[Research on effectiveness of occipito-odontoid angle in predicting dysphagia after occipitocervical fusion in patients with C 2, 3 Klippel-Feil syndrome].

Objective: To introduce a new occipitocervical angle parameter, occipito-odontoid angle (O-Da), for predicting dysphagia after occipitocervical fusion (OCF) in patients with C 2, 3 Klippel-Feil syndrome (KFS) and analyze its effectiveness. Methods: A total of 119 patients met selective criteria between April 2010 and November 2019 were retrospectively included as the study subjects. There were 56 males and 63 females. The age ranged from 14 to 76 years, with a median age of 51 years. There were 44 cases of basilar invagination and 75 cases of atlantoaxial subluxation. Forty patients were combined with C 2, 3 KFS. Seven patients underwent anterior decompression combined with posterior OCF and 112 patients underwent posterior OCF. The fixed segments were O-C 2 in 36 cases, O-C 3 in 51 cases, O-C 4 in 25 cases, and O-C 5 in 7 cases. All patients were followed up 21-136 months, with a median time of 79 months. The lateral cervical X-ray films before operation and at last follow-up were used to measure the occipital to C 2 angle (O-C 2a), the occipital and external acoustic meatus to axis angle (O-EAa), the occipital protuberance to axial angle (Oc-Axa), the O-Da, and the narrowest oropharyngeal airway space (nPAS). The differences of the above parameters between the last follow-up and the preoperative values were calculated (represented as dO-C 2a, dO-EAa, dOc-Axa, dO-Da, and dnPAS). Patients were divided into two groups according to whether they suffered dysphagia after operation, and the differences in clinical data and radiographic parameters were compared between the two groups. The correlation between occipitocervical angle parameters and nPAS in 40 patients with C 2, 3 KFS was analyzed respectively. In addition, sensitivity and specificity analyses were used to assess the effectiveness of dO-Da≤-5° for the prediction of postoperative dysphagia. Results: Thirty-one patients (26.1%) suffered dysphagia after OCF (dysphagia group), including 10 patients with C 2, 3 KFS; no dysphagia occurred in 88 patients (non-dysphagia group). There was no significant difference in age, follow-up time, fixed segment, proportion of patients with rheumatoid arthritis, proportion of patients with atlantoaxial subluxation, and proportion of patients with C 2, 3 KFS between the two groups ( P>0.05). The proportion of female patients was significantly higher in dysphagia group than in non-dysphagia group ( χ 2=7.600, P=0.006). The difference in preoperative O-C 2a between the two groups was significant ( t=2.528, P=0.014). No significant differences were observed in preoperative O-EAa, Oc-Axa, O-Da, and nPAS ( P>0.05). There was no significant difference in dO-C 2a, dO-EAa, dOc-Axa, dO-Da, and dnPAS between the two groups ( P>0.05). The dO-C 2a, dO-EAa, dOc-Axa, and dO-Da were positively correlated with dnPAS in 40 patients with C 2, 3 KFS ( r=0.604, P<0.001; r=0.649, P<0.001; r=0.615, P<0.001; r=0.672, P<0.001). Taking dO-Da≤-5° as the standard, the sensitivity and specificity of dO-Da to predict postoperative dysphagia in patients with C 2, 3 KFS were 80.0% (8/10) and 93.3% (28/30), respectively. Conclusion: The dO-Da is a reliable indicator for predicting dysphagia after OCF in patients with C 2, 3 KFS.

Sequential sagittal alignment changes in the cervical spine after occipitocervical fusion.

BACKGROUND: There are few studies regarding sequential changes in the sagittal alignment of the upper and lower cervical regions of the spine after occipitocervical fusion (OCF). In addition, no comparisons of cervical sagittal alignment (CSA) between patients with craniocervical junction disorders (CJDs) and normal populations have been reported. AIM: To compare the CSA of patients with CJDs with that of normal controls and investigate the sequential changes in the CSA of the upper and lower cervical spine after OCF. METHODS: Eighty-four patients who underwent OCF (OCF group) and 42 asymptomatic volunteers (control group) were included. Radiographic parameters, including the occipital to C2 angle (O-C2a), occipital and external acoustic meatus to axis angle (O-EAa), C2-7 angle (C2-7a), and pharyngeal inlet angle (PIA), were measured and compared pre- and postoperatively. The correlations among the parameters were analyzed using Pearson's correlation test. RESULTS: The O-C2a and PIA of the OCF group were smaller than those of the control group, while their O-EAa and C2-7a values were larger than those of the normal controls. There were no significant differences in O-C2a, C2-7a, or PIA in the OCF group at baseline, 1 mo, or the final follow-up after surgery. The Pearson's correlation results showed that there were significant correlations between the O-C2a and C2Ta, C2-7a, C2-7 sagittal vertical axis (SVA), and PIA at 1 mo after OCF surgery and between O-C2a and O-EAa, C2Ta, C2-7a, C2-7 SVA, and PIA at the final follow-up. CONCLUSION: Patients with CJDs have a more kyphotic upper CSA and a more lordotic lower CSA than normal controls. The effectiveness of OCF surgery in restoring CSA may be limited by the realignment of the craniocervical junction being neglected. The reduction in O-C2a after OCF surgery may increase C2-7a and decrease PIA.

