The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001). Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group. Cite this article: Bone Joint J 2013;95-B:825–30

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

We examined the effect of the Gamma nail on strain distribution in the proximal femur, using ten cadaver femora instrumented with six unidirectional strain gauges along the medial and lateral cortices. The femora were loaded to 1800 N and strains were determined with or without distal interlocking screws before and after experimentally created two-part and four-part fractures. Motion of the sliding screw and the nail was also determined. Strain patterns and screw motion were compared with previously obtained values for a sliding hip screw device (SHS). The Gamma nail was shown to transmit decreasing load to the calcar with decreasing fracture stability, such that virtually no strain on the bone was seen in four-part fractures with the posteromedial fragment removed; increasing compression was noted, however, at the proximal lateral cortex. Conversely, the SHS showed increased calcar compression with decreasing fracture stability. The insertion of distal interlocking screws did not change the pattern of proximal femoral strain. The Gamma nail imparts non-physiological strains to the proximal femur, probably because of its inherent stiffness. These strains may alter bone remodelling and interfere with healing. Distal interlocking screws may not be necessary for stable intertrochanteric fractures

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 nail was designed to treat unstable intertrochanteric and subtrochanteric fractures. The device was developed after cadaver studies and has been used clinically since February 1985 in a total of 421 patients. The results in 123 patients treated by the third version of this design are reported. The Gamma nail transmits weight closer to the calcar than does the dynamic hip screw and it has greater mechanical strength. A semi-closed operative technique is used, with an average duration of operation of 35 minutes and little blood loss. Distal locking screws can be used to maintain rotational stability, and can be inserted without the use of an image intensifier. Results showed satisfactory fracture union with little loss of position, even in comminuted fractures. Operative complications were few, but included fractures of the base of the greater trochanter. The most important postoperative complication, seen in one case, was fracture of the shaft of the femur at the distal end of the nail, but this healed well after re-nailing

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

The Gamma nail was introduced for the treatment of peritrochanteric fractures with the theoretical advantage of a load-sharing femoral component which could be implanted by a closed procedure. We report a randomised prospective study of 186 fractures treated by either the Gamma nail or a dynamic hip screw. Gamma nails were implanted with significantly shorter screening times, smaller incisions, and less intraoperative bleeding. The Gamma nail group had a shorter convalescence and earlier full weight-bearing, but there was no significant difference in mortality within six months, postoperative mobility, or hip function at review. More intra-operative complications were recorded in the Gamma nail group, mainly due to the mismatching of the femoral component of the nail to the small femurs of Chinese people. Use of a smaller modified nail reduced these complications. We conclude that with careful surgical technique and the modified femoral component, the Gamma nail is an advance in the treatment of peritrochanteric fractures

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

To investigate the origin of fractures at the distal locking site of the Gamma nail, we loaded ten paired human cadaver femora fixed with a Gamma nail in torsion until they fractured. When an awl was hammered in to start the hole for distal locking a fissure appeared in the lateral cortex of all the femora, and the mean torsional load to create a fracture was reduced by 57.8% compared with that in a control group in which the distal locking hole had been started with a centre drill. When an additional drill hole was made, the mean failure load in torsion decreased by 35.7%. We strongly recommend that an awl should not be used at the distal locking site of the Gamma nail; we recommend the use of a centre drill. Additional drill holes should be avoided because they act as stress raisers

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

We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups

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

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D). The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D. index. score) was significant in both groups compared with that before the fracture (p < 0.005). Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures. The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method

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