Intertrochanteric femur fractures account for approximately 45% of all hip fractures [1] and occur predominantly in the geriatric population due to osteoporosis and low-energy trauma. Intertrochanteric fracture is defined as the fracture that occurs between the greater trochanter and the lesser trochanter, distal to the neck of the femur with or without the involvement of one or both these two structures [2].  With the increasing life expectancy worldwide, the incidence of these fractures is expected to rise. The intertrochanteric region is made of weight bearing trabeculae that consist of cancellous bone and is extra-capsular, and highly vascular [3]. So, if untreated intertrochanteric fracture tends to malunite and has less chance of avascular necrosis or non-union [4].  Early surgical stabilization with the goal of rapid mobilization remains the standard of care.

Intramedullary fixation has gained widespread acceptance due to biomechanical advantages such as a shorter lever arm and improved load sharing. The PFNA system incorporates a helical blade that compacts cancellous bone, improving rotational stability and resistance to cut-out, particularly in osteoporotic bone [5]. Thus the PFNA blade is a more biomechanically suitable implant even for unstable and osteoporotic trochanteric fractures and also an exceptional device for reosteosynthesis [6]. The PFNA Asian variant further modifies nail geometry to suit Asian femoral anatomy. This study evaluates the radiological and functional outcomes of PFNA Asian fixation in geriatric intertrochanteric fractures.

Study design and Population: This prospective observational study was conducted at Vels Medical College and Hospital, Tiruvallur, TamilNadu, a tertiary care orthopedic center from July 2021 to July 2024 with a minimum follow up of 12 months. Geriatric patients aged 60 years and above who were independently mobile before fall, presenting less than 1 week of trauma with AO/OTA 31-A intertrochanteric femur fractures were included. Patients with pathological fractures, polytrauma, or prior ipsilateral hip surgery were excluded. Implant Used: Proximal Femoral Nail Antirotation Asian: (System) This implant made of titanium alloy. The PFNA is available in 170mm (extra-small), 200mm (small), 240mm and 300 to 420mm with 20 mm increments (long) sizes. The helical blade is available in lengths from 75 to 115 mm. The distal locking bolt of appropriate size. Surgical Technique: The patient is positioned supine on the fracture table, with the ipsilateral arm in a sling and the uninjured leg on a leg holder. The ipsilateral hip is adducted, and fracture reduction is achieved by applying traction along the limb, followed by internal rotation, verified with an image intensifier. The extremity and ipsilateral iliac crest are prepped and draped. A 5 cm incision is made proximal to the greater trochanter; the fascia and gluteus medius are split along fiber lines. In AP view, the PFNA entry point is at or slightly lateral to the tip of the greater trochanter; in lateral view, it aligns with the femoral canal axis. A guide wire is inserted centrally in the femoral shaft and neck, verified radiographically. Over the guide wire, the protection sleeve and drill are advanced, and the trochanteric area is reamed. A nail with a 130° neck-shaft angle is inserted manually to allow central or inferior blade placement. The helical blade is inserted over the guide wire hand-inserted in elderly to preserve bone and then locked. Distal locking screws are placed via the aiming arm. Final imaging confirms reduction, blade position, Tip Apex Distance, and neck-shaft angle. The wound is irrigated, closed in layers, and dressed. All fractures were treated using PFNA Asian following closed reduction on a fracture table under fluoroscopic guidance. Implant positioning was optimized with particular attention to Tip–Apex Distance (TAD) as emphasized by Baumgaertner et al [7] and Cleveland zone placement [8]. Tip Apex Distance and Cleveland Zones are important indices of blade tip position and predictors of blade migration as suggested by Gottfried et al in 2004 and concluded that PFNA may fail if the TAD is less than 20mm which leads to axial cut-out (medial migration) and if TAD is more than 30 mm it may cause cephalad cut-out [9]. Postoperative rehabilitation emphasized early mobilization and weight-bearing as tolerated. Soderman et al.in 2001 have shown that Harris hip score can be used by both doctor and physiotherapist as a tool to successfully assess hip function after surgery [10].

Table1: Radiological union

Table 2: Complication

Table 3: Harris hip score

Table 4: Parker and Palmer mobility score

Table 5: Association with parameters

A total of 70 patients were included in study, with a mean age of 78±9 years predominantly females (64%). The most common mechanism of injury was low-energy fall. Fracture union was achieved in 93% of patients by a mean duration of 10-16 weeks. The mean Harris Hip Score at final follow-up was 67%, with 26% of patients demonstrating good to excellent functional outcomes. Suboptimal implant positioning was associated with inferior functional scores.

