Radiological Determinants of Fixation Success in Intertrochanteric Fractures Treated with PFN and PFN-A
Radiological Determinants of Fixation Success in Intertrochanteric Fractures Treated with PFN and PFN-A
Author(s):Dr Mohit MP, Dr Megha Naikal, Dr Maruthi CV
Received: April 27, 2026
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Accepted: May 12, 2026
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Published:
June 3, 2026
Abstract
Background: Intertrochanteric fractures are a major cause of morbidity in the elderly, with cephalomedullary fixation widely accepted for unstable patterns. Proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFN-A) offer biomechanical advantages; however, comparative evidence from large Indian cohorts with extended follow-up remains limited.
Methodology: This retrospective observational study evaluated 286 skeletally mature patients with AO/OTA 31-A1 to A3 intertrochanteric fractures treated between 2022 and 2025 using closed reduction and internal fixation with PFN (n=162) or PFN-A (n=124). Postoperative radiological parameters including tip–apex distance (TAD), Cleveland index positioning, neck-shaft angle restoration and reduction quality were analysed. Fracture union was assessed up to two years. Statistical analysis was performed using SPSS version 22.
Results: Unstable fracture patterns constituted 79% of cases, and radiographic osteoporosis was present in 52%. Operative duration and haemoglobin drop were significantly lower in the PFN-A group (p<0.001). Radiological fixation quality was comparable between implants (mean TAD 22.1±4.2 mm; optimal Cleveland positioning 93%). Overall fracture union at two years was 97% (96% PFN vs 98% PFN-A; p=0.99). PFN-A demonstrated earlier radiological progression towards union and superior outcomes in osteoporotic patients (p=0.04). Complication rates were low and similar between groups. Logistic regression identified TAD >25 mm and negative reduction as independent predictors of fixation failure.
Conclusion: Both PFN and PFN-A provide reliable radiological and functional outcomes in intertrochanteric fractures. Fixation success is primarily influenced by reduction quality and optimal implant positioning rather than implant design alone, although PFN-A offers perioperative advantages and improved performance in osteoporotic bone.
Methodology: This retrospective observational study evaluated 286 skeletally mature patients with AO/OTA 31-A1 to A3 intertrochanteric fractures treated between 2022 and 2025 using closed reduction and internal fixation with PFN (n=162) or PFN-A (n=124). Postoperative radiological parameters including tip–apex distance (TAD), Cleveland index positioning, neck-shaft angle restoration and reduction quality were analysed. Fracture union was assessed up to two years. Statistical analysis was performed using SPSS version 22.
Results: Unstable fracture patterns constituted 79% of cases, and radiographic osteoporosis was present in 52%. Operative duration and haemoglobin drop were significantly lower in the PFN-A group (p<0.001). Radiological fixation quality was comparable between implants (mean TAD 22.1±4.2 mm; optimal Cleveland positioning 93%). Overall fracture union at two years was 97% (96% PFN vs 98% PFN-A; p=0.99). PFN-A demonstrated earlier radiological progression towards union and superior outcomes in osteoporotic patients (p=0.04). Complication rates were low and similar between groups. Logistic regression identified TAD >25 mm and negative reduction as independent predictors of fixation failure.
Conclusion: Both PFN and PFN-A provide reliable radiological and functional outcomes in intertrochanteric fractures. Fixation success is primarily influenced by reduction quality and optimal implant positioning rather than implant design alone, although PFN-A offers perioperative advantages and improved performance in osteoporotic bone.
Keywords: Intertrochanteric Fractures; Femoral Fractures; Bone Nails; Fracture Fixation, Internal; Osteoporosis; Treatment Outcome
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