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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1535-1542

Comparative study of gamma nail versus dynamic hip screw for the treatment of intertrochanteric hip fractures


1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, Hosh Eisa Central Hospital, Ministry of Health, El Beheira Governorate, Egypt

Date of Submission30-Jan-2022
Date of Decision16-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Mahmoud H Elsayed Basiouny
Sheta Street, Talaat Harb Neighborhood, Kafr Eldawar City, Elbehira Governorate 22628
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_42_22

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  Abstract 


Objectives
To compare the clinical and radiological outcomes between gamma nail and dynamic hip screw (DHS) in the treatment of intertrochanteric hip fractures in Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification subgroup 31-A1.3.
Background
In recent years, intertrochanteric fractures have become more prevalent, with a death rate of 30% within 5 years of the fracture. Trauma with high energy (rare; found in young male patients) or simple falls with low energy can cause intertrochanteric hip fractures (common; seen in elderly female patients).
Patients and methods
A prospective study was carried on 34 patients with intertrochanteric hip fractures, AO classification subgroup 31-A1.3, who were operated on using DHS or gamma nail, with 17 cases managed by DHS (group I) and 17 cases managed by gamma nail (group II). Inclusion criteria were skeletally mature (adult) and intertrochanteric fracture of the hip, AO subgroup 31-A1.3.
Results
In terms of functional grading, group I had 14 satisfactory outcomes and only three unsatisfactory results, whereas group II had 15 satisfactory results and only two unsatisfactory results; nevertheless, there were statistically insignificant differences in anatomical grading. For groups I and II, the percentage of patients who needed fewer than 12 weeks for union was 76.5 and 82.3%, respectively, and the mean time was 10 ± 2 and 9 ± 2 weeks, respectively. The union time discrepancies were not statistically significant.
Conclusion
Both gamma III nail and DHS techniques had satisfactory outcomes, namely, functional and anatomical. In addition, age, sex, medical history, and fracture classification had no influence on the outcome, may be because of the stable pattern of fracture enrolled in our study.

Keywords: dynamic hip screw, gamma nail, intertrochanteric hip fractures


How to cite this article:
Badawy EB, El-Mowafy HM, Ghonim HF, Basiouny MH, Elagroudy EE. Comparative study of gamma nail versus dynamic hip screw for the treatment of intertrochanteric hip fractures. Menoufia Med J 2022;35:1535-42

How to cite this URL:
Badawy EB, El-Mowafy HM, Ghonim HF, Basiouny MH, Elagroudy EE. Comparative study of gamma nail versus dynamic hip screw for the treatment of intertrochanteric hip fractures. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1535-42. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1535/359506




  Introduction Top


Intertrochanteric hip fractures are a typical complication of low-energy accidents, resulting in severe functional impairment and high socioeconomic burden[1]. These are fractures in the trochanteric area, which is bounded on the proximal side by the femur's neck and on the distal side by the lesser trochanter level. With the subtrochanteric extension variation, it may extend below the lesser trochanteric, forming a trochanteric fracture[2].

Intertrochanteric fractures have become more common in recent years, with a death rate of 30% within 5 years of the fracture[3]. Intertrochanteric fractures can be caused by trauma with high energy (rare; seen in young male patients) or simple low-energy falls (common; seen in elderly female patients). Intertrochanteric fractures with low energy are produced by a combination of increased fragility of the bone in the intertrochanteric part of the femur and age-related reduction in agility and muscle tone in this area[4].

A direct influence or a torsional force passed through the leg to the intertrochanteric area would result in a fracture when such forces are greater than the strength of the bone in the intertrochanteric area[5]. Patients with intertrochanteric fractures are less mobile and more dependent on their caregivers. The management of individuals with intertrochanteric hip fractures has vastly improved since the advent of internal fixations (IFs)[6]. As a result, IF is currently regarded a first-line treatment choice for patients who want early postoperative mobilization, good functional recovery, and fewer complications[7]. Since their development and promotion, IF devices have become more diverse, providing orthopedic surgeons more options, such as extramedullary fixation [e.g., dynamic hip screw (DHS)] or IF (e.g., gamma nail)[8].