The predictive ability of occipital to C3 angle for dysphagia after occipitocervical fusion in patients with combined C2-3 Klippel-Feil syndrome.

BACKGROUND: Improper occipitocervical alignment after occipitocervical fusion (OCF) may lead to devastating complications, such as dysphagia and/or dyspnea. The occipital to C2 angle (O-C2a), occipital and external acoustic meatus to axis angle (O-EAa) have been used to evaluate occipitospinal alignment. However, it may be difficult to identify the inferior endplate of the C2 vertebra in patients with C2-3 Klippel-Feil syndrome (KFS). The purpose of this study aimed to compare four different parameters for predicting dysphagia after OCF in patients with C2-3 KFS. METHODS: There were 40 patients with C2-3 KFS undergoing OCF between 2010 and 2019. Radiographs of these patients were collected to measure the occipital to C3 angle (O-C3a), O-C2a, occipito-odontoid angle (O-Da), occipital to axial angle (Oc-Axa), and narrowest oropharyngeal airway space (nPAS). The presence of dysphagia was defined as the patient complaining of difficulty or excess endeavor to swallow. Patients were divided into two groups according to whether they had postoperative dysphagia. We evaluated the relationship between each of the angle parameters and nPAS and analyzed their influence to the postoperative dysphagia. RESULTS: The incidence of dysphagia after OCF was 25% in patients with C2-3 KFS. The Oc-Axa, and nPAS were smaller in the dysphagia group compared to non-dysphagia group at the final follow-up (p < 0.05). Receiver-operating characteristic (ROC) curves showed that dO-C3a had the highest accuracy as a predictor of the dysphagia with an area under the curve (AUC) of 0.868. The differences in O-C3a, O-C2a, O-Da, and Oc-Axa were all linearly correlated with nPAS scores preoperatively and at the final follow-up within C2-3 KFS patients, while there was a higher R2 value between the dO-C3a and dnPAS. Multiple linear regression analysis showed that the difference of O-C3a was the only significant predictor for dnPAS (ß = 0.670, p < 0.001). CONCLUSIONS: The change of O-C3a (dO-C3a) is the most reliable indicator for evaluating occipitocervical alignment and predicting postoperative dysphagia in C2-3 KFS patients. Moreover, dO-C3a should be more than - 2° during OCF to reduce the occurrence of postoperative dysphagia.

[Relationship between O-EA angle and lower cervical curvature in patients with anterior atlantoaxial dislocation before and after occipitocervical fusion].

OBJECTIVE: To investigate the relationship between O-EA angle and lower cervical curvature in patients with anterior atlantoaxial dislocation undergoing occipitocervical fusion, and to analyze the effect of O-EA angle on lower cervical curvature. METHODS: The clinical data of 61 patients with anterior atlantoaxial dislocation undergoing occipitocervical fusion who were admitted between April 2010 and July 2018 and met the selection criteria were retrospectively analyzed. There were 32 males and 29 females, with an age of 14-76 years (mean, 50.7 years). The fixed segment included 19 cases of C 0-C 2, 27 cases of C 0-C 3, 14 cases of C 0-C 4, and 1 case of C 0-C 5. The O-EA angle, C 2-7 Cobb angle, and T 1 tilt angle were measured before operation and at last follow-up. According to the O-EA angle measured at last follow-up, the patients were divided into <95° group (group A), 95°-105° group (group B), and >105° group (group C), and compared the differences of gender, age, fixed segment (short segment was at C 3 and above, long segment was beyond C 3), and C 2-7 Cobb angle. Correlation analysis between the O-EA angle and C 2-7 Cobb angle before operation and at last follow-up, as well as the changes of O-EA angle and C 2-7 Cobb angle between before operation and at last follow-up were analyzed. RESULTS: All 61 patients were followed up 12-24 months, with an average of 22.4 months. There was no significant difference in O-EA angle, C 2-7 Cobb angle, and T 1 tilt angle before operation and at last follow-up ( P>0.05). According to the last follow-up O-EA angle grouping, there were 14 cases in group A, 29 cases in group B, and 18 cases in group C. There was no significant difference in age, gender composition, and fixed segment composition among the three groups ( P>0.05); the differences in C 2-7 Cobb angles among the three groups were significant ( P<0.05), groups A, B, and C showed a gradually increasing trend. The O-EA angle was positively correlated with C 2-7 Cobb angle before operation and at last follow-up ( r=0.572, P=0.000; r=0.618, P=0.000); O-EA angle change at last follow-up was also positively correlated with C 2-7 Cobb change ( r=0.446, P=0.000). CONCLUSION: The O-EA angle of patients with anterior atlantoaxial dislocation is positively correlated with C 2-7 Cobb angle. Too large O-EA angle should be avoided during occipitocervical fixation, otherwise it may accelerate the degeneration of the lower cervical spine.

