Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance?

Background: Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. Methods: In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. Results: No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. Conclusions: Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.

Plate Fixation for Atypical Fractures of the Femoral Diaphysis.

Background: Plate fixation for atypical femoral fractures has shown high failure rates compared to intramedullary nail fixation. The aim of this study was to evaluate the radiological results of patients treated with a plate and screws for atypical fractures of the femoral diaphysis. Methods: This study was conducted retrospectively on 16 patients who had undergone internal fixation using plates for treatment of atypical femoral complete fractures from 2007 to 2015. Nine patients were treated with lag screws and short plates while 7 patients were treated with position screws and long plates, which covered the whole femur. Radiologic evaluation was performed on all patients. Complications were also evaluated. Results: Bone union was achieved in all patients and the average bone union time was 17.7 weeks (range, 14-28 weeks). There was no correlation between the preoperative use of a bisphosphonate, plate length, postoperative teriparatide use, and the time to bone union. Regarding complications, 2 cases of complete fractures and 1 impending fracture occurred at the end of short plates. Conclusions: Satisfactory results were obtained with use of plates for patients with atypical femoral complete diaphyseal fractures, in whom intramedullary nails could not be applied due to severe bowing. In particular, it seemed advantageous compared with intramedullary nail fixation in that it could maintain the leg length through anatomical reduction and prevent iatrogenic fracture.

Osteoperiosteal Decortication and Autogenous Cancellous Bone Graft Combined with Bridge Plating for Non-hypertrophic Diaphyseal Nonunion.

BACKGROUD: The aim of this study was to evaluate results of osteoperiosteal decortication and autogenous cancellous bone graft combined with a bridge plating technique in atrophic and oligotrophic femoral and tibial diaphyseal nonunion. METHODS: We retrospectively reviewed 31 patients with atrophic or oligotrophic femoral and tibial diaphyseal nonunion treated with osteoperiosteal decortication and autogenous cancellous bone graft between January 2008 and December 2018. Patients with hypertrophic nonunion, infected nonunion, and nonunion treated with autogenous cancellous bone graft alone were excluded. The nonunion site was exposed by using the Judet technique of osteoperiosteal decortication. Nonunion with a lack of stability was stabilized with a new plate using a bridge plating technique or augmented by supplemental fixation with a plate. Nonunion with malalignment was stabilized with a new plate after deformity correction. Autogenous cancellous bone graft was harvested from the posterior iliac crest and placed within the area of decortication. A basic demographic survey was conducted, and the type of existing implants, mechanical stability of the implants, the type of implants used for stabilization, the operation time, the time to bone union, and postoperative complications were investigated. RESULTS: The average follow-up period was 33.3 months (range, 8-108 months). The operation time was 207 minutes (range, 100-351 minutes). All but 1 nonunion (96.7%) were healed at an average of 4.2 months (range, 3-8 months). In 1 patient, bone union failed due to implant loosening with absorbed bone graft, and solid union was achieved by an additional surgery for stable fixation with a new plate, osteoperiosteal decortication, and autogenous cancellous bone graft. There were no other major complications such as neurovascular injuries, infection, loss of fixation, and malunion. CONCLUSIONS: Osteoperiosteal decortication and autogenous cancellous bone graft combined with stable fixation by bridge plating showed reliable outcomes in atrophic and oligotrophic diaphyseal nonunion. This treatment modality can be effective for treating atrophic and oligotrophic diaphyseal nonunion because it is very helpful stimulating bone union.

Straight nail insertion through a laterally shifted entry for diaphyseal atypical femoral fractures with bowing: good indications and limitations of this technique.

PURPOSE: Inserting a straight (piriformis fossa entry) nail through the tip of the greater trochanter has been used for treating atypical femoral fractures (AFFs) with bowing. This study aimed to determine what degree of bowing can be successfully treated using a laterally shifted entry technique. METHODS: Twenty-three complete and six incomplete diaphyseal AFFs treated using the shifted entry technique were retrospectively analysed. Radiologic parameters and complications were evaluated. The complete AFFs were divided into two groups based on the severity of preoperative bowing: grade 0-II bowing and < 20° lateral bowing (minimal/moderate) and grade III bowing or ≥ 20° lateral bowing (severe). Comparison according to postoperative malalignment, a change of lateral or anterior bowing ≥ 5° was also performed. RESULTS: Three complete AFFs in the minimal/moderate group showed malalignment, as did all in the severe group (p < 0.001). The change of bowing was greater for the severe group in lateral and anterior bowing (p = 0.004 and 0.001, respectively). A greater fracture gap was found on AP and lateral radiographs in the severe group (p = 0.044 and 0.026, respectively). In the comparison according to postoperative malalignment, a significant difference was found for the percentage of severe deformity (p < 0.001). All incomplete AFFs were united without complication. CONCLUSION: Diaphyseal AFFs with grade 0-II bowing and < 20° anterior bowing were treated successfully by the shifted entry technique. However, postoperative malalignment was found in all cases of AFFs with severe bowing. Therefore, other techniques should be considered for AFFs with grade III bowing or ≥ 20° anterior bowing.

