Impact of Operative Position on Outcomes of Proximal Femoral Nailing: A Comparison Between Supine on a Traction Table and Lateral Decubitus.

Introduction Unstable intertrochanteric fractures are common in older adults and are best stabilised with cephalomedullary nails. Surgeons favour either a supine position on a traction table or a lateral decubitus position on a standard table, yet evidence comparing their clinical value is limited and often conflicting. The traction table may simplify reduction and imaging but introduces set-up delays and post-related complications; lateral positioning avoids the post but relies on manual traction. This study aims to determine whether patient position meaningfully impacts intraoperative, radiographic, and functional outcomes in proximal femoral nailing using a single implant and uniform perioperative protocol. Materials and methods This is a prospective observational study done at a tertiary trauma centre over 18 months. Sixty adults with AO Foundation/Orthopaedic Trauma Association (AO/OTA) 31-A2/A3 fractures were consecutively enrolled after informed consent and further allocated to either Group A (supine on traction table, n = 30) or Group B (lateral decubitus on standard table, n = 30) based on equipment availability. All underwent closed reduction and proximal femoral nail antirotation-II (PFNA-II) fixation by the same surgical team with identical anaesthesia and rehabilitation protocols. Outcomes measured were set-up time, operative time, ease of fluoroscopy/traction (4-point Likert scale), tip-apex distance (TAD), Cleveland-Bosworth quadrant, collodiaphyseal angle, four-week fracture gap, signs of union till 24 weeks by modified Radiographic Union Score for Hip (RUSH), and Harris Hip Score (HHS). Radiographs were read by two blinded observers. Standard parametric/non-parametric tests were used (α = 0.05). Results All patients completed a 24-week follow-up. Supine positioning required a longer set-up but a shorter operative time. Fluoroscopy and traction were rated "easy" more often in the supine group. Blood loss was similar between groups. Supine cases achieved lower TAD, more frequent central/central or inferior/central blade placement, and more neutral-to-valgus alignment. The early (four-week) fracture gap was smaller, and mobilisation occurred sooner in the supine cohort. Despite a larger early fracture gap, the lateral cohort showed earlier callus formation at 8-12 weeks, and by 16 to 24 weeks, union rates were comparable between the two groups. HHS trajectories were similar at baseline and four weeks, showed a transient lateral advantage at 12 weeks, and converged by 24 weeks. One transient sciatic neurapraxia occurred in the supine group; no deep infection, implant failure, or reoperation was recorded. Conclusion Supine traction-table positioning improves intraoperative control and early rehabilitation, while lateral decubitus achieves similar union and 24-week function without specialised equipment. Position can be selected to match resources and patient needs, provided reduction quality and implant placement are prioritised.