Open Journal of Orthopedics, 2013, 3, 234-242 Published Online September 2013 (
Proximal Femoral Nailing: Technical Difficulties and
Results in Trochanteric Fractures*
Janardhana Aithala P, Sharath Rao
Department of Orthopedics, Kasturba Medical College, Manipal, India.
Received June 5th, 2013; revised July 8th, 2013; accepted July 22nd, 2013
Copyright © 2013 Janardhana Aithala P, Sharath Rao. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Background: Proximal femoral nailing in communited intertrochanteric fractures is increasingly becoming popular in
view of superior biomechanics and prevention of varus collapse associated with Dynamic hip screw. However, techni-
cal difficulties and implant related complications have been described with this technique, thus we need more studies to
address these issues. Our study aims to understand technical difficulties involved in proximal femoral nailing, and spe-
cifically analyses neck shaft angle at follow-up indicating varus collapse and also to compare results of stable and un-
stable fractures. Materials and Methods: In this study, patients who presented to the Orthopedic Unit of Dr. TMA Pai
Hospital (An associated hospital of Manipal University, Manipal) with trochanteric fractures included and treated with
proximal femoral nailing. The technical difficulties involved with surgical procedure and techniques adapted to overcome
such difficulties were recorded. All patients were followed up for a period of 2 years and final outcome assessment in-
cluded the number of shortening, neck shaft angle and harris hip score. Results: 41 patients (mean age 71) who under-
went proximal femoral nailing from January 2004 to December 2009 were included in the study, 38 patients completed
2-year follow-up. The technical difficulties we faced were divided into 3 categories, difficulties in securing entry point
and guide wire placement especially when greater trochanter and piriform fossa were gathered, reduction was lost while
passing nail, and finally difficulties faced during placement of hip screws. In all except one, neck shaft angle of more
than 130 degrees was achieved, and this was also maintained in the final follow-up (Mean 131.9 degrees). All fractures
were united, with mean shortening of 2 mm. Conclusions: Although PFN is technically required, with a proper tech-
nique PFN gives excellent clinical results with almost negligible varus collapse even in unstable trochanteric fractures.
Regarding the techniques, reaming the proximal part of femur adequately and observing the nail passage with image
carefully are important in placing the nail correctly, while, placement of lag screw in the inferior part of neck in anterior
posterior projection and central in lateral projection reduces risk of implant failure.
Keywords: Trochanteric Fractures; Proximal Femoral Nailing; Varus Collapse
1. Introduction
Intertrochanteric fractures are one of the commonest frac-
tures in elderly people [1,2]. With the increase in life ex-
pectancy, we are seeing more and more such fractures in
our practice today [3]. Following the intertrochanteric frac-
tures as it affects elderly people, quality of life will be
poor unless fractures are stabilized and mobilized early.
With the aim of mobilizing these patients early from
the bed, surgical stabilization of these fractures is favored
[3,4] and many fixation devices are developed. However,
sliding hip screw device with a slide plate remains the
gold standard [3,5]. Although these devices produce ac-
ceptable reduction and healing in stable intertrochanteric
fractures, in unstable fractures, the results are unsatisfac-
tory [5-7]. Only about 50% can be expected to reach the
pre-injury activity status. Although union is not a big
problem in these patients, a significant number of pa-
tients will be confined to home and have significant
shortening due to excessive collapse in unstable trochant-
eric fractures [6-10]. To overcome these difficulties, a
biomechanically more stable, intramedullary device has
been tried. Theoretically, there is an improved biome-
chanical environment with an intramedullary device,
with a shorter lever arm, which provides more load shar-
*Conflict of interest: None.
Copyright © 2013 SciRes. OJO
Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures 235
ing and allows less collapse for a stable medial configu-
ration [7]. Also with limited access approach, one can
reduce the blood loss, soft tissue trauma and infection.