[Predictive abilities of O-C2 angle, O-EA angle, and Oc-Ax angle for the development of dysphagia in patients after occipitocervical fusion].

OBJECTIVE: To compare the predictive abilities of O-C2 angle (O-C2a), O-EA angle (O-EAa), and Oc-Ax angle (Oc-Axa) for development of dysphagia in patients after occipitocervical fusion (OCF). METHODS: Between April 2010 and May 2019, 114 patients who underwent OCF and met the selection criteria were selected as the research objects. Among them, 54 were males and 60 were females; they were 14-76 years old, with an average of 50.6 years old. The follow-up time was 13-122 months (median, 60.5 months). The O-C2a, O-EAa, Oc-Axa, and the narrowest oropharyngeal airway space (nPAS) were measured by the lateral X-ray films before operation and at last follow-up, and the differences before and after operation (dO-C2a, dO-EAa, dOc-Axa, and dnPAS) were calculated. Patients were divided into two groups according to whether they had developed postoperative dysphagia. The general data including age, gender, fixed segment, proportion of patients with rheumatoid arthritis (RA), atlantoaxial subluxation (AS), and combined with anterior release surgery (ARS), and imaging indicators were compared between the two groups. The correlations between dO-C2a, dO-EAa, and dOc-Axa and dnPAS in 114 patients were analyzed to further compare the predictive value of three imaging indicators for occurrence of dysphagia after OCF. RESULTS: Dysphagia occurred after OCF in 31 cases with the incidence of 27.2%. There was significant difference in gender between the dysphagia group and the non-dysphagia group ( χ 2=7.940, P=0.005). There was no significant difference between the two groups in age, fixed segment, the proportion of patients with RA, the proportion of patients with AS, and the proportion of patients combined with ARS ( P>0.05). There was no significant difference in O-C2a and Oc-Axa of 114 patients before operation and at last follow-up ( P>0.05). The differences in O-EAa and nPAS were significant ( P<0.05). There was no significant difference in preoperative O-EAa, Oc-Axa, and nPAS between the dysphagia group and the non-dysphagia group ( P>0.05); the difference in the O-C2a was significant ( t=2.470, P=0.016). At last follow-up, the differences in the above imaging indicators were significant ( P<0.05). There were significant differences in the dO-C2a, dO-EAa, dOc-Axa, and dnPAS between the two groups ( P<0.05). Correlation analysis showed that the dO-C2a, dO-EAa, dOc-Axa were all positively correlated with dnPAS ( P<0.05). The dO-C2a≤-5°, postoperative O-EAa≤100°, postoperative Oc-Axa≤65° were all related to postoperative dysphagia ( P<0.05), and the highest risk factor suffering postoperative dysphagia was dO-C2a ≤-5° with a significant OR of 14.4. CONCLUSION: The dO-C2a, postoperative O-EAa, and postoperative Oc-Axa can be used as the predictive indexes of dysphagia after OCF, among which dO-C2a has the highest predictive value.

Predictive abilities of O-C2a and O-EAa for the development of postoperative dysphagia in patients undergoing occipitocervical fusion.

