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From the University Hospital, Nottingham, England

We madea randomised prospective comparison of the the screw from the femoral head, a complication which
Dynamic Hip Screw and the Gamma locking nail for the has been related to inaccurate screw placement, severe
internal fixation of 200 pertrochanteric femoral fractures osteoporosis and fracture comminution. Failure of fixa-
in elderly patients. There was less intraoperative blood loss tion of the plate is much less frequent.
and a lower rate of wound complications in the patients The Gamma locking nail was introduced after the
treated by the Gamma nail. They had, however, a high success of closed intramedullary nailing of femoral shaft
incidence of femoral shaft fracture which we relate in part fractures. The theoretical advantage of using a femoral
to implant design. We do not recommend the use of the nail instead of a plate is that the nail is nearer to the axis
Gamma nail for these fractures. of weight-bearing through the femoral head and the
leverage is, therefore, reduced. The closed technique of
JBoneJoint Surg[Br] 1993; 75-B :789-93.
insertion may also be expected to be associated with less
Received 20 January 1993; Accepted 16 March 1993
blood loss and fewer wound complications.
The initial trials of the Gamma nail by Halder
Internal fixation of extracapsular fractures of the proxi- (1992) and Leung et a! (1992) were encouraging but the
ma! femur was a significant advance when popularised first of these was not a controlled trial and the second was
by Jewett (1941) and others. It allowed early mobilisation in Asiatic patients whose femoral anatomy, the authors
of the patient and reduced deformity due to malunion. concluded, was sufficiently different for a special ‘Asiatic’
Fixation of comminuted fractures, however, by the Gamma nail to be required. There have been several
original single-piece implants often failed due to collapse reports of complications of the use of the Gamma nail
at the fracture site and nail penetration of the head including fractures ofthe femoral shaft (Bridle et a! 1991;
(Dimon 1973 ; Bannister and Gibson 1983) and for this Leung et al 1992; Williams and Parker 1992). In an
reason the sliding nail-plate was introduced by Pugh in editorial Calvert (1992) commented that prospective
1955. randomised studies were required to “define more
There is biomechanical evidence that the fixation of precisely the best design and the indications for use of
a screw in the femoral head is better than that of a nail this new device”. We now report the results of such a
(Brodetti 1961) and a sliding screw-plate implant, such study, comparing the Gamma nail with the Dynamic
as the AO Dynamic Hip Screw, has become the standard Hip Screw (DHS).
treatment for such fractures in elderly patients. The
results have been inconsistent. In the hands of experi-
enced surgeons mechanical failure rates as low as 1%
have been reported (Mulholland and Gunn 1972), but in All patients aged 60 years or over with fractures were
routine practice serious complications including fixation eligible for inclusion and 200 patients were randomly
failure have occurred in up to 20% of cases (Wolfgang, assigned to have fracture fixation by either a DHS
Bryant and O’Neill 1982; Simpson, Varty and Dodd (Stratec Medical Ltd, Welwyn Garden City, UK) or a
1989). The commonest mode of failure is cutting out of Gamma nail (Howmedica (UK) Ltd, London, UK).
Preoperatively, we recorded age, sex, haemoglobin
level, concurrent medical problems, mental state using
P. J. Radford, MA, FRCS, FRCS(Orth), Senior Orthopaedic Registrar
M. Needoff, FRCS, Orthopaedic Registrar
the Mini-Mental State Examination (MMSE) (Cockrell
J. K. Webb, FRCS, Consultant Orthopaedic Surgeon and Folstein 1988), and prefracture housing and walking
DepartmentofFracture and Orthopaedic Surgery, University Hospital,
Queen’s Medical Centre, Clifton Boulevard, Nottingham NG7 2UH,
status, using simple five-point scoring systems. The
UK. fracture patterns were categorised as stable or unstable
Correspondence should be sent to Mr P. J. Radford. as described by Evans (1949).
©l993 British Editorial Society of Bone and Joint Surgery Only surgeons of registrar grade and above in our
0301-620X/93/S633 $2.00 department took part in the trial. They were already

