A Step-by-Step Surgical Guide: Understanding PFNA Nail Application in Proximal Femur Fractures

Proximal femur fractures—especially intertrochanteric and subtrochanteric fractures—are among the most common orthopedic injuries in elderly patients. With increasing life expectancy and the global rise in osteoporosis, the demand for reliable, stable, and minimally invasive fixation systems is higher than ever.

The PFNA Nail (Proximal Femoral Nail Antirotation) has emerged as one of the leading implants for these fractures due to its design, biomechanical superiority, and versatility. The 3rd-Generation PFNA Nail represents a major evolution, combining Blade Fixation, Dual Screw Options, and Lag Screw Fixation in a single 3-in-1 system, offering unmatched flexibility for surgeons.

This guide provides a comprehensive step-by-step surgical approach to PFNA Nail application—from patient selection and preparation to insertion, fixation, and postoperative care.

1. Introduction to PFNA Nail

The PFNA Nail is specifically designed to treat unstable and osteoporotic proximal femur fractures. Its helical blade or screw system ensures optimal anchorage in the femoral head, reduces rotational instability, and provides superior load distribution.

1.1 Advantages of PFNA Nail

• Minimally invasive technique

• Reduced operative time

• Reduced blood loss

• Strong fixation in osteoporotic bone

• Lower risk of cut-out compared to conventional screws

• Enhanced stability due to antirotational features

The newer 3-in-1 PFNA Nail brings flexibility to choose between Blade, Dual Screws, or Lag Screw fixation depending on the fracture pattern and bone density.

2. Indications for PFNA Nail Surgery

The PFNA Nail is recommended for:

• Unstable Intertrochanteric Fractures (AO 31-A2, A3)

• Subtrochanteric Fractures

• Reverse Oblique Fractures

• Osteoporotic fractures with high risk of collapse

• Pathological fractures involving the proximal femur

• Failed DHS fixation (revision cases in select situations)

2.1 Contraindications

• Skeletally immature patients

• Non-reconstructible femoral head

• Active infection

• Severe deformity not correctable with closed or open reduction

3. Preoperative Planning

Effective planning significantly improves surgical results.

3.1 Radiographic Assessment

• AP and Lateral X-rays of the hip and femur

• Full-length femur views to evaluate the canal, bow, and deformity

• CT scan in complex cases

3.2 Implant Selection

• Nail length: Short vs. long

• Nail diameter: Based on medullary canal

• Fixation method: Blade, Dual Screw, or Lag Screw

• Locking options: Static or dynamic

3.3 Patient Positioning

• Supine on a fracture table

• Injured leg in a traction boot

• Uninjured leg flexed and abducted

• C-arm positioned for AP and lateral views

Proper positioning ensures anatomical reduction and correct entry point visualization.

4. Step-by-Step Surgical Technique

Step 1: Achieving Anatomical Reduction

Closed reduction is attempted first using traction, rotation, and adduction maneuvers.

Goals:

• Restoration of medial cortical continuity

• Accurate alignment of the neck-shaft angle

• Correction of varus, valgus, or rotational deformity

If closed reduction fails, limited open reduction may be required.

Step 2: Determining the Entry Point

The starting point is crucial for proper nail placement.

Entry point:

• Tip of the Greater Trochanter or slightly medial

• Confirmed under fluoroscopy in AP & lateral views

A small skin incision (3–4 cm) is made proximal to the greater trochanter.

Step 3: Opening the Medullary Canal

• Introduce a guidewire into the trochanteric entry point

• Advance under fluoroscopy

• Use the cannulated entry reamer to open the proximal femur

The canal opening must be precise to avoid creating iatrogenic fractures.

Step 4: Inserting the Guidewire

Introduce the long guidewire down the femoral canal.

Confirm:

• Central position in the canal

• Correct alignment

• No cortical perforation

This guidewire determines the nail’s trajectory.

Step 5: Reaming the Canal (Optional)

Depending on the nail’s diameter and canal morphology:

• Perform progressive reaming 0.5–1 mm above the nail diameter

• Reaming is often skipped for short nails

• Essential in narrow or deformed canals

Reaming reduces insertion resistance and decreases bone stress.

Step 6: Inserting the PFNA Nail

Attach the nail to the targeting guide and insert it over the guidewire.

Key checkpoints:

• Advance gently with rotational oscillation

• Ensure no varus malalignment

• Confirm position in AP and lateral views

The nail should rest properly in the canal without force.

