Date: Sat, 30 Nov 2002 02:04:41 +0000

Subject: Re: Gamma nail varus malreduction

Does anyone have any tricks to avoiding a varus malreduction of pertroch/subtroch fractures treated with a gamma/IMHS/TFN. It seems that an anatomic reduction often tips into varus on final seating of the nail. Is this a starting point error, or just the nature of trying to insert a nail eccentrically into the femoral canal???

Jeff Richmond

Reply at: Orthopaedic Trauma Association forum

Date: Sat, 30 Nov 2002 08:39:37 -0500

From: Bill Burman

Bill Obremskey has addressed the gamma varus malreduction problem in a previous discussion.

He cited a paper by French and Tornetta in CORR 1998

Review of the article shows the varus complication rate was 61%. The authors recommended maintenance of reduction of the proximal fragment with a clamp prior to reaming and nail insertion plus avoidance of excessive adduction of the distal fragment during reaming and nail placement.

Bill Burman, MD
HWB Foundation

Date: Sat, 30 Nov 2002 09:45:29 EST From: OTS1

welcome to the wonderful world of IM nailing proximal femurs. It usually helps to do the procedure in 2 parts so that you abduct the femur once the nail is in to get enough valgus when you put in the screw. Otherwise you have to use a bone hook to pull the neck in and up.


Roy Sanders, MD,
Tampa, Florida

Date: Sat, 30 Nov 2002 10:52:06 -0500

From: Clifford B. Jones, M.D.

The main problem is a varus starting point. A varus starting point is a point that is on the lateral half of the greater trochanter. This is created by the soft tissue pushing each reamer more lateral. To avoid or correct this (even if a hole of 17mm is already created) one must manually push the reamer medially when reaming so that the harder medial aspect of the trochanter is reamed. This opening medially allows the nail to be inserted at the correct position. One may then place the nail in neutral or slightly valgus; therefore, reducing the varus reduction which in turn reduces the failure rate.

The other problem is trying to ream without the fracture site being reduced properly. Just because you make an incision to apply tenaculum clamps does not determine the amount of periosteal stripping.

Cliff Jones
Grand Rapids, MI

Date: Sat, 30 Nov 2002 11:04:35 EST

From: OTS1

well maybe, but if the fracture is thru the troch, the nail just goes where it wants. I typically use the tip of the troch to start, but by the time i am done the reamer and the nail go where they want. It is obviously true, and I agree with Cliff, that if you start too lateral, you will worsen the situation, but I have found that in certain fractures, an open or semi-open reduction is needed. Unfortunately since the cpt codes offer more money for nailing , this has become prevalent, and hip screws have fallen by the wayside. where this was largely a non problem, because the semi open nature of that operation allowed for a better reduction. Interestingly no one has ever seriously looked at the long term results of proximal femoral malunions and therefore one doesn't really know if this is an issue. One supposes it is, but how much? and how much at what age? etc, etc. All we can do right now is try for an anatomic reduction. One shouldn't be afraid to open the thing to get it done.


Roy Sanders, MD,
Tampa, Florida

Date: Sat, 30 Nov 2002 21:59:46 +0000

From: Jeff Richmond

Thanks for all the input. I have seen 4 gamma nails break: all through the large hole for the head screw, and all were nailed in varus. A study this does not make, but it does make me fear varus.

When possible/necessary, I will go back to either clamping a reduction or use a 95degree device.


Date: Sun, 1 Dec 2002 12:07 EST

From: Bill Burman

>Otherwise you have to use a bone hook to pull the neck in and up.


Thanks for your comments.

I'm trying to get some clarification of your "in and up" reduction manuever of the proximal fragment.

In an OTA BFC lecture Toney Russell is counteracting the abductors with lateral pressure on the proximal fragment. This would correspond to your "in".

In another discussion of an intertrochanteric fracture, Adam Starr suggests that psoas flexion deforming forces (if the lesser troch is still intact) on the proximal fragment may be at work which may require the proximal fragment to be pushed *down* instead of "up". When you say "up", are you talking about a situation where the lesser troch is broken off and you are lifting the sagging distal fragment up?

Bill Burman, MD
HWB Foundation

Date: Mon, 2 Dec 2002 08:12:23 -0500

From: James Carr

I find the gamma is hard to get in proper alignment with a young person who has a portion of the proximal femur intact. I think lateral decubitus nailing is the easiest, and takes care of a number of the deforming forces mentioned in the posts. Winquist had a paper on nailing subtroch's with the Zickel nail in the 80's, using the lateral decubitus. The key is having the ability to extend the down leg to get a good lateral x-ray of the hip. Contrary to popular misconception, the lateral hip view is usually better in the lateral decubitus position. However, the newer design fracture tables can make this a tough positioning if they have those extensions that project out directly underneath the patient e.g. Maquet. The old style tables with the extensions that rolled on the floor were much easier (eg OEC - these lasted about 6 months in use) . I think I'll stick to regular recon nails or fixed angle sub-q platings on the young patients when a portion of the proximal femur is intact. The Gamma is an easy device if the proximal femur is in multiple pieces. Finally, I wonder if we'll see the refracture problem taking these out like we saw with the Zickel nail. I once fractured two femurs in one sitting taking Zickel nails out for severe trochanteric pain.

James B. Carr, MD
Palmetto Health Orthopedics