BACKGROUND CONTEXT: Dysphagia is a common postoperative complication in patients undergoing occipitocervical fusion (OCF). Previous studies had proposed the use of two measures-the occipital to C2 angle (O-C2a) and the occipital and external acoustic meatus to axis angle (O-EAa)-to predict postoperative dysphagia after OCF. However, these studies had small sample sizes and the predictive abilities of both measures are still not clear. PURPOSE: To evaluate the predictive ability of O-EAa and O-C2a for dysphagia after OCF. STUDY DESIGN: A retrospective clinical study. PATIENT SAMPLE: A total of 109 consecutive patients who had undergone OCF. OUTCOME MEASURES: Presence of postoperative dysphagia, O-C2a, C2 tilting angle (C2Ta), O-EAa, and the narrowest oropharyngeal airway space (nPAS). METHODS: Between April 2010 and June 2018, 109 consecutive patients who had undergone OCF were reviewed. Patients were divided into two groups according to the presence of postoperative dysphagia. Radiographic measurements, including O-C2a, C2Ta, O-EAa, and nPAS, were evaluated at preoperative and 1 month postoperative and the findings were compared. Simple linear regression was used to measure the correlations between the parameters and the presence of dysphagia, and the correlations within the parameters. Multiple regression analysis was used to examine the variables that affected the change of nPAS (dnPAS%). Sensitivity and specificity analyses were used to evaluate the effectiveness of the previously proposed measures ("O-C2a change≤-5°" and "postoperative O-EAa<100°") for prediction of post-OCF dysphagia. RESULTS: The incidence of dysphagia after OCF was 26.6% (29/109). Preoperative values for the radiographic parameters were similar between patients with and without dysphagia. In the dysphagia group, both O-C2a and O-EAa values showed a dramatic decrease after surgery, which was accompanied by a decrease in nPAS. Postoperative O-C2a, O-EAa, and nPAS in the dysphagia group were significantly smaller than those in the nondysphagia group (p<.05). The changes in O-EAa, O-C2a, and nPAS showed a linear correlation with the presence of dysphagia (p<.05). In addition, linear correlations were found between two of the three parameters. Multiple regression showed the change of O-C2a and O-EAa were significant predictors for dnPAS% (ß=0.200, p=.022 and ß=0.549, p=.000). The sensitivity and specificity of "O-C2a change≤-5°" in predicting dysphagia were 75.9% and 80.0% respectively, and those of "postoperative O-EAa<100°" were 75.9% and 62.5%, respectively. However, the sensitivity of the combination of these two values in predicting postoperative dysphagia was as high as 96.6%. CONCLUSION: Both O-EAa and O-C2a could be critical predictors for postoperative dysphagia. During surgery, ensuring that the O-EAa exceeds 100° and simultaneously avoiding an O-C2a reduction greater than 5° could effectively avert postoperative dysphagia.

Treatment of L5 - S1 intervertebral disc herniation with posterior percutaneous full-endoscopic discectomy by grafting tubes at various positions via an interlaminar approach.

BACKGROUND: Depending on the location of the herniated disc at the shoulder, axilla, or ventral side of the compression nerve root, various puncture sites and channel entrances were selected so that the goal of targeted removal of the herniated disc could be achieved by a full-endoscopic technique. Achieving good clinical therapeutic efficacy through the natural gap of bones can maximally avoid related access complications, and the necessary techniques and relevant anatomical factors were analyzed. METHODS: Between August 2012 and August 2014, 98 patients with L5 - S1 intervertebral disc herniation were treated with posterior percutaneous full-endoscopic discectomy (PPFED) by grafting tubes at various positions via the interlaminar approach. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to assess the patients' back and leg pain and the improvements in daily function, and the modified Macnab standard was used to evaluate the treatment efficacy. RESULTS: All 98 patients successfully completed the surgery, 84 patients got out of bed and walked on the first postoperative day, and 14 patients got out of bed and walked on the second postoperative day. The preoperative ODI (56.032 ± 3.625) was significantly higher than the ODI score (8.147 ± 1.398) (F = 5343.054, P ≤ 0.001) 48 months after surgery. The preoperative VAS score (7.193 ± 0.875) was significantly higher than the postoperative VAS score (0.914 ± 0.500 points) (F = 1656.173, P ≤ 0.001). The differences in ODI and VAS scores before and after surgery were statistically significant (P < 0.05). Follow-up was conducted 1, 6, 12 and 48 months postoperatively, and the modified Macnab standard was used during the last follow-up to evaluate the efficacy: 67 cases were excellent, 20 cases were good, 7 cases were fair, and 0 cases were poor; the proportion of excellent and good cases was 92.6%. CONCLUSIONS: The treatment of L5 - S1 intervertebral disc herniation with PPFED by grafting tubes at various positions via an interlaminar approach is a safe, effective, and minimally invasive surgical method. Reaching the location of a disc herniation directly through the natural gap in the bones can maximally avoid collateral injury from spine surgery. TRIAL REGISTRATION: The registration number of this clinical study is ChiCTR1800014588; it has been retrospectively registered with a registration date of 05/01/2018.

