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American Journal of  
Life Science and Innovation (AJLSI)

Evaluating the Efficacy of  Proximal Femoral Nail Antirotation with Augmentation in 
Managing Osteoporotic Intertrochanteric Fractures: A Comprehensive Review

Ramadan Mohamed Elsaid Ahmed1*

Volume 3 Issue 2, Year 2024
ISSN: 2833-1397 (Online)

DOI: https://doi.org/10.54536/ajlsi.v3i2.2759
https://journals.e-palli.com/home/index.php/ajlsi

Article Information ABSTRACT

Received: May 25, 2024

Accepted: June 29, 2024

Published: July 03, 2024

Addressing intertrochanteric fractures in those with impaired bone quality using orthopedic 
surgery is a huge challenge. This review assesses the effectiveness of  Proximal Femoral Nail 
Antirotation (PFNA) with augmentation, cement being the best augmentation compared 
to others, in healing these fractures. Comparative analyses show that PFNA is significantly 
better than PFN, with reduced operative times, blood loss and complications, especially in 
high-risk elderly patients. This review compiles data from 15 articles which aims to provide 
an overall picture of  the present evidence on the use of  PFNA technique supplemented by 
the application of  osteoporotic intertrochanteric fractures. Augmentation methods, such as 
cement augmentation, have come to the forefront as important adjuncts to increase stability 
and effectiveness in PFNA procedures. Research has demonstrated that adapting the cement 
augmentation technique helps to restore load-bearing capacity, lower implant failure rate 
and to better the clinical results in total joint arthroplasty. PFNA with cement augmentation 
effectively treats intertrochanteric fractures in osteoporosis hips, providing satisfactory 
results and potential for further clinical development. This review brings to the forefront 
the necessity of  stabilizing the osteodensification and the proper cement augmentation, all 
of  which aid in enhancing stability, occasioning less complications and leading to better 
postoperative outcomes. The future development in PFNA techniques and the trending 
advancement of  augmentation strategies would allow the field of  surgery to benefit from an 
even more optimized way of  dealing with these fractures in the clinical setting which is both 
promising and favorable.

Keywords

Augmentation, Cement, 
Fracture, Osteoporotic 
Intertrochanteric Fractures, 
PFNA

INTRODUCTION
Osteoporosis is a prevalent disease caused by the low 
density of  bone mass, poor bone microarchitecture and 
fragility fractures. Osteoporosis has been a major concern 
worldwide, affecting 200 million people (Noh et al., 
2020). The high rate of  global morbidity osteoporosis is 
emphasized by its incidence in the population size of  the 
majority of  regions, estimating 18.3% of  the entire world 
population, with a gender disparity showing a higher 
incidence rate in females with 23.1%, as opposed to men 
with 11.7% (Salari et al., 2021). Such figures favor the 
importance of  developing health systems that take into 
consideration gender-specific factors, more especially 
the hormonal changes during and after menopause in 
women. 
Witnessing a similar situation in China where adults 
aged 40 and above reveal a considerably high incidence 
of  osteoporosis in men at 5.0% and women at 20.6% as 
well as a rather high occurrence of  vertebral fractures 
in males at 10.5% and females at 9.7%, the pattern 
also follows at the global level (Wang et al., 2021). The 
figures from China not only reflect the extensive gender 
discrepancy in osteoporosis prevalence, but also remind 
of  the worldwide challenge of  osteoporosis management. 
Surprisingly, though, only a small fraction of  patients 
with osteoporosis or patients who have suffered from a 
fracture are being properly treated in China, implying to 
the existence of  wide gap of  treatment. 

Proximal Femoral Nail Antirotation (PFNA)
PFNA is a cutting-edge orthopedic implant designed 
for managing proximal femoral fractures, which 
are commonly seen in the geriatric population with 
osteoporosis as fractures predominantly occur at the 
intertrochanteric site (Sachin, 2019). The intramedullary 
fixation gadget has changed shock management 
progressions by creating extreme stability and rotational 
control that is of  core significance in the management 
of  fracture cases (Bizzoca et al., 2023). Notably, this PFN 
has a threaded titanium alloy at its proximal end. The 
design of  the medical screw, the helical blade, is decisive 
in enhancing the primary stability of  the damaged area 
by engaging tightly to the cancellous bone from the neck 
to the head of  the femur (Wang et al., 2020). This links 
with the bone amalgamation within the bone readily 
reduces the chances of  implant migration as a result of  
complications that if  not addressed would be a setback 
in the treatment especially in the event of  osteoporotic 
bone where screw fixation may not be adequate.
Furthermore, the PFNA comes at the cutting edge of  
technology as its features allows for customization of  
the implant in line with patient anatomy and various 
fracture patterns. Doctors can design the implant in a 
way that exactly fits each case by accurately controlling 
the implant configuration according to the need of  each 
case, to enhance stability and provoke better healing 
(Ledet et al., 2018; Meng et al., 2023). The architecture of  

1 Rashid Hospital Trauma Centre, 315 Umm Hurair, Dubai, United Arab Emirates
* Corresponding author’s e-mail: rmdanelsaid@yahoo.com



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the PFNA is designed and developed very smoothly to 
take on the pressing forces that are experienced by the 
body during weight-bearing (Augat & von Rüden, 2020). 
Its novel generation eliminates the stress concentration 
close to the fractured part of  the femoral shaft and by 
the consequence, protects the implant’s integrity and 
prevents its possible failure. As many of  its effects are due 
to structural integrity, the PFNA enables early stages of  
mobilization and rehabilitation that could be invaluable 
for functional recovery and independence induction in 
patients. Through its function of  rendering the bone firm 
in position and by promoting wound endogenous healing, 
the PFNA aids in completing the recovery process faster 
and improves the patient’s general situation (Yu et al., 
2020). 

