THE
`
`GAMMA
`
`NAIL
`
`FOR
`
`PERITROCHANTERIC
`
`FRACTURES
`
`S. C. HALDER
`
`From
`
`the
`
`Royal
`
`Halifax
`
`Infirmary
`
`fractures.
`in a total
`
`The
`of 421
`
`1985
`
`interfrochanteric
`unstable
`to treat
`The Gamma
`subtrochanteric
`and
`designed
`nail was
`has been
`cadaver
`after
`studies
`was
`used
`clinically
`and
`developed
`device
`February
`since
`are reported.
`freated
`by the third version
`of
`in 123 patients
`The
`patients.
`results
`design
`this
`the dynamic
`screw and
`weight
`closer
`to the calcar
`than does
`The Gamma
`it has greater
`hip
`transmits
`nail
`of 35
`technique
`is used, with an average
`duration
`of operation
`A semi-closed
`mechanical
`sfrength.
`operative
`blood
`loss. Distal
`to maintain
`rotational
`liftie
`can
`be used
`locking
`screws
`stabifity,
`and
`can
`be
`minutes
`and
`the use
`of an image
`intensifier.
`inserted
`without
`little
`satisfactory
`fracture
`union with
`loss
`Results
`showed
`of
`the
`few,
`Operative
`complications
`were
`but
`included
`fractures
`in one
`case, was
`important
`complication,
`seen
`postoperative
`fracture
`end of
`the nail, but
`this healed
`well after
`re-nailing.
`
`of position,
`of
`base
`of
`
`in comminuted
`even
`the greater
`trochanter.
`the
`shaft
`of
`the
`femur
`
`fractures.
`The most
`the distal
`
`at
`
`of
`
`and
`
`the
`was
`
`la)
`
`the
`
`al
`
`or
`
`or
`
`bone
`
`of
`
`head,
`main
`
`a set
`
`and
`screw.
`
`screw
`was
`
`It
`
`studies
`wax
`canal
`in
`
`had
`eight
`
`in
`
`the mark-l
`The
`results
`three
`main
`
`caused
`
`by excessive
`
`to
`
`disengagement
`
`of
`
`the
`
`caused
`
`by
`
`rotation
`
`of
`
`the
`
`modified:
`
`proximally;
`
`subtrochanteric
`and
`intertrochanteric
`Unstable
`problems
`present
`can
`to
`fix
`and
`are
`difficult
`1986;
`Jones
`and
`Kassab
`ment
`(Esser,
`1987 ; Chang
`most
`The
`1987).
`et
`al
`screw
`uses
`a large
`method
`of
`fixation
`aspect
`on the
`lateral
`secured
`to a plate
`the
`This
`the
`disadvantage
`that
`has
`in
`line
`of
`load-bearing.
`Any
`defect
`the
`femur,
`due
`to imperfect
`reduction,
`metastasis,
`means
`that
`a varus
`stress
`the
`fixation
`with
`every
`weight-bearing
`cause
`cutting-out
`of
`the
`screw
`from
`(Davis
`et al 1990)
`or
`failure
`the
`at
`of
`the
`screws
`securing
`the
`plate
`1979; Amis,
`Bromage
`and Larvin
`The
`use
`of
`the
`Zickel
`nail
`objections,
`but
`is
`difficult
`to
`it
`of
`complications,
`as
`fracture
`such
`was
`trochanter.
`Gamma
`nail
`in an attempt
`to overcome
`some
`
`fractures
`in manage-
`Bergman
`et
`common
`current
`in the
`femoral
`head
`ofthe
`upper
`femur.
`plate
`is lateral
`to the
`the medial
`cortex
`of
`comminution
`a
`will
`be
`applied
`to
`step.
`This
`may
`head
`the
`femur
`the
`of
`nail-plate
`junction
`to
`the
`(Waddell
`1987).
`these
`of
`some
`meets
`own
`its
`and
`has
`insert
`greater
`base
`the
`the
`accordingly
`developed
`these
`problems.
