Gamma Nail: All You Need to Know for Recovery and Better Understanding

Did you suffer from a hip or femur fracture and had a gamma nail surgery?

Fractures of the femur are common among adults of all ages, and sometimes surgery is necessary. This can involve the placement of a gamma nail.

Why is a gamma nail used? What can you expect during the recovery time? What type of rehabilitation is needed? Are there any complications? Will the gamma nail need to be removed in the future or is it permanent?

As a physical therapist, I can answer these questions based on my experience and the most recent international studies.

Why is it called a gamma nail?

In the medical field, things are often referred to by different names, and the gamma nail is no exception. Here are a few different names for “gamma nail”:

• Femoral intramedullary nail
• Femoral center nail
• Short or Long gamma nail
• Trochanteric nail
• Minimally invasive osteosynthesis of trochanteric fractures
• Inter-locking nail

The term “gamma nail” comes from the Greek letter gamma (γ), which is the shape of the intramedullary nail used in the procedure. The nail has a curved shape resembling the letter gamma and is inserted into the femur to stabilize and align the bone during the healing process.

What does a gamma nail look like?

You’ll often hear the term “intramedullary nail” used when referring to a gamma nail. This means that the nail is inserted into the center of the medullary cavity, which is the part that runs through the middle of long bones. The medullary cavity contains:

• connective tissue,
• bone marrow,
• blood vessels,
• and nerves.

In addition to the nail, there are usually three screws that help secure it to other parts of the femur to ensure stability or to lock it in place.

If you’re feeling a little uneasy about the hardware in your body after surgery, seeing a picture of a gamma nail can help ease your mind. It’s normal to experience some discomfort when trying to walk or stand up after hip surgery, but your body will eventually get used to it.

The nail is made of titanium, which is a material that is very well tolerated by the body.

Understanding what the gamma nail is and how it works can help alleviate any concerns or anxiety about the recovery process.

What is a gamma nail procedure?

The first gamma nails have been around since 1988, so there’s a lot of experience with the surgery to insert a gamma nail.

Despite the nail being very long, there’s no need to make a big incision to insert it. Micro-incisions are made at several points on the thigh, which is enough to insert the nail. This means there are only small scars.

This reduces:

• the risk of infection;
• the risk of bleeding;
• the trauma to soft tissue.

Gamma nail insertion technique diagram A small incision is all it takes to insert a long nail! (Image: Stryker Gamma 3)

The cost of a gamma nail procedure is several thousand euros. This includes the equipment and hospital stay.

In France, this is fully covered by social security and private health insurance, except for daily rate and special services or fees in private facilities.

When is a gamma nail used for femur fractures?

A gamma nail is used to treat fractures of the femur, the thigh bone. Specifically, it’s used for fractures of the trochanter, a specific part of the upper thigh bone.

A gamma nail can be inserted for a fracture:

• of the cervico-trochanteric region
• pertrochanteric region
• subtrochanteric region
• trochantero-diaphyseal region.

The information in this blog post applies to all of these trochanteric fractures that require the insertion of a gamma nail.

There are also other surgical techniques to treat these trochanteric fractures, such as:

• dynamic hip screw (DHS),
• compression hip screw (CHS),
• percutaneous compression plate (PCCP),
• Medoff sliding plate,
• less invasive stabilization system (LISS),
• proximal femoral nail (PFN),
• open reduction and internal fixation (ORIF),
• and proximal femoral nail anti-rotating (PFNA)

All of these techniques are osteosynthesis, which means they join two bone parts together using a mechanical means.

Source: Cheng 2020

The gamma nail is used for pertrochanteric fractures of the femur.

Why is a gamma nail used for femur fractures?

Surgical treatment is often essential. Otherwise, there would be:

• Significant pain in the hip or even the entire lower limb, probably for life.
• Difficulties in all daily activities such as sitting, standing up, getting out of bed or a chair, walking, also for life. The lower limb could indeed deform and remain locked in a position.
• A higher risk of death from the fracture.

That’s why gamma nails are used, including for femur fractures in very elderly people. Some of my patients who underwent gamma nail surgery were over 90 years old.

Monitoring recovery after gamma nail surgery: what to consider?

The surgery to insert a gamma nail under general anesthesia carries the usual risks associated with this type of anesthesia. Specific monitoring will focus on:

• Gradual reduction of pain. The pain medication should be adjusted. Don’t hesitate to contact your doctor if the prescribed treatment at the hospital is not enough.
• Absence of infection at the surgical site (very rare).
• Proper healing (the risk of non-union is very low, less than 1% of patients).
• Gradual recovery of functional abilities.

What does the rehabilitation process look like after gamma nail surgery?

Rehabilitation will start the day after your surgery with a physiotherapist. It will take place in the hospital or clinic for a few days, and then at a rehabilitation center or at home.

It follows the main lines of rehabilitation after a hip fracture.

Rehabilitation and physical therapy at the hospital

You will stay a few days in the trauma ward where you had the operation.

The day after the surgery, you will be able to get up, go to the bathroom, and even take a few steps in the corridor. Most often, a physiotherapist will accompany you in these steps.

