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American Journal of  Medical 
Science and Innovation (AJMSI) 

Evaluating the Impacts of  Proximal Femoral Nail Anti-Rotation (PFNA) Augmentation 
in Osteoporotic Intertrochanteric Fractures

Ramadan Mohamed Elsaid Ahmed1*

Volume 3 Issue 1, Year 2024
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v3i1.2758
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: April 06, 2024
Accepted: May 11, 2024
Published: May 15, 2024

Surgical interventions are crucial for managing osteoporotic intertrochanteric fractures. 
Among these interventions, Proximal Femoral Nail Antirotation (PFNA) is preferred due 
to its advantages in reducing blood loss and surgical duration. This research study examined 
proximal femoral nail anti-rotation’s clinical and radiological outcomes with augmentation 
in osteoporotic intertrochanteric fractures. The surgical approach encompassed 50 patients 
with osteoporotic intertrochanteric fractures treated between November 2012 and April 
2014. The surgeries were performed in a supine position on a traction radiolucent table 
with general, regional, or spinal anesthesia. The incision and nail-blade angle were carefully 
selected, and postoperative outcomes, including range of  motion, infection rates, and 
complications, were assessed. Results showed a 96% success rate with PFNA, with most 
patients regaining pre-surgery range of  motion within six weeks. Fracture healing was 
effective in 94% of  cases within six months, although some required revision surgery or 
experienced mechanical failure. Postoperative complications, including superficial infections 
and nonunion, were observed in a small percentage of  cases. In conclusion, PFNA with 
augmentation is viable for treating osteoporotic intertrochanteric fractures, offering good 
clinical outcomes and a low complication rate. However, careful patient selection and 
surgical techniques are essential to minimize risks and ensure optimal results. 

Keywords
Osteoporotic, Fracture, 
Intertrochanteric, Hip Fractures, 
Research, Surgery

1 Rashid Hospital Trauma Centre, Dubai, UAE
* Corresponding author’s e-mail: ramadanahmed456@outlook.com

INTRODUCTION
Intertrochanteric fractures, often in frail patients 
with multiple medical comorbidities, are increasing in 
prevalence due to ageing and resulting in long hospital stays, 
necessitating effective treatment strategies (Haidukewych, 
3 march 2009). Intertrochanteric fractures are gender- 
and race-dependent, with elderly females experiencing 
63 per 100,000 fractures in the US and 34 per 100,000 
in males. Factors like advancing age, comorbidities, daily 
living dependency, and osteoporosis history contribute 
to these fractures and affect the regions shown in Figure 
1. Proximal femoral fractures (PFFs) have high mortality 
rates and are increasing in France (Farahmand et al., 2005; 
Green, 2010; Rosencher et al., 2005).
Extracapsular post-fracture fractures (PFFs) face instability 
due to comminution and rupture of  the posteromedial 

cortex. Dynamic screw plates, proximal intramedullary, 
and reconstruction nails have transformed management, 
but their superiority remains controversial. Mechanical 
complications, such as hardware-related fractures and 
blade cutouts, are high. The proximal femoral nail anti-
rotation (PFNA) was designed to minimize these risks, 
with preliminary results suggesting it may have achieved 
this goal (Bhandari et al., 2009; MishraA et al., 2017; 
Sommers et al., 2004).
Extracapsular fractures mainly involve cortical and 
compact cancellous bone, which occurs along the least 
resistance path through the proximal femur due to its 
complex stress configuration. The energy absorbed by 
the bone determines the fracture’s complexity. Fatigue 
fractures can occur due to repetitive loading, causing 
microscopic damage to the osseous structure and stress 
riser (Moroni et al., 2005; Smit Jakheria et al., 2020).
Intertrochanteric fractures can be unstable due to several 
risk factors, including loss of  medial buttress, markedly 
displaced fractures, reverse obliquity fractures, severe 
osteoporosis, and comminution at the fracture site. 
These fractures can result from severe soft tissue damage 
and loss of  stability due to the original bone contact. 
Wide gapping at the fracture is not considered marked 
displacement (Chen et al., 2016; Moroni et al., 2005).
Intertrochanteric fractures in the femur are classified 
into four types: Type 1, which extends along the 
intertrochanteric line; Type 2, which is comminuted 
with multiple fractures in the cortex; Type 3, which is 
subtrochanteric with at least one fracture passing across Figure 1: The regions where hip fractures occur