`
`of
`
`The
`
`DESIGN
`
`AND
`
`DEVELOPMENT
`
`Gamma
`The
`intramedullary
`femur,
`a
`
`screw
`
`three
`has
`nail
`down
`passed
`rod
`passed
`through
`
`main
`the
`a hole
`
`:
`
`components
`of
`upper
`shaft
`in
`the
`proximal
`
`an
`the
`
`S. C. Halder,
`The
`Royal
`Yorkshire
`
`MB BS, Associate
`Halifax
`Infirmary,
`HXI
`2YP,
`England.
`
`Specialist
`Free
`
`in Orthopaedics
`School
`Lane,
`
`Halifax,
`
`West
`
`Editorial
`$2.00
`1992;
`[Br]
`
`© 1992 British
`030l-620X/92/3398
`J Bone
`Joint
`Surg
`
`340
`
`Society
`
`ofBone
`
`and
`
`Joint
`
`Surgery
`
`74-B
`
`: 340-4.
`
`trochanter,
`greater
`implant;
`of
`the
`due
`deformity
`; and
`screw
`deformity
`shaft.
`implant
`the
`of
`screw
`
`hip
`
`accordingly
`was
`nail was
`reduced;
`was
`extended
`
`the
`into
`inserted
`rod
`the
`part
`the
`of
`rotation
`prevents
`which
`insertion.
`semi-closed
`for
`designed
`after
`produced
`A prototype
`was
`femoral
`of
`the
`made
`of
`shape
`been
`cadavers.
`on
`other
`and
`tested
`cadavers,
`some
`modifications
`design.
`After
`Mark-i
`used
`100
`patients.
`(Fig.
`was
`version
`in general,
`satisfactory
`but
`there
`were
`were,
`complications:
`of
`1) fracture
`medial
`curvature
`2)
`late
`coxa
`vara
`hip
`shoulder
`of
`the
`3)
`external
`rotation
`rod within
`the
`femoral
`Mark-2
`design.
`The
`1) the medial
`curvature
`2)
`the
`shoulder
`ofthe
`and
`the
`3)
`lb).
`
`facility
`
`to use
`
`distal
`
`locking
`
`screws
`
`was
`
`added
`
`(Fig.
`
`distal
`
`of
`
`spiral
`for
`used
`was
`screw
`locking
`The
`and
`length
`the
`control
`to
`fractures,
`subtrochanteric
`for
`disparity
`and
`fractures,
`comminuted
`of
`rotation
`femur
`producing
`and
`the
`nail
`diameter
`the
`between
`modification
`to the
`Another
`of
`rotation.
`poor
`control
`fracture
`compression,
`in
`an
`increase
`screw
`allowed
`through
`the
`head
`its
`penetration
`helping
`to prevent
`nail was
`used
`in
`second-generation
`the
`femur.
`This
`(Bridle
`et al 1991).
`pilot
`centres
`throughout
`Europe
`led to
`these
`clinical
`studies
`Mark-3
`design.
`The
`results
`of
`further
`modifications
`: the
`nail was
`shortened
`by 20 mm,
`to 200 mm,
`and
`nails
`ofthree
`distal
`diameters,
`12, 14 and
`
`hip
`
`of
`19
`
`THE JOURNAL
`
`OF BONE
`
`AND
`
`JOINT
`
`SURGERY
`
`ZIMMER 1043
`Page 1
`
`

`
`THE GAMMA
`
`NAIL
`
`FOR
`
`PERITROCHANTERIC
`
`FRACTURES
`
`341
`
`1(cid:1)
`
`11
`
`- v:(cid:1)-
`
`I,-
`
`- -
`
`(cid:1)-
`
`-
`
`I(cid:1)
`
`-
`
`- -
`
`A
`
`Fig.
`
`1
`
`-(cid:1)
`
`-
`
`C
`
`The
`angle
`Mark
`longer
`similar
`universal
`
`Gamma
`ofthe
`evolution
`of
`the
`shank
`and
`the
`a smoother
`2 (B)
`had
`and
`had
`(220 mm)
`to
`the
`previous
`set
`screw.
`
`and
`
`but
`
`(A) had
`design
`nail. The mark-i
`narrower
`was
`femoral
`neck
`screw
`diameter.
`shank
`curve
`a uniform
`Mark
`interlock.