Osteoporotic Intertrochanteric Fractures & PFNA
Osteoporotic fractures are linked to decreased quality 
of  life, greater morbidity and in some cases of  pelvic, 
spine and hip fractures, higher chances of  death (Gold et 
al., 2019). The fracture mostly affects the regions of  the 
hip, spine, and distal radius, with hip fractures, especially 
intertrochanteric fractures, being the most serious due to 
their higher rates of  morbidity, disability, and mortality 
(Bishnoi et al., 2018). However, the management of  
osteoporotic intertrochanteric fractures which causes 
bone demineralization in the elderly requires new 
advancement in orthopedic surgical methods to produce 
efficient treatment results. Intertrochanteric fractures 
near the proximal end of  the femur, one of  the most 
common types of  osteoporotic fractures, interfere with 
many daily tasks such as walking and performing other 
weight-bearing exercises. This can greatly reduce a 
patient’s quality of  life (Maffulli & Aicale, 2022). However, 
the issues that occur while treating these fractures are 
caused by compromised bone quality of  osteoporosis 
that usually result in problems with the achievement and 
maintenance of  a fixation which is stable (Chen et al., 
2022). The usual fixation techniques are very helpful in 
dealing with general bone damage, but when a problem 
arises in the context of  osteoporotic bone the approach 
is limited due to the lack of  bone mass and the specific 
changes in biomechanical properties. 
The PFNA system transformed orthopedic surgery 
through the development of  an advanced method for 
stabilizing and managing fractures in the proximal femur, 
increasing stability and aiding the natural bone healing 
process (Yu et al., 2020). This particular implant, was 
designed unmistakably to face to the problems caused 
by osteoporotic bone disease (Patil, 2019). Among its 
attributes that heighten the rigidness of  the implant 
fixation the PFNA stands out. The operation of  the 
PFNA system in antirotation is another remarkable 
feature that targets the high rate of  the rotation of  the 
femoral head and neck cost as an enormous failure of  
the conventional fixation systems (Chen et al., 2020). The 
PFNA system specifically addresses these drawbacks as 
it offers an internal alignment device that promotes the 

mechanical stability of  the fracture site, thereby enabling 
the patient to start rehabilitation earlier and decreasing the 
risk of  potential problems (Zheng et al., 2021). Through 
the use of  augmentation, the optimal observance of  the 
moderation principle is reached. As bone cement and a 
strong ligation structure strengthen the damaged area, 
they become an invaluable tool in the modern treatment 
of  intertrochanteric fractures in osteoporosis (Ni et al., 
2022). This context demonstrates the urgent need for 
pioneering and innovative surgical solutions like PFNA 
system to be developed in order to prevent the onset of  
osteoporotic fractures in an aging global population.
Moreover, the PFNA system provides an essential 
addition to the therapy of  these types of  bone fractures 
as they proceed towards the next level. Implants (pin, 
screws, plates, bone cements) are used to increase 
weight-bearing capacity, to reinforce the fixation, and 
to provide additional support to the osteoporotic bone 
(Hollensteiner et al., 2019). PFNA with hyperextension 
is developed with biomechanical principles of  fracture 
fixation in mind. Thus, the PFNA unit helps in bringing 
about a steady healing environment within the bone which 
enhances the chance of  bone healing. The PFNA design 
targets to reduce the strain on the bone, distribute uneven 
loads, and minimize the risk of  the head of  the femur 
twisting and collapsing, which are known complications 
in the healed intertrochanteric fracture in osteoporotic 
condition (Inginshetty, 2019; Lakhmania, 2020). 
The clinical data showed that the PFNA system 
was highly effective in managing fractures in the 
intertrochanteric region of  the bone associated with 
osteoporosis (Su et al., 2022). Studies have proven 
better results regarding shorter operating times, less 
bleeding and quick healing of  operated areas (Xu et al., 
2018). What is more, the amplified treatment has been 
demonstrated to considerably lower the risk of  implant 
failure and secondary procedures, solutions which bring 
in more risks in the treatment of  osteoporotic fracture. 
The general surgeon, patient screening, and technical part 
of  PFNA implantation involve some certain things to be 
considered so as to get all the benefits from the PFNA 
system. On top of  the healing benefits of  any other 
surgical intervention, the specific PFNA system has its 
own risks and complications, which stresses the need for 
all clinicians to know the indications, contraindications, 
and surgical principles for an optimal procedure.

Augmentation
Augmentation in orthopedic surgery is supplementary 
to bone-implant interfaces, parallelly improving stability 
and better treatment outcomes. It is very appropriate 
where the bone scenarios are challenging i.e. osteoporotic 
fractures. This approach bases its actions on several 
strategies directed at enhancing the fixation knowing 
and reducing the chance of  implant loss. Once the bone 
cement is injected, it comes around the implant, usually 
polymethyl methacrylate (PMMA), that it has been part of  
the fractured site (Soleymani Eil Bakhtiari et al., 2021). Its 



