Intertrochanteric fractures of the femur are among the most commonly encountered orthopedic injuries in the elderly, primarily resulting from age-related osteoporosis and an increased risk of falls [1]. These fractures contribute significantly to morbidity, functional decline, and mortality in the geriatric population, often necessitating prolonged hospitalization and leading to reduced quality of life [2]. With the global rise in life expectancy, the incidence of such fractures continues to increase, imposing a growing burden on healthcare systems, especially in low- and middle-income countries [3].

The central objective in managing intertrochanteric fractures is to achieve early mobilization, restore pre-injury functional levels, and minimize postoperative complications [4].

Internal fixation remains the mainstay of treatment, with a variety of devices employed, including dynamic hip screws (DHS), proximal femoral nails (PFN), and their antirotation modifications. Notably, the Proximal Femoral Nail Antirotation (PFNA) system has gained widespread acceptance due to its biomechanical advantages—namely, intramedullary load sharing, reduced surgical trauma, and superior rotational stability via a helical blade [5].

Several studies have shown that PFNA is particularly effective in osteoporotic bone and in complex fracture patterns, offering better stability and a lower complication rate compared to conventional implants like DHS [5,6].

Comparative analyses have also highlighted improved functional outcomes and early return to mobility with PFNA in elderly patients [3,4,7].

Despite increasing global use, data on the functional outcomes of PFNA in the elderly Indian population remain limited.

A clearer understanding of short-term recovery, complication rates, and ambulation outcomes is essential to guide clinical decision-making and optimize postoperative rehabilitation strategies in this vulnerable demographic [6].

This prospective observational study was conducted to evaluate the clinical and functional outcomes of intertrochanteric fractures treated with PFNA in elderly patients, using the Harris Hip Score (HHS) as a primary assessment tool over a six-month follow-up period.

Study Design and Setting

This was a prospective observational study conducted at the Department of Orthopaedics, Government Medical College, Srikakulam, Andhra Pradesh. The study was carried out over a period of six months, from January to June 2024.

Study Population

The study included elderly patients aged 60 years and above who presented with intertrochanteric fractures confirmed by radiographic evaluation and were treated surgically with Proximal Femoral Nail Antirotation (PFNA).

Inclusion Criteria

Patients aged ≥60 years.

Radiologically confirmed intertrochanteric femur fractures (AO/OTA classification 31-A1 to 31-A3).

Patients treated with PFNA.

Patients willing to provide informed consent and comply with follow-up visits.

Exclusion Criteria

Pathological fractures (e.g., due to metastasis or tumors).

Polytrauma patients or patients with multiple long bone fractures.

Pre-existing ipsilateral lower limb deformities or non-ambulatory status prior to injury.

Patients lost to follow-up or expired due to unrelated causes before 3-month evaluation.

Sample Size

A total of 100 patients were enrolled based on the inclusion and exclusion criteria using consecutive sampling.

Surgical Procedure

All patients underwent internal fixation with PFNA under spinal or general anesthesia. Standard operative protocols were followed, and all surgeries were performed or supervised by senior orthopedic surgeons. Postoperative care included early mobilization and thromboprophylaxis as per institutional protocol.

Data Collection

Baseline demographic data, comorbidities, fracture classification (AO/OTA), surgical details (duration, blood loss), and postoperative complications were documented. Patients were evaluated clinically and radiologically at regular intervals—2 weeks, 6 weeks, 3 months, and 6 months postoperatively.

Outcome Assessment

Functional outcomes were assessed using the Harris Hip Score (HHS) at 3 and 6 months postoperatively. Radiological union was evaluated through follow-up X-rays. Any complications such as wound infections, implant-related failures, or venous thromboembolism were recorded.

Ethical Considerations

Necessary permissions were obtained before starting the study. Informed written consent was obtained from all participants prior to enrollment.

A total of 100 elderly patients with intertrochanteric fractures treated with Proximal Femoral Nail Antirotation (PFNA) were enrolled in the study. The mean age of the participants was 74.6 ± 6.8 years, with 58% males (n = 58) and 42% females (n = 42). Most injuries (85%) resulted from low-energy falls, while the remaining 15% were due to road traffic accidents. The demographic profile and fracture classification are summarized in Table 1.

Table 1: Demographic and Fracture Characteristics of Study Participants (N = 100)

The mean duration between injury and surgery was 3.4 ± 1.2 days, and the mean hospital stay was 8.1 ± 2.5 days. Most patients (82%) were mobilized with partial weight-bearing within the first postoperative week. Surgical duration averaged 58 ± 10 minutes, and mean intraoperative blood loss was approximately 120 ± 30 mL.