Earlier results with Gamma nail did not produce any sig-
nificant benefit above sliding hip screw while there were
additional complications in perioperative and postopera-
tive proximal femoral fractures and also technical diffi-
culties while inserting the gamma nail [7,9,11,12]. Many
modifications were made, out of which it included pro-
ximal femoral nail with slightly reduced proximal di-
ameter of nail and two screw systems gained popularity
[9,13-15]. However, till today, in view of complications
like Z effect, proximal femoral fracture and technical dif-
ficulties, people still prefer DHS as the gold standard as
there are contradictory reports regarding the superiority
of one over the other. Various studies on intramedullary
devices have shown that there are complications with
nail to make screw cut out, proximal femoral fracture,
higher reoperation rates, wound infection [8,9,13,15-18].
Also, none of these studies have studied or described
how neck shaft angle is maintained in patients treated
with PFN, thus highlighting the superiority of PFN over
DHS in preventing varus collapse.
Following difficulties with Dynamic hip screw fixation,
especially in unstable trochanteric fractures, the authors
have started using proximal femoral nail in trochanteric
fractures since January 2004. This study aims to under-
stand the technical difficulties which are the main prob-
lem in using these nails and finding a solution to these
problems. The study also aims to analyze the overall re-
sults of proximal femoral nailing and look at the inci-
dence of varus collapse (loss of neck shaft angle) spe-
cifically following union, and to see if there is any dif-
ference between stable and unstable fractures with regard
to neck shaft angle.
2. Materials and Methods
All patients with pertrochanteric fractures from January
2004 to December 2009 were included in the study and
treated with proximal femoral nailing, using either Pitkar
or Inor make. All the patients gave the informed consent
for inclusion into study and the study was authorized by
the local ethical committee (UEC/04/13-14, Manipal
university ethics committee) and was performed in accor-
dance with the Ethical standards of the 1964 Declaration
of Helsinki as revised in 2000 (WMA declaration of Hel-
sinki—Ethical principles for medical research, All patients were evaluated at the end of
2 years. Fractures were classified using modified Evan’s
classification [19,20] as follows:
Stable :
Type 1: undisplaced, 2 part fractures.
Type 2: displaced but can be reduced to a stable posi-
Type 3: with communition of greater trochanter and
loss of posterolateral stability.
Type 4: with communition around lesser trochanter
and loss of medial stability.
Type 5: with loss of both medial and posterolateral sta-
R: with reverse obliquity.
Assessment of patient’s preoperative assessment in-
cluded, fracture classification, age, preoperative mobility
status, Harris hip score [21] and co moribund conditions.
Surgical technique included closed reduction (if there
was large spiral subtrochanteric fragment, minimal ac-
cess reduction was done using a bone holding forceps)
and closed intramedullary nailing with proximal femoral
nail. Surgeon was experienced in passing second genera-
tion intramedullary nails for femoral shaft fractures as
well as RT nails for complex femoral fractures. Despite
this, the time duration and complications in first 10 cases
were separately analyzed, as during these initial cases we
made several technical adjustments for the technique and
hence our surgical time and difficulty with which we
passed the nail became less in the subsequent cases. The
intraoperative characteristics studied were duration of sur-
gery, blood loss, technical difficulties during surgery along
with complications. For understanding the techniques of
PFN better, the technical details were classified into:
1) Entry point and guide wire placement problems:
Problems related to reduction; Problems related to entry
point; Problems related to guide wire passage.
2) Problems related to passing Nail.
3) Problems related to locking the nail with Lag screw
and derotational screws.
Methods used to solve these problems were noted in
the operative notes and these data were used for discus-
sion and analysis.
Postoperative characteristics studied are list of com-
plications, postoperative mobilization status, subsequent
return to maximum mobility status or death, amount of
shortening, Harris hip score at 2 years, and also radio-
logical assessment which included analysis of neck shaft
angle and implant status.
3. Results
A total of 41 patients were treated with Proximal femoral
nail from January 2004 to December 2009. 3 patients ex-
pired before 6 months with 2 of them within 1 month,
hence 38 patients were available for final follow up.
Mean age of patients was 71.39.
