3. INTRODUCTION
• Gamma Nails come in 3 neck-shaft angles: 120, 125 and
130°.
• The anatomical shape of the nail is universal for all
indications.
• The nail is cannulated for guide-wire-controlled
insertion and features a conical tip for optimal alignment
with inner part of the cortical bone.
• A range of three different neck-shaft angles are
available for cephalic screw entry to accommodate
variations in femoral neck anatomy.
• A single distal Locking Screw is provided to stabilize the
nail in the medullary canal and to help prevent rotation in
complex fractures. The hole allows for static locking.
4. Material:
Titanium alloy or Stainless Steel
• Nail length:
180mm,200mm,220mm
• Nail diameter:
proximal 15.5mm, distal: 11.0mm
• Proximal Nail angle range:
120°, 125°, 130°
• M-L bend for valgus curvature:
4 degrees
• End Caps in lengths of
0mm
• Distal hole for 6.255mm screws
INTRODUCTION
5. INTRODUCTION
Cephalic Screw and Set Screw Function
The Cephalic Screw are designed to transfer the load of the
femoral head into the nail shaft by bridging the fracture line to
potenitally allow more efficient and more secure fracture
healing. The load carrying thread design of the Gamma cephalic
screw allows for large surface contact to the cancellous bone.
This provides high resistance against cut out.
The Set Screw is designed to fit into one of the four grooves of
the cephalic screw shaft. This helps prevent both rotation and
medial migration of the cephalic screw. The nail allows sliding of
the cephalic screw to the lateral side for dynamic bone
compression at the fracture site to help enhance fracture
healing.
6. Technical Specifications
• Cephalic Screw diameter: 12.5mm
• Cephalic Screw lengths: 70−130mm in
5mm increments
•Cephalic Screw is designed for high load
absorption and easy insertion
• Self retaining Set Screw protects the
cephalic Screw against rotation and
simultaneously allows for lateral cephalic
screw sliding.
INTRODUCTION
7. INTRODUCTION
Distal Locking Screws
The distal Locking Screw has a short self-tapping tip which facilitates a faster and easier
start as well as easy screw insertion. It helps to promote excellent surface to bone contact
Technical Specifications
• Distal Locking Screw Diameter: 6.25mm.
• Distal Locking Screw lengths ranging from 40−100mm, in 5mm increments.
• Fully threaded screw design.
• Self-tapping screw tip with optimized short cutting flutes.
• Optimized diameter under the head helps to prevent micro
8. INTRODUCTION
Strength and Stability
The biomechanical features of the orthopedic implant gamma nail
system offers significantly greater strength and stability compared
with the DHS.
The Biomechanical Advantage
Since the load-bearing axis of the Gamma Nail is closer to the hip
joint fulcrum, the effective lever arm on the implant and femur is
significantly shorter than with an extramedullary plate. The
resultant force is transmitted directly down the femur using a nail
system. If DHS is used, the femur shaft may be weakened through
a high number of screws. The Gamma Nail increases both the
strength and reliability of the biomechanical repair.
Rehabilitation Benefits
Allows early weight-bearing even in patients with complex or
unstable proximal fractures .
Early mobilization and a less traumatic operative technique help to
increase the chance for more efficient recovery and reliable bone
union.
10. SURGICAL TECHNIQUE
Pre-operative Planning
The Gamma Nail with a 125° nail angle may be used in the
majority of patients. The 120° nail may be needed in patients
with coxa vara, and the 130° nail for coxa valga.
The femoral neck angle, (i. e. the angle between the femoral
shaft mid-axis and the femoral neck mid-axis) could be
measured using a goniometer, to select the apropriate angle
of implant to be used.
11. SURGICAL TECHNIQUE
Patient Positioning
The patient is placed in a supine position on the
fracture table and closed reduction of the fracture is
recommended. Reduction should be achieved as
anatomically as possible. If this is not achievable in a
closed procedure, open reduction may be necessary.
Traction is applied to the fracture to keep the leg
straight. The unaffected leg is abducted as far as
possible to make room for the image intensifier.
While maintaining traction, the leg is internally
rotated 10–15 degrees to complete fracture
reduction; the patella should have an either
horizontally or slightly inward position .
12. SURGICAL TECHNIQUE
Position the image intensifier so that anterior-
posterior and mediolateral views of the
trochanteric region of the affected femur can
be easily obtained. This position is best
achieved if the image intensifier is positioned
so that the axis of rotation of the intensifier is
centered on the femoral neck of the affected
femur.
It is important to ensure that a view of both
the distal and proximal ends of the nail can be
obtained during the procedure without
obstruction by the traction table.
Patient Positioning
13. SURGICAL TECHNIQUE
Incision
The tip of the greater trochanter may be located by palpation and a horizontal skin
incision of approximately 2−3cm is made from the greater trochanter in the direction
of the iliac crest.
A small incision is deepened through the fascia lata, splitting the abductor muscle
approximately 1−2cm immediately above the tip of the greater trochanter, thus
exposing its tip. A selfretaining retractor or tissue protection sleeve is put in place.