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role here is to seal the gaps within the porous bone as well 
as deliver stronger and better connection or an anchor 
for the implant. The ability of  cement augmentation to 
enhance the contact area of  the bone-implant and transfer 
the loads as well as provide biomechanical stability, which 
is vital for fracture healing success, is emphasized by a 
way of  hauling up the bone-implant contact area (Weiser 
et al., 2018). 
Further the concept of  augmentation extends beyond 
just the use of  extra grafts and pins, where additional 
fixation elements like cerclage wires or cables are also 
employed to strengthen the construct and minimize the 
stress concentrations (Thakur, 2022). These adjunctive 
stabilization techniques supplement the implant and even 
out the stress it faces. This may help to reduce the risk of  
implant migration failure. The use of  these enrichment 
techniques in orthopedic surgery is extensive to enhance 
the outcome in various procedures, such as the fixation 
of  fracture, joint arthroplasty, and spinal fusion (Schuetze 
et al., 2019). One of  the major functions of  augmentation 
is to reinforce implant stability and to merge bone-
implant integration that in turn will raise the chances of  
early mobilization and rehabilitation leading to the quick 
recovery of  the patients with an improved outcome 
(Tolstunov et al., 2019). Specifically, augmentation is 
a proven auxiliary treatment in orthopedic surgery 
providing biomechanical reinforcement, improving the 
general condition of  fractures and thus offering complex 
clinical care.
This review intends to report on the impact of  

employing the Proximal Femoral Nail Antirotation 
(PFNA) alongside the augmentation therapies in the 
care of  osteoporotic intertrochanteric fractures. This 
review aims to analyze the current literature representing 
a combination of  clinical studies and articles that 
will determine effectiveness and safety of  PFNA 
augmentation compared to standard fixation techniques. 
Primarily, the review will focus on the outcomes such as 
rate of  healing of  the fractures, stability of  the implants, 
complications after surgery and patient’s satisfaction with 
the recovery progress. Moreover, the examination reveals 
the possible pros and cons of  merging the augmentation 
procedure with the PFNA technique employed in the 
treatment of  osteoporotic intertrochanteric fractures, 
taking into account bone quality, the implant positioning, 
and surgical method. This review aims to summarize the 
positive impact of  PFNA in bone augmentation, aiming 
to improve treatment results and patient lives for femoral 
neck fractures.

METHODOLOGY
Search Strategy
The table 1 below shows the methods used in search 
strategies to identify corresponding studies of  the 
searched literature to the research topic. The strategy 
includes a set of  keywords and terms relevant to PFNA, 
osteoporotic fractures, augmentation techniques, and 
surgical fixation methods, as they are intended to provide 
the broadest coverage of  the journals containing the 
research on this topic.

Table 1: Search Strategy
S. no Search Strategies
1. (“Proximal Femoral Nail Antirotation”) AND (“PFNA”) AND (“Osteoporotic Fractures”) AND 

(“Osteoporotic Intertrochanteric Fractures”) AND (“Treatment Approaches to Osteoporosis”) 
2. (“Osteoporosis Management Strategies”) AND (“Augmentation Techniques”) AND (“Bone Cement 

Augmentation”) AND (“Surgical Fixation Methods”) AND (“Cement Augmentation Femur Fractures”) 
(“Biomechanical Studies on Augmentation”) 

Inclusion and Exclusion Criteria
The table 2 provides the details of  inclusion and 
exclusion criteria that are used to filter out the relevant 
studies with a focus on the role of  Proximal Femoral 
Nail Antirotation (PFNA) and augmentation in the 

management of  osteoporotic intertrochanteric fractures. 
Studies that met the desired criteria, dealt with the topic 
within the specified timeframe, and utilized the defined 
keywords as themes were included for analysis.

Table 2: Inclusion and Exclusion criteria
Inclusion Criteria Exclusion Criteria
Studies that focuses on the use of  Proximal Femoral 
Nail Antirotation (PFNA) and Augmentation in the 
management of  osteoporotic intertrochanteric fractures.

Studies that do not focuses on the use of  Proximal Femoral 
Nail Antirotation (PFNA) and Augmentation in the 
management of  osteoporotic intertrochanteric fractures.

Studies published within the last six years (2018-2023) 
have been included. 

Studies older than six years have been excluded. 

Studies that are in relation with the keywords from the 
title were included.

Studies that are not in relation with the keywords from the 
title were excluded.



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Article Selection
The table 3 below specifies criteria for article inclusion 
in the review and elucidates studies that assess the 
effectiveness of  Proximal Femoral Nail Antirotation 
(PFNA) and augmentation techniques in treating 

osteoporotic intertrochanteric fractures. The research 
covers several works published in different journals 
and various years. It analyzes both surgical strategies 
and their consequences, focusing on PFNA and general 
augmentation.

Table 3: Article Selection
S.no Author Journal Year Findings
1. Schuetze, Konrad MD; 

Eickhoff, Alexander MD; 
Röderer, Goetz MD; 
Gebhard, Florian MD; 
Richter, Peter H. MD

Journal of  
Orthopaedic 
Trauma

2019 The article offers insights into the efficacy of  
augmentation techniques in orthopedic surgery 
for managing osteoporotic fractures, addressing 
challenges related to mechanical failure and exploring 
diverse augmentation materials and strategies.

2. Dr. Vinod Nair, Dr. 
Shubhanshu Gupta, 
Dr. Anant Krishna, 
Dr. Amol Patil and Dr. 
Avinash Kumar

International 
Journal of  
Orthopaedics 
Sciences

2019 The study compared the effectiveness of  Proximal 
Femoral Nail (PFN) and Proximal Femoral Nail 
Antirotation (PFNA) in stabilizing unstable 
intertrochanteric fractures, finding PFNA 
significantly reduced operative duration, blood loss, 
and hospital stays.