As per Evan’s classification, there were two type 1
fractures, fourteen type 2 fractures (thus a total of 16
fractures which were considered stable), eight type 3
fractures, eight type 4 fractures, six type 5 fractures and
Copyright © 2013 SciRes. OJO
Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures
Copyright © 2013 SciRes. OJO
two reverse oblique fractures (thus a total of 24 patients
with unstable fractures) and finally one patient had a
subtrochanteric fracture.
3 patients expired before 6 months and hence excluded
from the analysis of results. In the remaining 38 patients,
2 patients need walker, one patient is not able to walk,
and 15 patients walk comfortably with the help of a sin-
gle stick. Remaining 20 patients walk without the stick.
In contrast, before the injury, 2 patients were using
walker and 7 patients were using single stick. Functional
assessment with harris hip score showed almost near re-
turn to preinjury score (preinjury score of 71 versus final
follow-up mean score of 66). Except 2 patients all frac-
tures showed union within 6 months. Remaining 2 pa-
tients, showed union at the end of 9 months. Mean neck
shaft angle achieved post reduction was 132.4 degrees
(38 patients) and at final follow up was 131.9 degrees (33
patients) with insignificant difference (Mean difference
of 0.5 degrees). Limb length discrepancy was assessed in
the final follow up and only two patients had shortening
of more than 2 cm (20 mm), with average shortening of 2
mm. In Majority of patients there was no shortening. One
patient needed a reoperation to reintroduce a longer hip
screw as the hip screw had backed out. Following this
patient had complete union and good function. Average
duration of surgery was 1 hour 45 minutes. For the first
10 cases average duration of surgery was 2 hours 40
minutes and for the next 31 cases it was 87 minutes.
Technical difficulties faced during the procedure in-
cluded, guide wire break in one patient, loss of reduction
with varus malalignment and intertrochanteric translation
(described in detail below) in 4 patients, widening of
intertrochanteric area in 3 patients, difficulty in closed
reduction requiring open reduction in 2 patients, fracture
extension into subtrochanteric area in one patient, and
trochanteric communition as a result of surgery in 2 pa-
tients. We made an attempt to categorize these technical
problems and are discussed below in detail during dis-
cussion. Immediate post operative radiograph was as-
sessed for hip screw position, 36 screws were in the cen-
tre or inferior position while 2 were in the superior part
of neck on Antero Posterior projection. Fracture reduc-
tion was good in 34 patients, while in 4 patients we no-
ticed translation of head and neck fragment downwards
along the axis of intertrochanteric line (intertrochanteric
translation), although neck shaft angle was above 130
degrees. There were 4 complications, fracture extension
to subtrochanteric area in one patient, screw missing the
nail in one patient, wound dehiscence in one patient, and
in two cases there was backing out of lag screw (in one
patient screw was reintroduced with a larger hip screw,
while in other patient, fracture united with varus col-
We compared the results of stable fractures (type 1 and
type 2) with unstable fractures (type 3 to 5) (Table 1).
Mean shortening was 1.2 mm in stable fractures while it
was 2.6 mm in unstable fractures. Neck shaft angle was
also well maintained in unstable fractures (Mean 131
degrees in unstable fractures and 133 in stable fractures)
Type 3 and 5 fractures have communition at greater tro-
chanter. We have analyzed and compared the results of
these patients with other patients (Ta b le 2 ). These frac-
tures showed slightly more shortening, with mean short-
ening of 2.8 mm. All these patients had good abductor
power indicating that nailing in communition of trochan-
ter do not effect the end result.
4. Discussion
The technical problems faced during surgery were cate-
gorized as follows:
1) Problems related to reduction and guide wire pas-
sage: Closed reduction was successful in all except 3
patients. Good reduction was achieved after placing these
patients on fracture table with boot traction. Reduction
should not be problem in all fresh fractures except one or
two special circumstances.
a) Long spiral fracture with subtrochanteric extension:
Table 1. Comparing outcome measures in stable fractures and unstable fractures.
