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The treatment of trochanteric fractures with the use of gamma nails has become an established method. Despite the good and reliable results, some typical failures and complications may occur. It was our purpose to analyse the most common complications and their treatment options.A total of 498 patients were treated with a gamma nail from January 1992 until December 2001. There were 77% pertrochanteric, 10% subtrochanteric, 11% reversed pertrochanteric and 2% lateral femoral neck fractures. The patients' mean age was 78.6 years (ranging from 29 to 98 years).There were a total of 78 general complications (16%) and implant-related complications in 8% (n=42). The most common complication was trochanteric pain necessitating removal of the gamma nail (n=30). Four patients fell after removal of the nail and sustained a neck fracture on the same side. Cut-out of the screw occurred in 19 patients. Sixteen of them had to be converted to a total hip replacement. Another 5 patients were converted to a total hip replacement because of pseudoarthrosis. During conversion to total hip replacements, the trochanter major refixation and length adjustment were the most problematic steps (intra- or postoperative dislocations necessitating anti-dislocation rings in three cases). Furthermore, cement extrusion at the femur and acetabulum occurred in 13 cases. Infections occurred in 3 patients. Five patients with a short gamma nail needed a conversion to a long gamma nail due to pseudoarthrosis (n=2) or femur fracture at the distal interlocking bolt (n=3). In addition, 7 patients sustained a distal femur fracture through the distal bolt, necessitating a plate osteosynthesis.Most complications after gamma nail fixation can be prevented by following certain rules. The other inevitable problems can be dealt with either through a conversion to a total hip replacement, a re-osteosynthesis with a long gamma nail or an additional condylar plate. Conversion to total hip replacement may be a demanding operation with a higher than normal complication rate. Removal of the gamma nail should be performed cautiously as re-fractures can occur.