Statistical analysis was performed to evaluate the association between demographic variables, fracture characteristics, and intraoperative parameters with radiological and functional outcomes. Age, sex, mode of injury, side of fracture, comorbidities, AO fracture type, intraoperative reduction quality, tip–apex index, Cleveland zone of blade position, and neck–shaft angle were analyzed against radiological union, surgical complications, Harris Hip Score (HHS), and Parker and Palmer mobility score. Age did not show a statistically significant association with radiological union (p = 0.723), surgical complications (p = 0.064), or Harris Hip Score (p = 0.122); however, a significant association was observed with Parker and Palmer mobility score (p = 0.007). Sex showed no significant correlation with union (p = 0.245), complications (p = 0.625), HHS (p = 0.840), or mobility score (p = 0.366). Similarly, mode of injury and comorbidities did not demonstrate statistically significant associations with any of the outcome parameters. AO fracture type was also not significantly associated with union, complications, HHS, or mobility score, although a trend toward poorer mobility outcomes was observed (p = 0.076). In contrast, Cleveland zone of blade position showed a strong and statistically significant association with surgical complications (p = 0.000), Harris Hip Score (p = 0.001), and Parker and Palmer mobility score (p = 0.002), highlighting its critical role in determining postoperative outcomes. Chi-square analysis revealed that increasing age was significantly associated with poorer Parker and Palmer mobility scores, particularly in patients above 90 years of age (p = 0.007). Blade placement in Cleveland Zone 2 was associated with a 100% complication rate and uniformly poor functional outcomes, whereas Zone 5 placement demonstrated the lowest complication rates and the highest proportion of excellent and good functional scores. Zone 8 showed intermediate outcomes. Overall, Cleveland zone of blade position emerged as the most significant predictor of complications and functional recovery, whereas most demographic variables did not significantly influence radiological union or clinical outcomes.

Figure 1. Intra operative steps of intertrochanteric fracture fixatioin using PFNA2

Figure 2. Serial Radiographs showing progressive union

Figure 3. Follow-up and Rehablitation Images

Trochanteric femoral fractures in the elderly, particularly unstable patterns, remain a significant therapeutic challenge. With increasing life expectancy, the burden of these fractures is expected to rise substantially. Despite advances in implant design, no single fixation device has proven ideal for all fracture configurations, largely due to osteoporotic bone quality and altered biomechanics in the geriatric population. Recent meta-analyses indicate that while intramedullary fixation facilitates earlier weight bearing, this advantage may be offset by implant-related complications and reoperation rates related to technical factors [11,12]. Conventional lag screw systems are associated with complications such as screw cut-out, varus collapse, and rotational instability, particularly in osteoporotic bone. Biomechanical tests have proved that the blade system has a significantly higher resistance for cut-out than the commonly used screw systems [9]. The introduction of helical blade technology aimed to overcome these limitations by improving fixation through cancellous bone compaction rather than bone removal. The helical blade provides an increase in the contact surface area between the purchase-holding device and the femoral head [13] and compresses the cancellous bone rather than removing the limited amount of bone when like the conventional screw [14].  The Proximal Femoral Nail Antirotation (PFNA) was developed to enhance implant stability while simplifying surgical technique. Once locked, the helical blade provides improved axial and rotational stability, and biomechanical studies have demonstrated superior resistance to cut-out compared with screw-based systems [15].

An additional advantage of the PFNA blade is that it is inserted without reaming the femoral head or neck, thereby preserving trabecular bone architecture essential for implant purchase. Excessive reaming compromises bone quality and fixation strength. The increased surface area of the helical blade enhances the bone–implant interface, reducing the risk of varus collapse and mechanical failure [16].

In this study,all the cases had TAD <25mm, which was significant when compared to other studies (Kumar et al [17] and Mallya et al [18]). This may be attributed to good reduction and proper visualization of the fracture in c-arm and the surgeon experience.

PFNA2 was subsequently introduced to better match femoral morphology in the Asian population, facilitating easier nail insertion and reducing the risk of iatrogenic femoral fractures [19]. Gavaskar et al [20] in their prospective study of 122 patients showed that good results with low complication rates could be achieved by PFNA in trochanteric fractures in elderly. In the present study, seventy patients with isolated intertrochanteric fractures treated with PFNA2 demonstrated satisfactory radiological union and functional outcomes, supporting its effectiveness in elderly patients with unstable trochanteric fractures.

Limitations:

Limitations of this study include a single-center design, limited sample size, and absence of a comparative control group. Larger randomized studies are required to validate these findings.

