The study investigated the horizontal positioning (HP) technique for accurate lateral insertion of a spiral blade guide pin in PFNA surgery in elderly patients with osteoporosis and intertrochanteric femoral fractures. It retrospectively included 86 patients, divided into the HP group (n=40) and the traditional lateral view (TLV) group. The HP group had a significantly shorter pin insertion time [1 (1–3) vs. 3 (2–5) min, p < 0.001] and fewer intraoperative lateral fluoroscopy images [1 (1–3) vs. 3 (2–6), p < 0.001]. The success rate of one-time lateral pin placement was higher in the HP group (95.7% vs. 85.0%, p = 0.138), the horizontal angle of anteversion reached 6.4 ± 6.3°. No significant differences were found in the quality of reduction, the position of the spiral blade, or short-term postoperative complications. The HP technique increases surgical efficiency and reduces radiation exposure while maintaining the safety and accuracy of nail placement.