Surgical Steps for Proximal Femoral Nail (PFN) in A2 Intertrochanteric Fractures
For A2 intertrochanteric fractures, perform closed reduction and cephalomedullary nail fixation using either spinal or general anesthesia, with immediate full weight-bearing postoperatively. 1, 2
Preoperative Preparation
- Anesthesia: Use either spinal or general anesthesia—both are equally appropriate (strong recommendation) 2
- Timing: Operate within 24-48 hours of admission for better outcomes 2
- Pain control: Administer preoperative iliofascial or peripheral nerve block as part of multimodal analgesia (strong recommendation) 1, 2
- Do NOT use preoperative traction (strong recommendation) 1, 2
Surgical Technique
Patient Positioning and Setup
- Position patient supine on fracture table
- Obtain proper fluoroscopic views: anteroposterior (AP) pelvis and true lateral hip views are essential for identifying malalignment 3
Fracture Reduction
- Achieve closed reduction whenever possible 4
- Aim for anatomic reduction of main fracture fragments 4
- Key radiographic parameters to verify:
- Neck-shaft angle restoration
- Anterior cortical line alignment on lateral view
- Calcar displacement assessment 3
Critical caveat: If closed reduction fails after reasonable attempts, proceed to open reduction with cerclage wires, particularly if multiple fragments or greater trochanter comminution exists 4. In such cases with extensive comminution, consider converting to dynamic hip screw with trochanter stabilizing plate 4.
Nail Selection and Insertion
- For A2 fractures specifically: Use cephalomedullary nail (strong recommendation for unstable intertrochanteric fractures) 1, 2
- Short vs. long nail: Either option is acceptable (limited evidence) 1, though most commonly 10mm diameter nails are used 5
- Make standard lateral incision at greater trochanter
- Establish entry point at tip or slightly lateral to greater trochanter
- Ream and insert nail under fluoroscopic guidance
Proximal Fixation
- Two-screw systems (traditional PFN) vs. single helical blade (PFNA2):
- Insert proximal lag screw(s) aiming for center-center or inferior-central position in femoral head
- Critical measurement: Tip-apex distance must be ≤25mm to prevent cut-out 3
- Verify position using Cleveland zones and Parker's ratio index 3
Important technical consideration: For right-sided fractures, pay particular attention to maintaining anterior cortical support during fixation, as clockwise torque during screw insertion tends to create negative anterior cortical support on right-sided fractures more than left 7
Distal Fixation
- For A2 fractures, distal interlocking may be omitted 8
- A2 fractures without distal interlocking show better rotational alignment, reduced operative time, less radiation exposure, and fewer lock-related complications 8
- If distal locking is performed, use dynamic locking screw to allow controlled compression at fracture site 5
Key pitfall: Using too-short proximal screws leads to cut-out—ensure adequate screw length 4
Postoperative Management
- Weight-bearing: Allow immediate full weight-bearing as tolerated (limited evidence, but standard practice) 1
- VTE prophylaxis: Use sequential compression devices in hospital plus pharmacologic prophylaxis (enoxaparin) for 4 weeks (strong recommendation) 1
- Transfusion threshold: Transfuse for symptomatic anemia or hemoglobin <8 g/dL in asymptomatic patients 1
- Bone health: Order vitamin D, calcium, PTH levels and outpatient DEXA scan; refer to bone health clinic (strong recommendation) 1
Expected Outcomes
- Operative time: Shorter with PFNA2 (especially short-nail design) 5
- Blood loss: Minimal with closed technique 9
- Union time: Average 2.9-5.8 months depending on technique 8, 10
- Functional recovery: Modified Harris Hip Scores improve significantly but rarely return to pre-injury baseline, particularly in elderly patients with osteoporosis 10
Final consideration: Despite optimal reduction and fixation, patients over 60 with osteoporosis and hypovitaminosis D (present in 92% of Indian populations) show persistent functional limitations at 6 months 10. Address bone health aggressively to optimize outcomes.