3. Mittal, Ankit; Gill, 
Simrat P.S.; Kumar, 
Dinesh; Singh, Jasveer; 
Kumar, Harish; Rajput, 
Ajay

MAMC Journal 
of  Medical 
Sciences

2021 This study compared the effectiveness of  PFNA and 
PFN in treating intertrochanteric fractures. Despite 
similar functional outcomes upon fracture union, 
PFNA exhibited fewer complications and shorter 
operative times, indicating potential benefits for 
osteoporotic, elderly patients.

4. Avate Shivaji, Gaonkar 
Kiran L., Vatsa 
Madhuranjan, Kumari 
Lipi, Patil Sudhir

Research Journal 
of  Pharmacy 
and Technology

2023 The study evaluated the functional outcomes 
of  PFN A-II implants for intertrochanteric and 
sub trochanteric femur fractures, revealing their 
stability, biomechanical acceptability, and minimal 
complications.

5. Noratep Kulachote, 
Paphon Sa-
ngasoongsong, 
Norachart 
Sirisreetreerux, Kulapat 
Chulsomlee, Sorawut 
Thamyongkit, Siwadol 
Wongsak,

Geriatric 
Orthopaedic 
Surgery & 
Rehabilitation

2020 The study assessed outcomes of  elderly 
intertrochanteric fracture patients treated with 
PFNA, with and without cement augmentation, 
finding higher return rates to prefracture ambulatory 
level with cement augmentation, suggesting its 
efficacy in improving functional outcomes in high-
risk geriatric patients.

6. Hu S, Du S, Xiong W, 
Chen S, Song H, Chang 
S

Chinese 
Journal of  
Reparative and 
Reconstructive 
Surgery

2021 The study evaluated the effectiveness of  proximal 
femoral nail anti-rotation (PFNA) in treating high 
plane intertrochanteric femur fractures, finding 
satisfactory outcomes, good fracture reduction 
quality, and prevention of  internal fixation failure.

7. Alexander M. Keppler, 
Daniel Pfeufer, Fabian 
Kau, Christoph Linhart, 
Christian Zeckey, Carl 
Neuerburg, Wolfgang 
Böcker, Christian 
Kammerlander

Injury 2021 The study evaluated the impact of  cement 
augmentation of  the Proximal Femoral Nail 
antirotation (PFNA) on postoperative load capacity 
in older adult proximal femur fracture patients, 
revealing a significant increase in early mobilization, 
especially in frail patients with poor bone quality.

8. Liqin Zheng, Xinmin 
Chen, Yongze Zheng, 
Xingpeng He, Jingxiong 
Wu & Ziling Lin

BMC 
Musculoskeletal 
Disorders

2021 A study using finite element analysis compared 
cement augmented PFNA in stable and unstable 
intertrochanteric fractures, finding that cement 
augmentation improves cutout resistance, especially in 
unstable fractures, suggesting potential clinical benefits.



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RESULTS AND DISCUSSION
Efficacy and Management of  PFNA with 
Augmentation 
The efficacy of  PFNA with augmentation in managing 
osteoporotic intertrochanteric fractures has been the 
focus of  relatively more interest and research within 
the orthopedic surgery as of  late. With the help of  an 
extensive literature review, it becomes apparent that 

the techniques of  augmentation, particularly the use of  
cement augmentation, are an essential part of  enhancing 
the efficiency of  PFNA and patients’ outcomes. 
Osteoporotic intertrochanteric fracture is a special 
challenge because of  its compromised bone quality and 
hence a high risk of  instrumentation failure (Rozell et 
al., 2019). PFNA is generally preferred intramedullary 
fixation device it does this through its central anchoring 

9. Konrad Schuetze, S. 
Ehinger, A. Eickhoff, C. 
Dehner, F. Gebhard & P. 
H. Richter

Archives of  
Orthopaedic 
and Trauma 
Surgery

2021 The study demonstrates the safety and efficacy of  
cement augmentation of  the PFNA blade, effectively 
preventing mechanical failure without increasing 
complications or mortality. Careful decision-making 
and preparation are emphasized to manage potential 
blood pressure changes during the procedure.

10. Navin Kumar Singh, 
Vijay Sharma, 
Vivek Trikha, Shiva 
Gamanagatti, Amit Roy, 
Avtar Singh Balawat, 
Aravindh Palaniswamy, 
Amrut Raje Diwakar

Journal of  
Clinical 
Orthopaedics 
and Trauma

2019 In a prospective study comparing PFNA-II and 
DHS in stable intertrochanteric fractures in elderly 
patients, comparable functional and radiological 
outcomes were found, indicating that PFNA-II 
may offer advantages in high-risk elderly patients, 
including shorter surgical time and reduced blood 
loss.

11. Ong-art Phruetthiphat, 
Teerapat Tutaworn, 
Yanin Plumarom, 
Thipachart 
Punyaratabandhu, 
Chaisiri Chaichankul, 
and Warat Tassanawipas

Journal of  
Clinical Case 
Studies

2019 In a preliminary study on elderly patients with 
unstable intertrochanteric fractures, cement-
augmented PFNA demonstrated no mechanical 
failures, suggesting its potential as a safe alternative 
for managing these fractures.

12. Eleonora Piccirilli, 
Ida Cariati, Matteo 
Primavera, Rebecca 
Triolo, Elena Gasbarra 
& Umberto Tarantino

BMC 
Musculoskeletal 
Disorders

2022 A literature review on augmentation techniques for 
osteoporotic fragility fractures found promising 
outcomes in stability and strength compared to 
non-augmented fractures. The review recommends 
considering augmentation techniques for elderly 
patients with comminuted fractures and poor bone 
quality.