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the proximal end of  the shaft, and Type 4, which is 
fractures of  the trochanteric region and the proximal 
shaft with fractures in at least two planes, often difficult 
to see on routine radiographs (Azar et al., 2020).
The biomechanics of  fixation devices involve ensuring 
the dynamic hip screw can slide freely in the side plate 
barrel. Adherence to two basic mechanical principles 
enhances the screw’s ability to slide. A higher-angle hip 
screw is more effective at accommodating dynamic and 
should be engaged deeply within the barrel (Wang et al., 
2020), as shown in Figure 2.

internal fixation techniques, with recent evidence 
supporting better results in pertrochanteric fractures 
treated with newly developed external fixators. The device 
typically consists of  one or two half  pins placed into the 
femoral neck to reduce the fracture and enhance callus 
formation. Load sharing between the fractured bone 
and the fixation is usually achieved, reducing damaging 
stresses on the fixator. Hydroxyapatite-coated external 
fixation pins can improve mechanical stability and reduce 
the risk of  pin loosening and infection in osteoporotic 
bone (Moradi et al., 2021), as shown in Figure 3.
Intramedullary nails, such as condylocephalic nails, 
internalize extracapsular fractures due to their reduced 
distance between the hip joint and implant, reducing 
bending moment, as shown in Figure 4. Examples 
include the Gamma nail, intramedullary hip screw, 
proximal femoral nail, Targon PF, Holland nail, and 
Kuntscher-Y nail. However, the Gamma nail has a higher 
risk of  adverse events, including intra-operative and later 
fractures around or below the implant (Huang & Wu, 
2021; Moon et al., 2022).

Figure 2: The joint reaction force in the femoral head 
consists of  two main components: the force producing 
dynamic force and the transverse force resisting dynamic 
force

Dynamic hip screws with two- or four-hole side plates 
offer comparable resistance to physiologic compressive 
loading, with longer screws reducing resistance (Davey et 
al., 2020).
The Sliding Hip Screw (SHS) is a commonly used extra 
medullary implant consisting of  a lag screw attached to a 
plate on the side of  the femur. These ‘dynamic’ implants 
allow for collapse at the fracture site, while the Medoff  
plate has an inner and outer sleeve that can slide between 
each other. Static implants like fixed nail plates and the 90 
or 95-degree blade plate are also used. External fixation 
can provide similar or better results than conventional 

Figure 3: A radiograph reveals a pertrochanteric fracture 
with a slight valgus reduction, with the fixator in a 
satisfactory position

Figure 4: Intramedullary nails over screw and plate 
fixation are attributed to a reduced distance between the 
hip joint and the implant

Hip arthroplasty is a crucial procedure for treating 
intertrochanteric hip fractures. Still, it presents unique 
challenges, such as the need for calcar replacement 
prostheses and managing the fractured greater trochanteric 
fragment, as shown in Figure 5. Bony deficiency from 

Figure 5: Salvage of  failed intertrochanteric fracture 
fixation with calcar replacement prosthesis



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fractures often results in a bone deficiency below the 
standard resection level for primary total hip arthroplasty. 
Femoral components with modular calcar augmentations 
are available for intraoperative flexibility. Either cemented or 
uncemented femoral-component fixation can be effective, 
with cemented fixation advantageous for elderly patients 
with osteopenic femoral canals (Masters et al., 2020).

Evans’s Classification of  Trochanteric Fractures
The Evans classification of  trochanteric fractures is a 
system that categorizes intertrochanteric hip fractures 
based on the proximal femur’s fracture pattern, 
encompassing five types.
“Type I: Undisplaced 2-fragment fracture. 
Type II: Displaced 2-fragment fracture.

