Intramedullary Femoral Nailing—Blade Versus Screw: A Risk Analysis of Implant-Related Complications in Trochanteric Femoral Fractures

Background/Objectives: Previous studies comparing helical blade and lag screw fixation have often compared different cephalomedullary nail systems, leaving the specific association of the cephalic fixation element with clinical outcomes unclear. This study compared implant-related complications after fixation with the Trochanteric Femoral Nail Advanced (TFNA) using either a helical blade or a lag screw. Methods: A retrospective single-center cohort study included consecutive patients treated with a TFNA for AO/OTA 31-A1 to 31-A3 fractures between January 2023 and December 2025. Mechanical complications, surgical revisions, revision-free survival and radiographic risk factors were evaluated using univariable and adjusted analyses. Results: A total of 277 patients were included (136 helical blade, 141 lag screw). Overall postoperative complications were comparable between groups (23.5% vs. 18.4%, p = 0.306). Surgical revision occurred significantly more frequently following helical blade fixation (22.1% vs. 12.1%, p = 0.037), remaining significant after adjustment (adjusted RR 1.84, 95% CI 1.07–3.15; p = 0.027). However, this association was not statistically significant in time-to-event analyses or in a sensitivity analysis additionally adjusting for continuous calendar time (screw vs. blade: adjusted RR 0.56, 95% CI 0.19–1.72; p = 0.313). Cut-in occurred exclusively after blade fixation (4.4% vs. 0.0%), although this exploratory difference was not statistically significant after correction for multiple comparisons, whereas conversion to total hip arthroplasty (10.3% vs. 5.0%, p = 0.114) and revision-free survival did not differ significantly. Poor Baumgaertner reduction quality was associated with postoperative complications (p = 0.004) and mechanical failure (p = 0.003), while selected measures of residual calcar and fragment displacement were also associated with adverse outcomes. Fracture classification, cortical thickness index, tip–apex distance and postoperative alignment were not associated with surgical revision (all p > 0.05). Conclusions: Within the TFNA system, helical blade fixation was associated with a higher observed risk of surgical revision in the primary analysis; however, this association was not confirmed in time-to-event or calendar-time-adjusted analyses. Reduction quality and residual fracture displacement remained key determinants of adverse outcomes, emphasizing the importance of meticulous fracture reduction.