Orthopaedics & Traumatology: Surgery & Research 101 (2015) 143–146

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Original article

The Asia proximal femoral nail antirotation versus the standard

proximal femoral antirotation nail for unstable intertrochanteric
fractures in elderly Chinese patients
J. Li 1 , L. Cheng 1 , J. Jing ∗
Department of Orthopaedics, The Second Hospital of Anhui Medical University, 678, Furong Avenue, Hefei, Anhui 230601, PR China

a r t i c l e i n f o a b s t r a c t

Article history: Background: The best options of internal fixation for unstable intertrochanteric fractures in elderly Chi-
Received 5 May 2014 nese patients remain controversial. The Asia proximal femoral nail antirotation (PFNA-II) was specifically
Accepted 17 December 2014 designed for Asian patients, which could be more effective than the regular proximal femoral nail antiro-
tation (PFNA). Compared to PFNA, whether PFNA-II is associated with shorter operative time and lower
Keywords: rates of complications is unknown.
PFNA Hypothesis: The rate of complications using PFNA-II is lower than PFNA for the treatment of unstable
PFNA-II
intertrochanteric fractures in elderly Chinese patients, and the operation using PFNA-II is quicker.
Unstable intertrochanteric fractures
Chinese
Materials and methods: Between June 2008 and December 2011, 188 patients with unstable
intertrochanteric fractures treated with the PFNA-II (n = 118) or PFNA (n = 70) were retrospectively eval-
uated. Follow-up evaluations were performed at 1, 3, 6, 9 and 12 months, and every year thereafter.
According to residual valgus-varus deformation, the quality of the fracture reduction was graded as poor
(>10◦ deformation), acceptable (5◦ to 10◦ deformation), or good (<5◦ deformation). The operative time,
intraoperative blood loss, overall time of fluoroscopy, blood transfusion volume, postoperative drainage,
length of hospital stay and postoperative complications were recorded.
Results: The mean operative time in the PFNA-II group was significantly shorter than that in the
PFNA group (66.25 ± 13.15 vs 79.50 ± 21.12 minutes; P < 0.05), intraoperative blood loss was smaller
(131.86 ± 69.16 vs 162.14 ± 66.18 mL; P < 0.05), and fewer local complications were observed (25% vs
46%; P < 0.05). There was no significant difference in the postoperative blood transfusions, overall time
of fluoroscopy, postoperative drainage, length of hospital stay, fracture reduction, the position of the
implant and tip apex distance between the two groups. At follow-up, no significant difference was found
between the two groups in Harris hip score (HHS) (86.19 ± 6.53 vs 85.27 ± 5.47; P > 0.05), visual analogue
scale (VAS) (0.87 ± 0.85 vs 0.97 ± 0.87; P > 0.05).
Discussion: Due to its special design for the Asian population, PFNA-II offers a better match with the
Chinese people’s proximal femur anatomic structure. This study showed that the rate of complications
using PFNA-II is lower than PFNA for the treatment of unstable intertrochanteric fractures in elderly
Chinese patients, and the operation time is shorter.
Level of evidence: Level III, case control study.
© 2015 Elsevier Masson SAS. All rights reserved.

1. Introduction fractures have osteoporosis [2]. This type of geriatric fracture

Intertrochanteric fractures are relatively common among
the elderly, 90% of such fractures occurring in persons aged
over 65 years [1]. Most elderly patients with intertrochanteric
∗ Corresponding author.
E-mail address: jingjuehuapaper@163.com (J. Jing).
1
Jun Li and Li Cheng contributed equally to this work.
has a relatively high mortality and causes severe impairment
of function [3]. Common treatment options for Chinese patients
include intramedullary nailing with either the proximal femoral
nail antirotation or Asia proximal femoral nail antirotation, both
of which represent the most commonly used implants for the
treatment of unstable intertrochanteric fractures [4–8].
The proximal femoral nail antirotation (PFNA) was used in clinic
for the first time in 2004. It is an original intramedullary device
which contain a helical blade inserted by impaction to result in bone

http://dx.doi.org/10.1016/j.otsr.2014.12.011
1877-0568/© 2015 Elsevier Masson SAS. All rights reserved.
144 J. Li et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 143–146

