Improving Radiological Quality of Proximal Femoral Nail Antirotation Fixation for Intertrochanteric Femoral Fractures: A Closed-Loop Clinical Audit of Reduction Quality, Tip–Apex Distance, and Helical Blade Position

BackgroundThe technical quality of proximal femoral nail antirotation (PFNA) fixation for intertrochanteric femoral fractures is influenced by fracture reduction and implant positioning.Reduction quality, tip-apex distance (TAD), and helical blade position are important immediate postoperative radiological indicators of fixation quality.This closed-loop clinical audit evaluated these parameters and assessed changes following targeted quality-improvement interventions. AimTo evaluate and improve the immediate postoperative radiological quality of PFNA fixation for intertrochanteric femoral fractures by comparing reduction quality, TAD, and helical blade position between baseline and re-audit cycles. MethodsA retrospective baseline audit included 21 consecutive patients with intertrochanteric femoral fractures treated with PFNA between February 4, 2025, and February 3, 2026.Immediate postoperative anteroposterior (AP) and lateral radiographs were assessed for fracture reduction using predefined radiological criteria, TAD with correction for radiographic magnification, and helical blade position using the Cleveland index.Following review of the baseline findings, targeted quality-improvement interventions were implemented between April and May 2026.These included case-based discussion of reduction techniques, reinforcement of intraoperative TAD assessment, teaching on optimal blade positioning using the Cleveland index, and reinforcement of key PFNA technical principles.Following a post-intervention implementation period, 18 additional PFNA cases were assessed from June 2026 using the same eligibility criteria, radiological definitions, and outcome indicators.Between-cycle comparisons were performed using appropriate exact statistical tests for categorical variables and Welch's independent-samples t-test for mean TAD. ResultsAt baseline, good reduction was achieved in 10/21 (47.6%) cases, TAD <25 mm in 14/21 (66.7%), and ideal blade positioning in 14/21 (66.7%), while poor reduction occurred in 4/21 (19.0%).At re-audit, good reduction increased to 12/18 (66.7%), representing an absolute increase of 19.0 percentage points, while ideal blade positioning increased to 14/18 (77.8%), an increase of 11.1 percentage points.Poor reduction decreased to 0/18 (0%).Achievement of TAD <25 mm increased modestly to 13/18 (72.2%), while mean TAD decreased from 23.6 ± 4.3 mm to 21.7 ± 3.2 mm.None of the principal between-cycle differences reached statistical significance. ConclusionFollowing targeted quality-improvement interventions, favorable changes were observed in fracture reduction and helical blade positioning, including elimination of poor reductions, while achievement of TAD <25 mm remained approximately 72%.Although the between-cycle differences were not statistically significant, the findings indicate encouraging quality-improvement trends and identify TAD optimization as an important target for subsequent audit cycles.Continued radiographic review, intraoperative attention to reduction and implant positioning, and periodic re-audit are recommended.