`provision
`for distal
`(200 mm)
`version
`was
`shorter
`
`a greater
`(arrow).
`It was
`3 (C) was
`and
`had
`a
`
`reamed
`Care
`
`is
`
`cortex
`the
`until
`reamer
`a flexible
`with
`is then
`patients
`in
`to
`over-ream
`is
`required
`not
`engaged.
`far
`as
`femur
`the
`end
`of
`bone.
`The
`proximal
`with
`porotic
`17 mm to accom-
`to
`trochanter
`is
`reamed
`the
`as
`lesser
`A Gamma
`nail
`nail.
`proximal
`part
`of
`the
`modate
`the
`the
`final
`reamer
`than
`diameter
`about
`2 mm less
`shaft
`with
`inserted
`by
`hand
`on
`and
`assembled
`the
`jig
`is
`selected,
`seen
`hole
`is
`on
`the
`the
`of
`lowest
`part
`hip
`screw
`until
`the
`lesser
`trochanter
`or
`level
`image
`intensifier
`to be
`with
`the
`the
`introduction
`the
`the
`inferior
`border
`of
`neck.
`During
`floor
`or
`in slight
`of
`the
`nail
`the
`jig
`is kept
`parallel
`to the
`retroversion.
`A small
`lateral
`incision
`is then made
`at
`the
`of
`level
`of
`the
`introducer
`hole
`the
`hip
`screw
`in thejig
`and
`deepened
`to bone.
`A soft-tissue
`guide
`sleeve
`followed
`by
`a guide
`wire
`is
`inserted.
`the
`The
`position
`of
`lateral
`anteroposterior
`and
`the guide wire
`is removed
`
`checked
`then
`is
`wire
`guide
`is unsatisfactory
`it
`If
`views.
`the nailpartially
`withdrawn
`
`and
`
`on
`
`were
`16 mm,
`use
`been
`in
`cases
`treated
`
`provided.
`since
`May
`in this way
`
`The
`1988
`are
`
`third
`(Fig.
`reported.
`
`version
`ic),
`
`of
`
`the
`the
`
`nail
`first
`
`and
`
`has
`123
`
`PATIENTS
`
`AND
`
`METHODS
`
`(n=10)
`
`(n=12)
`
`of
`
`with
`at
`
`to
`
`(n=15)
`
`(n=6)
`
`5
`
`STABLE
`
`1 & 2.
`
`UNSTABLE
`
`3,
`
`4,
`
`5.
`
`Fig. 2a
`
`The
`and
`are
`
`classification
`(1980)
`Jensen
`2 are
`stable
`; types
`3, 4 and
`those
`of each
`type
`of
`fracture
`
`of intertrochanteric
`5 are
`unstable.
`The
`in the most
`recent
`
`Types
`fractures.
`numbers
`in brackets
`I 23 cases.
`
`1
`
`SPIRAL
`
`#
`
`TRANSVERSE
`
`#
`
`at
`after
`the
`
`of
`
`al 199 1). The
`by traction
`limb
`in
`access
`over
`the
`at
`3.2 mm
`The
`
`fracture
`and
`internal
`a neutral
`or
`to the
`greater
`the
`tip
`of
`the
`correct
`site,
`guide
`wire
`femoral
`shaft
`
`is
`
`a
`
`Fig. 2b
`
`The
`(short
`
`Zickel
`and
`
`(1980)
`long)
`
`classification
`and
`transverse
`
`subtrochanteric
`of
`(proximal
`and
`
`fractures
`types.
`
`distal)
`
`into
`
`spiral
`
`patients
`156
`total
`a
`operatively
`treated
`We
`fractures
`femoral
`or
`subtrochanteric
`intertrochanteric
`until
`January
`1988
`Infirmary
`from May
`Halifax
`the Royal
`and
`eight
`period
`intertrochanteric
`1991
`. During
`this
`25
`methods,
`fractures
`treated
`by other
`subtrochanteric
`were
`not
`was
`in
`the
`the
`Gamma
`nail
`when
`expertise
`of
`use
`available.
`The mean
`those
`treated
`by the Gamma
`age
`of
`nail
`was
`80. 1 years
`100).
