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.

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured.

Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score.

Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups.

At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture.

We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C.

Lesions of the cartilage were found in 228 ankles (79.2%), more often on the talus (69.4%) than on the distal tibia (45.8%), the fibula (45.1%), or the medial malleolus (41.3%). There were more lesions in men than in women and in general they were more severe in men (p < 0.05). They also tended to be worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05). Within each type of fracture the lesions increased from subgroups 1 to 3 (p < 0.05). The anterior tibiofibular ligament was injured with increased frequency from type-B.1 to type-C.3 fractures (p < 0.05), but it was not torn in all cases. While lateral ligamentous injuries were seen more often in type-B than in type-C fractures (p < 0.05), no difference was noted in the frequency of deltoid ligamentous lesions.

Our findings show that arthroscopy is useful in identifying associated intra-articular lesions in acute fractures of the ankle.