A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures. Slotted intramedullary hip screw nails reduce proximal mechanical unloading. Intramedullary fixation of intertrochanteric hip fractures: a comparison of two implant designs. A comparative study of trochanteric fractures treated with the Gamma nail or the proximal femoral nail. Prospective randomized comparison of gliding nail and gamma nail in the therapy of trochanteric fractures. Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal. One and two femoral neck screws with intramedullary nails for unstable trochanteric fractures of femur in the elderly--randomised clinical trial. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail.
In this study, we initiated a prospective, randomised, clinical trial comparing the AMBI, TGN and PFN operations used for treatment of unstable fractures, for differences in intra-operative use, consolidation, complications and functional outcome.
                We have compared the pre-, intra- and post-operating variables of AMBI, TGN and PFN operations that were used for treatment of unstable trochanteric fractures, of 120 patients all above 60 years old diagnosed with extracapsular hip fractures classified as AO Type 31-A2 or Type 31-A3.
                According to our results the three methods are comparable in the treatment of unstable trochanteric fractures of patients above 60 years old.
                The AMBI remains the gold standard for the fractures of trochanteric region. TGN has an easier and faster procedure, facilitates early weight bearing and had minor late complications. An improper use of the PFN system was the reason for the most complications and the longer operation time of the device. PFN is also an accepted minimally invasive implant for unstable proximal femoral fractures but future modification of the implant to avoid Z-effect phenomenon, careful surgical technique and selection of the patients should reduce its high complication rate. The current prospective and randomized study was done to determine whether fixation of intertrochanteric femoral fractures that lack a medial buttress with a dynamically locked intramedullary hip screw prevents proximal stress shielding. Stress shielding was evident by the presence of cortical hypertrophy at the level of the tip of the nail and often was associated with midthigh pain. Of the 80 patients enrolled in this trial, 64 still were alive after 1 year. Among these patients, 30 had the nail classically locked with two screws transfixing the nail in two separate holes (Group A), and 34 had the nail locked with one screw passing through a slot (Group B). The average duration of followup was 37 months (range, 12-49 months). Tolerance to dynamically locked nails was significantly better, with only one patient in Group B having cortical hypertrophy of the femur at the level of the tip of the nail, compared with six patients in Group A. Other outcomes were equal in both groups. Late tolerance to this new dynamically locked intramedullary hip screw is good, while retaining the known advantages of nailing of these fractures. We report a randomised prospective study comparing two implants, the Gamma trochanteric nail and the ACE trochanteric nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and twelve patients were randomised on admission into two treatment groups. Fifty-six patients were treated with Gamma nail implants, and 56 were treated with ACE trochanteric nail. The average age of these patients was 78 years. Twenty fractures were stable and 92 unstable. The mean follow-up time was 8 months (6 -12). Regular clinical and radiological review was done 1, 3 and 6 months postoperatively. Operation time, fluoroscopy time, blood transfusion and complications were recorded. The mobility score was used to assess the pre-injury and postoperative mobility status. All the patients were treated within 36 h of their accident. There were no complications during surgery. All the patients were mobilised in the first 24 h postoperatively, regardless of the fracture type, and weight bearing was permitted as tolerated. Union of the fracture was achieved in all patients. There was no statistically significant difference between the two groups with regard to the studied parameters. There was no mechanical failure of the implants despite the early patient mobilisation. Early operation and early mobilisation resulted in a good functional outcome in all patients. Both the trochanteric gamma nail and ACE trochanteric nail provide effective methods of treatment for intertrochanteric fractures in elderly patients. The aim of the present paper is to compare the results obtained using two osteosynthesis systems developed for the surgical treatment of fractures of the trochanteric region of the femur, based on the principles of closed intramedullary nailing: the Gamma nail and the proximal femoral nail (PFN). A prospective study is presented of 125 trochanteric fractures of the femur treated with PFN and 125 treated with the Gamma nail in our service between the years 1997 and 2000, with the prerequisite of a minimum follow-up of 1 year. Fractures were classified according to the AO system, the most commonly recorded subtype encountered being the A2. Clinical and radiographic controls were performed upon admission and in the post-operative follow-up at 1, 3, 6, and 12 months, the corresponding assessment protocol being completed on each occasion. Of the 250 patients, 179 were women and the rest men. The average age was 78.9 years. Both systems enabled early mobilisation and walking in most of our patients. There were no significant differences in the use of either nail in terms of the recovery of previous functional capacity, nor in terms of the time required for fracture healing (12 weeks on average). With regard to the more significant technical complications recorded, shaft fractures and the cutting-out phenomenon were more common with the use of the Gamma nail, while secondary varus occurred at a greater rate when using the PFN. In a prospective randomized study, we compared the new intramedullary implant of the gliding nail to the gamma nail in the fixation of 80 unstable trochanteric fractures in elderly patients. The preconditions of both groups were comparable. We found no differences concerning the operation time, blood loss, period of stationary treatment or social situation. Also, the anatomic reconstruction and the long-term function according to the Merle d'Aubigne score were comparable. Regarding postoperative complications, the gliding nail showed a minor tendency of cutting out; this we attribute to the special design of the dynamic blade and regard it as the most favourable advantage of this new implant. The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point.
                Prospective, randomized.
                Level 1 trauma center.
                Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled.
                Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used.
                Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function.
                There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion.
                Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome. Intramedullary nailing has been the gold standard in the management of lower limb fractures by virtue of advantage of early joint mobilisation and weight bearing. They are being increasingly used in the peri-trochanteric fractures of femur. Biomechanical studies have proved the supremacy of single femoral neck screw construct over two femoral neck screws along with the intramedullary nails in osteoporotic bones due to lower incidence of complications. This randomised clinical trial was conducted to study the clinico-radiological outcome of single and two-femoral neck screw construct in the management of unstable trochanteric fractures in the elderly osteoporotic bones. Although there was no significant difference in the clinical outcome in the two groups, less sliding of the femoral neck screws was noted with two-femoral neck screw configuration. The tip-apex distance was also significantly lower in the two-screw construct compared to that of the single screw construct. This study to our knowledge is the first randomised control clinical trial evaluating the effectiveness of one and two femoral neck screw configuration of intra-medullary nails in the management of unstable trochanteric fractures. The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.
The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.