For treating trochanteric fractures, there are many devices used depending on two osteosynthesis procedures: the screw-plate and nailing systems[9]. A plethora of studies have compared screw-plate devices like the DHS to intramedullary nailing systems like the gamma nail. Most studies show no significant differences between the two systems[10]. The gamma nail was first used to treat peritrochanteric fractures in 1981 (Stryker Howmedica, Rutherford)[11]. The gamma nail received widespread clinical acceptability, but it had a number of drawbacks in terms of nail implantation and postoperative follow-up. The third generation (gamma III nail) was introduced in 2004 (Stryker) to avoid the inadequacies of the older gamma nail generation. It was created to use locked intramedullary nailing and lag screw fixation techniques[12].

The DHS is the most commonly used and well-studied implant for extracapsular hip fractures. It is an extramedullary fixation device that works by supporting the fracture while permitting the screw to glide in the barrel, allowing for controlled fracture collapse[13]. The device's proposed benefits include low cost, reduced blood loss, ease of use, low reoperation rate, and a thriving functional outcome[14]. The aim of the work was to compare the clinical and radiological outcome between gamma nail and DHS regarding the management of intertrochanteric fractures Arbeitsgemeinschaft für Osteosynthesefragen classification subgroup 31-A1.3.


  Patients and methods Top


Before conducting the study, an approval was obtained from the ethical research committee of the Faculty of Medicine, Menoufia University, before the beginning of the study.

A prospective study was conducted on 37 patients with intertrochanteric fractures Arbeitsgemeinschaft für Osteosynthesefragen classification subgroup 31-A1.3, who were included in this study from those consecutively admitted to the Department of Orthopedic Surgery and Traumatology in Hosh Eissa Hospital at El Beheira Governorate and Orthopedic Department at Menoufia University Hospital. Probability systematic random sampling technique of patients was included in this study, in which cases were treated by gamma nail, and then the next patient by DHS, following the same sequence. All patients were operated on within the first 2 weeks of injury.

They were operated on using gamma nail or DHS. A total of 18 cases were managed by DHS (group I) and 19 cases were managed by gamma nail (group II), but three cases were lost to follow-up, one of them treated by DHS and two by gamma nail; therefore, a total of 34 patients, 17 for each group, were included. Data collection period was from November 2019 to January 2021, and the follow-up up period for each patient was 6 months. The inclusion criteria in this study included skeletally mature (adult) and intertrochanteric hip fractures subgroup 31-A1.3. The exclusion criteria in this study included open fracture, pathological fracture, and nonunited fractures.

All patients had been examined at the time of hospitalization, and assessment was done by clinical examination to exclude other injuries, radiological evaluation of the fracture by plain radiograph on the femur showing hip and knee (anteroposterior and lateral views), and laboratory investigations such as preoperative assessment in the form of routine laboratory investigations (renal function test, complete blood picture, coagulation profile, random blood sugar, and liver function test).

Methods of treatment included the following: (a) preoperative management: plain radiograph images showing an anteroposterior view of the pelvis, encompassing both hip joints in 15° internal rotation, and the hip joint lateral view was acquired after primary stabilization of the patient, where stabilization of the patient included skin traction of the injured limb and maintaining general condition such as correction of both anemia and dehydration by transfusion of suitable infusions or blood transfusion if necessary. (b) Preoperative antibiotic prophylaxis: wide-spectrum antibiotics in the form of intravenous 1 g of third-generation cephalosporins was given an hour before surgery. (c) Anesthesia: depending on the anesthesia specialist, spinal or general anesthesia was used. The patient was transported to the traction table after the anesthetic was delivered. (d) Treatment of group I was done by DHS and group II by gamma nail. (e) Postoperative and follow-up for both groups: partial weight bearing was allowed after surgery if the reduction was stable. Full weight bearing was not permitted until the fracture had healed enough. Patients were re-examined at 2 weeks for suture removal, 6 weeks, 12 weeks, and 6 months for follow-up radiographs.