Type III: 3-fragment fracture without posterolateral 
support, owing to displacement of  greater trochanter 
fragment. 
Type IV: 3-fragment fracture without medial support, 
owing to displaced lesser trochanter or femoral arch 
fragment.
Type V: 4-fragment fracture without posterolateral and 
medial support (combination of  Type III and Type IV).
R: Reversed obliquity fracture”, shown in Figure 6.
This research study aimed to evaluate the clinical 
and radiological outcomes of  proximal femoral 
nail antirotation with augmentation in osteoporotic 
intertrochanteric fractures, hypothesizing good results 
due to improved support around the nail blade and early 
weight-bearing mobilization.

Figure 6: Evans classification of  trochanteric fractures

LITERATURE REVIEW
Osteoporotic intertrochanteric fractures often require 
surgical interventions, including open reduction and 
internal fixation (ORIF) methods like dynamic hip screw, 
compression hip screw, Percutaneous Compression Plate 
(PCCP), Medoff  sliding plate, and intramedullary fixation 
like Gamma nail, proximal femoral nail, and Proximal 
Femoral Nail Antirotation (PFNA). The PFNA technique 
is optimal due to lower blood loss and operative time 
(Cheng & Sheng, 2020).
Impaction or fixed angle plating is more commonly used 
for corrective osteotomies than primary hip fracture 
treatment. Mac Eachern found medial penetration with 
Jewett Nail compared to sliding hip screws, but modifying 
nail plates with osteotomies failed (Parker & Handoll, 
2009).
In a meta-analysis, Chinoy et al. examined sliding implants 
vs precisely fixed nail plates, involving 2855 individuals. 
Comparing fixed nail plates to sliding implants, the results 
indicated a higher risk of  cutout (13% vs 4%), nonunion 
(2% vs 0.5%), implant breakage (14% vs. 0.7%), and 
reoperation (10% vs. 4%). Furthermore, the death rate 

was greater for patients treated with fixed nail plates, and 
those who survived were more likely to experience hip 
pain that persisted and limited their range of  motion. 
These problems led to the abandonment of  fixed nail 
plates in favour of  the sliding hip screw, which was 
superior in the 1980s (Parker et al., 2002).
External fixation is a recommended treatment method 
for elderly high-risk patients with intertrochanteric 
hip fractures. Most of  these fractures occur in older 
populations with an average age of  around 80. The study 
found that external fixation was a better option than 
dynamic hip screws (DHS) in terms of  surgical time 
and pain reduction. The study also found that external 
fixation had benefits such as simple application in local 
anaesthesia, decreased time of  surgery, minimal blood 
loss, and less need for blood transfusion. It also provided 
satisfactory stability and early weight-bearing. External 
fixation could be considered an alternative for elderly 
high-risk patients, especially those with multiple injuries, 
religious refusal of  transfusions, and those who cannot 
tolerate routine spinal or general anaesthesia and open 
surgery (Mobushir et al., 2020).