`There
`were
`100 women
`(19
`to
`at
`and
`23 men
`with
`a
`follow-up
`of
`least
`one
`year.
`Intertrochanteric
`fractures
`were
`classified
`according
`and
`Jensen
`(1980),
`had
`distribution
`shown
`in Figure
`the
`2. Two
`intertrochanteric
`fractures
`were
`pathological
`and
`fracture
`one
`subtrochanteric
`was
`in Pagetic
`bone.
`Details
`recorded
`were
`of
`all
`patients
`prospectively
`including
`and
`drainage
`blood
`loss,
`transfusion
`required.
`The
`duration
`ofimage
`intensification
`was monitored.
`Patients
`were
`reviewed
`six weeks,
`three
`months,
`six months
`and
`one
`year
`injury,
`with
`clinical
`and
`radiographic
`assessment
`progress
`of
`healing
`and
`of
`complica-
`tions.
`Operative
`reduced
`rotation
`slightly
`trochanter.
`greater
`using
`passed
`
`(Halder
`technique
`an
`orthopaedic
`on
`10#{176}to
`15#{176},with
`of
`adducted
`position
`A small
`incision
`trochanter
`which
`double-action
`far
`as
`the
`
`as
`
`a
`
`VOL.
`
`74-B.
`
`No.
`
`3. MAY
`
`1992
`
`et
`table
`the
`to allow
`is made
`is broached
`drill
`over
`lesser
`trochanter.
`
`a
`
`ZIMMER 1043
`Page 2
`
`(cid:1)
`

`
`342
`
`S. C. HALDER
`
`When
`cannulated
`bone
`length
`
`the
`
`of
`is
`
`they
`
`are
`
`re-insertion.
`and
`rotation
`of
`adjustment
`for
`a
`satisfactory
`is
`guide
`wire
`position
`of
`the
`subchondral
`over
`to reach
`it
`drill
`is passed
`of
`appropriate
`head.
`A hip
`screw
`the
`femoral
`locked
`by a set
`screw.
`and
`then
`introduced
`locking
`screws
`are
`required
`distal
`When
`in a similar
`manner.
`introduced
`be
`cannot
`which
`fracture
`subtrochanteric
`A spiral
`open
`by
`is managed
`closed
`technique
`reduced
`by
`a Gamma
`wiring
`before
`circumferential
`reduction
`and
`that
`the
`way.
`Provided
`in
`the
`usual
`nail
`is
`inserted
`adequate
`reduction
`and
`radiograph
`shows
`postoperative
`nail
`position,
`patients
`are
`allowed
`to walk
`a satisfactory
`with
`full weight-bearing
`soon
`as comfort
`permits.
`
`the
`
`a
`
`as
`
`RESULTS
`
`follow-up
`The mean
`details
`to
`31),
`and
`the
`duration
`of
`operative
`blood
`fracture
`in Table
`Subtrochanteric
`image
`intensifier
`teric
`fractures.
`The
`radiological
`III.
`There
`
`Table
`
`of 123
`21 .7 months
`was
`patients
`in Table
`shown
`are
`of
`these
`intensifier
`time,
`image
`operation,
`the
`three
`types
`for
`given
`loss
`are
`of distal
`locking
`screws.
`as
`II,
`is the
`use
`longer,
`required
`more
`fractures
`took
`time
`bled more
`intertrochan-
`
`(12
`I. The
`and
`of
`
`and
`
`than
`
`results
`no
`
`in 71
`fatigue
`
`cases
`fractures
`
`are
`
`shown
`implant
`
`or
`
`in
`
`were
`
`fractures
`Thirty-eight
`failures.
`there
`In
`22 patients
`position.
`at
`the
`fracture
`compression
`showed
`shortening
`fracture
`case
`of nonunion,
`from one
`in all
`cases,
`including
`fractures
`(Fig.
`3).
`The main
`intra-operative
`iatrogenic
`fractures
`of
`the
`
`of
`
`loss
`no
`with
`healed
`lateral
`as
`as well
`axial
`was
`subtrochanteric
`no
`but
`site,
`4 mm.
