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Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results.

BACKGROUND
The surgical treatment of complex unstable proximal femur fractures from the trochanteric region to the middle shaft area is difficult and often highly invasive, especially in older patients with osteoporotic bones.


METHODS
In 1993, we began to treat all unstable proximal femur fractures from the trochanteric region to the middle third of the shaft with the long gamma nail (LGN) and allowed the patients immediate full weightbearing after surgery. Perioperative, postoperative, and follow-up data were analyzed.


RESULTS
During a 3-year period, we treated 37 patients with unstable proximal femur fractures with the LGN. Five of the patients had sustained pathological fractures, and four patients had sustained multiple trauma. The 37 operations were performed by 22 different surgeons with varying degrees of experience. The LGN implantations through maximal 40-mm skin incisions were performed in a mean skin-to-skin operation time of 125 minutes (range, 65-200 minutes) without any further complications. Thirty-one of the 37 patients 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 surgery (2). Three postoperative complications were as follows: one deep infection 4 months 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 weightbearing was allowed, there were no implant dislocations, implant failures, or other problems. The 30-day mortality was 0%. The follow-up examinations after a mean time of 6 months were very satisfying. All traumatic fractures were healed. The patients had symmetrical functional findings to the opposite side or before surgery, respectively, except for two patients with a leg shortening of 2 cm, two patients with an external 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 from the trochanteric region to the middle shaft area. The minimal invasive technique with low risks and minimal complications and the possibility of immediate full weightbearing sets a new standard, especially for older patients with osteoporotic bones.