13. Stefano Marcia, Mario 
Muto, Joshua A. Hirsch, 
Ronil V. Chandra, Nicole 
Carter, Paola Crivelli, 
Emanuele Piras & Luca 
Saba

Neuroradiology 2018 A narrative review on vertebral augmentation 
for osteoporotic vertebral compression fractures 
(VCFs) highlights its safety and effectiveness in 
reducing pain and disability, despite ongoing debate. 
The review indicates favorable outcomes with low 
rates of  serious complications and no increased risk 
of  subsequent fractures.

14. Leonardo Stramazzo, 
Salvatore Ratano, 
Francesco Monachino, 
Davide Pavan, Giuseppe 
Rovere, Lawrence 
Camarda

Journal of  
Clinical 
Orthopaedics 
and Trauma

2021 A systematic review emphasizes the safety and 
effectiveness of  cement augmentation in stabilizing 
trochanteric hip fractures, leading to satisfactory 
mobility outcomes and minimizing complications. 
Cement augmentation is identified as a valuable 
method for enhancing fixation in osteoporotic hip 
fractures.

15. An Sermon, Ivan 
Zderic, Roberto 
Khatchadourian, Simon 
Scherrer, Matthias 
Knobe, Karl Stoffel, 
Boyko Gueorguiev

Journal of  
Biomechanics

2021 The study found that bone cement augmentation 
significantly improves the cut-out resistance of  
PFNA and TFNA head elements in cadaveric 
femoral heads with poor bone quality, suggesting 
its potential as a valuable treatment option in these 
cases.



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in the proximal femoral canal (Patil, 2019). In the case of  
osteoporotic bone, on the other hand, the conventional 
fixation techniques may not be sufficient enough to 
guarantee enough stability throughout the healing period. 
This is the place where the augmentation techniques play 
an important role, which is to reinforce the construction 
and impede any mechanical failure (Schuetze et al., 2019). 
Several studies have examined the efficacy of  PFNA 
in augmentation, with a stronger interest on cement 
augmentation than in other bone graft augmentations 
(Piccirilli et al., 2022). The studies in this area clearly show 
these strategies to add stability and reduce shortcomings 
such as instrumentation cutout or implant failure. 
Achieving this goal is possible as PFNA in combination 
with cement bonding allows for improved implant 
fixation and better load distribution, thus reducing the 
risk of  implant failure (Guo et al., 2022). The PFNA and 
augmentation is quite prominent in this context as they are 
capable of  improving the outcome in the postoperative 
situation. Lower operative time, less amount of  bleeding 
and days of  hospital stay are documented in patients 
having cement augmentation rather enforced with the 
conventional PFNA fixation (Kulachote et al., 2020). This 
simply means less time spent in hospital, fewer resources 
used, and more positive feedback after discharge. Such 
outcomes not only help the hospital to cut costs, but also 
improve patient outcomes, which in turn contributes to 
their faster recovery.
Furthermore, along with PFNA, augmentation helps to 
promote early ambulation of  the elderly patients with 
osteoporotic fractures; thereby, this is very important 
(Piccirilli et al., 2022). Cement augmentation, as one of  
the augmentation techniques, was successful in restoring 
postoperative load capacity, allowing patients to bear 
weight and engage in rehab early. Early ambulation 
not only shortens the rehabilitation cycle but also 
minimizes the rate of  post-surgery problems like deep 
vein thrombosis and pressure ulcers caused due to long 
isolation (Wang et al., 2023). The evidence undoubtedly 
confirms that for the treatment of  osteoporotic fractures 
of  the femur that involves the intertrochanteric region, 
a PFNA osteosynthesis combined with augmentation 
technique is the best option. Techniques of  augmentation, 
including bone cement augmentation, ensure a good 
stability of  fracture but reduce the risk of  postoperative 
morbidity and accelerate the patient recovery, result 
in positive clinical outcomes (Chiapasco & Casentini, 
2018). Nevertheless, it should be noted that despite 
improvements in the augmentation strategies, one should 
also mind the need for more research to suitably optimize 
them and make sure that their long-term outcomes are 
good enough, especially concerning implant survival 
and healing fractures. In spite of  this, the augmented 
PFNA remains a very effective method of  managing the 
osteoporotic intertrochanteric fractures which should 
be employed not only in postoperative but in long-term 
patient’s care.
The research confirmed that bone cement reinforcement 

could increase the shear strength of  the PFNA and 
TFNA heads in human femoral heads with poor 
bone quality. This finding showed the possible use 
of  bone cement cementation in these situations. The 
comprehension of  literature also reveals that those 
patients did better in terms of  stability and strength 
after fracture repair which they previously did not have 
by being augmented compared to non-augmented 
patients. The review suggested the use of  supplemental 
techniques for elderly patients with comminuted fractures 
and bad bone stock (Sermon et al., 2021). Moreover, the 
examination provides evidence concerning the safety and 
efficiency of  strengthening the PFNA delivery system by 
augmenting the blade with cement, however, risks and 
complications are not increased and morality remains as 
it was (Schuetze et al., 2021). Typically, attention is paid 
towards the careful decision-making and early planning to 
allow proper management of  potential effects on blood 
pressure during the procedure. The evidence presented 
indicates that the use of  addition techniques, especially 
cement augmentation, plays a leading role in influencing 
the effectiveness of  the PFNA procedure. Interestingly, 
the outcome of  the procedure can be greatly improved in 
conditions where poor bone quality is detected.