Surgical outcomes of intramedullary nailing for diaphyseal atypical femur fractures: is it safe to modify a nail entry in bowed femur?

INTRODUCTION: The purpose of the study was to determine the surgical outcomes of intramedullary nailing in diaphyseal atypical femoral fractures (AFFs) and to evaluate the clinical outcomes of nail entry modification technique. MATERIALS AND METHODS: We retrospectively reviewed diaphyseal AFFs treated with IMN at nine institutions. In total, 82 patients were included. Surgical outcomes such as complication, union time, and femoral bowing were evaluated. We modified the nail entry of the straight nail from piriformis fossa to the tip of the greater trochanter in the bowed femur and compared the surgical outcomes between the original group and the modification group. RESULTS: The average union time was 20.1 weeks, and the union rate was 89.0%. The average union time was 13.1 weeks and 21 weeks in incomplete and complete AFFs, respectively. There was no nonunion in incomplete AFFs, but 13.8% in complete AFFs. Complete AFFs had 86.2% of union rate. There were 46 cases of group 1 with original entry point and 19 cases of group 2 with modified entry. In group 2, the union rate was similar to group 1 and union time was shorter. CONCLUSION: Changing the entry point laterally allowed the nail to be accommodated in bowed femurs, decreasing the risk of deformity and improving healing time. In severely varus femur, the lateral entry of the straight nail can be a useful technique.

Factors affecting fracture location in atypical femoral fractures: A cross-sectional study with 147 patients.

INTRODUCTION: Many studies have tried to determine the characteristics of atypical femoral fractures (AFFs) through age-, sex-, and ethnicity-matched comparison with non-AFFs. However, we hypothesized that diaphyseal AFFs would have characteristics different from those of subtrochanteric AFFs. The aim of this study was to evaluate the clinical features of diaphyseal/subtrochanteric AFFs and determine the factors related to fracture location. PATIENTS AND METHODS: One hundred forty-seven patients with AFF were enrolled, 114 patients (78%) had a history of bisphosphonate use. Forty-nine patients (33%) had bilateral lesion, and 35% of patients had thigh pain. Patients were divided into two groups according to fracture location: 52 patients (35.4%) with subtrochanteric AFF and 95 patients (64.6%) with diaphyseal AFF. The patient demographics and fracture characteristics of the two groups were compared. Multivariate logistic regression analysis was used to adjust for variables related to fracture location. RESULTS: The patients in the diaphyseal AFFs group were older and had lower BMI, lower BMD, and larger lateral and anterior bowing. Multivariate analysis revealed that age greater than 65 years and low BMD were related with diaphyseal location. With greater lateral bowing angle, the AFF location was moved from the subtrochanteric area to the diaphyseal area. CONCLUSION: This study demonstrated that patients with diaphyseal AFFs had different characteristics compared with those with subtrochanteric AFFs.

Abductor Reconstruction with Gluteus Maximus Transfer in Primary Abductor Deficiency during Total Hip Arthroplasty.

Abductor deficiency in native hip joint may cause severe limping and pain. It is more serious situation in case of arthroplasty due to instability and recurrent dislocation. Well-known causes of abductor deficiency are repeated surgery, chronic trochanteric bursitis, superior gluteal nerve injury, failure of repair of abductor tendon insertion to the greater trochanter. Author had experienced primary abductor deficiency during total hip replacement and treated successfully with the transfer of gluteus maximus. We'd like to introduce the operation technique with the review of literature.

Three-dimensional correlation between trochanteric fossa and the ideal entry point for antegrade femoral nailing.

