1. Do we need a proximal femoral nail ?
Mr Chris Oliver
DM, FRCS (Tr & Orth), FRCP, DMI RCSEd
Consultant Orthopaedic Trauma Surgeon
Edinburgh Orthopaedic Trauma Unit
Edinburgh, Scotland

2. Edinburgh Orthopaedic Trauma Unit
800,000 people local
tertiary referrals from 1.5 million
5500+ operations per year
45,000+ out-patients per year
50% of unit workload concerns orthogeriatric fractures
1000+ proximal femur fractures per year
PFN last year - zero!

3. Modern hip nailing systems
Gamma: 1989
Howmedica
PFN:1995
Stratec
IMHS: 1990
Richards

4. 400 consecutive patients 399 followed-up to one year or death.
Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur
Prospective, randomised controlled clinical trial with observer blinding.
400 consecutive patients 399 followed-up to one year or death.
Short-type Gamma nail (203 patients) or Richard's SHS (197 patients).
Outcome measurements were fixation failure and reoperation.
Functional outcome; pain, mobility status, range of movement were assessed until one year.
Adams CI, Robinson CM, Court-Brown CM, McQueen MM. 
J Orthop Trauma Aug;15(6):

5. Revision Gamma nail group 6%, Richard's group 4% p = 0.29
Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur
Revision Gamma nail group 6%, Richard's group 4% p = 0.29
One subcapital femoral fracture in the Richard's group.
Femoral shaft fractures Gamma nail group (2%) none in the Richard's group (p = 0.13). Three required revision to another implant.
Lag-screw cut-out Gamma nail group (4%) Richard's group (2%) p = 0.37
Postoperative complications - same.
No difference functional status at one year.
Adams CI, Robinson CM, Court-Brown CM, McQueen MM. 
J Orthop Trauma Aug;15(6):

6. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur
“The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications”.
“Routine use of the Gamma nail cannot be recommended over the current standard treatment of dynamic hip screw and plate”.
Adams CI, Robinson CM, Court-Brown CM, McQueen MM. 
J Orthop Trauma Aug;15(6):

7. Implant-related fractures of the femur following hip fracture surgery
Internal fixation or prosthetic replacement of the femoral head increases the risk of a later femoral fracture in susceptible osteoporotic patients.
Analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery.
January 1988 to December 1997, 6230 patients (median age, eighty-two years; male: female ratio, 1247:4983) who sustained a total of 6696 hip fractures
Prospective study
Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J.
J Orthop Trauma Aug;15(6):

8. Implant-related fractures of the femur following hip fracture surgery
141patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery.
Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years.
2/3 fractures propagated from tip of the implant.
Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence.
Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J.
J Orthop Trauma Aug;15(6):

9. Implant-related fractures of the femur following hip fracture surgery
The incidence # per 1000 person years
Gamma nail 18.74
Cementless hemiarthroplasty 11.72
Compression hip screw 4.46
Cannulated screws 4.50
Primary arthroplasty with cement 6.2
Arthroplasty with cement as a revision procedure following failure of a primary implant 22.39
Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J.
J Orthop Trauma Aug;15(6):

10. Implant-related fractures of the femur following hip fracture surgery
“Implant-related fractures following hip fracture surgery are more common than has previously been appreciated”.
“Risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture”.
Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J.
J Orthop Trauma Aug;15(6):

11. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail - K Khan (data in press)
Unit concept
“Span the femur and prevent periprosthetic fractures”
Prospective study
Mortality, functional outcome and complications
302 patients February 1994 to December 2001 (median age 78.5)
Inclusion
Subtrochanteric fracture
Low-energy trauma (fall from standing height or below)
Exclusion criteria
High-energy injuries
Pathological fractures due to metastatic tumour

12. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail
Initial cohort of 302 patients
74 patients died (24.5% mortality at 1 year)
10 patients: untraceable
7 patients: refused to participate
211 patients: Follow-up to 1 year
Peri-operative complications: 70 patients (23.2%)
43 (14.2%) treated non-operatively
27 (8.9%) required further surgery
18 required revision of the nail
Survivorship analysis Long Gamma Nail revised in 7.1%

13. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Union
96.8% union at 6 months
7 patients: nail removed for suspected non-union
3 fractures: united, no further action
4 fractures: non-union confirmed, nail revised
Nail breakage (1 patient): non-union

14. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Complications
Lag screw failure - 12 patients
Lag screw cut-out (9)
Lag screw penetration into acetabulum (1)
Lag screw back out (2)
AVN of femoral head (without cut-out)
Revised to long stem cemented THR

15. Fracture distal to the tip of the nail (5)
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Metaphyseal fracture
Fracture distal to the tip of the nail (5)
All elderly females - Osteoporosis
Marked bowing of femur
Nail abutting anterior cortex (x-ray)
Exchange nail (modified) & cerclage wire
Protrusion of nail tip through anterior cortex during insertion (2 cases)

16. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Nail shape

20. Edinburgh Long Gamma Nail - Functional outcome
Increased social dependence
209 patients living in their own home prior to injury

21. Edinburgh Long Gamma Nail - Walking ability
178 patients were initially independent ambulators

22. Edinburgh Long Gamma Nail - Walking aids
158 initially walked without aids

23. Edinburgh Long Gamma Nail - Pain

24. Versatile treatment option for elderly population
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail
Versatile treatment option for elderly population
“Spans femur” but does have problems
Acceptable rate of complications
Satisfactory functional outcome considering pre-morbid status
Now using Gamma3

25. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.
Meta-analysis eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients.
“Given the lower complication rate of the SHS in comparison with Intramedullary nails, it appears that the SHS is superior for trochanteric fractures”
“Further studies, reversed fracture lines and subtrochanteric fractures”.
Parker MJ, Handoll HH
Cochrane Database Syst Rev. 2004;(1):CD

26. 46 consecutive patients (47 fractures) Average age 76.4 years
Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail.
46 consecutive patients (47 fractures)
Average age 76.4 years
74.5% # unstable
re-operation rate was 19.1%
“PFN is a suitable implant for unstable fractures, but the high re-operation rate precludes its routine use for every pertrochanteric fracture”.
Fogagnolo F, Kfuri M Jr, Paccola CA
Arch Orthop Trauma Surg Jan;124(1):31-7. Epub 2003 Sep 11.

27. Do we need a proximal femoral nail ?
In Edinburgh!
No type of PFN used.
Sliding Hip Screw (DHS) used as preferred implant for intertrochanteric fractures.
If there is a subtrochanteric fracture we prefer to nail and “span the whole femur”.
Avoid totally the “tip fracture”
If patient over 55 with a femoral shaft fractures we use a reconstruction cephallomedullary nail.
Technology is still evolving.

28. Thank You