Non operative management of pertrochanteric fractures was practised prior to introduction of fixation devices. In the elderly patient this approach was fraught with high complication and mortality rates . Operative treatment of these fractures in the early allowed early rehabilitation and the best chance for functional recovery.
The implants for fixation of pertrochanteric fractures have evolved from fixed angle nail plate devices to the widely used to the newer generation cephalomedullary nails. The sliding hip screw is a tried and tested device for fixation of these fractures with excellent results reported . In unstable and reverse oblique inter-trochanteric fractures, the intramedullary devices have an advantage of being load sharing with smaller bending moments as their position is closer to the mechanical axis of the femur as compared to the sliding hip screw. Intramedullary devices have a shorter lever arm and have reduced tensile strain on the implant reducing the risk of implant failure.
Various intramedullary devices have been used for fixation of these fractures – Ender's nail, the Russel Taylor reconstruction nail, the Gamma nail, proximal femoral nail and the AMBI nail. Studies comparing the gamma nail and sliding hip screw have found higher incidence of complications and re-operation rates with the gamma nail and no difference in long term functional outcomes . Most peri-operative complications while using the Gamma nail were related to poor technique. The advantages with the Gamma nail were early mobilisation and full weight bearing . The surgical technique with the Russel Taylor reconstruction nails has been known to be demanding with high post-operative complications . Studies were the Proximal Femoral Nail (PFN) were used cited high intra-operative and post-operative complications. The PFN was also associated with high re-operation rates [10, 11]. The intramedullary nails are better implants for unstable reverse oblique fractures while the sliding hip screw better for stable inter-trochanteric fractures . No difference between the Gamma nail and the PFN were seen in terms of fracture healing, re-operation and mortality rates . Shorter operating times, fewer blood transfusion and shorter hospital stay have been found while using intramedullary nails as compared to the 95 fixed angle screw plate for unstable intertroachanterics fractures. Intramedullary nails have been advocated for reverse oblique fracture of the inter-trochanteric region in the elderly . A prospective randomised trail comparing different intramedullary nails for treatment of pertrochanteric fractures concluded that the AMBI nail was the gold standard while the PFN had the most complications and longest operation times . The general consensus in the literature is that the sliding hip screw is superior for fixation of stable inter-trochanteric fractures while the intramedullary nails are best reserved for the unstable and reverse oblique variety.
The patient cohort studied in our study demonstrated features typical of their demographic group including high levels of concomitant medical disease, a female predominance and low energy injury mechanisms i.e. simple falls. This group differs markedly from the younger adult population who generally sustain higher energy trauma and multiple injuries for which the conventional management for complex proximal femoral fracture is intramedullary fixation. The frailty of the elderly undoubtedly predisposes this group to high perioperative mortality rate due to poorer physiological reserve.
The Russell-Taylor reconstruction nail provided satisfactory fixation in the majority of elderly patients with complex and unstable proximal femoral injuries. This implant provided the opportunity for early mobilisation although most patients did not return to their pre-injury level of independence or mobility. The reconstruction nail used had the biomechanical benefits of intramedullary fixation compared to extramedullary techniques . However, implant-related failures did occur and revision surgery was required at levels consistent with other studies [4–6]. Actual mechanical failure of the nail occurred in only one patient who developed a non-union leading to implant failure.
A more common event was migration of the oblique proximal interlocking screw. This may arise due to the poor bone density of the femoral head which limited screw purchase and reflects one of the many problems associated with fixation in elderly, osteoporotic bone . Migration of the interlocking screws occurs within the nail as these do not secure rigidly within the device itself and is described in the literature as "Z" effect (Proximal migration of the proximal screw) and the "Reversed Z" effect (Distal migration of the proximal screw) [11, 15].
We found use of this implant to be technically challenging resulting in highly variable and long operating times particularly for the less experienced surgeons. Although this places high physiological demands on frail, elderly patients with co-morbidity who are already at high mortality risk from their injury  the reconstruction nail aided early rehabilitation of function and reduced the morbidity associated with prolonged immobilization. The intra-operative and post-operative complications, re-operation and mortality rates in our study were lesser than that were encountered in studies were other nails (Gamma nail, PFN, Trochanteric Gamma nails) were used.
Surgical management of proximal femur fractures in the elderly is a challenging prospect as there is no ideal fixation method. All fixation methods available are fraught with complications, increased morbidity and mortality. The reconstruction nail could be used as an intramedullary fixation device for these fractures despite the high morbidity, complications and mortality encountered in our study.