PURPOSE: To verify the practical correlation between the topographical features of the femur neck base and the ideal entry point by analyzing three-dimensional (3D) models virtually implanted with an antegrade femoral nail. MATERIALS AND METHODS: A total of 103 cadaveric femurs (50 males and 53 females) were enrolled. Specimens underwent continuous 1.0mm slice computed tomography (CT) scans. CT images were rendered into 3D images using image-processing software (Mimics®) to reconstruct the geometry of the cortex and medullary canal. A real cannulated femoral nail (CFN)® was processed into a 3D image using a 3D sensor at the actual size and optimally placed in the femur model using Mimics® for virtual implantation. The correlation between the ideal entry point in the cranial view of the proximal femur and the trochanteric fossa was assessed and overlap of trochanter overhang was verified. RESULTS: The entry point of 68 models (66.0%) was the trochanteric fossa, while the others were placed around the anterior border of the trochanteric fossa. The proximal end of the nail overlapped in 50 models (48.1%), and among them, the central point of 23 models (22.3%) was obscured by trochanteric overhang. There was a statistically significant risk associated with female gender (6.02 times) and type IV overhang of Grenchenig's classification (4.56 times). Despite the precise positioning of the trochanteric fossa, 11 models (10.7%) had the entry point covered by trochanteric overhang. CONCLUSION: The ideal entry point was over the trochanteric fossa in just half of the models, and could be hindered by trochanteric overhang even though the CFN was ideally positioned.

Incidence of Avascular Necrosis of the Femoral Head After Intramedullary Nailing of Femoral Shaft Fractures: A Multicenter Retrospective Analysis of 542 Cases.

The goal of this study was to determine the incidence of avascular necrosis of the femoral head (AVNFH) after intramedullary nailing of femoral shaft fractures and to identify risk factors for developing AVNFH.We retrospectively reviewed all patients with femoral shaft fractures treated with antegrade intramedullary nailing at 10 institutions. Among the 703 patients enrolled, 161 patients were excluded leaving 542 patients in the study. Average age was 42.1 years with average follow-up of 26.3 months. Patient characteristics and fracture patterns as well as entry point of femoral nails were identified and the incidence of AVNFH was investigated. Patients were divided into 2 groups according to open versus closed physis, open versus closed fractures, and age (<20 versus ≥20 years).Overall incidence of AVNFH was 0.2% (1 of 542): the patient was 15-year-old boy. Of 25 patients with open physis, the incidence of AVNFH was 4%, whereas none of 517 patients with closed physis developed AVNFH (P < 0.001). The incidence of AVNFH in patients aged < 20 versus ≥20 years was 1.1% (1 of 93) and 0.0% (0 of 449), respectively (P = 0.172), which meant that the incidence of AVNFH was 0% in adult with femur shaft fracture. Of 61 patients with open fractures, the incidence of AVNFH was 0%. The number of cases with entry point at the trochanteric fossa or tip of the greater trochanter (GT) was 324 and 218, respectively, and the incidence of AVNFH was 0.3% and 0.0%, respectively (P = 0.412).In patients aged ≥20 years with isolated femoral shaft fracture, there was no case of AVNFH following antegrade intramedullary nailing regardless of the entry point. Therefore, our findings suggest that the risk of AVNFH following antegrade femoral nailing is extremely low in adult patients.

Preoperative Incidence of Deep Vein Thrombosis after Hip Fractures in Korean.

BACKGROUND: The purpose of the current study was to investigate the incidence of preoperative deep vein thrombosis (DVT) after hip fractures in Korea. METHODS: In this prospective study, we enrolled 152 Korean geriatric patients who had suffered hip fractures due to a simple fall and were hospitalized between January 2013 and December 2013. There were 52 male and 100 female patients, and their mean age was 78.2 years. There were 96 trochanteric fractures and 56 femoral neck fractures. All patients were examined for DVT: 26 by ultrasonography and 126 by computed tomography venography. The patients having DVT underwent inferior vena cava filter insertion before the surgical intervention. RESULTS: Preoperatively, none of the patients had any signs or symptoms of DVT; however, 4 patients were identified as having asymptomatic DVT. The overall incidence of DVT was 2.6% (4/152). The mean time to arrival at emergency room after injury was 32.6 hours. Mean time elapsed to undergo surgery after hospitalization was 24.9 hours. The average time to hospitalization after injury was 237 hours for patients with DVT versus 27.5 hours for patients without DVT. DVT developed within 72 hours in two of the 137 patients (1.4%) and after 72 hours in two of the remaining 15 patients (13.3%) hospitalized. CONCLUSIONS: While the preoperative incidence of DVT after hip fractures was relatively low (2.6%) in the Korean geriatric population, we confirmed that getting no treatment within 72 hours after injury increased the incidence of DVT. Thus, we conclude from this study that a workup for DVT should be considered in cases where admission or surgery has been delayed for more than 72 hours after injury.

Unusual Cause of Hip Pain: Intrusion of the Acetabular Labrum.