Our study showed that PFNA Asian provides good results if careful attention is paid for factors like understanding of the biomechanical principle of the nail, good intra-op reduction, proper blade position and early mobilization. Biomechanical studies have shown that the PFNA2 is well suited for asian population femur in fixing the inter trochanteric femur fractures. The overall results were good to excellent in this study group with few failures. 4 failures which occurred in this study despite satisfactory reduction intra-op which suggests that further factors leading to the failure has to be studied in future. With this study, we conclude that the PFNA Asian, despite a few complications, is a satisfactory method of treatment in elderly intertrochanteric fractures and earlier mobilization of the patient post-op gives a good functional outcome.

1. Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. The Journal of arthroplasty. 2005 Apr 1;20(3):337-43.
2. Ahn J, Bernstein J. In brief: fractures in brief: intertrochanteric hip fractures.
3. Koval KJ, Zuckerman JD. Hip fractures: II. Evaluation and treatment of intertrochanteric fractures. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 1994 May 1;2(3):150-6.
4. Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. Journal of orthopaedic trauma. 2009 Jul 1;23(6):471-8.
5. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury. 2006 Oct 1;37(10):984-9.
6. Kristek D, Lovrić I, Kristek J, Biljan M, Kristek G, Šakić K. The proximal femoral nail antirotation (PFNA) in the treatment of proximal femoral fractures. Collegium antropologicum. 2010 Oct 1;34(3):937-40
7. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clinical Orthopaedics and related research. 1998 Mar(348):87-94.
8. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. JBJS. 1959 Dec 1;41(8):1399-408.
9. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clinical Orthopaedics and Related Research (1976-2007). 2004 Aug 1;425:82-6.
10. Söderman P, Malchau H. Is the Harris hip score system useful to study the outcome of total hip replacement?. Clinical orthopaedics and related research. 2001 Mar 1;384:189-97.
11. Parker MJ, Handoll HH. Cephalocondylic intramedullary nails for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews. 2004(3).
12. Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures: management and current controversies. JBJS. 2004 Feb 1;86(2):398-410.
13. Sommers MB, Roth C, Hall H, Kam BC, Ehmke LW, Krieg JC, Madey SM, Bottlang M. A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. Journal of orthopaedic trauma. 2004 Jul 1;18(6):361-8.

14. Parker MJ, Handoll HH. Cephalocondylic intramedullary nails for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews. 2004(3).
15. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury. 2006 Oct 1;37(10):984-9.
16. Goffin JM, Pankaj P, Simpson AH, Seil R, Gerich TG. Does bone compaction around the helical blade of a proximal femoral nail anti‑rotation (PFNA) decrease the risk of cut‑out? A subject‑specific computational study. Bone & Joint Research. 2013;2(5):79‑83. doi:10.1302/2046‑3758.25.2000150.
17. Kumar GK, Sharma G, Khatri K, Farooque K, Lakhotia D, Sharma V, Meena S. Treatment of Unstable Intertrochanteric Fractureswith Proximal Femoral Nail Antirotation II: Our Experience in Indian Patients. The open orthopaedics journal. 2015;9:456.
18. Mallya S, Kamath SU, Madegowda A, Krishnamurthy SL, Jain MK, Holla R. Comparison of radiological and functional outcome of unstable intertrochanteric femur fractures treated using PFN and PFNA-2 in patients with osteoporosis. European Journal of Orthopaedic Surgery & Traumatology. 2019 Feb 18:1-8.
19. Loo WL, Loh SY, Lee HC. Review of Proximal Nail Antirotation (PFNA) and PFNA-2–Our Local Experience. Malaysian Orthopaedic Journal. 2011;5(2):1-5.
20. Gavaskar AS, Subramanian M, Tummala NC. Results of proximal femur nail antirotation for low velocity trochanteric fractures in elderly. Indian journal of orthopaedics. 2012 Sep;46(5):556.

21. Kadirvel D, Vasudevan S, Selvamuthukumaran S, Rajput S, Kumar PG. Identifying the Prognostic Factors Affecting the Conversion From Laparoscopic Cholecystectomy to Open Cholecystectomy in Acute Cholecystitis. Cureus. 2024 Nov 19;16(11):e73975. doi: 10.7759/cureus.73975.
22. Aloraini A, Alanezi T, AlShahwan N. Subtotal laparoscopic cholecystectomy versus open total cholecystectomy for the difficult gallbladder: A systematic review and meta-analysis. Curr Probl Surg. 2024 Nov;61(11):101607. doi: 10.1016/j.cpsurg.2024.101607.