Methods of statistical analysis

The data that were supplied into the computer were analyzed using the IBM SPSS software programme, version 25.0 (IBM Corp., Armonk, New York, USA). To describe qualitative data, we used number and percentage. To ensure that the distribution was normal, the Kolmogorov–Smirnov test was applied. Quantitative data were described using range (minimum and maximum), mean, SD, and median. The significance of the acquired results was determined at a 5% level of significance. The used tests were Monte-Carlo correction or Fisher's exact, χ2 test, Student t test, Wilcoxon signed-rank test, and Mann–Whitney test.


  Results Top


The disparities in demographic data and clinical data of patients between the two groups are depicted in [Table 1]. With respect to sex distribution, there were 10 females and seven males in group I, whereas group II had nine females and eight males. The most common occupational category in group I was housewife (47%) followed by retired (35%), then work (11.8%), and no work (5.9%), whereas in group II, the most common category was retired, with an incidence of 41% and then followed by housewife (35.3%). The two studied groups were similar also in age distribution, with 10 patients above 65 years and seven patients below for each group, and the mean age was 64.30 ± 3.31 and 64.75 ± 3.51 years for groups I and II, respectively.
Table 1: Comparison between the two studied groups according to demographics data

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Regarding the mode of trauma, group one had 13 patients who fell down and only four patients had road traffic accident, whereas in group II, five patients had road traffic accident and 12 patients fell down [Table 1].

A total of nine patients in group I had diabetes mellitus (DM) and hypertension (HTN), whereas 10 patients in group II had DM and HTN, and patients with no significant medical history represented eight in group I and seven in group II. [Table 1] demonstrates that no statistically significant differences existed between the two groups according to medical history. No patient in either group had associated injury.

Method of evaluation: to compare between the two groups [group I (DHS) and group II (gamma nail)] as a method of treatment of peritrochanteric hip fractures, the Foster grading System, which was developed to evaluate treatment outcomes in traumatic trochanteric fractures of the femur, was chosen. Foster grading is a double grading system that separates functional results from anatomical results. Functional grading is considered the most important as it is more important for a high-risk patient to walk with slight varus deformity of the hip than to have a perfect position of union without walking.

Comparison between the two groups regarding function and anatomical grading revealed the following: according to the functional grading, the results were satisfactory in 14 and nonsatisfactory in three for group I, whereas group II had 15 satisfactory results and only two nonsatisfactory results; however, differences were found in anatomical grading, but again, the differences were not statistically significant. It is worth mentioning that satisfactory results are defined as good or excellent union and unsatisfactory results defined as poor or fair union [Table 2].
Table 2: Comparison between the two studied groups according to results

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Regarding the comparison between the two groups according to time of union, the differences in union time are illustrated in [Table 3]. The percentage of patients who needed less than 12 weeks for union was 76.5 and 82.3% for groups I and II, respectively, and the mean time was 10 ± 2 and 9 ± 2, respectively. The differences in the union time were not statistically significant. Most patients had right-sided fracture (52.94% for group I and 70.62% for group II); however, the differences in lesion side were not significant statistically (P = 0.749) [Table 3].
Table 3: Comparison between the two studied groups according to time of union

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Regarding the comparison between the two groups according to operative parameters, the mean duration before surgery 3.75 ± 2.45 days for both groups, the mean time of surgery was 64.75 ± 7.86 min for group I and 63.50 ± 8.13 min for no satisfactory group II, and 70.6% of patients in group I needed blood transfusion, whereas only 29.4% of patients needed blood transfusion in group II. The differences in all operational parameters were not significant [Table 4].
Table 4: Comparison between the two studied groups according to operation data

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Relation between functional and anatomical results revealed that in group I, there was no statistically significant association between functional and anatomical results; however, in group II, the relationship was statistically significant [Table 5].
Table 5: Relation between functional results and anatomical results in each group

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Case presentation

Case no. 1 [Figure 1] and [Figure 2]:
Figure 1: Plain radiograph showing anterior and posterior lateral views of right hip showing the trochanteric fracture before fixation.

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Figure 2: Plain radiograph showing anterior and posterior lateral views of right hip showing the trochanteric fracture after 3 months postoperatively of fixation by DHS. DHS, dynamic hip screw.