Femoroacetabular impingement and dysplatic hip joint is well known cause of osteoarthritis. In these diseases, labral tear and subsequent cartilage damage is thought to be main pathophysiology of development of osteoarthritis. If there are no known bony abnormalities, we called it as idiopathic osteoarthritis. Normal appearance of acetabular labrum is a continuous, usually triangular structure that attaches to the bony rim of the acetabulum and is completed at the inferior portion by the transverse acetabular ligament over the acetabular notch. A few authors reported intra-articular labrum and its relation to the development of osteoarthritis. But they didn't comment the primary bony abnormality especially acetabulum. We'd like to report x-ray, computed tomogram, magnetic resonance arthrogram and arthroscopic findings of a case had double contour sign of acetabular dome combined with intrusion of acetabular labrum.

Is Taking an Antiplatelet Agent a Contraindication for Early Surgery in Displaced Femur Neck Fracture?

PURPOSE: The purpose of this study was to evaluate whether we have to stop the antiplatelet agents prior to hemiarthroplasty surgery in patients with displaced femur neck fractures to reduce postoperative complications. MATERIALS AND METHODS: We enrolled forty-three patients with displaced femur neck fractures who were treated by bipolar hemiarthroplasty and were taking antiplatelet agents. Group I included 21 patients who discontinued antiplatelet agents and had delayed operations at an average 5.7 days and group II included 22 patients who had had early operations within 24 hours without stopping the antiplatelet agents. We compared the pre- and postoperative levels of hemoglobin, the volume of postoperative transfusion requirement and complications. Student's t-test and chi-square test were used for statistical analysis. RESULTS: The average differences between preoperative and postoperative hemoglobin was 1.4±0.4 g/dL decrease in group I and 2.1±0.5 g/dL decrease in group II (P<0.001). Patients who received a blood transfusion were 11 in group I and 13 in group II (P=0.66). Total number of blood transfusion was 13 pints in group I and 18 pints in group II (P=0.23). Pneumonia occurred in one patient in each group. Four pressure sores and three diaper rashes were developed in group I. But there were no patients requiring massive transfusion, reoperation due to hematoma and infection in each group. CONCLUSION: Although continuous taking of antiplatelet agents in displaced femur neck fracture is associated with an increased risk of postoperative bleeding, taking an antiplatelet agent itself is not a contraindication of early surgery.

A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis.

OBJECTIVES: To compare the clinical and radiologic results of conventional open plating (COP) and minimally invasive plate osteosynthesis (MIPO) in the treatment of noncomminuted humeral shaft fractures. DESIGN: Randomized prospective study. SETTING: Five level 1 trauma centers. PATIENTS: Sixty-eight consecutive patients were randomized into 2 study groups: those treated by COP (COP group; n = 32) and those treated by MIPO (MIPO group; n = 36). INTERVENTION: Simple humeral shaft fractures (AO/OTA classification types A and B) were reduced by open reduction or closed reduction and fixed with a narrow 4.5/5.0 locking compression plate, metaphyseal locking compression plate, or proximal humeral internal locking system plate to the anterior lateral aspect of the humerus. MAIN OUTCOME MEASUREMENTS: Fracture healing time, operative time, radiation exposure time, and intraoperative nerve injury. To assess shoulder and elbow function, we used the University of California, Los Angeles (UCLA) scoring system and the Mayo elbow performance index, including the range of motion and pain. Radiographic measurements included fracture alignment, delayed union, and nonunion. RESULTS: Thirty-one fractures (97%) healed in the COP group within 16 weeks, whereas 36 fractures (100%) were healed in the MIPO group by 15 weeks. No significant difference was observed in the operative time or complication rates. In both groups, all fractures achieved union without malunion and with excellent functional outcomes by definition of the Mayo elbow performance index and UCLA scoring system. CONCLUSIONS: This study confirmed a high overall rate of union and excellent functional outcomes in both MIPO and COP groups. MIPO is equivalent to COP as a safe and effective method for simple types of humeral shaft fractures when surgery is indicated, and the surgeon is experienced in the technique. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella.

