Intertrochanteric fractures are among the most common proximal femoral fractures in older adults. When these fractures occur in patients with reduced bone quality, achieving stable fixation can be challenging because the cancellous bone provides less support for proximal fixation elements.
Cement-augmented proximal femoral nail antirotation (PFNA) is a fixation strategy in which bone cement is used as an adjunct to improve implant anchorage in selected patients with poor bone quality. Clinical and biomechanical literature has investigated cement augmentation as a way of improving fixation stability and reducing mechanical complications associated with inadequate implant purchase.
For appropriate fracture patterns, a proximal femoral intramedullary nail provides load-sharing fixation close to the mechanical axis of the femur. The addition of cement augmentation may provide additional support around the proximal fixation element when bone quality is insufficient for reliable anchorage with the implant alone.
This article focuses on cement-augmented PFNA, with particular attention to the double-lag-screw proximal femoral nail used for proximal femoral fracture fixation.
Clinical note: Cement augmentation is an adjunct to fracture fixation and should only be performed when the selected implant system, compatible augmentation components, cement, and surgical technique are specifically indicated and supported by the applicable instructions for use. It should not be considered a substitute for anatomical or functional fracture reduction, appropriate implant positioning, or sound surgical technique.
Why Osteoporotic Intertrochanteric Fractures Are Difficult to Fix
1. Reduced Bone Quality Can Affect Implant Anchorage
In older adults, intertrochanteric fractures are frequently associated with reduced bone mineral density and compromised cancellous bone quality.
The proximal femur is particularly important because the proximal fixation element must obtain sufficient purchase in the femoral head and neck region.
Poor bone quality may contribute to:
Reduced screw or blade purchase
Decreased resistance to rotation
Loss of fixation stability
Proximal fixation migration
Varus collapse
Cut-out or other mechanical fixation failure
The stability of an intertrochanteric fracture therefore depends on several factors rather than on the implant alone.
These include:
Fracture pattern
Quality of fracture reduction
Implant selection
Proximal fixation position
Bone quality
Nail geometry
Distal locking
Postoperative loading and rehabilitation
For selected patients with poor bone quality, cement augmentation may provide an additional method of improving the implant-bone interface.
2. What Is Cement-Augmented PFNA?
Cement-augmented PFNA combines proximal femoral intramedullary fixation with controlled bone cement augmentation around the proximal fixation element.
The basic concept is straightforward:
Proximal femoral nail fixation
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Proximal lag-screw fixation
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Controlled cement augmentation when indicated
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Improved implant-bone interface
↓
Additional mechanical support in selected poor-quality bone
Research on cement augmentation of trochanteric fracture fixation has evaluated both polymethylmethacrylate-based and calcium-phosphate-based augmentation approaches. A systematic review identified studies involving proximal femoral nails with cement augmentation and reported generally acceptable functional and radiographic outcomes, while also emphasizing the need for appropriate patient and technique selection.
The purpose of cement augmentation is not to make the fracture heal faster simply because cement is present.
Instead, its principal mechanical rationale is to provide additional support around the proximal fixation element in bone that may not provide sufficient purchase on its own.
3.How Does Cement Augmentation Support PFNA Fixation?
3.1 Improved Proximal Implant Anchorage
In osteoporotic bone, the trabecular structure surrounding the proximal fixation element may be less dense.
When a compatible cement augmentation technique is used appropriately, cement can occupy selected spaces around the fixation element and create an augmented interface between the implant and surrounding bone.
This may improve:
The effect is particularly relevant when the surgeon considers the native bone stock insufficient for optimal fixation.
3.2 Additional Mechanical Support
The mechanical stability of a proximal femoral nail is determined by the interaction between the nail, proximal fixation elements, distal locking, fracture reduction, and bone.
Cement augmentation adds another mechanical component to this system.
However, augmentation should be regarded as an adjunct, rather than a replacement for correct reduction and implant positioning.
3.3 Potential Reduction in Fixation Failure
Cut-out and other forms of proximal fixation failure are recognized mechanical complications after fixation of proximal femoral fractures.
