Maintenance of Postoperative Reduction in Trochanteric Fracture Fixation: A Prospective Comparison of Helical Blades and Screws in a Single Cephalomedullary Nailing System.

Background: Cephalomedullary nailing systems, such as the trochanteric femoral nail advanced (TFNa), are standard of care for trochanteric fractures. The TFNa system allows for the use of either a helical blade or a lag screw for femoral neck fixation, but there is ongoing debate regarding which component provides superior outcomes. The aim of this study was to compare the performance of these two components in maintaining fracture reduction and preventing mechanical complications. Methods: A prospective cohort study enrolled 201 patients aged 50 years or older with type 31A1-31A2 (pertrochanteric) and 31A3 (intertrochanteric) fractures, as classified by the Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA), all treated with the short TFNa. Patients were allocated to helical blade (n = 101) or lag screw (n = 100) cohorts. Radiographic outcomes-changes in the tip-apex distance (TAD), femoral neck shortening, and changes in the neck-shaft angle (NSA)-were assessed at 3 months. Secondary outcomes included mechanical complications, patient-reported outcome measures (PROMs), and number of patients deceased at 1-year follow-up. Results: Radiographic outcomes among pertrochanteric fractures-femoral neck shortening, NSA, and TAD changes-were comparable between cohorts. Owing to limited power, no conclusions could be drawn for intertrochanteric fractures. Mechanical complication rates were similar between groups (blades: 4.0%, screws: 6.0%), with no significant association between femoral neck component and complications. A postoperative TAD greater than 20 mm was significantly associated with increased mechanical complications (odds ratio = 4.4, p = 0.023). PROMs improved similarly in both groups over time, and the number of patients deceased within 1 year after the operation was identical in both cohorts. Conclusions: The findings indicate that helical blades and lag screws offer comparable stability in pertrochanteric fracture fixation within the TFNa system. Femoral neck component choice does not significantly affect mechanical complication rates or clinical outcomes. Rather, optimal implant placement and a postoperative TAD under 20 mm are key to successful outcomes. These results support prioritizing surgical precision over component selection in managing pertrochanteric fractures. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.