The Gamma nail--a significant advance or a passing fashion?

EDITORIALS The Gamma nail-a significant advance or a passing fashion? According to a report from the Royal College of Physicians (1989) there were, in 1985, in the United Kingdom 46 000 proximal femoral fractures taking up 20% of the nation's orthopaedic beds. If the age-specific incidence continues to rise at its current rate the number will be 1 1 7 000 by the year 2016. Approximately half are peritrochanteric fractures and almost all are treated by reduction and internalfixation to allow early mobilisation of the patient (Hornby, Grimley Evans and Vardon 1989). In the United Kingdom the usual device for internal fixation of such fractures is a sliding hip screw. It has a higher success rate than fixed-angle devices but, nevertheless , there is a mechanical failure rate of between 10% and 20% Varty and Dodd 1989). The most common problem is cutting-out of the screw from the femoral head (Davis et al 1990), but others include separation of the plate from the femoral shaft, plate breakage and disengagement of the implant components. Failure is related to instability of the fracture, inadequacy of reduction, inaccurate placement of the screw within the head and osteoporosis. If the implant fails then the primary objective of the operation has not been achieved, and the large number ofpatients means that even failure rates oflow percentage create a serious problem in terms of medical resources. The potential commercial gains for the manufacturer who produces the most popular device are also large. These factors, combined with the current vogue for closed intramedullary fixation of diaphyseal fractures, made it almost inevitable that an implant such as the Gamma nail would be developed, combining intra-medullary fixation in the femoral shaft and a screw in the femoral head. The implant can be inserted by a closed technique and allows sliding between the two parts to permit controlled collapse of the unstable fracture, as with the sliding hip screw. The smaller exposure required may be associated withlower blood loss, shorter operating time and less wound morbidity. In addition, there may be mechanical advantages, the more medial position of the distal fixation resulting in a shorter lever arm and a lower bending moment on the device. the use of the Gamma nail for the treatment of peritrochanteric fractures. The article by Rosenblum et al on page 352 describes the biomechanical properties of the nail and produces some surprising results. As they …