Comparative Analysis of  PFNA with Other 
Instruments
Comparative study between Proximal Femoral Nail 
Antirotation (PFNA) and Proximal Femoral Nail (PFN) 
are essential for the selection of  suitable treatment 
techniques for intertrochanteric fractures, particularly the 
osteoporotic and elderly individuals (Nair et al., 2019). 
The analysis of  influential studies in connection with 
PFNA indicates that PFNA has unique benefits of  better 
stability, outcomes, and complication risk compared 
to the PFN. In trials wherein PFNA and PFN were 
compared, PFNA more often turned out to be the option 
most preferred for managing intertrochanteric fractures, 
particularly among patients with osteoporotic bone 
quality (Mittal et al., 2021). While both PFNA and PFN 
provide similar functional results after fracture union, the 
additional advantages of  superior biomechanical support 
and fixation failure prevention contribute to choosing 
PFNA over PFN in addressing the patients. 
Not only does PFNA reduce the operative duration 
as well as its incumbent morbidity, but it also has a 
shorter period of  convalescence in comparison to PFN 
(Duramaz & İlter, 2019). Several comparative studies 
revealed that the operative time for PFNA was shorter, 
which was attributed to the design features of  PFNA as 
it is known to be easy to insert and has many advanced 
features. Besides reduced bleeding inside the operating 
room anesthesia time will be minimized and patients will 
have improved outcomes not being into such exposure 
for a long time (Patil, 2019). Apart from this, PFNA is 
associated with a lower rate of  complications than in the 
case of  PFN and therefore, the superiority of  PFNA is 
obvious in the management of  intertrochanteric fractures 



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(Mittal et al., 2021). There are potential complications 
related to the implant’s migration, cutout, and secondary 
fractures, but the frequency of  these events is lower with 
PFNA that exhibits better biomechanical properties and 
stability of  its fixation. This is notably the case for elderly 
patients whose osteoporosis puts them at heightened risk 
of  the fixation breakdown and the subsequent revision 
surgery.
The results of  the prospective study that compared the 
outcomes between Proximal Femoral Nail Antirotation 
(PFNA-II) and Dynamic Hip Screw (DHS) for stable 
intertrochanteric fractures among elderly patients were 
similar with respect to functions and radiology images. 
The results imply PFNA-II is quite effective procedure, 
especially for elderly patients in high-risk group with 
less surgical time and blood loss volume (Singh et al., 
2019). These outcomes bring emphasis to PFNA-II as a 
prime preference in such group of  patients with benefit 
of  simple yet direct implants that cope with skeletal 
complications and sophisticate patient’s outcomes. The 
research carried out a particular PFNA-II implants, 
used for intertrochanteric and sub-trochanteric femoral 
fractures, for the ability of  stability, biomechanical 
acceptability, and low complications. This outcome shows 
that such PFNA-II implants with augmentation equally 
enable the reduction of  lateral fracture union in high-risk 
elderly individuals, which usually leads to the recovery of  
acceptable functional outcomes (Avate et al., 2023). 

Functional Results of  Augmentation in Conjunction 
with PFNA-II Implants
The PFNA-II implants evaluation for intertrochanteric 
fractures indicates not only their intrinsic stability 
and biomechanical compatibility but also stresses the 
significance of  utilized augmentations for optimum 
recovery. Augmentation, mainly with cement, gives 
more strength to the PFNA-II fixations by improving 
fixation and resistance to a variety of  complications 
(Ni et al., 2022). Cement augmentation plays a vital role 
together with PFNA-II implant, the added lateral stability 
and biomechanical support for the osteoporotic bone 
help prevent prosthesis migration. This increase in the 
concrete content side by side with the cement augments 
the surgeons’ ability to achieve a stronger implant 
stronger anchorage with femoral heads utilizing the load 
distribution for the prevention of  implant migration, 
cutout, and secondary fractures. This is particularly 
meaningful in elderly patients with impaired bone quality 
in a high-risk geriatric category, where conventional 
fixation methods may lead to fractures that are incapable 
to endure physiological stresses (Singaram & Naidoo, 
2019).
Some studies show that cementing as well as augmentation 
can produce satisfactory functional outcomes and 
adequate fracture reduction when used concurrently 
with PFNA-II implants (Yang et al., 2020). The addition 
of  cement to the implant is not only beneficial to the 
biomechanical characteristics of  the implant but also 

assists the motion process of  the patient and accelerates 
the whole healing process, thus, lead to the better 
patient satisfaction and faster recovery. On the one 
side the absence of  complications involving PFNA-II 
implant may also have been facilitated by use of  cement 
augmentation which implies even greater reliability of  this 
option for fracture fixation in high-risk geriatric patients. 
The additional stability provided by cement augmentation 
mitigates complications like implant migration, breakout 
and secondary fractures resulting in improved clinical 
outcomes and reduced number of  revision surgeries. 