The 3 objectives of physiotherapy sessions in the days following the placement of a gamma nail are:

1. to be able to move independently and safely by walking with crutches or a walker, especially if the person has a post-fall syndrome;
2. to begin to regain proper mobility of the hip and knee on the operated side;
3. to limit pain, hematoma, and swelling and reassure about their benign nature.

Physiotherapy sessions often take place in the room or in the corridor. In France, they are daily (excluding weekends).

Hip rehabilitation at home or in a rehabilitation center

After the hospital, there are two options:

• to return home and follow physiotherapy sessions at home or in a clinic;
• to go to a rehabilitation center for a few weeks.

The medical and paramedical team of the hospital or clinic that operated on you will co-decide with you on the best orientation for you. In general, rehabilitation center is relevant for people who live alone at home and who already had motor difficulties before the intervention.

In any case, the objectives of the physical therapy sessions will be the same:

• to help you gradually regain the ability to perform all your daily activities, to walk without technical assistance;
• to check that your place and way of life are adapted to prevent the type of accident that led to the hip fracture from recurring. If necessary, put in place actions to prevent the risk of falling;
• to monitor the gradual decrease in pain, edema, and hematoma.

There is no study that compares the effectiveness of rehabilitation methods or frequencies with others or with the absence of rehabilitation.

The average recovery times I observe in my patients after gamma nail are as follows:

	Recovery time
Absence of hip and thigh pain	Decrease from the first postoperative days Total absence of pain 1 to 12 months after surgery
Return to walking with assistive devices (crutches, walker) over a few meters	The day after surgery or a few days later at most
Return to walking with assistive devices (crutches, walker) over more than 500 meters	1 to 3 weeks after surgery if there are no problems walking before the operation
Return to walking without any assistive devices	1 to 4 months
Return to all daily activities without assistance (cleaning, cooking, shopping, etc.	2 to 5 months
Return to driving a car	1 to 3 months
Return to sport	2 to 12 months depending on the sports

Are there any movements that should be avoided after gamma nail surgery?

No movement is prohibited after a gamma nail surgery.

However, moving may sometimes trigger pain. That’s why it’s important to gradually resume all activities.

If you experience pain, stop the movement or activity, then gradually resume it next time.

When can weight-bearing and walking be resumed after gamma nail surgery?

Weight-bearing usually resumes the day after gamma nail surgery but should be partial. This is why crutches or a walker are recommended.

Sometimes weight-bearing is not allowed immediately. Surgeons determine whether weight-bearing is allowed based on the type of fracture, postoperative x-ray, age, and overall health of the patient.

Even if weight-bearing is not allowed, walking is encouraged the day after hip surgery to prevent complications, with the help of a walker or cane to support the upper body and uninjured leg.

It is possible to walk again the day after a gamma nail surgery.

What are the possible complications after gamma nail surgery?

Most of the time, there are no complications after a gamma nail insertion, which has been a commonly performed surgery for femur fractures for many decades.

Surgical, medical, and paramedical teams make every effort to prevent the development of complications, which are well-known. Compression stockings or socks are often recommended (unless contraindicated) to prevent the risk of deep vein thrombosis.

Here are the results of a study that followed over 600 people who underwent a gamma nail surgery for more than 13 years, which is the study conducted on the largest number of people and for the longest duration (Horner 2017).

The complications observed were as follows:

• 2% of patients experienced discomfort in the hip area,
• 3.8% had a new fracture,
• and 1.1% had movement of the nail screw.

Less than 1% of patients experienced complications such as poor wound healing, infection at the surgical site, nail breakage, and one person out of 644 passed away during the operation.

However, the vast majority of people who undergo gamma nail surgery do not experience any complications in the days, weeks, months, and years following the operation.

When is gamma nail removal necessary for femur fractures?

When one decides to remove the material used to stabilize a fracture, it is referred to as “implant removal”, “hardware removal“, “removal of intramedullary nails” or “gamma nail removal”.

It is not always necessary as some people can live with their hardware for their entire lives, such as a gamma nail, without experiencing any problems.

However, in some cases, the surgical team may, in consultation with the patient, decide to remove the material, typically one year after its insertion (once the bone is well-consolidated) or rarely in the months or years following the initial surgery.

Some hospitals report up to 80% of hardware removals while others report much fewer. Therefore, research teams have examined the legitimacy of these practices and the criteria that should lead to considering the removal of the material, as well as the associated risks.

Indications for hardware removal include:

• patient complaints such as localized pain,
• bursitis,
• discomfort,
• detection of metal by security equipment,
• infection,
• delayed consolidation,
• migration of the material,
• fractures,
• allergies.

In pediatrics, the current trend is to remove centromedullary nails in children. Even in the absence of specific problems. Although few articles document complications related to their presence. Except in cases where the metallic implants affect the growth plate, which justifies the removal of the material as it can hinder growth.

The risks of hardware removal include:

• direct and indirect financial costs, such as the cost of missed work,
• as well as complications such as fractures, infections, and anesthetic risk.

In summary, the removal of a gamma nail in the femur is not mandatory and is only performed if it causes discomfort. Therefore, if the hardware is not causing any problems and everything is going well, there is generally no reason to remove it, and it can be left in the body for life as it is designed not to be rejected by the body.

(Swiss Medical Review 2009)