Abstract
Based on the analysis of their group of 75 patients treated for the fracture of proximal femur by means of the Gamma nail and on the analysis of data from the literature the authors present a comprehensive list of all complications resulting from this technique: - inadequate reduction, - jamming of nail, - fracture displacement by nail isertion, - perforation of the head, - incorrect length of the lag screw, - problems with distal locking, - fracture of the femoral shaft, - rotation of head on the lag screw, - rotation of diaphysis on the nail, - failure of the healing of the wound and infection, - breaking of the nail, - non-union, - healing in the varus position, - aseptic necrosis of the head, - incorrect rotational position of the limb, - unequal length of lower limbs, - problems with the set of instruments, - migration of the set screw. Ensuing from the analysis are the main principles of the surgical technique.
Indication: unstable intertrochanteric fractures, comminuted fractured (Kyle IV) of trochanteric regions and some subtrochanteric fractures. Reduction: in case of unstable fractures it is advantageous to correct them in a slightly valgus position, in the lateral projection it is necessary to achieve linear position of fragments.
Antibiotics: recommended in case of elderly patients, in younger patients, only in risk involving cases. Position: the leg to be operated on has to be in adduction with regard to the body.
Selection of the nail: diameter 12 mm, angle 130°. Reaming: in the distal direction it is necessary to ream medullary cavity by 2 mm more than is the diameter of the nail, in the proximal direction it must be reamed up to 17 mm.
Insertion of the nail: should be done manually, never use a hammer! If too much resistance is felt when advancing the nail, it is necessary to ream a larger hole or choose a thinner nail. Insertion of the lag screw: in AP projection along the longitudinal axis of the neck and head or slightly below, in the axial one exactly along the axis of the neck and head.
Compression: only in cases where there is a diastasis between the fragments alignment with the trochanteris region. Compression: only in cases where there is a diastasis between the fragments alignment with the trochanteris region.
Fixation of the set screw: should be done in such a way to prevent rotation but at the same time to allow free sliding of the lag screw, i. e. to screw it and subsequently unscrew by one quarter of a turn. Releasing of the traction after the insertion of the lag screw: in cases where there is diastasis between the femoral shaft and trochanteric region, special care should be taken in case of subtrochanteric fractures.
Distal locking: is performed by one screw inserted in the proximal hole, care should be taken not to lever the targeting device or the guide sleeve, slipping of the drill bit should be avoided. The use of a short 1 screw is not suitable.Tightening should be done carefully, checking by image intensifier is recommendend.
R-drainage: always into the nail wound, in case of the lag screw incision it should be considered from the viewpoint of bleeding.