Does the Entry Point of Proximal Femoral Nail Antirotation Affect the Malalignment of Intertrochanteric Fracture? A Cadaveric Study


  • Chittawee Jiamton, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
  • Nonpawit Nimmankiatkul, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
  • Pongsakorn Rungchamrassopa, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
  • Wichan Kanchanatawan, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
  • Pariyut Chiarapatanakom, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
  • Wirat Kongcharoensombat, MD Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand



proximal femoral nailing, intertrochanteric fracture, entry point, cadaveric femurs


Purpose: Proximal femoral nailing (PFN) is a reliable and common procedure for treating intertrochanteric fractures. The optimal entry point is considered a critical step in avoiding malreduction. This study investigated the effects of various entry points on fracture displacement and force reduction.

Methods: Twenty-four cadaveric femurs were randomly categorized into three groups: the greater trochanter (GT) tip, medial to the GT tip, and lateral to the GT tip. Each intact femur was provisionally stabilized using a ring external fixator. The entry point was identified and reamed to accommodate the nail insertion. After osteotomy was performed to simulate an A1-type fracture, the PFN was inserted. Digital calipers were used to measure horizontal fracture displacements. The force required to reduce displaced fractures to the anatomical position was measured using a digital force gauge. Fluoroscopic images were recorded to assess changes in the neck-shaft angle.

Results: The lateral entry group showed significantly displaced fractures in the coronal plane, whereas the medial and tip entry groups were insignificant. Displacement in the sagittal plane was not significantly different between the groups. The lateral entry group showed significantly irreducible displaced fractures compared with the other groups. After nail insertion, the changes in the neck-shaft angle were 0.77° varus, 3.66° valgus, and 3.16° varus in the tip, medial, and lateral entry groups, respectively. The degree of neck-shaft angle change demonstrated significant differences between the groups.

Conclusions: The lateral entry point of PFNA tends to displace reduced fractures, resulting in malalignment and irreducibility. Lateral entry points should be avoided to prevent surgery-related complications.


Metrics Loading ...


Endo Y, Aharonoff GB, Zuckerman JD, et al. Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men. J Orthop Trauma 2005;19:29-35. DOI:

Arirachakaran A, Amphansap T, Thanindratarn P, et al. Comparative outcome of PFNA, Gamma nails, PCCP, Medoff plate, LISS and dynamic hip screws for fixation in elderly trochanteric fractures: a systematic review and network meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol 2017;27:937-52. DOI:

Müller F, Doblinger M, Kottmann T, et al. PFNA and DHS for AO/OTA 31-A2 fractures: radiographic measurements, morbidity and mortality. Eur J Trauma Emerg Surg 2020;46: 947-53. DOI:

Ponce SJ, Laird MP, Waddell JP. Intramedullary nailing in pertrochanteric fractures of the proximal femur. Eur J Trauma Emerg Surg 2014; 40:241-7. DOI:

Ma K-L, Wang X, Luan F-J, et al. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res 2014;100: 859-66. DOI:

Liu Y, Tao R, Liu F, et al. Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA). Injury 2010;41: 810-7. DOI:

Jiamton C, Boernert K, Babst R, et al. The nail-shaft-axis of the of proximal femoral nail antirotation (PFNA) is an important prognostic factor in the operative treatment of intertrochanteric fractures. Arch Orthop Trauma Surg 2018;138:339-49. DOI:

Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 2005;19:681-6.

Pan S, Liu X-H, Feng T, et al. Influence of different great trochanteric entry points on the outcome of intertrochanteric fractures: a retrospective cohort study. BMC Musculoskelet Disord 2017;18:107. DOI:

Chon C-S, Kang B, Kim HS, et al. Implications of three-dimensional modeling of the proximal femur for cephalomedullary nailing: An Asian cadaver study. Injury 2017;48:2060-7. DOI:

Jeong J-H, Jung G-H. The determination of optimal entry point for proximal femoral nail antirotation-II by fluoroscopic simulation: A cadaveric study. J Korean Fract Soc 2017;30:173-9. DOI:

Zhao J-X, Su X-Y, Zhao Z, et al. Predicting the optimal entry point for femoral antegrade nailing using a new measurement approach. Int J Comput Assist Radiol Surg 2015;10:1557-65. DOI:

Link B-C, van Veelen NM, Boernert K, et al. The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter. Sci Rep 2021;11:18404. DOI:

Park PJ, Weinberg DS, Petro KF, et al. An anatomic study of the greater trochanter starting point for intramedullary nailing in the skeletally immature. J Pediatr Orthop 2017;37:67-73. DOI:

Olsen M, Goshulak P, Crookshank MC, et al. Biomechanical testing of a 3-hole versus a 4-hole sliding hip screw in the presence of a retrograde intramedullary nail for ipsilateral intertrochanteric and femur shaft fractures. J Orthop Trauma 2018;32:419-24. DOI:

Seral B, Garca JM, Cegoino J, et al. 3D finite element analysis of the gamma nail and dhs plate in trochanteric hip fractures. Hip Int 2004; 14:18-23. DOI:

Kashigar A, Vincent A, Gunton MJ, et al. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J 2014;96-B:1029-34. DOI:

Streubel PN, W Wong AH, Ricci WM, et al. Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? J Orthop Trauma 2011;25:202-7. DOI:

Grechenig W, Pichler W, Clement H, et al. Anatomy of the greater femoral trochanter: clinical importance for intramedullary femoral nailing. Anatomic study of 100 cadaver specimens. Acta Orthop 2006;77:899-901. DOI:

Farhang K, Desai R, Wilber JH, et al. An anatomical study of the entry point in the greater trochanter for intramedullary nailing. Bone Joint J 2014;96-B:1274-81. DOI:

Ziran BH, Morganstein A. Preventing eccentric reaming of the trochanter during trochanteric nailing. J Orthop Trauma 2014;28:e88-90. DOI:




How to Cite

Jiamton C, Nimmankiatkul N, Rungchamrassopa P, Kanchanatawan W, Chiarapatanakom P, Kongcharoensombat W. Does the Entry Point of Proximal Femoral Nail Antirotation Affect the Malalignment of Intertrochanteric Fracture? A Cadaveric Study. JseaOrtho [Internet]. 2022 Oct. 6 [cited 2023 Nov. 30];47(1):30-7. Available from:



Original Articles