`Apart
`than
`of more
`satisfactory
`healing
`there
`was
`with
`severely
`comminuted
`
`those
`
`complications
`of
`the
`greater
`
`small
`were
`trochanter
`
`base
`
`Table
`
`I. Details
`
`of
`
`123
`
`patients
`
`treated
`
`by Gamma
`
`nailing
`
`Fracture
`
`Intertrochanteric
`
`Subfrochanteric
`
`±5D)
`
`Age (years
`Male
`Female
`
`status
`
`Mental
`Normal
`Impaired
`
`Walking
`Unaided
`Stick
`Frame
`Unable
`
`of admission
`Source
`home
`Own
`Old people’s
`Nursing
`home
`Hospital
`
`home
`
`10.57
`
`80.10±
`19
`79
`
`66
`32
`
`54(55.1%)
`(8.2%)
`8
`19 (19.4%)
`17 (17.3%)
`
`48 (49.0%)
`23 (23.5%)
`9
`(9.2%)
`18 (18.4%)
`
`± 13.22
`
`77.96
`5
`20
`
`19
`6
`
`13(52.0%)
`4(16.0%)
`7(28.0%)
`(4.0%)
`1
`
`14 (56.0%)
`5 (20.0%)
`3(12.0%)
`3(12.0%)
`
`Table
`
`II. Operative
`
`details
`
`for 123 patients
`
`treated
`
`by Gamma
`
`nailing
`
`Intertrochanteric
`
`Stable
`(n=22)
`
`Unstable
`(n=76)
`
`SubtrOch*nteriC
`(n=25)
`
`Total
`(n=123)
`
`Age
`
`(years±sD)
`
`79.2±
`
`1 1.6
`
`80.4±
`
`10.2
`
`78.0±
`
`13.2
`
`79.7±
`
`11.2
`
`± 21.8
`
`ofoperation
`Duration
`(mins ± an)
`
`Imageintensifier
`(mins±sD)
`
`Bloodloss
`(ml ±sn)
`
`Distalscrews
`(number
`
`of cases)
`
`28.0±
`
`8.9
`
`30.6±
`
`13.9
`
`57.6 ± 32.8
`
`35.6
`
`4.3±1.4
`
`5.4±3.0
`
`7.6±3.0
`
`5.7±3.0
`
`114.1±88.9
`
`153.2±99.3
`
`285.6±172.7
`
`173.1±130.4
`
`1
`
`ii
`
`ii
`
`23
`
`Table
`review
`
`Radiological
`III.
`at 18 months
`
`results
`
`in the 71 patients
`
`who
`
`survived
`
`and were
`
`available
`
`for
`
`Intertrochanteric
`
`Stable
`
`Unstable
`
`SubtrOchanteriC
`
`No
`
`change
`
`in position
`
`Compressionbyito4mm
`
`Fracture
`
`of greater
`
`trochanter
`
`Varus
`
`angulation
`
`Screw
`
`cut-out
`
`Postoperative
`
`shaft
`
`fracture
`
`Nonunion
`
`ii
`
`5
`
`0
`
`1
`
`0
`
`0
`
`0
`
`17
`
`15
`
`3
`
`2
`
`1
`
`1
`
`1
`
`10
`
`2
`
`0
`
`0
`
`1
`
`1
`
`0
`
`Total
`
`38
`
`22
`
`3
`
`3
`
`2
`
`2
`
`1
`
`THE JOURNAL
`
`OF BONE AND JOINT
`
`SURGERY
`
`ZIMMER 1043
`Page 3
`
`

`
`THE GAMMA
`
`NAIL FOR PERITROCHANTERIC
`
`FRACTURES
`
`343
`
`Comminuted
`technique
`
`and
`intertrochanteric
`combined
`distal
`locking
`screws
`to maintain
`
`subtrochanteric
`rotation
`and
`
`fracture,
`length.
`
`and
`
`showing
`
`fixation
`
`by a Gamma
`
`nail
`
`using
`
`a closed
`
`Fig.
`
`3
`
`seen
`the
`There
`
`in three
`femur
`was
`
`but
`cases,
`was
`adequately
`a mild
`coxa
`vara
`
`did
`
`were
`These
`operation.