VOL. 15-B, No. 5, SEPTEMBER 1993 789


experienced in the use of the DHS and in intramedullary surgeons : four senior registrars, two registrars and one
femoral nailing, and they were personally instructed in consultant. There was no significant difference in the
the operative technique for the Gamma nail by one of seniority level of the surgeons who performed the
the authors (PJR). The first two Gamma nail operations operations in each group or in the operating time. The
performed by each surgeon were not included in the trial. measured operative blood loss was significantly less
The operations were performed using image inten- (p < 0.05) in the Gamma-nail group (120 ml) than in the
sification. Closed reduction was achieved, if possible, on DHS group (250 ml).
the traction table. Ifthis was not possible, open reduction There was no significant difference between the two
was performed during the procedure. For both implants groups in the rate of postoperative mobilisation. Despite
we aimed to have a central position of the screw in the the difference in peroperative blood loss, the haemoglobin
femoral head on both anteroposterior and lateral views, levels and the requirements for blood transfusion were
with its tip S to 10 mm from the subchondral bone. The similar in the two groups. There was no significant
DHS used was the four-hole, 135#{176}
plate with a screw of difference in the hospital stay of those who were
appropriate length. For the Gamma nail a preoperative discharged between the two groups, and similar numbers
radiograph of the other hip was compared with implant in each group were transferred to long-term care.
templates to decide the angle of the chosen nail. At the three-month and one-year follow-up, there
For Gamma nailing, the tip ofthe greater trochanter were no significant differences between the groups, after
was opened with an awl, hand reamers were passed into excluding from analysis those patients who had developed
the medullary cavity and used to measure its diameter the complications discussed below.
and to enlarge it to at least 2 mm greater than the Complications. The main difference between the two
diameter of the intended nail. The proximal femur and groups of patients was in the frequency of postoperative
entry point were reamed to at least 17 mm in all cases. complications.
Power was used only when reaming could not be Death. At three months, 12 patients in the Gamma nail
satisfactorily performed by hand. Distal locking of the group and 10 in the DHS group had died. In none of
nail in the femoral shaft was performed only when these was death directly related to a complication of the
indicated for longitudinal instability (due to poor reduc- fracture fixation.
tion, fracture comminution or subtrochanteric exten- Wound healing. Eight patients in the DHS group and
sion), or for rotational instability due to a poor interface three in the Gamma-nail group had delayed wound
between nail and femur. Suction drains were used in all healing or persistent discharge sufficient to create the
cases. Perioperative antibiotic prophylaxis was with suspicion ofinfection and for another course of antibiotics
cephradine. to be given. None of these developed a proven infection.
The operating time was recorded, perioperative Infection. By three months there had been four bacterio-
bloodloss measured, and any specific technical difficulties logically proven wound infections in the DHS group and
were noted along with a rating of the overall level of none in the Gamma-nail group. By nine months one
difficulty. patient in the Gamma nail-group had developed a deep
Postoperatively, patients were mobilised from the infection due to Streptococcus pneumoniae, shortly after
second postoperative day after removal of the drains. being treated for pneumonia.
The haemoglobin level, any postoperative complications, Thromboembolism. Six patients in the DHS group and
the length of hospital stay and the housing status at eight in the Gamma-nail group developed proven deep-
discharge were recorded. The postoperative radiographs vein thrombosis during their stay in hospital.
were examined to determine the position of the screw in Nonunion. No case of fracture nonunion was encountered
the femoral head and the quality of fracture reduction. in this study.
The patients were reviewed at three months and at Fixationfailure. There were three cases in the DHS group
one year.
Table I. Preoperative data of the 200 patients with pertrochanteric
femoral fractures
Dynamic hip screw Gamma nail
There were 100 patients in each group, which were (n=100) (n=100)

similar in terms of age, sex, mental status, intercurrent Average age (years; range) 18 (60 to 90) 83 (60 to 91)
medical conditions, prefracture mobility and housing
Male:female 16:24 79:21
scores (Table I).
The pre- and postoperative radiographs showed no MMSE (per cent < 23/30) 21 24

significant differences between the two groups in the Number with diabetes 4 6
numbers of fractures graded as stable or unstable (Evans
Average prefracture mobility score 3.7 3.9
1949). In the DHS group, 43% were unstable, and in the
Gamma-nail group, 38%. Average prefracture housing score 4. 1 4.3

The operations had been performed by seven S Mini-Mental State Examination (Cockrell and Folstein 1988)