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  1. Patient profile: a 41-year-old male patient, retired from Hosh Essa El Behara Governorate, had road traffic accident and experienced intertrochanteric fracture of the right femur. No other injuries were reported. No pre-existing medical diseases and no previous operations were noted. The surgery was done on the second day after the trauma.
  2. Fracture grading: intertrochanteric fracture A/O 31-A13.
  3. Treatment modality: open reduction IF by DHS.
  4. Intraoperative difficulties: none.
  5. Postoperative program: we postponed partial weight bearing until 6 weeks after surgery.
  6. Follow-up period: 3 months.
  7. Complication: none.
  8. Final result: there was no infection, and the fracture united and consolidated within 8 weeks. The postoperative walking level was excellent with a full range of motion and minimal hip or knee pain.
  9. Postoperative score: excellent.


Case no. 2 [Figure 3],[Figure 4],[Figure 5]:
Figure 3: Plain radiograph showing anteroposterior of left hip the trochanteric fracture before fixation.

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Figure 4: Plain radiograph showing lateral view of left hip showing the trochanteric fracture before fixation.

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Figure 5: (a) Anterior and posterior plain radiograph of left hip after 3 months of gamma nail fixation of trochanteric fracture. (b) Lateral view plain radiograph of left hip after 3 months of gamma nail fixation of trochanteric fracture.

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  1. Patient profile: a 55-year-old male patient, a teacher from Hosh Essia El Behara Governorate, fell down and experienced intertrochanteric fracture of the left femur. No other injuries were noted. The patient had a medical history of DM and HTN and no previous operations. The surgery was done on the 3 day from trauma.
  2. Fracture grading: intertrochanteric fracture A/O 31-A13.
  3. Treatment modality: closed reduction IF gamma III nail.
  4. Intraoperative difficulties: none.
  5. Postoperative program: we postponed partial weight bearing until 6 weeks after surgery.
  6. Follow-up period: 3 months.
  7. Complication: none.
  8. Final result: there was no infection, and the fracture united and consolidated within 10 weeks. The postoperative walking level was excellent with a full range of motion and minimal hip or knee pain.
  9. Postoperative score: excellent.



  Discussion Top


As the population ages, hip fractures are becoming increasingly common in various parts of the world. Trochanteric and femoral neck fractures are the most typical kinds of hip fractures, with death rates ranging from 15 to 30% in the United States[15]. Early mobilization and fewer problems are possible with surgical therapy with stable fixation. Plate fixation (DHS) and intramedullary implants (gamma III nail) are the two main stabilization methods for trochanteric fractures[16] The DHS has long been the gold standard in the treatment of trochanteric fractures.

However, as compared with intramedullary implants, it has a biomechanical disadvantage owing to the higher distance between the implants and the weight-bearing axis. In recent years, the gamma III nail has been popular for treating trochanteric fractures[17]. Despite the fact that there have been multiple reports demonstrating the benefits of gamma III nail[18]. It was still linked to technological failures. Gamma III nail is also much more expensive than DHS[19].

Our biggest observation in this study was that the two techniques had the same outcome regarding functional and anatomical grading according to the Foster score for functional and anatomical grading, which meant more than 80% of cases had satisfactory results for both groups, specifically five patients with excellent functional grading, nine patients good, two fair, and one patient poor in group I (DHS). In group II (gamma nail), there are five patients with excellent functional grading, 10 patients with good, one patient with fair, and one patient with poor. Regarding anatomical grading, we found five excellent patients, 10 good, two fair, and no poor cases in group I (DHS), whereas in group II (gamma nail), there were four excellent patients, 12 good, one fair, and no poor cases also. Therefore, there were no statistically significant differences between both groups in the treatment of intertrochanteric fractures.

Regarding the time of union, in our study, group I (DHS) had 75% of patients who united in less than 12 weeks, whereas group II (gamma nail) had 81% of patients who united in less than 12 weeks. There was no statistically significant relation between time of union and the functional and anatomical outcomes in both groups. The intraoperative parameters like blood transfusion were in favor of gamma nail, where cases treated with DHS were more vulnerable to blood transfusion, and the duration of surgery was comparable.

