the nail through a minimal cutaneous incision can offer all the advantages of closed intramedullary nailing, such as reduced complications, small blood loss, and unrestricted, early mobilization of the patient

Introduction: The Gamma nail is an often used implant in trochanteric femur fractures. With the intramedullar application it is especially suitable for osteosynthesis of unstable fractures with a lack of medial buttress. Since first using this implant in the late 80s, the design has been changed twice. 1992 we started to use the Gammanail, since then 835 nails have been inserted by 165 different surgeons. The design changed 1996 and 2004. The aim of this study is to compare the results of the three different designs and to prove the good results of the latest Gamma3-nail. Materials and Methods: The first series was done from 1992 to 1996 (157 Patients), the second from 1996 to 2001(234 Patients) and the third from 2004 up to now(208 Patients). We analysed operation- and follow-up reports, as well as available radiographs with a main interest in implant-related complications. The complications were analysed by dividing them into intraoperative and late complications. The three groups were similar in relation to the epidemiology in a trauma1-center. The average age was 79,8 years (49 to 101y), 40 different surgeons in each group, the mean operation time 49 min. (15 to 139 min.) and the fracture types were (according to the AO-classification): A1 28%, A2 56%, A3 11% and B2 3%. Those treated with a long nail or with a pathological fracture were excluded. Results: The intraoperative complications (open reduction, splitting of the major trochanter, distal locking, fractures of the shaft) were 34% in the first series, 10.5% in the second series and 5.3% in the third series. The postoperative and late complications related to the implant (sintering of the fracture, cut out, pseudarthrosis, infection and malunion) was 24% in the first group, 10% in the second group and only 3.3% in the third group of the new design. Therefore the reoperation rate was the same, as all patients of this complication-group in all series were re-operated. General complications were exitus letalis 8.5%, pneumonia 5.2%, illeus 2%, CVI 3.9%, TVT 2%, ACS 1.3% - the same in each series. Conclusion: In comparison to the data of our earlier studies on this gamma nail, patients treated with the new design and the new instruments had fewer complications and have a lower re-operation-rate than reported in the literature. This evolution of the design and the instruments of this sort of nail lead to a very low complication-rate according to the age-group and number of surgeons that were involved. The low complication-rate allows the broad usage of this nail, despite the fact that it is more expensive than other comparable implants

Objective: To evaluate the clinical and radiographic outcomes of unstable proximal femoral fractures treated by minimal invasive technigues. Method: In a retrospective study, between 1991–2003, 93 patients with closed pertrochanteric femoral fractures were treated with gamma-nail.This intramedullary device was used only for unstable intra and subtrochanteric( A3 and A,B respectively, according A.O. clasiffication) fractures and only in cases which adeguate closed reduction was attainable. There were 32 men and 61women with an average of 76 years( range 50 to 95 years). Immediate weight bearing was permitted in 75 patients. Sixty eight patients were available for clinical and radiographic assesment (at least 1 year F.U.). Results: At 6 months 92% of the fractures were healed. Complications included intraoperative was: 1 diaphyseal fracture required cerclage wiring ,and postoperative were:2 diaphysial fractures at the distal end of nail, 1migration of the lag screw within the femoral head,2 perforations of lag screw towards cranial,1 infection and 2 nonunions reguired T.H.R. Two patients complained of thigh pain. Conclusions: Gamma nail is a good minimal invasive implant of unstable proximal femoral fractures, if closed reduction is feasible. Permitts early immobilization and weight bearing even and in elderly patients

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment. Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score. Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants. The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment. Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score. Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score. The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur

Introduction. Locking nail have considerably improved the treatment of long weight bearing bones. However, distal locking needs experience and may expose to radiations. Many methods have been proposed to facilitate distal locking and improve safety. Recently, an external distal targeting device adapted to the ancillary of the Long Gamma Nail has been proposed. We report our experience with this device through a comparative series of distal lockings. Aim of this work was to assess feasibility and advantages brought about with this targeting device when considering time or dose of irradiation. Material and methods. Two prospective series of 50 distal locking performed by an experienced surgeon have been compared. Two methods were compared: the classical freehand technique using a Steinmann rod with the image of rounded holes, and the external distal targeting device. The following datas were collected: technical difficulties with either technique, locking mistakes and duration of exposure to radiations. Results. Two locking errors were observed using the targeting device, in pathological fractures with the use of a titanium nail. These cases belonged to the five earliest cases. External targeting device requires a learning curve that is reasonnably short with little difficulties encountered. Ther is a fundamental difference between the two series concerning exposure to radiations. In the freehand technique mean exposure was 25,8s (6–38) and it was 8,6s (6–18) with the dital targeting device. Discussion. A short learning curve confirms the ease of use of the distal targerting device. Diminution of exposure to radiation is effectively obtained. Some factors may increase the risk of error: the use of very long nails and the use of titanium nails as this may increase motion at distal end. Conclusion. The external visor is an efficient device as it facilitates distal locking and alllows for a diminution of irradiation time