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The study examined the clinical and radiological results of  
external fixation and proximal femoral nail anti-rotation 
(PFNA) to manage unstable intertrochanteric fractures in 
older patients. The findings indicated that PFNA resulted 
in more blood loss, a lengthier surgery, and increased 
fluoroscopy time. Functional outcomes in PFNA were 
superior to those in external fixation. External fixation 
did not result in fewer overall problems than PFNA 
(Liang et al., 2022).
In a comparative study between Proximal Femoral 
Nail (PFN) and Dynamic Hip Screw (DHS) for 
intertrochanteric hip fractures, PFN performed better in 
terms of  range of  motion, limb length discrepancy, blood 
loss, postoperative pain, and infection incidence (Gill et 
al., 2017).
The most popular technique for treating stable 
intertrochanteric fractures, or type 1 and type 2 Boyd 
and Griffin fractures, is still the sliding hip screw and 
plate. The objectives include reduced blood loss, shorter 
hospital stays for the fixation procedure, and the ability 
to bear weight at an early age. With an average size of  
3 cm, the mean incision length of  the MIDHS is much 
shorter than the typical 8–10 cm of  a 4-5 holed DHS 
barrel plate. The average operating time for our patients 
was 28 minutes, which is less than usual. Since there is 
less soft tissue dissection after surgery, the incidence of  
postoperative problems is still low in MIDHS. Therefore, 
in stable intertrochanteric fractures, the results of  a 
minimally invasive procedure utilizing a two-hole DHS 
plate are comparable to those of  a conventional DHS 
requiring a longer incision (Walia et al., 2010).
According to Alobaid et al., a minimally invasive approach 
for fixing intertrochanteric hip fractures dramatically 
minimizes blood loss and operating time without 
compromising fixation stability or bone healing (Alobaid 
et al., 2004).
To produce unstable three-part intertrochanteric 
fractures, McLaughlin et al. examined the biomechanical 
strength and stiffness of  a DHS with a 2-hole side-
plate in Comparison to a 4-hole side-plate design. They 
concluded that the 2-hole DHS is just as biomechanically 
stable as the 4-hole DHS (McLoughlin et al., 2000).
Bulhofner et al. found that using a 135-degree sliding hip 
screw with a two-hole side plate results in satisfactory 
healing, minimal blood loss, shorter surgery time, and 
preservation of  side plate fixation (Bolhofner et al., 1999).
A novel self-dynamically implant and a minimally invasive 
technique for internal fixation of  femur fractures were 
presented. Between 2000 and 2008, the self-dynamically 
internal fixator (SIF) was used on 849 patients for 871 
fractures. The average operating time was 44 minutes, 
the average fluoroscopy duration was 12 seconds, and 
the average blood loss was 90 millilitres. There were no 
reported problems during the intraoperative phase. The 
SIF is particularly useful for minimally invasive surgery 
and helps treat femur fractures, especially comminuted 
fractures (Mitkovic et al., 2012).

A dynamic hip screw (DHS) with two horizontal blades 
has been developed in a novel way to improve fixation 
stability. Under the biaxial rocking motion, nine standard 
DHSs and nine DHSs from the Orthopedic Device 
Research Center (ODRC) were tested. Concerning the 
traditional DHS, the ODRC DHS showed fewer axial 
migration, more loading cycles, and reduced bending 
and torsional strain. With the addition of  two horizontal 
wings, the suggested ODRC DHS enhanced the contact 
surface between the implant and bone, reduced the load 
on the screw, enhanced anti-rotational implant effect, and 
enhanced migration resistance (Chen et al., 2017).
When treating unstable senile intertrochanteric fractures 
with osteoporosis, a study comparing cemented 
hemiarthroplasty and proximal femoral nail anti-rotation 
(PFNA) found no statistically significant differences in 
the rate of  reoperation, length of  surgery, or Harris Hip 
Score at a one-year follow-up. On the other hand, PFNA 
offers benefits for hospital stays, medical problems, 
transfusion rates, and intraoperative blood loss. Higher 
surgical trauma and a higher frequency of  postoperative 
medical issues have been linked to hemi arthroplasty. 
According to the research, PFNA is superior to hemi 
arthroplasty in treating intertrochanteric fractures in 
older people (Luo et al., 2017).
The study examined the prognostic implications of  
bipolar hemi arthroplasty (BHA) and proximal femoral 
nail anti-rotation (PFNA) for elderly patients with 
unstable comminuted intertrochanteric fractures (ITFs). 
Comparing hospitalization, surgery, blood loss, weight-
bearing duration, Harris hip scores, 10-m walking speed, 
gait, and postoperative complications comparing the 
two groups, the study examined 62 ITF patients. The 
hospital stay, length of  operation, blood loss, length of  
weight bearing, Harris hip score, walking speed, gait, 
and postoperative problems did not significantly differ, 
according to the results. The study found that although 
BHA permits a faster return to weight-bearing activities, 
it eventually offers treatments as effective as PFNA (Song 
et al., 2022).

METHODOLOGY 
Study Design
The present research study was prospective to assess 
the clinical and radiological results of  proximal femoral 
nail antirotation with augmentation in osteoporotic 
intertrochanteric fractures, with a surgical process of  7 
days.

Study Setting Duration
The current study was conducted involving 50 cases with 
osteoporotic intertrochanteric fractures caused by minimal 
or trivial trauma for the period of  November 2012 to 
April 2014. Patients underwent surgical management at a 
governmental hospital, with cases ranging from 6 months 
to 1 year, involving internal fixation and proximal femoral 
nail antirotation.