Table II. Femoral shaft fractures in patients treated

by the Gamma nail

Peroperative Postoperative

Number 6 5

No treatment required 3 0

Traction treatment 2 2

Revision operation 1 3

United 6 5

and two in the Gamma-nail group in which the fracture

collapsed into varus and the screw cut out of the femoral
head. All required revision operations. In none had the
screw been placed within the central one-third of the
femoral head in both views on the postoperative
Fracture of the femoral shaft. There was one case of
femoral shaft fracture in the DHS group and eleven in
the Gamma-nail group.
The fracture in the DHS group occurred through an
undisplaced and unrecognised fracture extending into
Fig. 1 Fig. 2
the subtrochanteric area which had not been adequately
Figure 1 - At the tip of a Gamma nail there is an undisplaced cortical
controlled by the DHS plate. split which was not treated. Figure 2 - An extensive displaced split of
The 1 1 femoral shaft fractures in the Gamma-nail the femoral shaft around a Gamma nail. The fracture was treated by
bedrest and traction.
group occurred either peroperatively or postoperatively
(Table II). Three of the six peroperative fractures were
minor splits in the cortex at the tip ofthe nail (Fig. 1) and
were not treated. The patients mobilised well without
further problems. The other three were more serious (Fig.
2) and required either a period of treatment in traction
or a revision operation. All the fractures eventually
Five patients sustained postoperative femoral shaft
fractures (Fig. 3). Careful scrutiny of the postoperative
radiographs of four of these failed to show any predispos-
ing complications. In the fifth patient an initial attempt
at locking of the nail had failed, leaving a hole in the
cortex of the femur at the tip of the nail ; the fracture
occurred through this (Fig. 4). The postoperative frac-
tures all occurred from 12 to 26 days after the operation
and none was caused by significant trauma, although two
of the patients had stumbled. In the other three patients
the leg gave way without warning. Two patients were
treated, in the early part of the study, by traction ; later
in the series a long (36 cm) version of the Gamma nail
became available and was used for the other three cases.
Figure 3 - A typical postoperative femoral shaft fracture. Figure 4 -
Lateral view of a fracture through a distal locking hole. There is a
metallic fragment and lucency posterior to the nail tip from an initial
locking screw which missed the nail.

Our results for these two implants in patients aged over

60 years with pertrochanteric fractures of the proximal and a small split in the abductor muscle. By contrast the
femur show a very similar outcome when patients with DHS needs a much longer incision and elevation of
specific complications are excluded from the analysis. vastus lateralis. Also, we performed only minimum
The peroperative blood loss was significantly less reaming of the femoral shaft to reduce medullary blood
with the Gamma nail probably because of the closed loss. Despite these advantages we were unable to show
operative technique which requires only a 3 cm incision any benefit for the patients, since the postoperative

