Complications of fixation of unstable trochanteric fractures with gamma nail. How to avoid it?

Background
The incidence of intertrochanteric fractures is increasing worldwide due to the aging of the population. These fractures are common among osteoporotic people who may suffer from multiple comorbidities. Early surgical intervention is a must. Trochanteric fractures may be stable or unstable. Unstable fractures always tend to cause more complications during or after surgery such as femoral shaft medialization, varus collapse, malunion, delayed union, nonunion, and implant failure. Intertrochanteric fractures can be fixed by extramedullary devices such as DHS or intramedullary devices such as intramedullary gamma nail. Gamma nail has a locked fixed junction between the lag screw and the nail preventing femoral shaft medialization that decreases the bone-to-bone contact and increases the incidence of mechanical complications. Other theoretical advantages are that the technique is percutaneous with reduced blood loss, reduced sepsis, minimal tissue damage, and a shorter operating time.


Patients and methods
This is a retrospective study of 77 patients with recent unstable intertrochanteric fractures between December 2021 and June 2022. 70 patients of them continued till the last follow-up. All of them were fixed by intramedullary gamma nails. The age of the patients ranged from 61 to 99 years with a mean value of 71.64. This study included 19 (27.1%) males and 51 (72.9%) females. 50 (71.4%) patients had a history of associated comorbidities such as diabetes mellitus, hypertension, cardiac,….) and 20 (28.6%) patients were free. All fractures were classified according to Evan’s classification to be unstable (Evan’s type III, IV, V, and VI).


Results
At the end of the follow-up period, 58 (82.9%) patients achieved full radiological union, and 12 (17.1%) cases found to be failed of total 70 cases: 6 cases with screw cut out, 4 cases with broken nails and 2 cases with lag screw back out. According to Harris hip score, 11 (15.7%) patients did excellently, 35 (50%) patients did good, 12 (17.1%) patients did fair and 12 (17.1%) patients did poorly. There was a significant correlation between Evan’s type V and failure rate, failure rate and quality of reduction failure rate and tip apex distance, failure rate and lag position, and failure rate and postoperative neck-shaft angle. But, no significant correlation between failure rate and length of gamma nail, or failure rate and lateral wall thickness was found.


Conclusion
It is concluded that this study supported the previous series in the literature, which proved that intramedullary gamma nails give good results when used to fix unstable intertrochanteric fractures. They have a lower complication rate when compared with other type of implants. Ideal fracture reduction, ideal implant choice, and application can lessen the rate of complications.