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Patients Selection
Inclusion Criteria 
➢ Male and female patients of  old age were included 

in the study. 
➢ Patients with osteoporotic intertrochanteric femur 

fractures
➢ Patients who have experienced osteoporotic 

intertrochanteric femur fractures due to indirect trauma, 
where the fracture does not involve the neck of  the femur.

Exclusion Criteria 
➢ Patients with non-osteoporotic intertrochanteric 

femur fractures
➢ Patients who refused surgery.

Patients Demographics
Sex Distribution
They were 38 females (76%) and 12 males (24%).

Age Distribution
The age ranged from 44 to 90 years, with a mean age of  73.

The Preoperative Period between Trauma and 
Surgery
The mean preoperative period was 1.3 days (0-6).

Preoperative Preparation of  the Patient
Two units of  blood were saved for each patient, and the 
affected limb was marked with a permanent marker pen 
before surgery.

Types of  Fractures-according to AO Classification

Surgical Procedure
The operations were performed under regional, spinal, 
or general anaesthesia, with patients placed on traction 
tables with one or two c-arms and routine scrubbing and 
draping performed.

Antibiotic Prophylaxis
Cefuroxime 1.5 g intravenously was administered 
preoperatively at the time of  induction of  anaesthesia.

Implants Used in the Series
Proximal femoral nail anti-rotation (PFNA) with a helical 
blade is used in all cases with a special cannula, and cement 
augmentation is used in 15 cases (Fig. 43 A and B).

Experimental Procedure
Patient Positioning 
All of  the patients underwent supine surgery on a 
traction radiolucent operating table. The unaffected leg 
was abducted as much as possible and placed on leg 
support to enable free fluoroscopic examinations. The 
upper body was then abducted by roughly 10 to 15° to 
the unaffected side, or both together, and the inter-point 
was finally made easy. 

Fracture Reduction
Every patient underwent general, regional, or spinal 
anaesthesia during their operations. Following 
anaesthesia, all patients had a closed reduction using a 
traction radiolucent table guided by a C-RAM. Of  these, 
48 patients (96%) had a successful outcome, while 2 (4%) 
required an open reduction. Reduction and surgery were 
performed under one c-arm only, and a check X-ray was 
performed before starting surgery in all patients.

Approach 
After scrubbing and draping as standard, time out is done 
in all cases, and a confirmed surgical incision marked 
3-5 cm starting proximally from the tip of  the greater 
trochanter or may be proximal in obese patients. A 
parallel incision of  the fasciae of  the gluteus medius and 
split the gluteus medius in line with the fibres. 

Determination of  Entry Point
The entry point in the anteroposterior and lateral views 

Figure 7: Classifying fractures according to AO 
classification in patients

Cement Augmentation
Without cement augmentation, 35 cases (70 %) and 15 
cases (30 %) with cement augmentation.

Operative Stage
Asepsis
Patients underwent surgery in a conventional operating 
room, ensuring complete aseptic condition for the 
affected femur and hip, with skin edges sealed with 
opposite sheat. Figure 8: Femur guide wire position in AP (A) and lateral 

(B) views case no. 6



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was determined in all cases. With an ML angle of  6°, 
the PFNA entrance site in the curved expansion of  the 
medullary cavity was on the tip, or slightly lateral to, the 
greater trochanter tip in AP view. The entrance point 
aligned with the intramedullary canal’s axis when viewed 
laterally, as shown in Figure 8.

Femur Opening
The femur was then opened using a cannulated drill 
with sleeve protection, ensuring proper nail size, angle 
and diameter per the preoperative plan, which was 
reconfirmed before nail insertion. Out of  47 patients 
(96%), no reaming of  the medulla was required before 
nail insertion, while in 3 patients, reaming was necessary 
with a 1mm larger diameter than the nail.

Selection of  Nail Blade 
The preoperative AP x-ray view was utilized to determine 
the nail-blade angle; however, if  the measurement of  the 
angle is not available, the maximum valgus angle (130 
degrees) was employed; in 44 cases (88%), the angle was 
130 degrees, and in 6 cases (12%) it was 125 degrees.