The femur is a common site for skeletal metastases. The Gamma2 nail has proved effective in relieving pain and restoring function. Little data exists on the use of the Gamma3 Long Nail (GLN) in this condition. Improved instrumentation is suggested to reduce operative time and facilitate minimally invasive surgery. This study reports a series of patients treated in a District General Hospital.

A retrospective casenote review was performed of all patients treated with the GLN for femoral metastatic disease over a five year period. Patients were followed-up for a minimum of one year. Functional level was assessed using the Parker Mobility Score (PMS).

12 patients underwent 15 nailings. Mean age was 75.4 years (median 75.7, range 61-92). In bilateral cases, the operations were performed during the same hospital admission. There were seven prophylactic nailings for impending fracture from proximal femoral lesions, seven procedures for actual fractures distal to the intertrochanteric line, and one basicervical fracture associated with multiple femoral metastases. Primaries were four prostate, two breast, two lung, one bowel, one bladder, one renal, and one myeloma.

Average anaesthetic time for all procedures was 134 mins (median 125, range 90-210). Average peri-operative drop in serum haemoglobin was 2.3g/dL (median 2.1, range 0.6-4.8). Five patients with actual fracture and one patient with impending fracture required blood transfusion, receiving 2.2 units on average.

In-hospital mortality rate was 0.83%, with only one patient not surviving to discharge. One year mortality was 83.3%. Only two patients were alive one year post-operation. Of the remaining patients, average survival was 3.2 months (median 3, range 1-6). Patients spent an average of 17 days on an acute orthopaedic unit (median 14, range 4-80). Two patients required further convalescence in a rehabilitation unit.

There were three surgical complications. Two impending fractures became complete, One intra-operatively and one post-operatively. In the case of basi-cervical fracture, the proximal screw cut out of the femoral head, requiring revision to a long-stem bipolar hemiarthroplasty. This was the only re-operation required in this series.

Average pre-operative PMS was 5.2 (median 4, range 2-9). Average peri-operative drop in PMS was two points (median 1.5, range 0-6). Of the 11 patients who survived to discharge, 10 were independently mobile and returned to their pre-operation residence. Nine required a change in walking aids. Only one patient reported post-operative pain.

This small patient series suggests that the Gamma3 Long Nail is a suitable treatment option for impending and actual metastatic femoral fractures in the District General setting. Length of stay, in-hospital mortality and re-operation rates compare favourably with published data on the Gamma2. There was a significant drop in Parker Mobility Score but all patients bar one were independently mobile and returned to their home. Anaesthetic time was not lower than with the Gamma2, suggesting little tangible benefit of the new instrumentation.

Purpose: The assessment of long term results and complications rate using the GN and PFN nailing systems for the treatment of peritrochanteric fractures of the femur.

Material-Methods: Between 1991–2002, 195 patients (102 male, 93 female, average age 61.2 years) with a peritrochanteric fracture of the femur (80 A2, 86 A3, 12 pathological, and 17 combined) underwent intra-medullary nailing with the GN (134 patients) or the PFN (61 patients) system. Mean follow up period was 6.5 years. Outcome analysis included time of healing, delayed union or nonunion, infection, hip function (Salvati & Wilson scale), technical complications (cut out, Z effect, malrotation) and mechanical failures (bending fatigue, loosening, breakage of the implant or screws and fracture below the tip of the nail). Intraoperative difficulties in the application of the nails or screws were registered as well.

Results: Solid union of the fracture was achieved in 171 cases (87.6 %). 25 patients died from reasons unrelated to the implant. The overall complication rate was 20.51 % (10 infections, 3 nonunions, 5 implant breakages, 11 cut-out of the neck screws, 5 Z effects and 6 distal screws failures. The Salvati and Wilson score was > 30 in 121 patients (71.1%).

Conclusions: Use of the GN and PFN systems yielded good results in our study. Technical or mechanical complications were mostly related to the operative technique and the type and preoperative reduction of the fracture, rather than these systems themselves. Z effect is a specific complication of PFN in cases with a fracture reduction in varus, especially when comminution of the medial cortex is present.