Postoperative complications occurred in 10 patients. These included superficial wound infection in 5%, implant-related complications (e.g., screw cut-out or Z-effect) in 3%, and deep vein thrombosis in 2%. No cases of implant breakage or periprosthetic fractures were observed. Details of postoperative outcomes are listed in Table 2.

Table 2: Postoperative and Clinical Outcomes

Functional recovery was assessed using the Harris Hip Score (HHS) at 3 months and 6 months postoperatively. At 3 months, the mean HHS was 78.6 ± 8.7, with 12% of patients rated as excellent and 34% as good. By 6 months, functional scores improved substantially, with 28% of patients achieving excellent results and 46% good. Only 6% had poor outcomes at the final follow-up. The progression of functional recovery is detailed in Table 3.

Table 3: Functional Outcomes According to Harris Hip Score (N = 100)

Figure 1. Functional Outcomes by Harris Hip Score at 3 and 6 Months

Radiological union was achieved in 96 patients, with an average time to union of 14.2 ± 2.1 weeks. Independent ambulation (with or without assistive devices) was restored in 92% of patients by the end of 6 months. Additionally, 78% of the cohort had resumed pre-injury levels of physical activity. There were two mortalities during the follow-up period, attributed to unrelated medical conditions.

This prospective observational study evaluated the functional outcomes of intertrochanteric femur fractures treated with Proximal Femoral Nail Antirotation (PFNA) in a cohort of 100 elderly patients over a six-month period. The findings demonstrated that PFNA provided satisfactory results in terms of radiological union, early mobilization, and restoration of function, with a low incidence of complications.

The mean age of patients in our study was 74.6 years, consistent with global trends showing increased incidence of intertrochanteric fractures among the elderly due to osteoporosis and fall-related trauma [13]. In our cohort, 85% of fractures resulted from low-energy falls—this etiology aligns with established patterns of geriatric injuries observed in similar populations [13].

Radiological union was achieved at an average of 14.2 weeks, comparable to the union times reported in previous studies evaluating PFNA and similar intramedullary devices, which ranged between 12 to 16 weeks [9,11]. Early weight-bearing was achieved in 82% of patients, affirming the biomechanical stability of PFNA and its capacity to support early mobilization, as corroborated by Yu et al. and Zhang et al. [8,11].

Functional recovery, as assessed by the Harris Hip Score (HHS), demonstrated significant improvement between the 3-month and 6-month follow-ups, with 74% of patients achieving good to excellent outcomes. Similar postoperative improvements in HHS have been observed in earlier studies involving PFNA in elderly patients, reinforcing its role in promoting functional restoration [8,10,12].

The complication rate in our study was low, with superficial wound infections noted in 5%, implant-related issues in 3%, and DVT in 2%. These findings are in line with previous literature, which highlights PFNA’s reduced complication profile, particularly in osteoporotic bones [9,12]. Compared to dynamic hip screws, PFNA’s intramedullary location provides a shorter lever arm and improved biomechanical load-sharing, contributing to enhanced fracture stability and reduced surgical trauma [10,12].

The helical blade design of PFNA, which compacts cancellous bone rather than cutting through it, has been shown to improve purchase in osteoporotic femoral heads, minimizing the risk of implant migration or cut-out [8,9]. Moreover, comparative studies have demonstrated PFNA’s superiority or equivalence to alternative fixation methods, including InterTAN nails and hemiarthroplasty, in terms of both functional outcome and complication rates [9,10,11].

In summary, our findings affirm the effectiveness of PFNA in the treatment of intertrochanteric fractures in the elderly, with outcomes aligning well with those reported in recent international literature [8–13]. However, continued evaluation through multi-center trials with longer follow-up durations is warranted to further validate these results.

A notable strength of this study is its prospective design and focus on short-term functional recovery in a real-world public hospital setting. However, limitations include the single-center nature of the study, absence of a control group, and a relatively short follow-up duration of six months. Long-term follow-up studies are needed to assess implant survival, late complications, and quality of life measures.

The present study demonstrates that Proximal Femoral Nail Antirotation (PFNA) is an effective and reliable method for the management of intertrochanteric fractures in elderly patients. It offers stable fixation, facilitates early mobilization, and leads to satisfactory functional outcomes with a low rate of complications. Most patients regained independent ambulation and achieved good to excellent scores on the Harris Hip Score within six months. The intramedullary design of PFNA provides mechanical advantages, especially in osteoporotic bone. Although our findings are promising, further multi-center studies with longer follow-up are recommended to evaluate long-term functional recovery and implant longevity in this vulnerable population.