Insertion of  the Guide Wire into the Neck
After that, a neck guide wire was inserted; in 40 cases 
(80%), it was central in AP and lateral views; in 10 cases 
(20%), it was posterior and inferior. The guide wire trail 
typically stops 5 to 10 mm from the joint after insertion, 
especially in cases where cement augmentation is required; 
however, in two instances, it was planned for the cement 

augmentation wire to reach the joint, so no leakage test 
was performed for these cases, as shown in Figure 9&10.

Open Lateral Cortex for PFNA Blade Insertion
Following the completion of  the lateral cortical opening, 
the blade was hammered inside and halted 5–10 mm 
from the joint line in 49 cases (98%) and 14 mm from 
the joint line in one case in both the AP and lateral views. 
Blades are entirely locked after insertion (figs. 49 and 51); 
failure is presumed if  they are not fully locked, as shown 
in Figures 11 and 12.

Figure 9: Central position of  the guide wire in AP (A) 
and lateral (B) views

Figure 10: Guide wire central in AP (A) and lateral (B) 
views case no 06

Figure 11: PFNA blade unlocked in A and after fully 
locked in B

Figure 12: Intraoperative incomplete blade locking 
because of  metal mechanical problem and surgery needed 
(B) Metal failure case no 8

Determination of  Possible Cement Leakage into 
Joint
Leakage testing was performed in 17 cases, including 
planned cement augmentation; of  those, 2 cases (11.7%) 
tested positive; these 2 cases were at the start of  the series, 
with the wire piercing the joint; the test was not repeated 
if  the wire reached the joint.
A tiny quantity of  cement reached the fovea in one case 
(6.6%), but the patient was joined and mobilized with full 
range of  motion, and no osteoarthritis symptoms were 
observed in the joint until the end of  the series. Fifteen 
patients (30%) had cement augmentation.
Distal locking was completed, one oblique screw for 
short nails and one or two distal locking screws for long 
nails, after clinical and x-ray verification of  the rotation 
by comparing the lesser trochanter to femoral condyles.



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RESULTS
Mobilization
34 (94%) of  patients regained their pre-surgery range of  
motion within six weeks, one patient with revised surgery 
regained the range of  motion after 3 months from the 
first surgery, with one patient requiring arthroplasty, 
and no difference was reported in mobilization between 
cemented and non-cemented cases.

Pain
There was no pain in 34 patients (94%); one had mild 
pain from a protruded blade, and the other had surgery 
revised.

Radiological Outcome
The fracture healed without incident in six months, 
on average between ten and sixteen weeks. Thirty-four 
fractures healed effectively (94%), 2 patients (5%) needed 
revision surgery before being united, and 1 patient’s blade 
protruded and needed to be removed six months after the 
patient’s arthroplasty and surgery. 

Mechanical Failure
One case (2.7%) of  a female patient 76 years old (case no. 
8) reported a mechanical failure of  the blade, resulting in 

a fall one month after surgery. It was caused by the blade 
not being fully unlocked, which caused it to come out 
again, as shown in Figures 13 A, B and 14.
After revision, cement was used, causing a mild collapse 
at the fracture site and a protruding blade that was not 
clinically palpable, as shown in Figures 15 A and B.

Figure 13: Blade back out AP (A) and lateral views (B) 
case no. 8

Figure 14: Incomplete locking of  blade case no 8

Figure 15: Blade back out AP (A) and lateral views (B) 
case no. 8

Nonunion
In a case (26), a 2.7% nonunion was observed in a patient 
requiring arthroplasty after blade removal, who had a 
history of  fall and refracture, as shown in Figure 16.

Cement in the Joint Case no. 16
A 2.7% hip joint cement case was diagnosed, and a CT 
scan was performed, showing no significant issues with 
hip pain, AVN, or arthritis, with the full range of  motion, 
as shown in Figures 17 and 18.