Our findings are in agreement with Saarenpää et al.[20]. The purpose of this prospective study was to look at the short-term outcomes of DHS fixation and gamma nail, focusing on functional features, reoperations, and mortality. There were 134 patients in each group. There were no significant differences between the DHS and gamma nail groups when it came to the site of residence at 4 months or returning to the prefracture dwelling (78 vs. 73%, P = 0.224). When compared with the prefracture state, the DHS group demonstrated a better walking ability change at 4 months (P = 0.042), despite the fact that there was no difference in the way used for walking assistance. The DHS group had a decreased frequency of reoperations throughout the first year (8.2 vs. 12.7%, P = 0.318). Finally, the researchers found that both procedures were effective in treating trochanteric femoral fractures, albeit the results favored DHS fixation in terms of walking ability and mortality.

However, the study by Sharma et al.[21] aimed to analyze and compare the clinical and radiological outcomes of patients with stable intertrochanteric fractures treated with proximal femoral nail versus DHS, and the results showed that the DHS group had a marginally lower 1-month Harris Hip Score than the proximal femoral nail group. However, the DHS group had higher mean scores than the proximal femoral nail group at the 3- and 6-month follow-up visits; at the 1-year follow-up, both groups had similar scores, leading to the conclusion that the proximal femoral nail provides a significantly shorter surgery with a smaller incision, resulting in fewer wound-related complications. When comparing the proximal femoral nail to the DHS, the rate of technical errors was substantially higher in the proximal femoral nail due to the fact that it is a technically more challenging surgery, which results in more implant failures and reoperations.

Jewell et al.[22] mismatched our results as they found quite different outcome success rates. They wanted to test the hypothesis that gamma III nail would provide a stronger build than the DHS plate, and they came to the conclusion that the gamma III nail would be especially useful in patients with poor-quality, osteoporotic bone, and unstable fracture topologies.

Giessauf et al.[23] studied 62 patients with intertrochanteric fractures fixed with the gamma III nail. The patients' ages ranged from 23 to 79 years, with a mean of 57.6 years. They found that fair and poor functional outcomes (33%) were concentrated in the older patient groups. This coincides with the results in this study, where age significantly affected the functional results, as there were three patients out of 17 patients who had unsatisfactory functional Foster's grading, and those patients were older than 65 years. So, we considered that the younger the patient's age the better the functional results.

Giessauf et al.[23] studied the results of treatment of intertrochanteric fractures by gamma III nail in 61 patients, comprising 35 males and 26 females. They found no significant correlation between the sex of the patients and the final functional outcome of the patients. In our study, 17 patients were treated with gamma III nail, comprising eight male patients and nine female patients. There was no significant correlation between the sex of the patient and the final anatomical or functional results.


  Conclusion Top


For the treatment of intertrochanteric hip fractures, both DHS and gamma III nail methods demonstrated good functional and anatomical outcomes. Both techniques are comparable without significant merits of one technique over the other one. In addition, age, sex, medical history, and fracture classification have no influence on the outcome may be because of the stable pattern of fracture enrolled in our study. Therefore, postoperative rehabilitation, rate of healing of these fractures, and results were found acceptable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahn J, Bernstein J. Fractures in brief: intertrochanteric hip fractures. Clin Orthop Relat Res 2010; 468:1450–1452.  Back to cited text no. 1
    
2.
Baumgaertner M, Oetgen M. Intertrochanteric hip fractures. In: Browner B, Jupiter J, Levine A, Trafton P, (editors). Skeletal trauma: basic science, management, and reconstruction. Philadelphia, PA: Elsevier; 2008. 115–133.  Back to cited text no. 2
    
3.
Lee SH, Chen IJ, Li YH, Fan Chiang CY, Chang CH, Hsieh PH. Incidence of second hip fractures and associated mortality in Taiwan: a nationwide population-based study of 95,484 patients during 2006-2010. Acta Orthop Traumatol Turc 2016; 50:437–442.  Back to cited text no. 3
    