Parameter Stable fracture Unstable fracture
No, of patients 16 25
Union status United United
Available for follow up 16 (one telephonic) 22 (3 expired, 4 telephonic)
Walking status Unaided: 12, single stick: 3,
walker assistance: 1
Unaided: 8, single stick: 12, walker assistance: 1,
not walking: 1
Average difference in harris hip score 4 8
Mean shortening 1.2 mm (n = 15) 2.58 mm ( n = 18)
Mean neck shaft angle 133 degrees (n = 15) 131 degrees (n = 18)
Abductor power Grade 4 plus in all Grade 4 plus in 20, in 2 patients could not be assessed
Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures 237
Table 2. Comparing results of fractures with trochanteric communition and without communition.
Parameters Type 3 and 5 fractures All other fractures
Number of patients 12 26
Neck shaft angle 130 degrees (n = 11) 133 degrees (n = 22)
Mean shortening. 2.8 mm (n = 11) 1.63 mm (n = 22)
Walking status Unaided: 5, single stick: 5, walker assistance: 1,
not walking: 1
Unaided: 15, single stick: 10,
walker assistance: 1
Abductor power Grade 4 plus in all except one Grade 4 plus in all except one
Union status All united All united
Mean harris score difference 7 6
In these fractures abduction of trochanteric fragment is a
problem. It is best to make a limited access at the apex of
spiral fragment and put a bone holding forceps after se-
curing reduction (Figure 1).
b) Gross communition with 4 part fracture and separa-
tion of trochanteric fragment. In these fractures posterior
sagging of the trochanteric fragment is a problem [22].
Due to this, there will be excessive anteversion of neck
leading to difficulty in passing the nail as well as subse-
quent hip screw placement. At the time of passing nail,
an assistant is asked to push the trochanteric fracture up
with one hand and then press the distal fragment down
from the other hand. One should also observe the passage
of nail into distal fragment carefully with image, so by
manipulating jig, nail can be passed into distal fragment.
There are also reports of passing a pin into the proximal
fragment into acetabulum so that distal fragment can be
moved independent of proximal fragment, although we
have not tried this method [23].
Guide wire insertion can be problematic at times. Stan-
dard entry point for PFN is tip of greater trochanter.
However in intertrochanteric fractures fracture involves
tip of trochanter with communition. If it is a simple frac-
ture extending to tip of trochanter without communition,
it is easy to put guide pin as fracture site itself provides
the entry point. But in practice, there is always some
communition at tip of trochanter or fracture line is not
exactly through tip. In fact we have seen fracture ex-
tending to 3 - 4 mm lateral to tip of trochanter (Figure
Figure 1. Long spiral fracture reduced by bone holding
2). Due to this even if an entry is made in tip of tro-
chanter, due to narrow bone bridge lateral to tip of tro-
chanter and medial to fracture line, guide wire and sub-
sequent reamers fall into fracture line thus making the
entry lateral to tip of trochanter. Some times there will be
communition with an additional coronal split so that
there is no lateral support at the entry region while ream-
ing or putting nail. All these things lead to lateral entry of
nail. However we believe these things will not affect the
final outcome as communited fragments sit around the
nail and mould and unite thus there will not be signifi-
cant abductor weakness. Important technical aspect here
is to start the entry from tip of trochanter and slightly an-
terior in the lateral plane and then aim to pass the guide
wire into shaft of femur in the centre, once guide wire is
passed into shaft we ignore the lateralization of guide
wire at tip of trochanter. Edward T. Su et al. [24] found
that entry of either pyriformis fossa or tip of greater tro-
chanter do not make any difference in AP projection.
During subsequent reaming and passing nail, we take
care to adduct limb nicely and also keep the reamer or
nail handle as close to flank as possible so that reaming
and nail passes as medial as possible (reaming of lateral
edge of proximal fragment). If the guide wire goes out
Figure 2. Shows how entry awl can slip from tip of trochanter
into fracture site. The guide wire also takes the same route.