Figure 16: Collapse at the fracture site with mild pain 
case no.26



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Figure 17: Left hip X-ray case no.16 showed cement 
reaching the hip joint in both the AP (A) and lateral views 
(B)

Figure 20: Distal locking screws loose (B) but fracture 
united (A) case no.46

Figure 18: CT scan of  left hip coronal (A) and axial (B) 
cuts showing cement in fovea case no 16

Fracture Lateral Wall
In 4 cases (11%), the undisplaced lateral wall fracture was 
reported after surgery; these individuals were mobilized 
to full weight bearing and united in 3-6 months without 
requiring additional surgery, as shown in Figure 19.

Metal Jamming
In one case, no 25, metal jamming occurred once after the 
locking blade screwdriver was left in place and the case 
was cemented. The screwdriver was removed along with 
the blade and replaced with a new one, at which point 
the case began full weight-bearing mobilization the day 
after the operation and was united within three months, 
as shown in Figure 21.

Figure 19: Fracture of  lateral cortex in 2 different views

Figure 21: Case no. 25 had a screwdriver jammed in the 
blade, which was removed with a blade, changing the 
preoperative AP view (A) and the postoperative AP view 
(B) three months later

Back Out of  Distal Locking Case no.46
In one case, there was no need for adjustments or the 
removal of  screws since the fracture combined with 
local irritation or infection but showed back out of  distal 
locking, as shown in Figure 20.

Table 1: Comparison between cemented and non-cemented cases
No Age F: M ASA Score Blood 

Loss 
Intra-opt 
Complication

Post Opt 
Complication

Stay Singh 
Index

Cemented 12 80 11:1 3.1 150 16% 16% 10.4 1.6
Non cemented 24 71.9 17:7 3 150 12% 4% 10.5 2.6



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Summary of  Outcomes
The series involved 50 patients, with 70% without cement 
augmentation and 30% with cement augmentation, 
ranging in age from 44 to 90 years, with a mean age of  74.
The study involved 36 cases (72%), 66% non-cemented 
and 33% cemented, with follow-up lasting 6-12 months. 
Two cases died within a month post-operatively in the 
hospital before discharge; both of  them had an ASA 
score of  4 preoperative; the first one extubation failed 
and died in ICU one month after respiratory failure, and 
the other one had acute myocardial infarction and died in 
CCU after 2 weeks from the surgery.
The study analyzed 34 cases, resulting in 97.2% 
uncomplicated outcomes, with only 2 requiring revision 
surgery, one requiring a hip joint replacement, and two 
patients experiencing superficial infection recurrence 
after multiple debridement.

Results Grading
➢ Excellent result - 31 cases (86.1%)
➢ Good result - 3 cases (8.3%)
➢ Fair result - one case (2.7%)
➢ Poor result - one case (2.7%)

DISCUSSION
Surgical interventions are frequently necessary for 
osteoporotic intertrochanteric fractures. These 
interventions include intramedullary fixation, which 
provides for gamma nails, proximal femoral nails, and 
proximal femoral nail anti-rotation (PFNA), as well as 
open reduction and internal fixation (ORIF) techniques 
like dynamic hip screws, compression hip screws, 
Percutaneous Compression Plate (PCCP), and Medoff  
sliding plates. The PFNA approach is the best option 
because it requires less blood loss and less time during 
surgery.
PFNA is more successful in treating unstable fractures 
in elderly individuals; however, it may lead to higher 
bleeding, prolonged surgical procedures, and longer 
fluoroscopy times. PFN performs better regarding blood 
loss, postoperative discomfort, limb length disparity, 
range of  motion, and infection incidence.
In osteoporotic intertrochanteric fractures, the present 
research assessed the clinical and radiological outcomes 
of  proximal femoral nail anti-rotation with augmentation 
in 50 osteoporotic intertrochanteric fractures from 
November 2012 to April 2014, involving internal fixation 
and proximal femoral nail anti-rotation at a governmental 
hospital.
The study involved patients who underwent supine 
surgery on a traction radiolucent operating table, with 
the unaffected leg abducted to allow free fluoroscopic 
examinations. After surgery, all patients underwent 
general, regional, or spinal anaesthesia, with 96% having 
a successful outcome. The approach involved a marked 
3-5 cm incision, a parallel incision of  the fasciae of  the 
gluteus medius, and splitting the gluteus medius in line 
with the fibres. 

