Minimal invasive treatment of proximal femur fractures with the long gammanail: Indication, technique, results

Background: The surgical treatment of complex unstable proximal femur fract ures from the trochanteric region to the middle shaft area is difficult and often highly invasive, especially in older patients,with osteoporotic bone s. Methods: In 1993, we began to treat all unstable proximal femur fractures f rom the trochanteric region to the middle third of the shaft with the long gamma nail (LGN) and allowed the patients immediate full weightbearing afte r surgery. Perioperative, postoperative, and follow-up data were analyzed. Results: During a 3-year period, we treated 37 patients with unstable proxi mal femur fractures with the LGN. Five of the patients had sustained pathol ogical fractures, and four patients had sustained multiple trauma. The 37 o perations were performed by 22 different surgeons with varying degrees of e xperience. The LGN implantations through maximal 40-mm skin incisions were performed in a mean skin-to-skin operation time of 125 minutes (range, 65-2 00 minutes) without any further complications. Thirty-one of the 37 patient s were allowed immediate full weightbearing after the second postoperative day. The six patients who were not allowed full weightbearing were the ones who had multiple trauma (4) and those who were unable to walk before surge ry (2). Three postoperative complications were as follows: one deep infection 4 mon ths after surgery, one superficial infection 3 weeks after surgery, and one deep vein thrombosis 2 weeks after discharge. All three complications occurred in the group of patients who had sustained only one trauma. All traumatic fractures (n = 32) healed without any bone grafting, which means a union rate of 100%. Although immediate full weightb earing was allowed, there were no implant dislocations, implant failures, o r other problems. The 30-day mortality was 0%. The follow-up examinations after a mean time of 6 months mere very satisfyi ng. All traumatic fractures were healed. The patients had symmetrical funct ional findings to the opposite side or before surgery, respectively, except for two patients with a leg shortening of 2 cm, two patients with an exter nal malrotation of 10 degrees, and one patient with a hip extension deficit of 10 degrees after a pathological fracture. Conclusion: The LGN is, after appropriate introduction and training, a safe and easy implant for the treatment of complex proximal femur fractures fro m the trochanteric region to the middle shaft area. The minimal invasive te chnique with low risks and minimal complications and the possibility of imm ediate full weightbearing sets a new standard, especially for older patient s with osteoporotic bones.