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Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures
through the medial cortex, cannulated reamer is passed
over the guide wire and by manipulating the reamer, to-
wards the centre of medullary cavity, guide wire can be
directed easily in to the medullary canal (Figure 3).
2) Problems while passing nail: Two important prob-
lems were noticed during nail insertion. One is possibil-
ity of fracture of proximal femur, second one is related to
loss of reduction. During passage of nail, it can breach
medial or anterior cortex, and is responsible for proximal
femur fracture while passing the nail. This happens just
below lesser trochanter. If one is not able to identify the
problem, then one can end up with subtrochanteric or
proximal femoral fracture (Figure 4). In our series, one
patient developed subtrochanteric fracture, but then we
ignored the fracture and passed the nail into distal frag-
ment, and union of both intertrochanteric and iatrogenic
fractures were achieved. In literature, there are reports of
such fractures due to failure to anticipate this problem.
Technical trips for easy passage of nail and prevention
of proximal femoral fracture:
a) Always ream adequately. Our surgical technique in-
cluded reaming the medullary cavity initially upto 10
mm beyond isthmus if there is narrowing of proximal
femoral canal with adequate good cortical bone stock. In
very elderly with gross osteoporosis with wide canal this
step can be bypassed. Then we ream upto 15 mm upto
the level of lesser trochanter. This will allow passage of
nail easily.
b) Pass a smaller diameter nail which goes easily. Any-
Figure 3. Use of cannulate d aw l to guide the guide wire.
Figure 4. shows iatrogenic proximal femoral fracture.
way, unless there is subtrochanteric extension, diameter
of distal part of nail is unlikely to influence stability of
fixation of fracture. The proximal diameter of nail is
same in all nails.
c) While passing the nail, continuously monitor with
C-arm and identify the path of nail and ensure it does not
break either anterior cortex or medial cortex. Then the
direction of nail can be adjusted. A slightly anterior entry
point in the lateral projection could prevent hitting the
anterior cortex while adducting the limb and keeping the
nail insertion device handle as close to flank as possible
will help to prevent breach of medial cortex.
We also noticed another important phenomena during
nail insertion, as the broader portion of nail passes
through the intertrochanteric area, the proximal fragment
translates along the intertrochanteric line. This is a prob-
lem not discussed by any of earlier authors although va-
rus reduction due to entry reamer was discussed by Hak
D. J. et al. [25]. As nail takes its position in the proximal
half of femur, the proximal end of nail pushes proximal
fragment downwards (Figures 5, 6(a) and (b)). Usually
at this position, the tip of nail will be hitting against me-
dial cortex and manipulating jig medially to direct the
nail to central part of canal will produce lever action and
larger proximal part of nail pushes the proximal fragment
downwards along with some distraction at fracture site.
We call this translation in the plane of intertrochanteric
line and can be associated with varus reduction also. Also
the distal fragment is pushed by the nail laterally causing
widening at intertrochanteric area (distraction). This phe-
nomenon is unlikely to effect the final result as long as
neck shaft angle is maintained and fracture has not
aligned into a varus position. We had persistent transla-
tion in two cases but union and good functional result
was achieved in both these patients. However the distrac-
tion effects of nail can be minimized by over reaming the
Figure 5. Mechanism of intertrochanteric translation and
displacement. Big arrows show deforming force exerted by
the nail on the bone, while small arrows show direction of
fracture displacement.
Copyright © 2013 SciRes. OJO
Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures 239
proximal part of femur till subtrochanteric area upto 15
mm with flexible reamers. The solid reamers can push
trochanter laterally without actually reaming it. Recently,
Hak D. J. et al. [25] mention about overdistraction while
entry reamer, this will ream the lateral edge of medial
fragment, which is the main reason for varus and distrac-
tion, but we have found our methods useful. Also one can
insert a long artery forceps with a small incision on the
anterolateral aspect of thigh in the lesser trochanter re-
gion under the neck of femur and push it up while pass-
ing nail preventing translation (Figure 7). Excessive
reaming also prevents distraction as nail goes easily, an
assistant can maintain some pressure over trochanter
while passing last part of nail. There are also reports of
removing a small bone from lateral edge of medial frag-
ment [26]. Even after this if some distraction is present
this can be corrected by using the lag screw first to com-
press the fracture site. One should study the neck shaft
Figure 6. (a) and (b) Shows fracture displacement as nail
passes through proximal femur.
