Lateral versus supine positioning for proximal femoral nailing of unstable intertrochanteric fractures in geriatric patients: A prospective randomized comparative study

Background: Patient positioning for proximal femoral nailing (PFN) in unstable intertrochanteric fractures remains controversial and may influence operative efficiency, radiation exposure, and reduction quality. This study compared lateral decubitus PFN without traction versus the conventional supine traction-table technique in geriatric patients. Methods: This prospective randomized comparative study enrolled patients aged >60 years with AO/OTA A2 unstable intertrochanteric fractures who were randomized to supine traction-table PFN (Group A) or lateral decubitus PFN on a radiolucent table (Group B). Primary outcomes were setup time, fluoroscopy (radiation) exposure, and operative time. Secondary outcomes included blood loss, need for open reduction, neck–shaft angle (NSA), tip–apex distance (TAD), and modified Baumgartner reduction quality. Results: Setup time was markedly shorter with lateral positioning (13.73 ± 2.26 vs 43.73 ± 6.19 min; P < 0.001), and radiation exposure was lower (60.53 ± 15.98 vs 68.48 ± 14.65 s; P = 0.023). Blood loss was higher in the lateral group (328.75 ± 84.65 vs 288.75 ± 48.68 mL; P = 0.011), and open reduction was more frequent (57.5% vs 17.5%; P < 0.001). Operative time was comparable (78.53 ± 15.13 vs 74.48 ± 8.56 min; P = 0.145). NSA (135.88 ± 5.94 vs 136.12 ± 6.27°; P = 0.864), TAD (23.58 ± 2.14 vs 23.15 ± 1.73 mm; P = 0.331), and reduction quality (good: 90% in both; P = 1.000) did not differ. Conclusions: Lateral decubitus PFN without traction improved setup efficiency and reduced radiation exposure while maintaining comparable radiographic outcomes, at the expense of more frequent open reduction and modestly higher blood loss.