`during
`because
`healing
`not
`influence
`implant.
`by
`the
`immobilised
`cases.
`in three
`deformity
`femoral
`the
`through
`cut
`screw
`the
`hip
`cases
`In two
`revision
`from a previous
`after
`: one was
`superiorly
`head
`in
`a pathological
`fracture
`was
`the
`other
`;
`and
`plate
`pin
`to a metastasis
`from carcinoma
`of
`the
`breast.
`Two
`due
`patients
`sustained
`postoperative
`fractures
`at
`the
`lower
`end
`ofthe
`prosthesis.
`One
`had
`penetration
`ofthe
`anterior
`cortex
`of
`the
`femur
`during
`operation
`; the
`other
`fell
`out
`bed
`six weeks
`and
`sustained
`a spiral
`fracture
`of
`femur.
`Both
`were
`treated
`by
`the
`insertion
`of
`a
`version
`of
`the Gamma
`nail with
`results
`(Fig.
`good
`There
`were
`no cases
`ofdeep
`infection,
`two
`superficial
`The
`infections
`settled
`with
`oral
`antibiotic
`therapy.
`age
`postoperative
`mortality
`was
`high,
`as expected
`in this
`group
`of
`patients,
`12.2%
`within
`one month
`and
`30.1%
`within
`one
`year,
`there was
`the usual
`range
`of medical
`and
`complications
`including
`pneumonia,
`congestive
`heart
`failure,
`deep-vein
`thrombosis
`and myocardial
`infarction.
`
`at
`
`of
`the
`long
`4).
`
`and
`
`fractures
`peritrochanteric
`For
`and
`Gibson
`fixation
`(Bannister
`by a variety
`has
`been
`replaced
`give
`satisfactory
`screw
`plates.
`These
`but
`fractures,
`in unstable
`fractures,
`fragment
`medial
`has
`been
`impaction
`is
`there
`with
`shortening
`(Templeton
`femur
`and
`Saunders
`et
`al
`1990).
`Davis
`This
`shortens
`arm of
`the
`lever
`abductors.
`is
`transmitted
`the
`calcar,
`
`of
`
`femur
`the
`; Esser
`1983
`of dynamic
`results
`where
`reduced
`the
`of
`; Chang
`leg
`and
`of
`the
`a plate
`
`1979
`the
`Most
`and
`
`DISCUSSION
`
`not
`
`hip
`down
`
`VOL.
`
`74-B, No.
`
`3, MAY
`
`1992
`
`pin
`
`plate
`and
`1986)
`al
`et
`compression
`in most
`stable
`the
`postero-
`anatomically,
`the
`neck
`of
`et al 1987;
`reduces
`the
`body-weight
`supporting
`
`Fig.
`
`4
`
`Postoperative
`intertrochanteric
`a long
`version
`position.
`
`fracture
`spiral
`by
`fracture
`the Gamma
`
`of
`
`to
`
`due
`a Gamma
`nail,
`and
`
`an
`fixation
`after
`fall
`a
`for
`nail was
`changed
`nail. The
`in good
`both
`fractures
`healed
`
`of
`
`or
`
`some
`be
`must
`screw
`nail
`either
`therefore
`is
`It
`line.
`weight-bearing
`1986 ; Chang
`et al
`tension
`(Esser
`1987).
`An
`intramedullary
`device
`calcar,
`subject
`to
`less
`tension,
`
`et
`
`to the
`lateral
`distance
`considerable
`under
`; Friedl
`al
`1987
`close
`is
`very
`and
`is more
`
`et
`
`al
`the
`to
`stable.
`
`ZIMMER 1043
`Page 4
`
`

`
`with
`in patients
`are
`important
`
`It must
`wire.
`of
`its anterior
`to its
`tip.
`of
`abnormal
`
`or
`
`porotic
`(Bridle
`
`enter
`third
`
`the
`and
`
`excessive
`
`and
`phase
`considerations
`1991):
`the
`guide
`of
`junction
`the
`lateral
`just
`presence
`shaft.
`malaligned
`
`drill
`
`holes
`
`before
`
`the
`than
`nail
`ofthe
`by twisting
`
`reamer.
