Introduction: The objective of this study was to prospectively evaluate the clinical outcome of traumatic subtrochanteric fractures fixed with long proximal femoral nail (PFN) or long gamma nail with particular emphasis on our experience of surgical techniques. Materials and Methods: We reviewed the results of 49 consecutive patients who had undergone intramedullary fixation specifically with a long PFN or a long gamma nail for traumatic subtrochanteric fractures in our hospital during a 2-year period from January 2003 to December 2004. The average age of the patients was 53 years. Clinical and radiographic analyses were performed when follow-up was made at 6 weeks, 12 weeks, 6 months, 1 year and 2 years. Results: All the 49 traumatic subtrochanteric fractures healed uneventfully except 1 case of delayed union. Walking and squatting ability was completely restored in every case at follow-up examination 6 months postoperatively. Among them, 32 fractures were successfully reduced with traction on a fracture table under fluoroscopy, but cerclage wiring or cable bandage through a small incision was needed in the other 17 cases. The average operative time was 46 minutes (range, 21 to 98). Eighteen Seinsheimer type II fractures were left unlocked distally, and static distal interlocking with 1 bolt was carried out in the other 31 cases. No complications such as cutout or breakage of the implants were encountered. Conclusions: This study suggests that long PFN or long gamma nail is a reliable implant for subtrochanteric fractures, leading to high rate of bone union and minimal soft tissue damage. Intramedullary fixation has biological and biomechanical advantages, but the operation is technically demanding. Gradual learning and great patience is needed in order to make this method truly minimally invasive.
Subtrochanteric fractures of the proximal femur have been defined as the fractures involving the area between the lesser trochanter and the isthmus of the femur. Although these fractures are the most difficult to manage in the femur, our improved understanding of the complex biology and biomechanics of the trochanteric region as well as the rapid development of orthopaedic philosophy and implants has led to consensus on the treatment of trochanteric fractures.1 However, the appropriate implant for the internal fixation of subtrochanteric fractures remains debatable; and a multitude of different intra- and extramedullary devices for their surgical fixation have been advocated.2-6 The subtrochanteric region of the femur is subjected to many stresses resulting from bending movements and compressive forces generated by body weight and the hip muscles, thus leading the malunion and nonunion of the fractures and mechanical failure of the implants.7,8
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