Intertrochanteric fractures are extracapsular fractures occurring between the greater and lesser trochanters of the femur, most frequently seen in elderly patients after trival fall. These fractures account for nearly 50% of all hip fractures and are a major public health concern due to the associated morbidity, loss of function, and increased mortality, particularly in the elderly population [1].

Historically, treatment options included conservative management, but due to high risks of complications such as deep vein thrombosis, pneumonia, and pressure sores, surgical intervention has become the standard of care [2]. Surgical fixation provides early mobilization, reduces hospital stay, and improves functional outcomes [3].

The evolution of surgical implants has shifted from extramedullary devices like the Dynamic Hip Screw (DHS) to intramedullary nails such as the Proximal Femoral Nail (PFN), especially for unstable fracture patterns. PFN provides a biomechanical advantage due to its load-sharing capacity and shorter lever arm, which reduces the risk of implant failure [4].

The Proximal Femoral Nail Anti-Rotation (PFNA) system was further developed to address complications related to earlier PFN models. The PFNA-2 is an improved variant specifically designed for Asian populations, featuring a reduced mediolateral angle, smaller diameter, and enhanced helical blade fixation to reduce cut-out risk in osteoporotic bone [5,6].

Clinical studies comparing PFNA-2 with other implants have demonstrated superior or equivalent outcomes in terms of operative time, intraoperative blood loss, radiographic union, and complication rates [7,8]. Moreover, short PFNA-2 nails are particularly advantageous in elderly patients due to ease of insertion, reduced operative trauma, and decreased implant-related complications [9].

Despite its increasing usage, regional data evaluating PFNA-2 in Indian or South Asian populations is still limited. This study aims to assess the functional and radiological outcomes of short PFNA-2 for intertrochanteric fractures in a tertiary care setting.

Aims and Objectives

Aim:

To evaluate the functional and radiological outcomes of intertrochanteric fracture fixation using the short Proximal Femoral Nail Anti-Rotation-2 (PFNA-2) in a prospective clinical setting.

Objectives:

1. To assess the demographic profile (age, sex, side of fracture) of patients with intertrochanteric fractures treated using short PFNA-2.
2. To evaluate intraoperative variables such as operative time and blood loss during PFNA-2 fixation.
3. To assess postoperative functional outcomes using the Harris Hip Score (HHS).
4. To assess radiological union time and complication rates following surgery.
5. To determine the overall effectiveness and safety of short PFNA-2 in intertrochanteric fracture fixation.a

This prospective observational study was conducted over a period of 18 months in the Department of Orthopaedics at Maharishi Markandeshwar Institute of Medical Sciences and Research. A total of 50 patients with intertrochanteric femur fractures were included based on defined inclusion and exclusion criteria. Institutional ethical clearance was obtained prior to the commencement of the study, and written informed consent was taken from all participants.

Inclusion Criteria:

1. Patients aged 50 years and above with fresh intertrochanteric femur fractures.
2. Closed fractures.
3. Patients fit for surgery under spinal or general anesthesia.
4. Patients willing to participate in the study.

Exclusion Criteria:

1. Pathological fractures other than osteoporosis.
2. Polytrauma patients or those with associated injuries in the same limb.
3. Patients with history of previous hip surgery.
4. Open fractures or fractures older than 3 weeks.
5. Patients unfit for surgery due to medical

contraindications.

Patient Evaluation and Preoperative Workup:

All patients underwent detailed clinical evaluation, routine blood investigations, and radiographic assessment including anteroposterior (AP) and lateral views of the affected hip and Pelvis with Bilateral Hips Anterior view. Fractures were classified according to the Boyd and Griffin classification system.

Surgical Technique:

All surgeries were performed on a fracture table under spinal anesthesia using a standardized technique. Closed reduction was confirmed with C-arm imaging. A short PFNA-2 implant of appropriate size was inserted under fluoroscopic guidance. Postoperative radiographs were taken to confirm implant position and fracture reduction.

Postoperative Protocol:

Patients were encouraged to begin static quadriceps and ankle pump exercises from day one. Partial weight-bearing was initiated from the 3^rd to 5^th postoperative day depending on pain tolerance and stability of fixation. Full weight-bearing was allowed based on radiological evidence of union.

Follow-up and Assessment:

Patients were followed up at 6, 12, and 24 weeks postoperatively. At each visit, functional outcome was assessed using the Harris Hip Score (HHS). Radiological union was evaluated on plain radiographs. Delayed union, implant failure, or cut-out were documented where present.

Data Collection and Statistical Analysis:

Demographic and clinical data including age, sex, side of fracture, fracture classification, operative time, and intraoperative blood loss were recorded. Functional and radiological outcomes were compared across different fracture types. Data were analyzed using SPSS software. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages. A p-value < 0.05 was considered statistically significant.