`by partial
`it
`in the
`
`not
`
`learning
`the
`during
`following
`the
`bone,
`l99l;Halderetal
`etal
`1) Exact
`placement
`greater
`trochanter
`posterior
`two-thirds,
`2) Special
`care
`in the
`curvature
`of
`the
`femoral
`3) No
`attempt
`to
`correct
`inserting
`distal
`screws.
`2 mm narrower
`4) Selection
`of
`a nail
`5) Correction
`alignment
`ofrotational
`withdrawal
`and
`re-introduction,
`engaged
`position.
`
`at
`
`344
`
`S. C. HALDER
`
`as
`
`nail
`
`the
`et
`
`(Kuok-
`Czitrom
`Zickel
`1987)
`use
`
`these
`
`in
`
`to
`no
`In
`
`most
`even
`comminution
`compression
`
`in
`
`there
`porotic
`poor
`bone
`the
`fracture
`
`Enders
`the
`such
`devices
`Intramedullary
`; Waddell,
`1986
`and
`Lauttamus
`kanen,
`Korkala
`al
`1988)
`and
`et
`1987;
`Sernbo
`and
`Simmons
`al
`; Bergman
`1977
`and
`Anderson
`nail
`(Ashby
`their
`make
`difficulties
`tried
`but
`technical
`have
`been
`1980).
`(Waddell
`1979; Ross
`and Kurtz
`uncommon
`of
`The Gamma
`nail
`allows
`semi-closed
`fixation
`fractures,
`facilitating
`union
`without
`major
`changes
`proximal
`femoral
`anatomy.
`Some
`comminuted
`fractures
`(Jensen
`types
`4 and
`showed
`an
`increased
`tendency
`5)
`varus
`deformity,
`but
`in
`cases
`was
`subsequent
`displacement
`very
`bone.
`some
`cases, marked
`and
`quality
`resulted
`in
`excessive
`at
`and
`mild
`varus
`deformity.
`without
`be achieved
`Stability
`can
`comminuted
`of
`the
`posteromedial
`rotation
`control
`of
`locking
`provides
`difficult
`subtrochanteric
`the
`especially
`screws
`can
`be
`inserted
`distal
`3). The
`intensification.
`image
`123 cases
`reported,
`being
`fracture
`did
`influence
`which
`To
`minimise
`this
`and
`
`tion
`distal
`fractures,
`type
`(Fig.
`the
`use
`of
`In the
`commonest
`the
`trochanter,
`outcome.
`
`anatomical
`fragment,
`in
`
`reduc-
`and
`unstable
`spiral
`without
`
`complications
`around
`the
`other
`
`few,
`were
`greater
`the
`or
`final
`course
`complications
`
`not
`
`is grateful
`author
`The
`Mr W.
`J. Nicol,
`Oyston,
`the
`consultant
`orthopaedic
`patients,
`and
`to the
`surgeons
`clinical
`trials.
`
`to Mr
`Mr
`
`J. K.
`Mr
`J. G. Gill, Mr B. M. Flood,
`J. A. Chapman
`and Mr C.
`J. Chadwick,
`surgeons
`who
`allowed
`me
`to
`treat
`their
`at 19 European
`centres
`who
`undertook
`
`I am also grateful
`colleagues
`at
`Calderdale
`Orthopaedic
`Secretary
`Computer
`Consultant,
`International,
`London,
`
`to Mr M. Morris, Medical
`Health
`Authority,
`the Royal
`Halifax
`at
`Calderdale
`College,
`England,
`who made
`
`and
`Photographer
`S. Maddock,
`Mrs
`G.
`Infirmary,
`and Mr D. Hull,
`Halifax,
`and Howmedica
`this
`device.
`
`his
`
`The
`professional
`to the
`subject
`
`author
`use
`of
`
`or will
`received
`from
`a commercial
`this
`article.
`
`receive
`party
`
`for
`benefits
`related
`directly
`
`personal
`or
`indirectly
`
`or
`
`Amis
`
`JD, Larvin M. Fatigue
`screw-plate
`device
`after
`
`fracture
`bone
`
`sliding
`a femoral
`of
`union.
