Intertrochanteric Fractures: Ten Commandments for Getting Good Results with Proximal Femoral Nailing

Intertrochanteric (IT) fractures in the elderly are a major orthopaedic challenge due to osteoporotic bone quality, implant anchorage difficulties, and associated comorbidities. These factors contribute to nearly one-third mortality within a year of injury, representing a significant global health and economic burden.

Historically, stable IT fractures were treated with surface implants such as dynamic hip screws (DHS), whilst intramedullary (IM) implants like proximal femoral nails (PFN) were reserved for unstable patterns. Evidence from 1999 to 2010, including Cochrane reviews, supported this practice. However, recent studies and updated Cochrane data advocate intramedullary fixation for both stable and unstable fractures. The authors draw from their extensive experience on intertrochanteric fracture management, ten important principles on fixing intertrochanteric fractures using PFN.

Current evidence supports the use of intramedullary implants as the preferred method for intertrochanteric fracture fixation. The authors concur with this trend and share practical tips to improve outcomes using PFN. Emphasis is placed on achieving optimal fracture reduction, which directly correlates with surgical success. Once adequate reduction is attained, a variety of intramedullary devices can effectively maintain alignment. These principles are presented as ten commandments in this article.

Intramedullary fixation, particularly with proximal femoral or trochanteric fixation nail (TFN) utilising a dual screw system, is recommended for both stable and unstable intertrochanteric fractures in the elderly. Despite the availability of single screw systems favoured for their ease of use, the authors maintain preference for the two-screw design due to enhanced stability. Surgical expertise in achieving and maintaining reduction remains paramount to successful outcomes.