14. SURGICAL TECHNIQUE
Entry Point
The correct entry point is located at the junction of
the anterior third and posterior two-thirds of the tip
of the greater trochanter and on the tip itself.
The medullary canal has to be opened under image
intensification. The use of the curved Awl (CPC622) is
recommended.
15. SURGICAL TECHNIQUE
Preparation of the Medullary Canal
Instruments
CPC620 Guide Wire Olive
FRS68 Flexible reaming shaft
RH09 Reaming heads 9, 10, 11, 12, 13 mm
16. SURGICAL TECHNIQUE
Preparation of the Medullary Canal
Guide Wire olive(CPC620) is recommended as a reamer
guide. Pass the guide wire into the shaft of the femur
using the T Handle.
Rotating the Guide Wire during insertion makes it easier
to achieve the desired position in the middle of the
medullary canal.
Flexible reamers are used to ream the shaft of the femur
in stages starting from 9mm diameter and increasing in
1mm increments . The canal should be reamed at least
2mm larger than the distal diameter of the nail, 13mm for
the 11mmGamma Nail. When reaming is performed, the
entire femoral canal should be over-reamed down through
the isthmus in order to avoid stress riser in the bone.
17. SURGICAL TECHNIQUE
In order to accommodate the proximal part of the
Gamma Nail, the subtrochanteric region must be
opened up to 15.5mm . This can be done by reaming
with the reamer.
Preparation of the Medullary Canal
18. SURGICAL TECHNIQUE
Assembly of Targeting Jig
Instruments
CPC629 Holding jig
CPC632 Insertion bolt
CPC633 Driver for gamma nail
CPC635 Universal Wrench
19. SURGICAL TECHNIQUE
Nail Assembly
The selected Gamma Nail is now assembled to the holding jig(CPC629)
as shown in Figure. Ensure that the locating pegs fit into the
corresponding notches of the proximal part of the nail.
Fully tighten the insertion bolt(CPC632)with the driver for gamma nail
and universal wrench, so that it does not loosen during nail insertion.
Before starting surgery the following functions of the holding jig have
to be checked:
1. Secure fixation between Nail and jig.
2. Lag Screw Guide Sleeve matches the selected nail angle.
3. Distal locking sleeve matches the hole of the distal hole of gamma
nail.
20. SURGICAL TECHNIQUE
Pass the protection sleeve for
proximal locking and guide wire
sleeve for gamma nail gently
through the hole of the jig. Check
correct nail angle using the guide
wire. Remove the protection sleeve
and guide wire.
The protection sleeve for distal
locking and drill sleeve for distal
locking are passed through the jig
until its final position is achieved.
Check position with the Drill Sleeve
and 5.5mm Drill bit.
Nail Assembly Check
21. SURGICAL TECHNIQUE
Nail Insertion
Insert the Gamma Nail by hand.
Even if some resistance is felt during nail
insertion, never hammer to insert the nail,
because these high forces will create stress
to both bone and to the nail. It may create
micro fractures in the bone or deform the
nail, which may lead to a reduced targeting
accuracy when drilling.
22. SURGICAL TECHNIQUE
The final nail depth position is monitored with the image intensifier C-Arm; the projected
axis of the cephalic screw may be projected with a ruler on the monitor screen to ensure
that the cephalic screw is placed in the optimal position.
Proceed until the axis of the cephalic screw hole (visible as a crescent shape on the
screen) is aligned with the lower half of the femoral neck . The objective is to position the
cephalic screw centrally or slightly inferior in femoral head in the frontal plane.
The Lag Screw should be placed in the central position of the femoral head in the lateral
view
Nail Insertion
23. SURGICAL TECHNIQUE
Cephalic Screw Insertion
Instruments
PSL794 Protection sleeve for proximal locking
PS921 Guide wire sleeve
CPC638 Guide wire for cephalic screw
IBS755 Pointer for proximal locking
WCS800 Tap for cephalic screw
CPC626 Cannulated reamer for cephalic screw
WC70 Wrench for cephalic screw
24. SURGICAL TECHNIQUE
Assemble the protection sleeve for proximal
locking(PSL794) with the pointer for proximal
locking(IBS755) and pass them through the jig to the level
of the skin. Make the skin incision down to the bone .When
the tip reaches the bone, replace the pointer to the guide
wire sleeve(PS921).
For an accurate cephalic Screw length measurement, the
outer protection sleeve
must be in good contact with the lateral cortex of the femur.
Insert guide wire for cephalic screw(CPC638) into neck. The
objective is to position the cephalic screw in the centre or
below the centre of the femoral head in the antero
posterior view and centrally in lateral view provides the best
load transfer to the cephalic screw.
Cephalic Screw Insertion
25. SURGICAL TECHNIQUE
Cephalic Screw Insertion
The guide wire sleeve is now removed and
cannulated reamer(CPC626) is passed over
the guide wire through the protection
sleeve for proximal locking(PSL794).
The drilling process, especially when the tip
of the drill comes close to its final position in
the femur head, should be controlled under
an image intensifier to avoid hip joint
penetration.