The entry point was determined using an ML angle of  
6°, and the femur was opened using a cannulated drill 
with sleeve protection. The nail-blade angle was selected 
using the preoperative AP x-ray view. A neck guide wire 
was inserted into the neck, with 80% being central in AP 
and lateral views. 
The blade was hammered inside and halted 5-10 mm 
from the joint line in 49 cases (98%) and 14 mm in one 
case in both AP and lateral views. Leakage testing was 
performed in 17 cases, with 2 (11.7%) testing positive. In 
one case, a tiny amount of  cement reached the fovea, but 
the patient was joined and mobilized with a full range of  
motion.
It was found that 94% of  patients regained their pre-
surgery range of  motion within six weeks after surgery, 
with one patient requiring arthroplasty. No difference 
was reported in mobilization between cemented and 
non-cemented cases. In six months, fractures healed 
without incident, with 94% healing effectively. However, 
two patients needed revision surgery before being united, 
and one patient’s blade protruded and needed removal 
six months after the surgery. Mechanical failure occurred 
in one case, causing a fall one month after surgery. 
Two cases collapsed at the fracture site, resulting in a 
protruding blade. 
A 2.7% nonunion was observed in a patient requiring 
arthroplasty after blade removal. A 2.7% hip joint 
cement case was diagnosed, and a CT scan showed no 
significant issues with hip pain, AVN, or arthritis. In four 
cases, undisplaced lateral wall fractures were mobilized 
to full weight bearing and united in 3-6 months without 
additional surgery.
Out of  36 cases (72%), two died post-operatively. The 
study found that 97.2% of  cases were uncomplicated, with 
only two requiring revision surgery and one requiring hip 
joint replacement. Two patients experienced superficial 
infection recurrence after multiple debridement.

LIMITATIONS
➢ The study sample of  50 osteoporotic 

intertrochanteric fractures may not fully represent the 
diverse population of  patients with such fractures, 
limiting the generalizability of  the findings. 
➢ Because of  its unique patient demographics, surgical 

techniques, and protocols, the research conducted at a 
single governmental hospital may introduce bias and 
potentially impair the results’ external validity.
➢ The study’s retrospective nature may introduce 

selection bias and hinder the control for confounding 
variables that may affect the outcomes of  interest.

CONCLUSION
It was concluded that surgical interventions, particularly 
PFNA with augmentation, are crucial in managing 
osteoporotic intertrochanteric fractures. PFNA offers 
advantages such as reduced blood loss, shorter surgical 
durations and improved clinical outcomes compared to 
other techniques like dynamic hip screws or compression 



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hip screws. Despite potential drawbacks like increased 
bleeding and longer fluoroscopy times, PFNA remains 
a preferred option, especially for unstable fractures in 
elderly patients. Comprehensive assessments of  these 
presented 50 cases yielded a high success rate of  96% with 
minimal complications. Noteworthy outcomes included a 
high percentage of  patients regaining pre-surgery range 
of  motion within six months, effective healing rates 
within six months, and few instances of  mechanical 
failure or nonunion. Complications such as postoperative 
deaths, revision surgeries, and infections were relatively 
low at 2.8%, highlighting the overall efficacy and safety 
of  the PFNA approach with augmentation in treating 
osteoporotic intertrochanteric fractures.

RECOMMENDATIONS
➢ A systematic surgical approach with uniform 

entry locations, nail-blade angles, and protective sleeves 
during drilling is recommended for proximal femoral 
nail anti-rotation with augmentation in osteoporotic 
intertrochanteric fractures.
➢ Choosing the right implant size and shape can help 

minimize intraoperative difficulties. It can be achieved 
through careful preoperative planning, which includes an 
accurate assessment of  the kind of  fracture, the quality 
of  the bone, and patient-specific characteristics.
➢ Develop a comprehensive strategy that involves 

a multidisciplinary team of  orthopaedic surgeons, 
infectious disease specialists, and rehabilitation specialists 
to treat issues such as infections, nonunion, mechanical 
failures, and blade protrusion.

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