The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001).

Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group.

Cite this article: Bone Joint J 2013;95-B:825–30.

Introduction. Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique. Aim. The aim of the study was to review consecutive patients who underwent closed femoral rotational or shortening osteotomy using an intramedullary saw over a ten-year period. Material & Methods. Forty femoral rotational and/or shortening osteotomies using an intramedullary saw were performed on thirty-six patients, between January 2001 and June 2011. The main indications were post-traumatic leg length discrepancies and congenital rotational abnormalities. Clinical & radiological follow up mean was 16.3 months. Results. Twenty one osteotomies were performed for femoral shortening with the mean correction of 3.5 cm. Nineteen osteotomies were performed for correction of torsion; there was a mean correction of 28.64 degrees with Internal rotation and 35 degrees with external rotation osteotomies. Fourteen patients required removal of locking screws. There were two patients with heterotrophic ossification, two patients with wound infection (one deep infection). One patient had a materiovigilance incidence and one patient had vascular complication requiring embolisation. The subjective results showed 37 osteotomies were satisfied with their operation, functional recovery and aesthetic appearance of the scars. Conclusion. Closed osteotomy of femur for correction of LLD and torsion using an intramedullary saw represents a reliable and effective procedure. Despite the complications, the original goal of the surgery was achieved in 37 of the 40 limbs treated. Patient satisfaction was achieved in 92.5 % of 40 osteotomies

Introduction Patients sustaining fractures of the proximal femur, with co-morbid medical problems, have increased rates of morbidity and mortality. Chronic renal failure is one such co-morbidity. This study examines the outcome in patients with chronic renal failure who sustain fractures of the proximal femur. Patients and Methods All patients with a fractured neck of femur who presented to our department from September 1997 to March 2004 were retrospectively reviewed. Eighteen of these patients were found to have chronic renal failure requiring dialysis. Medical records were reviewed and information was collected and analysed. A full literature review was conducted. Results There were nine intra-capsular fractures and nine extra-capsular fractures. Four patients with intra-capsular fractures were treated by internal fixation and four by arthroplasty. One patient with an intra-capsular fracture was treated non-operatively. Eight patients with extra-capsular fractures were treated with a dynamic hip screw device and one was treated using a cephalo-medullary nail. There were sixteen deaths at a mean of seven months post-operatively (range 0 to 24). Factors that may influence outcome and the relevant literature are discussed. Conclusions Patients with chronic renal failure who sustain fractures of the proximal femur appear to have a poor outcome regardless of type of fracture or its subsequent management

Purpose of study. The addition of interlocking screws to intramedullary nails adds greatly to the stability of these constructs, yet the placement of distal screws accounts for a significant proportion of the total fluoroscopy and operative times. The Sureshot® (Smith and Nephew™) is a computerised system that allows placement of distal screws without fluoroscopy by using electromagnetic guided imagery. The purpose of this study is to compare traditional free-hand technique to the Sureshot® technique in terms of operating time, radiation dose and accuracy. Methods. Between September 2011 and March 2012 we prospectively randomised 66 consecutive patients presenting to us with femur shaft fractures requiring intramedullary nails to either free-hand (n=33) or Sureshot® assisted (n=28) distal locking. Fractures warranting only one distal locking screw, or those requiring retrograde or cephalo-medullary nailing, were excluded. Five patients' data was not suitable for analysis. The two groups were assessed for distal locking time, distal locking radiation and accuracy of distal locking. Results. The average total operative time was 51 minutes (range 25–88) for the free-hand group and 59 minutes (range 40–103) for the Sureshot® group. The average time for distal locking time was 10 minutes (range 4–16) with free-hand and 11 minutes (range 6–28) with Sureshot®. The average radiation dose for distal locking was 746.27 μGy (range 200–2310) for the free-hand group and 262.54 μGy (range 51–660) for the Sureshot® group. There were 2 misplaced drill bits in the free-hand group and 3 in the SureShot® group. Conclusion. SureShot® assisted distal locking reduces radiation exposure, but in a high-volume institution like ours it didn't reduce operative time or improve our accuracy. The benefits of this reduction in radiation still need to be quantified. The slightly higher number of misplaced drill bits and screws may represent our learning curve with SureShot®. NO DISCLOSURES

Aims

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.