A total of 50 patients with intertrochanteric fractures were included in this prospective study. The age of the patients ranged from  50 to 87 years, with the majority (56%) falling within the 60–74 years age group. There was a male predominance (54%). The fracture distribution showed a slight predominance on the right side. The Boyd and Griffin classification revealed most cases were of type II fractures. Table 1 summarizes the demographic and clinical profile.

Table 1: Demographic and clinical characteristics of patients

Fractures were classified radiographically according to the Boyd and Griffin system. Most patients presented with Type II fractures (36%), followed by Type I (26%). This classification helped in determining the surgical approach and expected stability. Table 2 shows the distribution by type.

Table 2: Boyd and Griffin classification of fractures

Intraoperative parameters such as operative time and blood loss were recorded. The operative time ranged from 55 to 76 minutes, and blood loss varied from 85 to 108 mL. These figures reflect minimal invasiveness and controlled operative conditions. The descriptive data are provided in Table 3.

Table 3: Intraoperative parameters

Functional outcomes were evaluated at 6 months postoperatively using the Harris Hip Score (HHS). A majority of patients (80%) had good to excellent outcomes, reflecting the efficacy of the short PFNA-2 system. Only 6% had poor results, likely due to preexisting comorbidities or delayed rehabilitation. The outcomes are summarized in Table 4.

Table 4: Functional outcome based on Harris Hip Score at 6 months

The radiological union was monitored at regular follow-ups. The majority of fractures (82%) united between 12 and 14 weeks. Delayed union was noted in only 2 cases. Table 5 presents the time distribution for fracture union.

Table 5: Time to radiological union

A range of postoperative complications was recorded in patients treated with short PFNA-2 for intertrochanteric fractures. The most commonly observed complication was superficial infection, managed effectively with dressings and antibiotics. Other minor complications included limb shortening, varus collapse, and screw-related irritation. There were no cases of implant breakage or deep infection. The distribution of complications is summarized below.

Table 6: Postoperative complications among patients (n=50)

Bar graph: Age wise distribution of patients with intertrochanteric fractures.

Bar graph 2:Functionaloutcome based on Harris Hip score.

Intertrochanteric fractures are among the most common injuries in the elderly, primarily due to osteoporosis and an increased risk of falls. Early surgical fixation is essential to restore mobility, reduce hospital stay, and prevent complications. In this prospective study of 50 patients treated with PFNA-2 for intertrochanteric fractures, we evaluated demographics, operative parameters, functional and radiological outcomes, and complications.

The majority of patients (56%) were in the 60–74 years age group, with a slight male predominance (54%). This is somewhat in contrast to Western literature, which typically shows a female predominance due to postmenopausal osteoporosis [10]. However, this gender distribution may reflect regional variations in physical activity levels and occupational exposure.

The most prevalent kind of fracture was a type 2 fracture (36%). Our findings are consistent with earlier studies that compared these implant types. Shah et al. compared the PFNA (helical blade) to the PFN and discovered that the PFNA had a lower cut-out rate [11,12]. The postoperative complication rate was low. Superficial infections were observed in 6% of patients, managed conservatively. Limb shortening greater than 1 cm was noted in 8% of patients. There were no cases of deep infections, implant breakage, or blade cut-out. These findings are in line with existing literature, which also reports low complication rates with PFNA-2 [18,19].

Overall, the PFNA-2 system demonstrated favorable functional outcomes, early union, and minimal complications. It remains a reliable implant for intertrochanteric fracture management, especially in the elderly with osteoporotic bone.

This study evaluated the functional outcomes and complication rates of intertrochanteric femur fractures treated using the proximal femoral nail anti Rotation  2 (PFNA-2)  in a geriatric population. The majority of the patients in this study were aged between 60–74 years, and there was a nearly equal gender distribution. Most fractures were classified as Type 2 or Type 1 according to the Boyd and Griffin classification, and the right side was slightly more commonly involved.

The proximal femoral nail anti rotation 2 proved to be an effective fixation device, offering stable internal fixation with a relatively short operative time and moderate intraoperative blood loss. A majority of patients achieved excellent to good outcomes according to the Harris Hip Score, reflecting the biomechanical advantage and minimally invasive nature of PFN. Complications were minimal and manageable, with few cases of infection, screw cut-out.

Our findings support that PFNA-2 is a reliable implant in managing intertrochanteric fractures, especially in elderly patients, due to its intramedullary design, decreased soft tissue disruption, and early mobilization potential. With careful surgical technique and proper patient selection, PFN can significantly enhance recovery and reduce morbidity in this high-risk population.

Future studies with larger cohorts and long-term follow-up are recommended to validate these findings and assess implant longevity, complication patterns, and patient-reported outcomes across varied clinical settings.

Conflict of interest: Nil

Funding: Nil

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