PURPOSE: Among patients over 50 years of age, separate vertical wiring alone may be insufficient for fixation of fractures of the inferior pole of the patella. Therefore, mechanical and clinical studies were performed in patients over the age of 50 to test the strength of augmentation of separate vertical wiring with cerclage wire (i.e., combined technique). MATERIALS AND METHODS: Multiple osteotomies were performed to create four-part fractures in the inferior poles of eight pairs of cadaveric patellae. One patella from each pair was fixed with the separate wiring technique, while the other patella was fixed with a combined technique. The ultimate load to failure and stiffness of the fixation were subsequently measured. In a clinical study of 21 patients (average age of 64 years), comminuted fractures of the inferior pole of the patellae were treated using the combined technique. Operative parameters were recorded from which post-operative outcomes were evaluated. RESULTS: For cadaveric patellae, whose mean age was 69 years, the mean ultimate loads to failure for the separate vertical wiring technique and the combined technique were 216.4±72.4 N and 324.9±50.6 N, respectively (p=0.012). The mean stiffness for the separate vertical wiring technique and the combined technique was 241.1±68.5 N/mm and 340.8±45.3 N/mm, respectively (p=0.012). In the clinical study, the mean clinical score at final follow-up was 28.1 points. CONCLUSION: Augmentation of separate vertical wiring with cerclage wire provides enough strength for protected early exercise of the knee joint and uneventful healing.

Intramedullary nailing versus submuscular plating in adolescent femoral fracture.

BACKGROUND: Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. MATERIALS AND METHODS: We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11-17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. RESULTS: Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 10° or limb length discrepancy over 1 cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn's criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group. CONCLUSION: Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing.

A biomechanical analysis of locking plate fixation with minimally invasive plate osteosynthesis in a subtrochanteric fracture model.

OBJECTIVE: The objective of this study was to establish the relative fixation strengths of a locking plate, a dynamic condylar screw (DCS) plate, and a long proximal femoral nail (PFN). METHODS: The study involved three groups of composite large femoral synthetic bones of five specimens per group; plating using a locking compression plate-distal femur (LCP-DF), plating using a DCS plate, and nailing using a long PFN. A gap osteotomy model was used to simulate a comminuted subtrochanteric femur fracture. For each femur, a minimal preload of 100 N was applied before loading to failure. A vertical load was applied at 10 mm/min until femur failure. Load to failure, mode of failure, and displacement at load to failure were documented. RESULTS: Fixation strength (load or moment to failure) of LCP-DF (1,330 N; range, 1,217-1,460 N) was 26.6% and was greater in axial loading compared with DCS (1050.5 N; range, 956.4-1194.5 N) and 250% less in axial loading compared with long PFN (3633.1 N; range, 3337.2-4020.4 N; p=0.002). Ultimate displacement in axial loading was similar for LCP-DF (18.4 mm; standard deviation [SD], 1.44), DCS (18.3 mm; SD, 3.25), and long PFN (16.7 mm; SD, 1.82). CONCLUSIONS: The LCP-DF construct proved stronger than the DCS in terms of ultimate strength by biomechanical testing of a simulated subtrochanteric femur fracture with comminution. Although the nail construct proved strongest, the biomechanical performance of the locking plate construct may lend credence to the use of a locking plate versus the DCS plate for minimally invasive plate osteosynthesis of subtrochanteric femur fractures, which may be technically difficult to fix using a nail.

Minimally invasive plate osteosynthesis of subtrochanteric femur fractures with a locking plate: a prospective series of 20 fractures.

BACKGROUND: Intramedullary nailing is a mainstay in the treatment of subtrochanteric femoral fractures. But nailing is often unsuitable for difficult fracture patterns with comminution or when the medullary canal is narrow. The purpose of this study was to clarify the efficacy of minimally invasive plate osteosynthesis (MIPO) with locking compression plate in the treatment of subtrochanteric fractures. METHODS: Twenty patients with subtrochanteric fractures (mean age 49.6 years) were prospectively treated using the MIPO technique using a locking plate. Indications of procedure were fractures with the greater trochanter or medial comminution, and multiple injured patients with a narrow femoral canal. According to the AO/OTA classification, there were three of type A, eight of type B, and nine of type C. RESULTS: All healed without bone graft, at an average of 20.1 weeks (range 16-32). With the exception of two patients with minor internal rotation deformity and one patient with 1 cm of shortening, most achieved acceptable alignment. All patients were able to walk with no or only a slight limp, and median Merle d'Aubigne score was 17.3 (15-18). Four patients complained of a slight pain in the trochanteric area due to plate prominence. The MIPO technique with a locking plate provides an alternative method for fixing subtrochanteric femur fractures, when IM nailing is inappropriate. This technique provides stable fixation, with a high union rate and a minimal complication rate.

Failure on attempted removal of a Gamma nail in two young patients.

We experienced failures in attempting to remove a Gamma nail and a long Gamma nail, both of which were used for fixation of a subtrochanteric fracture in two young patients. We suspect that new bone forms in the notch, which is located beneath the screw thread in the lag screw, and causes jamming of the lag screw in young patients after fracture consolidation.