Figure 7. Use of artery forceps to reduce the intertrochan-
teric translation and distraction.
angle clearly during this malreduction, and if there is
varus, then that should be corrected as it is impossible to
place 2 screws correctly, while a little bit of translation or
distraction can be accepted.
3) Problems while locking the nail: One should always
pass the lag screw in the inferior part of neck in AP pro-
jection and centre in the lateral plane. If lag screw is in
the centre then sometimes derotation screw goes too su-
periorly and even out of superior cortex of neck of femur.
In two of our cases, position of lag screw was slightly
superior and in both cases screw had backed out.
Initially we were using derotation screw first and then
the compression screw, but when there was some widen-
ing of fracture, we found it would be advantageous to put
the compression screw first. We usually put both guide
wires first, then put lag screw to compress the fracture
keeping derotation screw guide wire in place and then
finally place the derotation screw. One can put the dero-
tation screw first, but then achieving compression across
fracture site can be a difficult task. In literature there is
no clear consensus on this.
There can be problems while reaming over guide wire
for hip screw, as guide wire may bend slightly as it
reaches subchondral bone (Figure 8). Now if one starts
reaming over this, guide wire may break. We had 2 such
incidences, in one case we removed the guide wire, in
other patient, we could not. Also in 2 cases we were able
to detect bending of guide wire, we could remove the
guide wire before it actually broke. To prevent guide wire
breakage, we reamed upto subchondral level, then pulled
the guide wire upto subchondral level and then proceeded
with reaming under C-arm guidance. The guide wire was
reinserted after the removal of reamer for screw insertion.
The guide wire can bend at outer cortex also but this can
be prevented with predrilling the entry point at lateral cor-
tex with a drill bit. Some times there will be problems
with negotiating the reamer for hipscrew through the nail
due to some manufacture or implant assembly related prob-
lems. We had two such problems, one for hip screw and
other for derotation screw. Reaming with smaller sized
reamer and proceeding with regular reamer will help. One
should also check the jig whether it is loosened or not.
(a) (b)
Figure 8. Showing (a) bending of guide wire and (b) subse-
quent reaming after removal of guide wire.
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Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures
In literature, when we analyse failures of PFN, we
found that most of these are due to faulty techniques, like
failure to reduce properly, surgery done by residents,
failure to anticipate nail touching anterior cortex while
hammering, use of larger decortical screw. J. Pajarinen et
al. [4] in their study of comparison between dynamic hip
screw and proximal femoral nail found that use of PFN
has a positive effect on the speed of restoration of walk-
ing mainly due to restoration of near normal anatomy.
Al-Yassari et al. [27] and Simmermacher et al. [28] also
observed restoration of preoperative mobility in ap-
proximately 40% - 50% of the patients treated with PFN.