Advantages and Disadvantages of  Cement 
Augmentation
Cement augmentation is one of  the main techniques 
used in the management of  intertrochanteric fractures 
associated with osteoporosis, an especially common 
choice in cases where the poor bone quality hampers the 
obtainment of  a stable fixation. Cement augmentation 
helps to increase the fixation through the stimulation 
of  bone interface, which limits the movement and 
subsequently boosts the clinical outcomes (Weiser et 
al., 2018). Among the many advantages that cement 
augmentation presents are the fast mechanical support it 
brings. Adding bone cement to fill the gaps between the 
implant and surrounding bone eliminates the effect of  
dynamic forces, increasing the stability and durability of  
the implant, and as a result, it will be less susceptible to 
loosening or displacement. This is very much evident in 
osteoporosis bone tissue, during which the bone healing 
is very much dependent on the after fixation of  the bone 
(Winkler et al., 2018). 
Cement augmentation of  a fracture site creates more 
equal distribution of  the load, disappearing the potential 
stress concentration at bone-implant interface and thus 
promoting better healing outcomes. Given that, bone 
regeneration is the means by which this is achieved 
and results in better implant fixation and reduced rates 
of  implant failure. It provides for earlier mobilization 
and weight-bearing which was proven to be beneficial 
for patients recovering and rehabilitation. Conversely, 
reinforcement of  surrounding cement is not without 
possible risks either. In individuals with osteoporosis, 
cement augmentation of  internal fixation in hip 
fractures improves stability and lowers the chance of  
implant failure. Its safety and effectiveness in stabilizing 
trochanteric fractures are demonstrated by this systematic 
review, providing this susceptible group with a viable 
therapy alternative (Stramazzo et al., 2021). One of  the 
possible damaging effects is cement leakage that arises 
when cement extravasation into the surrounding tissues 
and causes problems ranging from embolism to nerve 
injury and pulmonary complications (Yousuf  et al., 
2021). Precise technique and the full employment of  
recommended procedures can give certain guarantees 
to operate without any leakage of  cement and any of  
the associated problems. The association of  use of  
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Anti-rotational (PFNA) device is a latest development 
in treatment options of  osteoporotic intertrochanteric 
fractures, especially in elderly people with non-optimal 
bone quality. Literature has regularly shown this induction 
of  the load capacity to postoperative state which has 
the influence of  the fixation within the femoral head, 
increasing the resistance to physiological loads and lesser 
probability of  failure in fixation.
In addition, cement augmentation aids in preventing 
the fragility endpoints, most frequently seen with 
osteoporotic intertrochanteric fractures. Through 
putting cement into the femoral head voids, surgeons 
increase implant stability and hence the probability of  
failure or implant migration lowering. Through the use 
of  this, not only the treatment of  fractures is improved 
but also revision surgical needs are reduced, therefore 
decreasing health costs as well as the patients’ suffering. 
The utilization of  cement augmentation does not imply 
any major increase in the complication rates or mortality, 
clearly indicating the safety and efficiency of  such method 
as a surgical support in the course of  the osteoporotic 
intertrochanteric fracture management. The figures 
establish that cement augmentation has performed well 
while the rate of  complications like infection, cement 
leakage, and pulmonary embolism has minimal positive 
effects. The above mentioned points emphasize the use 
of  cement augmentation to exclude it out of  the surgical 
intervention of  the osteoporotic intertrochanteric 
fractures which might be very harmful to geriatric patients 
(Roth et al., 2021; Ulusoy et al., 2018; Yu et al., 2023).
Making sure that thorough preoperative planning and 
good technique are performed as much as possible is 
essential to minimize risk of  these complications. Since 
cement augmentation will most likely eliminate reliance 
on adjusting construction for future revision if  fixation 
fails or nonunion, it could affect the patient’s success rate 
(Schlundt et al., 2018). These risks still exist; however, 
then them, the advantages of  a cement-augmented nail 
compensate them, above all for those geriatric patients 
who are prone to fractures and who have poor bone 
quality.

Future Strategies & Advancements in PFNA 
Technology
PFNA in the future together with further advancements 
will be instrumental in shifting management of  
osteoporotic intertrochanteric fractures to a whole new 
level, offering new pathways for better outcomes. The 
biomechanical development has been at the edge of  
the latest technology of  the implant design refinement, 
researchers will always strive to work better under the 
unique challenges posed by osteoporotic bone (Chandra 
& Pandey, 2021). In so doing, the above-mentioned 
process would include improving implant topography, 
material constitution, and surface properties so as to 
ensure better bone integration and more satisfactory 
bone repair. Moreover, the trend is to develop new 
strategies of  PFNA augmentation incomparable with 

the fixation. Scientists are testing new tissue substitutes 
like bioresorbable polymers as well as biologics, which 
enhances implant incorporation and final outcomes 
thereby improve long-term results (Sharma et al., 2021). 
These advancements demonstrate the ability for the 
creation of  even more stable types of  fixation as well 
as reducing the risk of  fixation failure in the generally 
high-risk of  the geriatric patients who also suffer from 
compromised bone quality.
With MI (Minimally Invasive) technique being a 
promising fundamental element of  PFNA technology, 
this is another remarkable area that needs to be explored 
(Villena Gonzales et al., 2019). Technology advances 
in percutaneous insertion techniques as well as guided 
navigation systems are intended to decrease surgical 
trauma, reduce soft tissue damage and facilitate speedy 
recovery while maintaining the highest possible quality of  
reduction and fixation of  the fracture (Karkenny et al., 
2019). This means that these innovations could transform 
the surgical practice with better patient experiences, 
reduced recovery time, and greater operational end result. 
Moreover, the smart implant technology integration 
carries with it the advantages of  not only monitoring in 
real-time implant performance, but also patient recovery 
status (Gaobotse et al., 2022). The data generated through 
the use of  sensors and wireless communication systems 
could provide critical information concerning the cyclic 
load and fracture healing trajectories that would be used 
to tailor personalized care for the individual patient and 
to optimize the treatment plan.
Additionally, research on biological enhancement options, 
like growth factors, stem cells or bone substitutes, are 
likely to explore other strategies are effectively to improve 
the healing of  fractures and implants integration (Perez 
et al., 2018). Preclinical trials and clinical trials should 
be conducted to understand the safety and efficacy of  
the combination of  novel treatment modalities with the 
PFNA fixation. At the end of  the day, these innovations 
greatly affect the quality of  care and ultimate results 
of  patient outcomes. Much good can come from 
individualized treatment plans designed to accommodate 
given patient peculiarities and features of  their particular 
fracture (Moore, 2019). Such an approach can help to 
control complications and optimize treatment outcomes. 
The new advanced operating techniques and minimally 
invasive approaches are the major aspects that guarantee 
enhanced patient experience characterized by the 
shortening of  postoperative pains, early recovery and 
mobilization of  a patient. With the innovations that 
are yet to be fully implemented, a new future awaits the 
treatment of  osteoporotic intertrochanteric fractures. It 
will heavily rely on more efficient and precise approaches 
that will cater for the individual’s needs.