`Biomaterials
`
`REFERENCES
`
`device
`the Zickel
`J Nail Med Assoc
`
`for
`1977
`
`a malunited
`; 69:623-4.
`
`plate
`nail
`Jewett
`? : a randomised
`1983;
`65-B:2l8.
`
`or AO dynamic
`prospective
`
`screw
`hip
`controlled
`
`Jensen
`
`und
`
`A, Boriana
`nail. Howmedica
`trochanteric
`fractures.
`
`5,
`
`KS. Operative
`Leung
`1991.
`International,
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`T. Belastbarkeit
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`Unfall-
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`JS. Classification
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`1980; 51 :803-10.
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`H, Korkala
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`: a review
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`
`trochanteric
`1986;
`Surg
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`of
`
`Lauttamus
`73
`cases.
`
`N.
`
`Ross
`
`PM,
`fixation:
`
`Kurtz
`acase
`
`Sernbo
`
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`Johnell
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`compression
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`
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`
`subsequent
`147:131-3.
`
`1980;
`
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`
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`
`fracture
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`report.
`C/in Orthop
`intertrochanteric
`JA. Unstable
`0, Gentz
`CF, Nilsson
`compared
`with
`Ender
`pins
`the
`hip : treatment
`with
`1988 ;
`J Bone
`Joint
`Surg
`hip
`screw.
`[Am]
`70-A:
`
`a
`
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`femur
`JP.
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`patients.
`JP,
`Waddell
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`femur.
`proximal
`Subtrochanteric
`RE.
`1980; 11:555-68.
`
`EA. A review
`Saunders
`iS,
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`Subtrochanteric
`fractures
`J Trauma
`19:582-92.
`
`1979;
`
`fractures
`of
`C/in Orthop
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`
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`1979;
`141 :213-6.
`: a review
`of 130
`
`EH.
`1987;
`femoral
`
`Ender
`27:911-6.
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`
`nailing
`
`in fractures
`
`of
`
`the
`
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`
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`
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`
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`1987; 8:153-7.
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`fractures
`trochanteric
`for
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`Surg[Br]
`JBoneJoint
`GD, WinqUiSt
`RA, Mayo
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`: fixation
`fracture
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`femur
`Surg[Am]
`1987; 69-A:l032-40.
`
`KA, Hansen
`ST.
`using
`the Zickel
`
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`nail.
`J Bone
`
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`
`Bridle
`
`FT.
`AD, Bircher M, Calvert
`SH,
`Patel
`of the
`femur
`: a randomised
`fractures
`teric
`Nail
`and
`dynamic
`of
`the Gamma
`1991 ; 73-B:330-4.
`[Br]
`
`the
`
`hip
`
`of
`
`Fixation
`prospective
`J Bone
`screw.
`
`intertrochan-
`comparison
`Joint
`Surg
`
`JD, Kummer
`Zuckerman
`Chang WS,
`of
`anatomic
`reduction
`evaluation
`in
`unstable
`intertrochanteric
`osteotomy
`1987; 225:141-6.
`TRC,
`JL,
`Sher
`fractures
`: mechanical
`Surg[Br]
`1990;
`72-B
`
`Davis
`
`Horaman
`failure
`:26-31.
`
`et
`A,
`after
`
`Intertrochanteric
`a].
`internal
`fixation.
`
`femoral
`J Bone
`Joint
`
`FJ,
`
`Fraukel
`versus
`
`VH.
`medial
`fractures.
`
`Biomechanial
`displacement
`C/in
`Orthop
`
`Easer MP, Kassab
`a randomised
`with
`the
`dynamic
`B :557-60.
`
`Trochanteric
`Jones DHA.
`JY,
`prospective
`trial
`comparing
`J Bone
`Joint
`hip
`
`screw.
`
`femur:
`ofthe
`fractures
`the
`Jewett
`nail-plate
`Surg
`[Br]
`1986;
`
`68-
`
`Zickel
`
`THE JOURNAL
`
`OF BONE
`
`AND
`
`JOINT
`
`SURGERY
`
`ZIMMER 1043
`Page 5