compaction around the blade to retard rotation and varus collapse

[9]. Several studies showed few complications and positive results
with PFNA for unstable intertrochanteric fractures [10–12]. How-
ever, the proximal end of the nail was not matched with the specific
anatomy of some short elderly patients. Further modifications of
the nail are necessary for the elderly Chinese population, intra- and
postoperative complications, such as difficulty inserting it, pain in
the hip and thigh, lateral blade migration, femoral shaft fracture,
and lateral cortex splitting intraoperatively, have been reported
since it began being used in Asian patients [4,13]. In response to
these concerns, AO/ASIF developed the Asia proximal femoral nail
antirotation (PFNA-II) specifically for Asian patients. Although both
nails have been reported to have good clinical outcomes, no study
has compared the outcomes of the PFNA and PFNA-II. Therefore, we
conducted a case control study to assess if the PFNA-II was associ-
ated with shorter operative time and lower rates of complications.
We hypothesized that the rate of complications using PFNA-II is
lower than PFNA for the treatment of unstable intertrochanteric
fractures in elderly Chinese patients, and the operation using PFNA-
II is quicker.

2. Patients and methods

2.1. Patients

From June 2008 to December 2011, all patients with unstable
intertrochanteric fractures were treated with a PFNA or a PFNA-II
(Synthes GmbH, Oberdorf, Switzerland) in our hospital. The study
was approved by the Ethics Committee of The Second Hospital of
Anhui Medical University. All patients have provided their written
informed consent to participate in this study. We did not conduct
our clinical investigations outside of our country of residence.
The PFNA or PFNA-II was chosen according to surgeon prefer-
ence and availability of the device. Patients eligible for the study
were at least 60 years of age. Exclusion criteria included patholog-
ical intertrochanteric fractures, open fractures, multiple fractures,
presence of degenerative osteoarthritis/arthritis in the injured hip
and severe concomitant medical condition (grade V on the Ameri-
can Society of Anesthesiologists [ASA] scale) [14]. All the patients’
records, including gender, age, body mass index (BMI), ASA class
rating and fracture type according to AO/OTA classification, were
complete.
2.2. Surgery and rehabilitation
Surgery was carried out under general anaesthesia. A fracture
table and image intensifier were used in all cases. The PFNA was
inserted without diaphyseal reaming, which was a solid titanium
nail 170, 200 or 240 mm in length and 10 or 11 mm in diameter. The
helical blade which attached to a particular inserter was introduced
over the guide wire with hammer. While the introduction was fin-
ished, the helical blade could be fixed to prevent rotation. The PFNA
could be distally fixed either statically or dynamically. Somewhat
differently, the PFNA-II nail used in the study is a solid titanium nail
that is 170 or 200 mm long and 9, 10, or 11 mm in diameter. The
surgical procedure was the same as the one used for the standard
PFNA [6,10].
Postoperatively, analgesic care and diet were related to local
standards and equal for both groups. Antithrombotic prophylaxis
was administered using low-molecular-weight heparin (Lovenox
40 mg) for 3–5 days, and all patients received prophylactic antibi-
otics (Cefotiam 4.0 g) for 3 days. As the importance of rehabilitation,
patients were encouraged to move the hip, knee and ankle joints on
the first postoperative day and partial weight bearing was allowed
with the aid of crutches on the following day.
Fig. 1. A: anteroposterior hip radiographs of intertrochanteric fracture treated with
PFNA. B: anteroposterior hip radiographs of intertrochanteric fracture treated with
PFNA-II.
2.3. Method of assessment
Follow-up evaluations were performed at 1, 3, 6, 9 and 12
months, and every year thereafter. The operative time, blood loss
during surgery, amount of transfused blood, overall fluoroscopy
time, postoperation drainage, duration of hospitalization, postop-
erative complications, and assessment of nail handling for Asia
proximal femoral nail antirotation were compared with those of
proximal femoral nail antirotation.
Plain anteroposterior and lateral radiographs were obtained at
each visit (Fig. 1). At the last follow-up, the degree of pain was
measured by visual analogue scale (VAS) and the functional out-
come was evaluated on the basis of Harris Hip Score (HHS) [15]. The
radiographs of affected hip were achieved in the AP. The mediolat-
eral planes at every follow-up visit, the extent of fracture and any
changes in the position of the implant were noted.
The quality of the fracture reduction was graded as poor
(>10◦ varus/valgus), acceptable (5◦ –10◦ varus/valgus), or good (<5◦
varus/valgus). The position of the implant was graded as optimal if
the blade was placed into the centre of the neck on a lateral view
and lower half on a AP view [6]. Which was graded as suboptimal
if the blade was not placed into the centre of the neck on a lateral
view or lower half on a AP view.
2.4. Statistical analysis
Statistical analysis was performed using SPSS statistical
package, version 16.0 (SPSS Inc., Chicago, IL, USA) for Windows.
Quantitative variables were analysed using the Student’s t-test and
categorical variables were analysed by the 2 test or Fisher’s exact
test where appropriate. The level of statistical significance was set
at a two-sided P-value of 0.05.
3. Results
Between June 2008 and December 2011, 188 elderly Chinese
patients with unstable intertrochanteric fractures were treated
 J. Li et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 143–146 145

Table 1 Table 3
Patient demographics. Postoperative complications.