Impact of the occiput and external acoustic meatus to axis angle on dysphagia in patients suffering from anterior atlantoaxial subluxation after occipitocervical fusion.

BACKGROUND CONTEXT: Dysphagia is a complication that sometimes occurs after occipitocervical fusion (OCF). An appropriate O-C2 angle (O-C2a) is recognized as a critical factor for preventing dysphagia. The occiput and external acoustic meatus to axis angle (O-EAa) has some advantages over the O-C2a and is now recognized to outperform O-C2a in predicting dysphagia. However, there are no data on this topic from patients with anterior atlantoaxial subluxation (AAS). PURPOSE: To evaluate the relationship between the O-EAa and dysphagia in patients suffering from AAS after OCF surgery. STUDY DESIGN: A retrospective clinical study. PATIENT SAMPLE: Data from 22 consecutive AAS patients who had undergone OCF were reviewed retrospectively. OUTCOME MEASURES: The outcome measures included the O-EAa, O-C2a, the narrowest oropharyngeal airway space (nPAS), and the morbidity of dysphagia after OCF. METHODS: Between September 2011 and September 2017, data from 22 consecutive AAS patients who had undergone OCF were reviewed retrospectively. The patients were divided into two groups according to whether they had suffered postoperative dysphagia by face-to-face questioning or telephone interview. Lateral radiographs were analyzed to determine the pre- and postoperative O-EAa, O-C2a, angle formed by the inferior endplate of C2 and the EA-line (C2Ta), and smallest anteroposterior diameter of the oropharynx between the levels of the uvula and the tip of the epiglottis (nPAS). RESULTS: The incidence of dysphagia after OCF was 18.18% (4/22). The pre- and postoperative mean nPAS values were significantly different between the groups (p<.05). The postoperative mean O-EAa of the group with dysphagia was significantly smaller than that of the group without dysphagia (p<.05). The mean change in nPAS was significantly larger in the group with dysphagia than that in the group without dysphagia (p<.05). The changes in the O-EAa, O-C2a, and nPAS were linearly correlated within patients. The marginal R2 values for the patients were 0.452 and 0.202 for the O-EAa and O-C2a, respectively. CONCLUSIONS: The O-EAa impacts dysphagia in patients with AAS after OCF. Measuring this angle intraoperatively may be a simple and effective procedure. The O-EAa may be used as a practical index to avoid postoperative dysphagia in patients with AAS after OCF.

Analysis of Treatment and Prognosis of 863 Patients with Spinal Tuberculosis in Guizhou Province.

The objective of this study was to investigate the treatment and prognosis of patients with spinal tuberculosis in Guizhou province. A total of 863 patients with spinal tuberculosis admitted to our hospital from 2006 to 2017 were included in this study. All patients underwent standardized quadruple antituberculosis treatment. Eighty patients were lost to follow-up due to a change of their contact information or noncompliance. A total of 783 patients completed the follow-up. The average follow-up period was 20.33 ± 8.77 months (range: 6 to 38 months). Among these patients, 145 patients underwent conservative treatment, while 638 patients underwent surgical treatment. All patients in the surgery group were treated with lesion removal, bone graft fusion, and internal fixation. Preoperative and postoperative standard quadruple antituberculosis treatment was administered. The clinical efficacy was evaluated according to erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), visual analogue scale (VAS), Cobb angle correction, neurological functional recovery, and interbody fusion with bone graft and tuberculosis outcome. A total of 608 patients achieved clinical cure. The symptoms, physical signs, blood tests and imaging findings were improved in 143 patients. Twenty patients showed refractory clinical symptoms, and 12 patients had local tuberculosis recurrence. Conservative and surgical treatments are the mainstream treatments for spinal tuberculosis. According to the patients' individual conditions, individualized treatments should be used to achieve good efficacy. Standardized antituberculosis treatment should be applied over the course of spinal tuberculosis.

[Treatment of thoracolumbar burst fractures by posterior laminotomy decompression and bone grafting via injured vertebrae].

