Dubrana F, Poureyron Y, Tram J, Genestet M, Rizzo C, Le Nen D, Lefevre C
Service d'Orthopédie et de Traumatologie, CHU Cavale-Blanche, 29609 Brest Cedex, France.
Rev Chir Orthop Reparatrice Appar Mot. 2002 May;88(3):264-70.
The standard gamma nail is commonly used for the treatment of trochanteric fractures but cannot be used if the fracture lies at the level of the distal locking. Theoretically, the long gamma nail would overcome this inconvenience and could be used for all cases of subtrochanteric and trochanteric-shaft fractures.
Clinical and radiological charts were established in 1990 for a multicentric study. The radiology work-up included an AP view of the pelvis and an oblique lateral view of the hip. Two classifications were used: Seinsheimer and Muller as modified by Nazarian. Three stages of fracture reduction were recorded: 1=anatomic reduction, 2=acceptable reduction, 3=poor reduction. From January 1995 to December 1999, 46 patients were treated with the long gamma nail. Twenty-four cases were excluded for various reasons (from which 3 early death). 22 remaining patients were followed for more than six months. Mean age was 68 years (range 42-96); there were six women and 16 men. Ten patients were traffic or work accident victims and 12 had had a home accident.
Mean duration of surgery was 70 minutes. Three patients required revision surgery within a week of the initial osteosynthesis. Mean hemoglobin level before surgery was 12.9 g/dl; 8.9 g/dl during the first postoperative week. Mean hospital stay was 14 days. Weight-bearing with support was possible early after surgery in 16 patients who walked with crutches or a walker. Mean delay to weight-bearing was 11 days. At three months, all patients were using an aid for walking; at six months, four patients used a walker. Bone healing was achieved on the average at the twelfth week. Radiological reduction was anatomic in four, acceptable in three and poor in 15.
We advocate the AO classification as it allows a structured analysis of all fractures within a unique system. We compared our results with nine series reported in the literature using other therapeutic methods (screw-plate, nail-plate, Ender nail). The operative time for the long gamma nail (70 min) was comparable with that for other surgical techniques. Treatment with the long gamma nail favors bone healing and limits the risk of infection. Radiological results in our series were poor, but there were no cases with nonunion and the morbidity was low.
标准伽马钉常用于治疗转子间骨折，但如果骨折位于远端锁定水平则无法使用。从理论上讲，长伽马钉可以克服这一不便，可用于所有转子下和转子下-骨干骨折病例。
1990年建立临床和放射学图表用于多中心研究。放射学检查包括骨盆前后位片和髋部斜位片。采用了两种分类方法：经纳扎里安修改的塞因斯海默分类法和米勒分类法。记录了骨折复位的三个阶段：1 =解剖复位，2 =可接受复位，3 =复位不佳。1995年1月至1999年12月，46例患者接受了长伽马钉治疗。24例因各种原因被排除（其中3例早期死亡）。其余22例患者随访超过6个月。平均年龄68岁（范围42 - 96岁）；女性6例，男性16例。10例患者为交通或工作事故受害者，12例为家庭事故受害者。
平均手术时间为70分钟。3例患者在初次骨固定术后一周内需要翻修手术。术前平均血红蛋白水平为12.9 g/dl；术后第一周为8.9 g/dl。平均住院时间为14天。16例使用拐杖或助行器行走的患者术后早期即可在支撑下负重。平均负重延迟时间为11天。3个月时，所有患者均使用辅助器具行走；6个月时，4例患者使用助行器。平均在第12周实现骨愈合。放射学复位中解剖复位4例，可接受复位3例，复位不佳15例。
我们提倡使用AO分类法，因为它能在一个统一的系统内对所有骨折进行结构化分析。我们将我们的结果与文献中报道的使用其他治疗方法（螺钉钢板、钉板、恩德尔髓内钉）的9个系列进行了比较。长伽马钉的手术时间（70分钟）与其他手术技术相当。长伽马钉治疗有利于骨愈合并限制感染风险。我们系列的放射学结果不佳，但没有骨不连病例，且发病率较低。