1. Singh NK, Sharma V, Trikha V, Gamanagatti S, Roy A, Balawat AS, et al. Is PFNA-II a better implant for stable intertrochanteric fractures in elderly population? A prospective randomized study. J Clin Orthop Trauma. 2019 Oct;10(Suppl 1):S71–6. doi:10.1016/j.jcot.2019.02.004.
2. Kulachote N, Sa-Ngasoongsong P, Sirisreetreerux N, Chulsomlee K, Thamyongkit S, Wongsak S. Predicting factors for return to prefracture ambulatory level in high surgical risk elderly patients sustained intertrochanteric fracture and treated with proximal femoral nail antirotation (PFNA) with and without cement augmentation. Geriatr Orthop Surg Rehabil. 2020 Mar 12;11:2151459320912121. doi:10.1177/2151459320912121.
3. Rai B, Singh J, Singh V, Singh G, Pal B, Kumar D, et al. Evaluation of the outcomes of proximal femoral nail antirotation II in the treatment of trochanteric fracture in elderly patients. Cureus. 2022 May 10;14(5):e24896. doi:10.7759/cureus.24896.
4. Shah MR, Shah MM, Shah IM, Shah KR. Surgical and functional outcomes of the results of conventional two-screw proximal femoral nail (PFN) versus helical-blade anti-rotation proximal femoral nail (PFNA2). Cureus. 2023 Aug 18;15(8):e43698. doi:10.7759/cureus.43698.
5. van der Sijp MPL, de Groot M, Meylaerts SA, du Pré KJ, Verhage SM, Schipper IB, et al. High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study. Arch Orthop Trauma Surg. 2022 Jul;142(7):1459–67. doi:10.1007/s00402-021-03824-0.
6. Swaroop S, Gupta P, Bawari R, Marya SK, Patnaik S. Factors affecting the outcome of unstable intertrochanteric fractures managed with proximal femoral nail anti-rotation 2: A prospective outcome study in elderly Indian population. Cureus. 2020 Dec 8;12(12):e11973. doi:10.7759/cureus.11973.
7. Tang Y, Wang D, Wang L, Xiong W, Fang Q, Lin W, et al. The PFNA in treatment of intertrochanteric fractures with or without lateral wall fracture in elderly patients: a retrospective cohort study. Eur J Med Res. 2023 Sep 27;28(1):380. doi:10.1186/s40001-023-01332-y.
8. Yu W, Zhang X, Zhu X, Hu J, Liu Y. A retrospective analysis of the InterTan nail and proximal femoral nail anti-rotation-Asia in the treatment of unstable intertrochanteric femur fractures in the elderly. J Orthop Surg Res. 2016 Jan 15;11:10. doi:10.1186/s13018-016-0344-7.
9. Zhou X, Chen T, Jiang YL, Chen DB, Tian ZY. Comparison of the clinical outcomes between proximal femoral nail anti-rotation with cement enhancement and hemiarthroplasty among elderly osteoporotic patients with intertrochanteric fracture. BMC Musculoskelet Disord. 2024 Apr 15;25(1):290. doi:10.1186/s12891-024-07414-0.
10. Yalın M, Golgelioglu F, Key S. Intertrochanteric femoral fractures: A comparison of clinical and radiographic results with the proximal femoral intramedullary nail (PROFIN), the anti-rotation proximal femoral nail (A-PFN), and the InterTAN nail. Medicina (Kaunas). 2023 Mar 13;59(3):559. doi:10.3390/medicina59030559.
11. Zhang H, Zeng X, Zhang N, Zeng D, Xu P, Zhang L, et al. INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis. J Int Med Res. 2017 Aug;45(4):1297–309. doi:10.1177/0300060517710584.
12. Liu W, Liu J, Ji G. Comparison of clinical outcomes with proximal femoral nail anti-rotation versus InterTAN nail for intertrochanteric femoral fractures: a meta-analysis. J Orthop Surg Res. 2020 Oct 29;15(1):500. doi:10.1186/s13018-020-02031-8.
13. Adulkasem N, Phinyo P, Khorana J, Pruksakorn D, Apivatthakakul T. Prognostic factors of 1-year postoperative functional outcomes of older patients with intertrochanteric fractures in Thailand: A retrospective cohort study. Int J Environ Res Public Health. 2021;18(13):6896. doi:10.3390/ijerph18136896.