OBJECTIVE: To study the effectiveness of posterior laminotomy decompression and bone grafting via the injured vertebrae for treatment of thoracolumbar burst fractures. METHODS: Between November 2010 and November 2012, 58 patients with thoracolumbar burst fractures were treated by posterior fixation combined with posterior laminotomy decompression and intervertebral bone graft in the injured vertebrae. There were 40 males and 18 females with a mean age of 48 years (range, 25-58 years). According to Denis classification, 58 cases had burst fractures (Denis type B); based on neurological classification of spinal cord injury by American Spinal Injury Association (ASIA) classifications, 5 cases were rated as grade A, 18 cases as grade B, 20 cases as grade C, 14 cases as grade D, and 1 case as grade E. Based on thoracolumbar burst fractures CT classifications there were 5 cases of type A, 20 cases of type B1, 10 cases of type B2, and 23 cases of type C. The time between injury and operation was 10 hours to 9 days (mean, 7.2 days). The CT was taken to measure the space occupying of vertebral canal. The X-ray film was taken to measure the relative height of fractured vertebrae for evaluating the vertebral height restoration, Cobb angle for evaluating the correction of kyphosis, and ASIA classification was conducted to evaluate the function recovery of the spinal cord. RESULTS: The operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-18 months (mean, 15 months). CT showed good bone graft healing except partial absorption of vertebral body grafted bone; no loosening or breakage of screws and rods occurred. The stenosis rates of fractured vertebral canale were 47.56% ± 14.61% at preoperation and 1.26% ± 0.62% at 1 year after operation, showing significant difference (t = 24.46, P = 0.00). The Cobb angles were (16.98 ± 3.67)° at preoperation, (3.42 ± 1.45)° at 1 week after operation, (3.82 ± 1.60)° at 1 year after operation, and (4.84 ± 1.70)° at 3 months after removal of internal fixation, showing significant differences between at pre- and post-operation (P < 0.05). The relative heights of fractured vertebrae were 57.10% ± 6.52% at preoperation, 96.26% ± 1.94% at 1 week after operation, 96.11% ± 1.97% at 1 year after operation, and 96.03% ± 1.96% at 3 months after removal of internal fixation, showing significant differences between at pre- and post-operation (P < 0.05). At 1 year after operation, the neural function was improved 1-3 grades in 56 cases. Based on ASIA classifications, 1 case was rated as grade A, 4 cases as grade B, 10 cases as grade C, 23 cases as grade D, and 20 cases as grade E. CONCLUSION: Treatment of thoracic and lumbar vertebrae burst fractures by posterior laminotomy decompression and bone grafting via the injured vertebrae has satisfactory effectiveness, which can reconstruct vertebral body shape and height with spinal cord decompression and good vertebral healing. It is a kind of effective solution for thoracolumbar burst fracture.

[Revision cause and effect of gamma nail fixation].

OBJECTIVE: To investigate the reasons of failure of Gamma nail treatment for intertrochanteric fractures and define operative techniques of the revision surgery. METHODS: From January 1999 to January 2008, 20 cases of 432 patients treated with Gamma nails for intertrochanteric fractures were revised. There were 9 males and 11 females, aged 24-87 years (median 65 years). Among them, there were 4 cases of femoral shaft fracture, 2 cases of screw penetrating the femoral head, 11 cases of screw cutting out the femoral head and neck, 2 cases of internal rotation malformation, and 1 case of infection. The operative procedures of revision were as follows: 4 cases were treated with the long Gamma nail, 4 cases by adjusting the position of Gamma nail, 11 cases with artificial femoral head replacement, and 1 case by removing Gamma nail and debriding and re-implant the Gamma nail. RESULTS: The hospitalization days were 16-28 days (21.2 days on average); the bleeding volume during operation was 150-600 mL (380 mL on average). All wounds healed by first intention. Bed rest days were 7-15 days (12.5 days on average). All the patients were followed up for 1-8 years (5 years on average). The operations were successful, the femoral intertrochanteric fracture and femoral shaft fracture reached bony union. Complications such as loosening, breakage of hardware and coxa adduct were not observed. No loosening and dislocation of the prosthesis occurred. Among the patients with complications, 9 patients were treated with a Gamma nail again. Fracture healing was achieved within 2 to 5 months, with an average of 3 months. According to the WANG Fang et al. criterion for hip joint function, the results were excellent in 7 cases and good in 2 cases. In 11 patients who received artificial femoral head replacement, the hip joint function restored to normal. Harris score was 90-93. CONCLUSION: Various causes such as osteoporosis, tip-apex distance (> or =25 mm), femoral shaft malformation, Gamma nail shortcomings may lead to complications after Gamma nail treatment for intertrochanteric fractures. Good results will be achieved by different revision techniques.