VOL. 75-B, No. 5, SEPTEMBER 1993


haemoglobin levels and transfusion requirements of the

two groups were similar, perhaps because most blood
loss occurs at the fracture itself before and after surgery.
The wound infection rate with the DHS (4%) did
not differ significantly from the overall infection rate
(2.7%) in elderly patients with fractures of the proximal
femur of all types previously documented in our unit
(North et a!, unpublished data). The wound infection
and wound complication rates for the Gamma nail were
significantly lower (p < 0.05), and no doubt were the
result ofthe closed operative technique. This is analogous
to open and closed intramedullary nailing of femoral
shaft fractures in which it has also been shown that
infection rates of 3.2% with open nailing can be reduced
to less than 1% with closed nailing (Browner, Mast and
Mendes 1992).
The rate of cut-out of the screw from the superior
part of the femoral head was similar for the two devices
and all these cases required revision surgery because of
pain. In all, inadequate positioning of the screw, either
in the superior third or in the anterior third ofthe femoral
head, could be identified on the postoperative radio-
graphs. These cases were failures of surgical technique.
The worst complication was the 1 1% incidence of
femoral shaft fractures which occurred with the Gamma
nail. This can be devastating and extremely difficult to
manage. Fig. Sa Fig. Sb
Six of these fractures occurred during the operation,
Radiographs of two typical femora at follow-up with good clinical
although three were no more than minor cortical splits at results and uniting fractures. There is mismatch of the shape of the nail
and the femoral shaft despite nail entry being well lateral in the
the tip of the nail, similar to those seen occasionally in trochanter.
uncemented hip arthroplasties. These fractures were
ignored and the patients were mobilised without further
problems. The other three peroperative fractures and the unexpected, as the nail is straight and the femur has an
five postoperative fractures all interfered with rehabili- anterior convexity. The tip of the nail therefore impinges
tation and required treatment either by traction or by against the anterior femoral cortex. More surprising was
reoperation. When a longer version of the Gamma nail the mismatch in the sagittal plane. The Gamma nail has
became available we were able to revise three of these a 10#{176}
valgus curvature to allow its insertion through the
fractures successfully with this device, reinserting the tip of the greater trochanter. This does not match the
femoral head screw along the original track. All the shape of the proximal femur, and comes to lie in the
fractures united but the patients’ outcome was markedly proximal part ofthe femoral shaft (Fig. 5); measurement
compromised. ofthe postoperative anteroposterior radiographs revealed
It is clear that the peroperative fractures were caused an average of 5.6#{176}
(SD 3.8#{176})malalignment of the femoral
by the too forceful insertion of the nail into the femoral shaft axis with the Gamma nail axis.
shaft, often by a hammer. In all except one, the nail used The mismatch in shape means that even after
was the smallest available (12 mm diameter); in the other overreaming of the femur by 2 mm more than the
case it was 14 mm. In all the surgeon had passed a hand diameter of the nail, the nail when introduced has three-
reamer, 2 mm greater in diameter than the nail, along point fixation in the femoral shaft. This causes stress
the medullary cavity. concentration at these three points particularly at the tip
One of the postoperative fractures was through a of the nail and on its medial side at the site of curvature.
distal locking hole ; the other four were similar in pattern, As a result of relative overload in these areas a smaller
being spiral fractures extending proximally from the tip force than that normally needed to break the bone may
of the nail (Fig. 3). They all occurred without significant result in a fracture. This can occur at the time of nail
trauma. introduction and should be avoidable but it can also
Scrutiny of the postoperative radiographs of the occur postoperatively from physiological weight-bearing
Gamma nail group showed that there was a consistent forces, and then it results in a very serious complication.
mismatch between the shape of the nail and the shape of We used distal locking screws only for cases in
the proximal femur. In the coronal plane this is not which they were specifically indicated ; we had theoretical



concerns about screw-holes in the cortex of the femoral Browner BJ, Mast G, Mendes M. Principles of internal fixation. In:
Browner B, Jupiter J, Levine A, Trafton P0, eds. Skeletal trauma.
isthmus. Since the distal part ofthe nail already produces
London, etc: WB Saunders, 1992 :257.
a concentration of stress at that site, weakening of the
Calvert PT. The Gamma nail : a significant advance or a passing
bone by the presence of screws should be avoided fashion? J Bone Joint Surg [Br] 1992; 74-B :329-31.
whenever possible. Cockrell JR, Folsteln MF. Mini-mental state examination (MMSE).
Physchopharmaco/ But! 1988 ; 24 :689-92.
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no longer use the Gamma nail in the management of Evans EM. The treatment of trochanteric fractures of the femur. J Bone
femoral fractures. We believe that the frequency of JointSurg[Br] 1949; 3l-B:l90-203.
femoral fractures after Gamma-nailing more than out- Halder SC. The Gamma nail for peritrochanteric fractures. J Bone Joint
Surg[Br] 1992; 74-B :340-4.
weighs the benefits.
Jewett EL. One-piece angle nail plate for trochanteric fractures. J Bone
No benefits in any form have been received or will be received from a Joint Surg 1941 ; 23:803-10.
commercial party related directly or indirectly to the subject of this
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screws for peritrochanteric fractures : a randomised prospective
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failure. Injury 1989; 20 :227-31.
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Brodetti A. An experimental study on the use of nails and bolt screws Wolfgang GL, Bryant MH, O’Neill JP. Treatment of intertrochanteric
in the fixation of fractures of the femoral neck. Acta Orthop Scand fracture ofthe femur using sliding screw plate fixation. C/in Orthop
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VOL. 75-B, No. 5, SEPTEMBER 1993