RESULTS
The trend to examine the effectiveness of  proximal 
femoral nail antirotation (PFNA) with augmentation as 
a method for treatment of  osteoporotic intertrochanteric 



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fractures can be seen as an especially strong trend in 
recent orthopedic surgery (Jin et al., 2021; Zheng et al., 
2021). However, during extensive literature review, it soon 
comes apparent that allocation techniques, particularly 
cement augmentation, has been largely adopted as in to 
boosting the effectiveness of  PFNA and to better the 
patients’ prospects. The problem of  intertrochanteric 
fracture in osteoporosis is particularly complicated 
because of  loss of  bone quality, an effect that raises the 
risk of  instrumentation failure. Among others, PFNA is a 
preferred intramedullary fixation as its central anchoring 
of  the proximal femoral canal makes it possible to 
overcome the problem of  giving the fixation the 
desired amount of  stability in the cases of  osteoporotic 
bone (Patil, 2019). Precautionary augmentations, thus, 
rationalizes stress reinforcement and also reduces risks 
of  failure. 
Although PFNA and augmentation approaches have 
shown indisputable positive results, the research and 
development still require continued development of  
these modalities to guarantee long-term success. Though 
the procedure has proved its effectiveness in regard to 
stability and its inherent complication reduction, future 
research should thus be directed to improving cement 
filling and the development of  more advanced cement 
substitutes that could minimize the risk of  leakage (Yee et 
al., 2020). Besides, we also need study designs comparing 
different types of  augmentations and implant styles 
in order to choose the most effective strategy for the 
treatments of  osteoporotic intertrochanteric fractures. 
In addition, evaluating the effectiveness of  biological 
augmentation approaches, such as growth factors or stem 
cells, in promoting the integration of  both the healing 
of  fractures and implants, are worth studying before 
trials during which preclinical and clinical trials will be 
implemented. Clinicians can utilize research results to 
optimize therapeutic measures and improve patient 
outcomes in proximal femoral fracture fractures.
Introduction of  PFNA with augmentation in the site 
of  osteoporotic intertrochanteric fractures will have 
a profound effect on the health care system and better 
outcomes for the patients. The augmentation techniques, 
generally the cement augmentation, provide stability better, 
faster surgeries, and shorter hospitalization time instead 
of  traditional fixation methods. While such innovative 
technologies contribute to better cost management of  the 
healthcare facilities, they also yield the improved patient 
experience and faster recovery outcomes. In addition, 
the employment of  these augmentation techniques 
makes it possible for ambulation earlier and for partial 
weight-bearing, which is necessary for reducing the 
complications of  postoperative and ensuring the fracture 
heals properly (Chirayath et al., 2024). By using PFNA 
together with enhancement in clinical practice, surgeons 
can have an osteoporotic intertrochanteric fractures 
adequate treatment and a good patient outcome.
There is the effectiveness of  PFNA in conjunction with 
augmentation discovered in managing the trochanteric 

fractures. So, this progress contributes some stability and 
additional support of  bones injured by osteoporosis in 
orthopedic surgery. The employment of  constructing 
procedures especially using cement augmentation 
techniques at their core has proven to be the crucial 
aspects greatly targeted at achieving stability and achieving 
reduced risk of  complication common with initial fixation 
methods. Nonetheless, for augmentation to be old and 
trusted, more scientific exploration has to be done such 
as on the most effective strategies as well as for the long-
term success. Exploration of  these areas of  inquiry helps 
clinicians develop better treatment methods and enhance 
patient outcomes by providing more effective things 
in the management of  osteoporotic intertrochanteric 
fractures which, in turn, will improve quality of  life and 
be beneficial to patients in care.

CONCLUSION
This review underscores the credibility of  Proximal 
Femoral Nail Antirotation (PFNA) with augmentation, 
which significantly boost the chances of  this approach 
being favored for the management of  osteoporotic 
intertrochanteric fractures. The comparative research 
justifies the use of  PFNA instead of  the known proximal 
femoral nail (PFN) especially in the high risk elderly 
patients. Cement incorporation will be the undeniable 
support throughout the postoperative period, as research 
shows the high load capacity and implant stability. In 
short, cement augmentation along with PFNA technique 
based on the results of  15 concerns included in this 
review provides a reliable way to treat fractures produced 
due to osteoporosis in the intertrochanteric area of  the 
femur.

RECOMMENDATION
Future study should examine the long-term effects 
of  PFNA with cement augmentation in osteoporotic 
intertrochanteric fractures, as well as comparing its 
efficacy and safety to alternative stabilizing procedures 
in randomized controlled trials, in order to optimize 
treatment protocols for this high-risk population.

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