PFNA-II PFNA P PFNA-II PFNA P-value

Man: woman 52:66 32:38 0.88 Systemic complications 28 19 0.728

Age (y) 67.42 ± 16.40 66.31 ± 16.44 0.655 Pneumonia 3 3 0.819
(60–98) (60–88) Cardiovascular disorder 4 2 1
BMI 22.49 ± 3.88 22.94 ± 3.56 0.425 Urinary tract infection 5 3 1
(13.89–34.65) (16.69–34.19) Hypoproteinemia 10 6 1
Side (left/right) 58:60 34:36 0.939 Deep vein thrombosis 1 1 1
Injury mechanism 0.779 Pressure sore 5 4 0.916
Fall at home 82 50 Local complications 29 32 0.004
Traffic accident 36 20 Superficial infection 2 1 1
AO type of fracture 0.446 Deep infection 1 1 1
31A2 98 55 Fat liquefaction 8 5 1
31A3 20 15 Haematoma 10 5 0.745
ASA classification 0.456 Cutout 0 2 0.267
ASA 1 15 14 Thigh pain 8 18 0
ASA 2 48 26
PFNA-II: Asia proximal femoral nail antirotation; PFNA: proximal femoral nail
ASA 3 45 22
antirotation.
ASA 4 10 8
Follow-up (months) 29.08 ± 9.07 29.49 ± 9.29 0.772
(12–36) (12–36) Table 4
PFNA-II: Asia proximal femoral nail antirotation; PFNA: proximal femoral nail Outcome of follow-up according to Harris and visual analogue scale.
antirotation; BMI: body mass index; ASA: American Society of Anesthesiologists.
PFNA-II PFNA P-value

HHS 86.19 ± 6.53 (58–93) 85.27 ± 5.47 (66–93) 0.326

with PFNA (n = 70) or PFNA-II (n = 118). No significant differences
were found between the two groups in gender, age, BMI, side of
fracture, type of fracture, ASA score and follow-up time (Table 1).
The mean surgical time in the PFNA-II group was 66 min and was
significantly shorter than that in the PFNA group, in which the mean
time was 79 min (P < 0.05) (Table 2). Blood loss was significantly less
than in the PFNA-II group than that in the PFNA group (P < 0.05).
There was no significant difference in amount of transfused blood,
overall fluoroscopy time, postoperation drainage and duration of
hospitalization between the two groups (P > 0.05) (Table 2).
Fracture reduction was considered good or acceptable in 181
patients (113 in the PFNA-II group, 68 in the PFNA group) on post-
operative radiographs. The position of the implant was optimal in
155 patients (102 in the PFNA-II group, 53 in the PFNA group). The
mean tip apex distance was 19.25 mm in the PFNA-II group and
19.04 mm in the PFNA group. There was no significant difference
between the two groups in fracture reduction, the position of the
implant and tip apex distance (P > 0.05) (Table 2).
In our study, six main postoperative systemic complications
occurred, including pneumonia, cardiovascular disorder, urinary
tract infection, hypoproteinemia, deep vein thrombosis and pres-
sure sore. No significant difference was found between the two
groups in systemic complications. Two cutouts occurred in the
PFNA group, but none occurred in the PFNA-II group. Several
patients reported thigh pain during the follow-up period: 8 patients
in the PFNA-II group and 18 in the PFNA group (P < 0.05). In the
VAS 0.87 ± 0.85 (0–3) 0.97 ± 0.87 (0–3) 0.448
Mortality (%) 7 6 0.557
PFNA-II: Asia proximal femoral nail antirotation; PFNA: proximal femoral nail
antirotation; HHS: Harris Hip Score; VAS: visual analogue scale.
PFNA-II group, fewer local complications were observed (P < 0.05)
(Table 3).
The mean HHS was 86.19 in the PFNA-II group and 85.27 in the
PFNA group, and the mean VAS was 0.87 in the former and 0.97
in the latter group. The mortality rate at one year was 7% in the
PFNA-II group, compared with 6% in the PFNA group. No significant
difference was found between the two groups in HHS, VAS and the
one-year mortality rate (P > 0.05) (Table 4).
4. Discussion
In the present study, we compared PFNA and PFNA-II for the
treatment of unstable intertrochanteric fractures in elderly Chi-
nese patients. Our results suggested that the rate of complications
using PFNA-II was lower than PFNA for the treatment of unsta-
ble intertrochanteric fractures in elderly Chinese patients, and the
operation time was shorter.
A weakness of this study is that the operations were performed
by different surgeons, however, a single observer collected data
and the surgical procedure was the same. The study design was a