4.
Suthar PP, Patel CD, Gamit M, Dave DJ, Wadhwani C, Suthar BP. Orthopaedic aspect of anatomy and radiology of proximal femur. Int J Res Med Sci 2017; 3:1820–1824.  Back to cited text no. 4
    
5.
Della Rocca GJ, Moylan KC, Crist BD, Volgas DA, Stannard JP, Mehr DR. Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil 2013; 4:10–15.  Back to cited text no. 5
    
6.
Browner B, Levine A, Jupiter J, Trafton P, Krettek C. Skeletal trauma E-book: expert consult. London: Elsevier Health Sciences; 2003.  Back to cited text no. 6
    
7.
Arslan A, Utkan A, Koca TT. Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures. Indian J Orthop 2016; 50:636–640.  Back to cited text no. 7
    
8.
Kanakaris NK, Tosounidis TH, Giannoudis PV. Nailing intertrochanteric hip fractures: short versus long; locked versus nonlocked. J Orthop Trauma 2015; 29 (Suppl 4):S10–S16.  Back to cited text no. 8
    
9.
Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res 1980; 146:53–61.  Back to cited text no. 9
    
10.
Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001; 15:394–400.  Back to cited text no. 10
    
11.
He W, Zhang W. The curative effect comparison between prolonged third generation of gamma nail and prolonged dynamic hip screw internal fixation in treating femoral intertrochanteric fracture and the effect on infection. Cell Biochem Biophys 2015; 71:695–699.  Back to cited text no. 11
    
12.
Yang E, Qureshi S, Trokhan S, Joseph D. Gotfried percutaneous compression plating compared with sliding hip screw fixation of intertrochanteric hip fractures: a prospective randomized study. J Bone Joint Surg Am 2011; 93:942–947.  Back to cited text no. 12
    
13.
Koval K, Zuckerman J. Trochanteric fractures. In: Koval K, (editor). Handbook of fractures. 3rd ed. Philadelphia: JB Lippincott Company; 2006. 38–49.  Back to cited text no. 13
    
14.
Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018; 32 (Suppl 1):S1–s170.  Back to cited text no. 14
    
15.
Canale ST, Beaty JH. Campbell'soperative orthopaedics. 11th ed. St Louis, MO, USA: Mosby/Elsevier, USA; 2007.  Back to cited text no. 15
    
16.
Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2010; 9:Cd000093.  Back to cited text no. 16
    
17.
Gadegone WM, Salphale YS. Proximal femoral nail – an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop 2007; 31:403–408.  Back to cited text no. 17
    
18.
Huang Z, Liu X, Su J. Dynamic hip screw vs. proximal femur nail in treatment of intertrochanteric fractures in patients aged over 70 years old. Shanghai Med J 2010; 33:1042–1049.  Back to cited text no. 18
    
19.
Pires RE, Santana EOJr, Santos LE, Giordano V, Balbachevsky D, Dos Reis FB. Failure of fixation of trochanteric femur fractures: clinical recommendations for avoiding Z-effect and reverse Z-effect type complications. Patient Saf Surg 2011; 5:17.  Back to cited text no. 19
    
20.
Saarenpää I, Heikkinen T, Ristiniemi J, Hyvönen P, Leppilahti J, Jalovaara P. Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients. Int Orthop 2009; 33:255–260.  Back to cited text no. 20
    
21.
Sharma A, Sethi A, Sharma S. Treatment of stable intertrochanteric fractures of the femur with proximal femoral nail versus dynamic hip screw: a comparative study. Rev Bras Ortop 2018; 53:477–481.  Back to cited text no. 21
    
22.
Jewell DP, Gheduzzi S, Mitchell MS, Miles AW. Locking plates increase the strength of dynamic hip screws. Injury 2008; 39:209–212.  Back to cited text no. 22
    
23.
Giessauf C, Glehr M, Bernhardt GA, Seibert FJ, Gruber K, Sadoghi P, et al. Quality of life after pertrochanteric femoral fractures treated with a γ nail: a single center study of 62 patients. BMC Musculoskelet Disord 2012; 13:214.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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