Step 7: Placing the Blade/Screw Fixation

With the nail in place, the head-neck fixation is performed.

7.1 Guidewire Placement

• Insert the guidewire into the femoral head

• Confirm TAD (Tip-Apex Distance) between 20–25 mm

• Maintain center–center position in both views

7.2 Reaming for Blade or Screw

• Perform cannulated reaming depending on the chosen fixation method

• Do not over-ream, especially in osteoporotic bone

7.3 Inserting the Blade / Dual Screws / Lag Screw

PFNA Blade:

• Compacts surrounding cancellous bone

• Best for osteoporotic conditions

• Provides strong antirotation stability

Dual Screw System:

• Ideal for comminuted fractures requiring added rotational control

Lag Screw:

• Best for younger patients with dense bone

• Reduces risk of lateral wall blow-out

Advance fixation under fluoroscopy until ideal position is achieved.

Step 8: Distal Locking

Distal locking provides rotational and axial stability.

Static Locking:

• For unstable or comminuted fractures

• Prevents telescoping

Dynamic Locking:

• Permits controlled collapse

• Used for stable patterns

Distal locking is performed using the aiming arm or freehand technique.

Step 9: Final Fluoroscopic Check

Before closing:

• Confirm head fixation position

• Verify nail rotation

• Check for cortical breach

• Ensure fracture reduction is maintained

• Evaluate TAD, neck–shaft angle, and implant alignment

Once satisfied, remove instruments.

Step 10: Wound Closure

• Irrigate the incision site

• Close in layers

• Maintain sterile dressing

Because PFNA is minimally invasive, tissue trauma is reduced, and wounds are small.

5. Postoperative Protocol

5.1 Immediate Postoperative Care

• Monitor vital signs and wound dressing

• Pain management

• Initiate physiotherapy as early as tolerated

5.2 Mobilization

• Early mobilization is highly encouraged

• Partial weight-bearing usually allowed depending on fracture stability

• Full weight-bearing can be initiated once callus formation is visible

5.3 Follow-Up Schedule

• 2 weeks: Suture removal

• 6 weeks: X-ray to evaluate healing

• 3 months: Progress assessment

• 6 months and annually: Long-term evaluation

Most fractures heal within 8–12 weeks, depending on severity and patient factors.

6. Complications and How PFNA Reduces Them

Common Complications in Proximal Femur Fixation

• Cut-out of the screw

• Varus collapse

• Implant failure

• Nonunion

• Infection

• Malrotation

How PFNA Minimizes These Risks

• Helical blade compacts bone → stronger hold

• 3-in-1 fixation options allow customized stability

• Proximal geometry reduces stress on lateral wall

• Central insertion path prevents varus collapse

• Distal locking options provide controlled load sharing

This makes PFNA Nail one of the most reliable implants for intertrochanteric fractures.

7. Tips for Surgeons: Achieving Optimal Outcomes

✔ Choose the right fixation type (Blade/Screw/Lag Screw)

Tailor it to bone quality, fracture type, and patient age.

✔ Reduce the fracture perfectly

No implant compensates for poor reduction.

✔ Maintain ideal TAD

A TAD below 25 mm significantly reduces cut-out risk.

✔ Prevent varus malposition

This is the most common technical error.

✔ Ensure correct entry point

A wrong entry point leads to postoperative deformities.

8. Why the 3rd-Generation PFNA Nail Stands Out

The latest PFNA design provides unmatched versatility:

• Single implant with 3 fixation options

• Improved rotational stability

• Greater purchase in osteoporotic bone

• Lower stress on the implant-screw interface

• Better adaptation to different fracture patterns

This flexibility is a major advantage for surgeons dealing with complex or high-risk fractures.

Conclusion

The PFNA Nail has become a standard of care for proximal femur fractures due to its biomechanical superiority, minimally invasive technique, and predictable outcomes. Understanding the step-by-step surgical process allows surgeons to consistently achieve excellent reduction, strong fixation, and faster patient recovery.

With the introduction of the 3rd-Generation PFNA Nail, offering Blade, Dual Screw, and Lag Screw options in a single system, surgeons now have a powerful tool designed for maximum flexibility and stability. When applied with proper technique, the PFNA Nail provides exceptional results even in challenging osteoporotic or unstable fracture patterns.