Published literature suggests that cement augmentation may improve fixation stability in selected osteoporotic trochanteric fractures, although clinical outcomes depend on multiple factors and cement augmentation should not be presented as a guarantee against cut-out or other complications.
4. The Role of PFNA in Intertrochanteric Fracture Fixation
A proximal femoral nail is a type of cephalomedullary intramedullary fixation device.
Compared with an extramedullary plate-based construct, the nail is positioned within the femoral medullary canal and provides load-sharing fixation.
Current clinical guidance supports cephalomedullary fixation for unstable intertrochanteric fractures and for subtrochanteric or reverse-obliquity fracture patterns. For stable intertrochanteric fractures, either a sliding hip screw or a cephalomedullary device may be appropriate depending on the fracture and clinical circumstances.
This makes the proximal femoral nail an important fixation option for:
Stable intertrochanteric fractures
Unstable intertrochanteric fractures
Selected subtrochanteric fractures
Proximal femoral fractures associated with poor bone quality
The specific implant length and configuration should be selected according to fracture morphology, anatomy, and surgical requirements.
5. Cement-Augmented PFNA for Elderly Patients With Osteoporotic Intertrochanteric Fractures
Older patients with osteoporotic intertrochanteric fractures present a particular fixation challenge.
The objective is not simply to insert an intramedullary nail. The fixation construct should provide appropriate stability while minimizing the risk of mechanical failure.
For selected patients with compromised bone quality, cement augmentation may be considered when additional proximal fixation support is required.
A typical treatment concept can be represented as:
Osteoporotic intertrochanteric fracture
→ Accurate fracture reduction
→ Proximal femoral nail insertion
→ Double-lag-screw fixation
→ Cement augmentation when indicated and supported
→ Distal locking
→ Postoperative imaging and rehabilitation
The decision to augment should be individualized according to:
Bone quality
Fracture morphology
Proximal fixation quality
Implant position
Patient factors
Cement and implant compatibility
Surgeon experience
Applicable device instructions for use
6. Double-Lag-Screw Proximal Femoral Nail Design
The proximal fixation configuration is particularly important in cement-augmented PFNA.
The double-lag-screw proximal femoral nail uses two proximal fixation elements rather than relying on a single proximal screw.
The design is intended to provide:
Proximal femoral head and neck fixation
Rotational control
Axial support
Load transfer through the proximal femur
A platform for selected augmentation techniques when compatible with the system
The two lag screws should not be described as universally superior to every single-element fixation system. Instead, their value lies in the specific fixation geometry and the way the two proximal elements interact with the femoral head and neck.
The final stability of the construct remains highly dependent on fracture reduction, screw position, bone quality, nail position, and the overall fixation strategy.
7. ATOM Proximal Femoral Nail Type I – Double Lag Screw
The ATOM Proximal Femoral Nail Type I – Double Lag Screw is designed for proximal femoral fracture fixation, including intertrochanteric and subtrochanteric fractures.
The system uses a double-lag-screw proximal configuration and a pre-contoured intramedullary nail. The product page identifies titanium alloy TC4 as the material and lists intertrochanteric fractures, subtrochanteric fractures, proximal femur fractures in osteoporotic bone, and selected pathological fractures among its indicated applications.
For an article focused on cement-augmented PFNA, this double-lag-screw configuration provides the central implant platform around which the discussion of proximal fixation and augmentation can be developed.
8. Cement Augmentation and the Double-Lag-Screw Configuration
When cement augmentation is clinically indicated and the implant system is specifically configured and approved for the technique, the cement is intended to supplement the fixation interface rather than replace the mechanical function of the nail and lag screws.
Nail
provides intramedullary load-sharing support
Double lag screws
provide proximal fixation and rotational control
Bone cement augmentation
may provide additional anchorage in selected poor-quality bone
Augmented proximal femoral fixation construct
This combination can be particularly relevant when the surgeon encounters poor cancellous bone quality around the proximal femur.
However, cement distribution and volume must be carefully controlled. Excessive cement, inappropriate cement placement, leakage, or damage to surrounding structures may create additional risks.
