Journal List > J Korean Fract Soc > v.20(1) > 1037606

Lee and Lee: Complications of Femoral Pertrochanteric Fractures Treated with Proximal Femoral Nail (PFN)



We analyzed the complications of femoral pertrochanteric fractures treated with proximal femoral nail (PFN®) to reduce the its complications.

Materials and Methods

We evaluated the complications among 198 patients who were treated with PFN® from June 2001 to August 2005 in our hospital.


The complications were presented in 28 cases (14.1%). Cut-out of lag screw was in 1 case, cut-out of lag screw and antirotation screw were in 3 cases, cut-out of antirotation screw in 3 cases, of these femoral head fracture was in 1 case. Femoral neck fracture in 1 case, Osteonecrosis of femoral head in 1 case, cortical fracture during the insertion of distal interlocking screw in 1 case, breakage of drill bit intraoperatively in 1 case, fibrous union in 2 case, thigh skin irritation due to screw back-out in 3 cases, periprosthetic fractures in 2 cases, varus collapse more than 10 degrees in 4 cases, superficial and deep infections in 3 cases, breakage of nail in 1 case, varus collapse after PFN removal in 1 case, persistent thigh pain in 1 case. Of all these cases, 9 cases (4.5%) were required reoperation with general or spinal anesthesia. Complications related with screws or fracture reduction were 19 cases (9.6%) and, of these, 17 cases (89.5%) showed increased TAD (tip apex distance) or nonanatomical reduction.


To reduce the complications of PFN®, we need to exact surgical technique and anatomical reduction and consider the modification of implant design to prevent of cut-out of screws.

Figures and Tables

Fig. 1

(A) 59 years old male with intertrochanteric fracture, preoperative AP radiogrpah.

(B) Immediate postoperative AP radiograph showed that antirotation screw placed higher than greater trochanter.
(C) Antirotation screw showed Z-effect and penetrated the hip joint in the oblique radiograph.
(D) We removed the antirotation screw.
(E) Femoral head fracture was occurred after fall down.
(F) Bipolar hemiarthroplasty was performed.
Fig. 2

(A) AP radiograph showed relatively extracapsular basicervical fracture.

(B) Immediate postoperative AP and lateral radiograph showed anatomical reduction.
(C) Postoperative 8 months, osteonecrosis of femoral head had developed.
(D) Femoral head had been replaced.
Fig. 3

(A) Periprosthetic fracture was developed but fracture line was not seen definitely in the AP radiogrpah.

(B) In the lateral radiograph, fracture line was observed easily near the inappropriate drilling hole which had been made intraoperatively.
Fig. 4

(A, B) Postoperative radiogrpah showed non-anatomical reduction in the lateral plane.

(C) Reverse Z-effect phenomenon was shown at postoperative 8 months.
Fig. 5

(A) Immediate postoperative AP radiograph showed that antirotation screw placed higher than greater trochanter.

(B) Antirotation screw showed Z-effect phenomenon and penetrated hip joint at the postoperative 6 weeks.
(C) We removed antirotation screw.
(D) Lag screw migrated proximally and penetrated hip joint again.
Fig. 6

(A, B) Postoperative radiogrpah showed non-anatomical reduction in the lateral plane.

(C) Reverse Z-effect phenomenon was shown at postoperative 8 months.
Table 1

Anatomical reduction criteria

Table 2

Analysis of complications according to age and sex.



1. Ahn SJ, Park JH. Proximal femoral nail (PFN) for the treatment of the femoral trochanteric fracture. J Korean Fract Soc. 2004; 17:7–12.
2. Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002; 33:395–399.
3. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998; 348:87–94.
4. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the gamma nail. Clin Orthop Relat Res. 2000; 375:30–42.
5. Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN) - a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand. 2003; 74:53–58.
6. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomized prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991; 73:330–334.
7. Butt MS, Krikler SJ, Nafie S, Ali MS. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury. 1995; 26:615–618.
8. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury. 1994; 25:99–104.
9. Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with a proximal femoral nail. Int Orthop. 2001; 25:298–301.
10. Gadegone WM, Salphale YS. Proximal femoral nail - an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. 2006; Epub ahead of print.
11. Harrington P, Nihal A, Singhania AK, Howell FR. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury. 2002; 33:23–28.
12. Haynes RC, Poll RG, Miles AW, Weston RB. Failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the gamma locking nail and AO dynamic hip screw. Injury. 1997; 28:337–341.
13. Herrera A, Domingo LJ, Calvo A, Martinez A, Cuenca J. A comparative study of trochanteric fractures treated with the gamma nail or the proximal femoral nail. Int Orthop. 2002; 26:365–369.
14. Kim BS, Lew S, Ko SH, Cho SD, Yang JH, Park MS. Treatment of femoral intertrochanteric fracture with proximal femoral nail. J Korean Fract Soc. 2004; 17:1–6.
15. Kukla C, Pichl W, Prokesch R, et al. Femoral neck fracture after removal of the standard gamma interlocking nail: a cadaveric study to determine factors influencing the biomechanical properties of the proximal femur. J Biomech. 2001; 34:1519–1526.
16. Mahomed N, Harrington I, Kellam J, Maistrelli G, Hearn T, Vroemen J. Biomechanical analysis of the gamma nail and sliding hip screw. Clin Orthop Relat Res. 1994; 304:280–288.
17. Moon DH, Choi JS, Kim GB, Kim JW, Kim KT. Treatment of unstable intertrochanteric femoral fracture with the AO/ASIF proximal femoral nail (PFN). J Korean Soc Fract. 2003; 16:136–142.
18. Moon YW, Suh DH, Kang ST, Kwon DJ, Ji YN, Lee KB. The proximal femoral nail for intertrochanteric fracture of the femur. J Korean Soc Fract. 2003; 16:29–36.
19. Osnes EK, Lofthus CM, Falch JA, et al. More postoperative femoral fractures with the gamma nail than sliding screw plate in the treatment of trochanteric fractures. Acta Orthop Scand. 2001; 72:252–256.
20. Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, Lambiris E. A randomized comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures. Arch Orthop Trauma Surg. 2005; 125:462–468.
21. Saudan M, Lubbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma. 2002; 16:386–393.
22. Shin DK, Kwun KW, Kim SK, Lee SW, Choi CH, Kim KM. Proximal femoral nail (PFN) for femur intertrochanteric fracture. J Korean Soc Fract. 2002; 15:328–335.
23. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures. Injury. 1999; 30:327–332.
24. Werner-Tutschku W, Lajtai G, Schmiedhuber G, Lang T, Pirkl C, Orthner E. Intra- and perioperative complications in the stabilization of per- and subtrochanteric femoral fractures by means of PEN. Unfallchirurg. 2002; 105:881–885.
25. Yang KH, Choi YW, Won JH. Femoral neck fracture after removal of the intramedullary nail for the fixation of an intertrochanteric fracture: report of 2 cases. J Korean Orthop Assoc. 2003; 38:768–770.
Similar articles