Pajarinen explains that early walking ability in PFN is
due to better anatomical restoration in comparison to
DHS where there is greater impaction of fracture leading
to shortening of femoral neck. M. S. G. Ballal et al. [9] in
their study found 5% PFN failures and opined that In
PFN fixations, proper alignment between the 2 main
fragments and proper placement of the lag screws in the
femoral head should be ensured. In their study it so hap-
pened that all failed PFN fixations were performed by
Our study concurs with these findings, as mean short-
ening in our series was less than 4 mm. Only one patient
had a shortening of 2.5 cm. This is definitely less than
shortening observed with DHS (mean shortening 10.8
mm in J. Pajarinen et al.). However, J. Pajarinen et al. [4]
do not establish clear superiority of PFN in view of in-
creased operation time, same redisplacement rate and
final outcome at one year being same. Similarly in an-
other study by Saudan et al. [3], they found no statistical
difference between two groups with reduced mobility in
PFN group and higher screw failure rate for PFN. How-
ever it was mentioned that in these screw failure groups,
the screws were placed more superiorly. Looking at these
studies, we believe it is more of technical failure rather
than failure of implant, if properly done we believe PFN
gives superior results. We believe during reduction of
these fractures accurate anatomical reduction is not re-
quired as it is impossible in unstable fractures, but reduce
to a position where the neck shaft angle is maintained
and there is medial continuity. One should not do varus
reduction. If correct neck shaft angle and version are
maintained, irrespective of communition, irrespective of
nonanatomical reduction fracture will unite with minimal
shortening. Placement of hip screw is critical to the final
result as placement of hip screw in superior part of neck
can lead to cut out or varus collapse. In view of this, we
believe, most important technical aspect of this surgery is
maintaining the proper neck shaft angle and placing the
hip screw in the centre of hip. Both are interlinked as
screw placement angle is prefixed and hence unless good
neck shaft angle is achieved, it is impossible to put the
hip screw correctly. In the AP Projection, varus angula-
tion or intertrochanteric translation is the main problem
to place the screw in centre, which is largely due to broad
proximal part of nail pushing the lateral edge of proximal
fragment down as described earlier in our analysis of
technical results and supported by others (Huk D. J. et al.
[25]), while in lateral projection posterior sagging of
trochanter is the problem in putting the hip screw cen-
T. Moihara et al. [14] also opine that hip pin should be
shorter by atleast 15 mm otherwise it could take weight
and can back out or migrate into joint leading to cut out.
In our study, we placed hip pin of at least 20 mm shorter
compared to hip screw. As a result we had only one
loosening of lag screw and one patient had slight varus
collapse (Figure 9). This is in contrast to some of earlier
reports [3,27,28] which give higher cut out rates.
In our series, our mean neck shaft angle was 132 de-
grees and mean shortening was just 2 mm, which shows
excellent results compared to any of previous DHS re-
sults, We have also shown that the results are excellent
when there is gross communition including loss of me-
dial and lateral walls (Figures 10 and 11 show type 5
fractures with good union). Table number 2 shows excel-
lent maintenance of neck shaft angle and union in such
patients, and also good Harris hips score, although, our
comparison with preinjury scores may not be reliable
completely, as preinjury scores are very subjective and
retrospective. But good union and good walking ability
Figure 9. Back out of lag screw with varus malunion.
Figure 10. A type 5 fracture with good outcome.
Copyright © 2013 SciRes. OJO
Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures 241
indicated that the varus collapse seen with DHS is less
likely in these patients. By giving importance to technical
problems mentioned above it is possible to avoid most of
technical problems mentioned in literature, while for
people who are already experienced in placing interlock-
ing nails for complex femoral fractures, it is not that dif-
ficult to master the technique and reduce the time for
surgery also. Once the proper technique is mastered, op-
eration time, bleeding and risk of infection are minimal
with Proximal femoral nail.
Communition of greater trochanter: Communition of
greater trochanter leads to technical difficulty in passing
nail and nail entry point may get lateralized, and tip of
trochanter can get splayed. However in the final follow-
up, almost all patients have good abductor strength and
do not have any significant disability related to that (Fig-
ures 12 (a)) and (b)) show final result following nailing
Figure 11. Another case of type 5 fracture with good union.
Figure 12. (a) and (b) Type 3 fracture with gross trochan-
teric communition showing union.
in gross trochanteric communition).
5. Conclusion
Our study shows that, proximal femoral nailing produces
good results with negligible varus collapse and shorten-
ing in unstable fractures and hence should be preferred in
these fractures. Although surgery is technically required,
if one gives careful attention to minute technical details
at each step as discussed above, good outcome can be
achieved and this should not be a problem for those sur-
geons who are already experienced in nailing complex
femoral shaft fractures. In the final analysis, we believe,
achieving a good reduction between two main fragments
without varus malalignment and placement of hip screw
in a correct position are two important technical aspects
which prevent most of the complications associated with
these procedures.
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