Therefore, cement augmentation should always follow the applicable product-specific surgical technique and instructions for use.
9. Why Implant Positioning Matters Even With Cement Augmentation
One of the most important principles of cement-augmented PFNA is that cement does not correct poor implant positioning.
A well-designed proximal femoral nail still requires:
Appropriate entry point
Satisfactory fracture reduction
Correct nail alignment
Appropriate lag-screw trajectory
Adequate position within the femoral head
Appropriate distal locking
If the proximal fixation element is placed in an unfavorable position, adding cement does not automatically eliminate the mechanical consequences.
Therefore, the best results depend on combining: Good reduction + accurate implant positioning + appropriate fixation + selective augmentation rather than relying on cement augmentation alone.
10. Cement-Augmented PFNA vs Conventional PFNA
| Feature | Conventional PFNA | Cement-Augmented PFNA |
|---|
| Intramedullary nail fixation | Yes | Yes |
| Proximal fixation | Yes | Yes |
| Double-lag-screw configuration | Depending on system | Depending on system |
| Cement augmentation | No | Yes, when indicated |
| Additional implant-bone support | Standard bone purchase | May be enhanced in selected poor-quality bone |
| Use in osteoporotic bone | Possible | May be considered when additional anchorage is required |
| Main objective | Stable fracture fixation | Stable fixation with additional proximal anchorage |
| Patient selection | Based on fracture pattern and anatomy | Requires additional consideration of bone quality and augmentation suitability |
11. Limitations and Safety Considerations
Cement-augmented PFNA is not appropriate for every patient.
Potential considerations include:
Cement leakage
Thermal effects associated with polymerizing cement
Difficulty with revision surgery
Incorrect cement distribution
Excessive cement volume
Damage to surrounding structures
Implant-cement compatibility
Patient-specific contraindications
The choice of cement material is also important. Published studies of cement augmentation in trochanteric fracture fixation have included different cement types, including PMMA and calcium-phosphate formulations.
12. Patient Selection for Cement-Augmented PFNA
Cement augmentation may be considered particularly when several factors are present:
Poor Bone Quality：Reduced bone density may compromise proximal fixation.
Fragility-Type Intertrochanteric Fracture：Older patients with low-energy proximal femoral fractures may have compromised bone stock.
Concern About Proximal Fixation：If the surgeon anticipates insufficient purchase from the native cancellous bone, augmentation may be considered.
Complex Fracture Configuration：Unstable fracture patterns may place greater mechanical demands on the fixation construct.
However, the decision should remain individualized.
Cement augmentation is an adjunct—not a mandatory component of every proximal femoral nail procedure.
13. Clinical Considerations for Older Patients
The treatment of an elderly intertrochanteric fracture should extend beyond the implant.
Older patients may have:
Therefore, fracture fixation should be integrated into a broader perioperative and rehabilitation program.
Clinical guidelines emphasize interdisciplinary management of older hip-fracture patients, including appropriate surgical timing, medical optimization, rehabilitation, and prevention of subsequent complications.
For patients with osteoporosis, long-term bone-health management should also be considered after the acute fracture has been treated.
Conclusion
Cement-augmented PFNA represents an important fixation concept for selected elderly patients with osteoporotic intertrochanteric fractures.
The fundamental principle is to combine the mechanical advantages of proximal femoral intramedullary fixation with additional cement support when native bone quality may not provide sufficient proximal implant anchorage.
A double-lag-screw proximal femoral nail provides a proximal fixation configuration designed to support rotational and axial stability. When cement augmentation is clinically appropriate and supported by the applicable implant system, cement can serve as an adjunct to reinforce the implant-bone interface.
However, cement augmentation should never replace the fundamentals of fracture treatment.
Accurate reduction, appropriate implant selection, correct proximal fixation, controlled augmentation, distal locking, and individualized postoperative management remain essential.
For orthopedic professionals evaluating fixation solutions for intertrochanteric and subtrochanteric fractures, the Proximal Femoral Nail Type I – Double Lag Screw provides a proximal femoral intramedullary fixation option that can be considered within a comprehensive fixation strategy for patients with compromised bone quality.
