The early failure of the gamma nail and the dynamic hip screw in femurs with a wide medullary canal. A biomechanical study of intertrochanteric fractures

Background: Intertrochanteric fractures may occur in a bone with a wide medullary canal that may lead to significant mobility of a intramedullary nail, contrary to an extramedullary device. This study evaluates the Dynamic Hip Screw and the gamma nail in AO 31.A2.1 fractures in these circumstances. Methods: Synthetic femora with canals drilled to 18 mm were used. Five fixation types were examined: a 2 - hole and a 4 - hole Dynamic Hip Screw with a 2 - hole plate, a standard gamma nail with dynamic and static distal locking and a long gamma nail. The specimens were tested with cyclic axial loading, from 500 N increasing of 50 N increments in each cycle. Force at failure, overall stiffness, stiffness at the fracture site, location and mode of failure were recorded. Findings: The short gamma nails dislocated into varus under preload because the nail migrated laterally. The Dynamic Hip Screw was initially stable, but some specimens rotated around the lag screw. The gamma nail was rotationally stable. Both implants failed through femur fracture, The long gamma nailed failed by screw cut - out at forces lower than the ultimate force of the short gamma nail. Interpretation: This study shows that the gamma nail is unstable in a large medullary canal but offers better rotational stability of the proximal fragment. A modification of the nail design or the operative technique may be considered.