26. SURGICAL TECHNIQUE
Cephalic Screw Insertion
The chosen cephalic screw is then attached to the
wrench for cephalic screw(WC70).
In a case where compression is to be applied, a
shorter cephalic screw length should be chosen to
avoid the end sticking out too far in to the lateral
cortex . Ensure that the pins of the wrench are in the
slots of the cephalic screw.
The cephalic screw assembly is now passed over the
guide wire, through the protection sleeve for
proximal locking, and threaded up to the end of the
pre-drilled hole of the femur head. Check the end
position of the cephalic screw on the image
intensifier.
27. SURGICAL TECHNIQUE
Cephalic Screw Fixation
The handle of the cephalic screwdriver
must be either parallel or perpendicular
(90°) to the jig to ensure that the Set
Screw fits securely into one of the 4
Grooves on the Lag Screw shaft.
If the T-Handle is not perpendicular
or parallel to the Target Arm, turn it
clockwise until it reaches this position.
Never turn the cephalic screw
Counter clockwise.
28. SURGICAL TECHNIQUE
Compression / Apposition
If compression or apposition of the fracture gap is
required, this can be achieved by gently turning the
thumbwheel of the wrench for cephalic screw
clockwise against the protection sleeve. In osteoporotic
bone care must be taken to prevent cephalic screw
pullout in the femoral head. The selected cephalic
screw should be shorter depending on the expected
amount of compression.
Cephalic Screw Fixation
29. SURGICAL TECHNIQUE
Cephalic Screw Fixation
Assemble the Set Screw to the Set Screw driver(IBS747).
Insert the Set Screw along the opening of the post of the
jig and advance it through the insertion bolt pushing the
Set Screwdriver.
Push the Set Screw Driver down until you are sure, that the
Set Screw engages the corresponding thread in the nail.
You may feel a slight resistance while pushing down the
assembly.
Turn the Screwdriver handle clockwise under continuous
pressure.
Keep on turning the Set Screw until you feel contact in one
of the grooves of the cephalic screw.
30. SURGICAL TECHNIQUE
Cephalic Screw Fixation
To verify the correct position of the Set Screw,
try to turn the wrench for cephalic screw gently
clockwise and counterclockwise. If it is not
possible to turn the wrench for cephalic screw,
the Set Screw is engaged in one of the grooves.
If the wrench for cephalic screw still moves,
recorrect the handle position and tighten the
Set Screw again until it engages in one of the
four grooves.
After slightly tightening the Set Screw it should
then be unscrewed by one quarter (¼) of a
turn, until a small play can be felt at the Lag
Screwdriver. This ensures a free sliding of the
Lag Screw.
Make sure that the Set Screw is still engaged in
the groove by checking that it is still not
possible to turn the cephalic screw with the
wrench for cephalic screw.
31. SURGICAL TECHNIQUE
Instruments
PSL793 Protection Sleeve for distal Locking
IBS715.40 Drill sleeve for Distal Locking
IBS738 Drill Bit for distal locking
IBS747 Screw driver for distal locking
Distal Locking
32. SURGICAL TECHNIQUE
Distal Locking
• Disconnect the wrench for cephalic screw loosening the end thumbwheel, remove the
wrench, cephalic screw protection sleeve and guide wire.
Important points to remember before distal locking procedure:
• Ensure that the insertion bolt is still fully tightened
• Avoid soft tissue pressure on the distal locking sleeve assembly. Adequate skin incision
is important.
• Check that the distal locking sleeve assembly (with the trocar removed) is in contact
with lateral cortex of the Femur .Confirm final locking screw placement with A/P and
Lateral fluroscopy.
• Do not apply force to the Targeting jig.
• Start the power tool before having bone contact with the drill.
• Use sharp drills only.
33. SURGICAL TECHNIQUE
• Assemble the protection sleeve for distal
locking(PSL793),drill sleeve for distal
locking(IBS738), and advance it through the
hole of the target arm down to skin.
• A small incision is started at the tip of the
trocar, and is extended down to the lateral
cortex.
• Insert the protection sleeve(PSL793) and drill
sleeve for distal locking(IBS715.40) till the
lateral cortex of femur.
Distal Locking
34. SURGICAL TECHNIQUE
• Use drill for distal locking
5.5mmx120mm(IBS738) to drill through first and
second cortex. This can be monitored by image
intensifier.
• Use depth guage to measure length of the
distal locking screw after removing the drill
sleeve.
• Insert the 6.25mm distal locking screw through
the drill sleeve for distal locking with the help of
screwdriver. Advance the screw head until it is in
direct contact with the cortex.
Distal Locking
35. SURGICAL TECHNIQUE
Insert End Cap
• It is recommended to use an end cap to close the
proximal part of the nail to prevent bone in growth.
• Remove the insertion bolt using the driver for
gamma nail and universal wrench.
• Load the End Cap (0mm) to one of the Screwdrivers
and pass the assembly through the top of the jig
down into the nail.
• Turn the handle clockwise until it stops
mechanically. Remove the
• Screwdriver and remove the jig in the cranial
direction.
• Alternatively, the End Cap could be inserted free
hand after removal of the jig.