Table 2
Operative records of patients.

PFNA-II PFNA P-value

Operation time (min) 66.25 ± 13.15 (43–128) 79.50 ± 21.12 (49–142) 0

Blood loss (mL) 131.86 ± 69.16 (30–300) 162.14 ± 66.18 (100–350) 0.004
Blood transfusion (U) 2.37 ± 0.88 (1–4) 2.75 ± 0.87 (1–4) 0.221
Fluoroscopy time (s) 87.36 ± 21.80 (25–200) 87.64 ± 13.41 (60–121) 0.921
Postoperation drainage (mL) 68.56 ± 26.34 (20–200) 71.34 ± 21.61 (30–150) 0.456
Hospitalization duration (d) 10.81 ± 3.28 (6–16) 10.30 ± 2.56 (6–15) 0.234
Fracture reduction 0.775
Good 93 58
Acceptable 20 10
Poor 5 2
The position of implant 0.075
Optimal 102 53
Suboptimal 16 17
Tip apex distance (mm) 19.25 ± 4.71 (9–36) 19.04 ± 4.70 (10–31) 0.766

PFNA-II: Asia proximal femoral nail antirotation; PFNA: proximal femoral nail antirotation.
146 J. Li et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 143–146
retrospective design; the two groups were comparable according
to major variables (gender, age, BMI, side of fracture, type of
fracture, ASA score and follow-up time). However, a randomized,
prospective study is needed in the future to further confirm the
current findings.
Intertrochanteric fractures is one among the most common
injuries in the elderly population, and patients’ quality of life is
affected significantly [16–19]. The goal of treating these osteo-
porotic fractures is the same as for other hip fractures: to decrease
pain and to restore the patient’s walking ability to the pre-injury
level [20,21]. The treatment of unstable intertrochanteric fractures
remains challenging to orthopedic surgeons, because of old age
and poor bone quality [22–24]. Moreover, the ideal treatment for
unstable intertrochanteric fractures in elderly patients remains
controversial [25–27]. The proximal femoral nailing (PFN) has been
widely used in the unstable intertrochanteric fractures [28]. The
AO/ASIF group further modified PFN to the PFNA to ameliorate the
angular and rotational stability with one single element. It is an
intramedullary device with a helical blade rather than a screw for
better purchase in the femoral head and was tested in a clinical
study [10]. Because of the height in Asian population on average is
less than that of Americans or Europeans, the femoral neck diam-
eter and proximal femoral length are relatively shorter [29]. The
standard proximal femoral nail antirotation nail has a mediolateral
angle of 6◦ and a proximal diameter of 17 mm. To insert the nail, a
much larger femoral canal needs to be prepared to accommodate
the nail of the given diameter [30]. This means that a mass of corti-
cal bone has to be reamed, thus weakening the osteoporotic bone in
most patients. The study shows that the necessary over reaming of
the shaft weakens the entire shaft, and that reaming of the medulla
can result in increased blood loss [31,32]. Moreover, this geomet-
ric mismatch between the proximal end of the nail and proximal
femur is the most probable cause of the intraoperative complica-
tions of jamming and fracturing of the lateral cortex. The PFNA-II
was designed to avoid these problems, which was designed to have
a mediolateral angle of 5◦ and a proximal diameter of 16.5 mm. The
modified nail has a considerably better anatomic fit. This effectively
decreases the hoop stress inside the femoral shaft and may have
led to a significant decrease in intraoperative and postoperative
diaphyseal fractures [33].
Unstable intertrochanteric fractures were treated successfully
with the PFNA or PFNA-II in elderly Chinese patients. However,
PFNA-II is superior to PFNA in terms of surgical time, intraopera-
tive blood loss, and postoperative complications in elderly Chinese
patients. Further study is needed to confirm these early results.
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
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