Comparative Analysis of Functional Outcome in the Management of Unstable Intertrochanteric Fractures by Proximal Femoral Nailing versus Dynamic Hip Screw

Abstract

Introduction: Unstable intertrochanteric fractures require fixation that provides mechanical stability, facilitates early mobilization, and restores functional independence. Proximal femoral nailing (PFN) offers an intramedullary load-sharing construct, whereas dynamic hip screw (DHS) remains a widely used extramedullary device.

Aim & Objective: To compare functional outcomes of unstable intertrochanteric fractures treated with PFN and DHS using Harris Hip Score (HHS) at one, three, and six months, and to evaluate perioperative and postoperative outcomes between both groups.

Materials & Methods: This prospective comparative interventional study was conducted over two years in the Department of Orthopaedics, Mysore Medical College and Research Institute, Mysuru. Thirty-two patients aged 40–80 years with unstable closed intertrochanteric fractures were divided equally into PFN and DHS groups (16 each). Functional outcome was assessed using HHS at 1, 3, and 6 months. Operative duration, blood loss, tip-apex distance, and complications were also evaluated. Statistical significance was set at p<0.05.

Results: Mean operative duration was significantly shorter with PFN than DHS (85.50±10.99 vs 103.00±14.99 minutes; p=0.001), while mean blood loss was lower with PFN (136.88 vs 253.13 mL). The groups were comparable for age, fracture laterality, and Boyd-Griffin fracture type, with Type 2 fractures predominating overall and no significant difference in fracture classification. HHS improved in both groups, but remained higher with PFN at 1 month (66.94 vs 60.13), 3 months (82.69 vs 73.69), and 6 months (86.88 vs 79.56). Tip-apex distance was comparable, and complication rates were similar in both groups.

Conclusion: Both techniques were effective, but PFN provided superior perioperative efficiency and consistently better functional recovery, supporting its preferential surgical use in unstable intertrochanteric fractures.

REFERENCES

1. Kani KK, Porrino JA, Mulcahy H, Chew FS. Fragility fractures of the proximal femur: review and update for radiologists. Skeletal Radiol. 2019;48(1):29-45. https://doi.org/10.1007/s00256-018-3008-3
2. Maffulli N, Aicale R. Proximal femoral fractures in the elderly: a few things to know, and some to forget. Medicina (Kaunas). 2022;58(10):1-13. https://doi.org/10.3390/medicina58101314
3. Feng JN, Zhang CG, Li BH, Zhan SY, Wang SF, Song CL. Global burden of hip fracture: the Global Burden of Disease Study. Osteoporos Int. 2024;35(1):41-52. https://doi.org/10.1007/s00198-023-06907-3
4. Knobe M, Gradl G, Ladenburger A, Tarkin IS, Pape HC. Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany? Clin Orthop Relat Res. 2013;471(9):2831-2840. https://doi.org/10.1007/s11999-013-2834-9
5. Switzer JA, O'Connor MI. AAOS management of hip fractures in older adults evidence-based clinical practice guideline. J Am Acad Orthop Surg. 2022;30(20):1297-1301. https://doi.org/10.5435/jaaos-d-22-00273
6. Jonnes C, Shishir S, Najimudeen S. Type II intertrochanteric fractures: proximal femoral nailing (PFN) versus dynamic hip screw (DHS). Arch Bone Jt Surg. 2016;4(1):23-28. https://doi.org/10.1186/isrctn43959180
7. Prakash AK, Shanthappa AH, Venkataraman S, Kamath A. A comparative study of functional outcome following dynamic hip screw and proximal femoral nailing for intertrochanteric fractures of the femur. Cureus. 2022;14(4):1-11. https://doi.org/10.7759/cureus.23803
8. Xu H, Liu Y, Sezgin EA, Tarasevičius Š, Christensen R, Raina DB, et al. Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res. 2022;17(1):1-11. https://doi.org/10.1186/s13018-022-03189-z
9. Zhang C, Chen Z, Wang M, Chen W, Ding Z. Comparison of clinical outcomes with proximal femoral nail anti-rotation versus dynamic hip screw for unstable intertrochanteric femoral fractures: a meta-analysis. Medicine (Baltimore). 2023;102(6):1-14. https://doi.org/10.1097/md.0000000000032920
10. Agharkar Y, Chandrakumar V, Sasikumar K, Pugazhendi G. A comparative study between the outcomes of proximal femoral nail versus dynamic hip screw for the treatment of intertrochanteric fractures of the hip. Int J Spec Educ. 2026;41(8s):1307-1317. https://doi.org/10.1922/pjs.16.6s.2026.1008
11. Backman C, Lam A, Papp R, Kolle AT, Engel FD, Li W, et al. Comparing intramedullary nails versus dynamic hip screws in the treatment of intertrochanteric hip fractures on postoperative rehabilitation outcomes: a systematic review and meta-analysis. Geriatr Orthop Surg Rehabil. 2025;16:1-37. https://doi.org/10.1177/21514593251350490
12. Kumar R, Singh R, Singh B. Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture femur. J Clin Orthop Trauma. 2012;3(1):28-36. https://doi.org/10.1016/j.jcot.2011.12.001
13. Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Pertrochanteric fractures: is there an advantage to an intramedullary nail? A randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma. 2002;16(6):386-393. https://doi.org/10.1097/00005131-200207000-00004
14. Huang X, Leung F, Xiang Z, Tan PY, Yang J, Wei DQ, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. ScientificWorldJournal. 2013;2013:1-8. https://doi.org/10.1155/2013/805805
15. Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br. 2006;88(8):1053-1059. https://doi.org/10.1302/0301-620x.88b8.17534
16. Reindl R, Harvey EJ, Berry GK, Rahme E. Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Joint Surg Am. 2015;97(23):1905-1912. https://doi.org/10.2106/jbjs.n.01007
17. Shen L, Zhang Y, Shen Y, Cui Z. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res. 2013;99(4):377-383. https://doi.org/10.1016/j.otsr.2012.12.019
18. Zeng C, Wang Y, Wei J, Gao S, Zhang F, Sun Z, et al. Treatment of trochanteric fractures with proximal femoral nail antirotation or dynamic hip screw systems: a meta-analysis. J Int Med Res. 2012;40(3):839-851. https://doi.org/10.1177/147323001204000302
19. Matre K, Vinje T, Havelin LI, Gjertsen JE, Furnes O, Espehaug B, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am. 2013;95(3):200-208. https://doi.org/10.2106/jbjs.k.01497
20. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058-1064. https://doi.org/10.2106/00004623-199507000-00012
21. Uzun M, Ertürer E, Ozturk I, Akman S, Seckin F, Ozcelik I. Long-term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results. Acta Orthop Traumatol Turc. 2009;43(6):457-463. https://doi.org/10.3944/aott.2009.457
22. Aros B, Tosteson AN, Gottlieb DJ, Koval KJ. Is a sliding hip screw or IM nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res. 2008;466(11):2827-2832. https://doi.org/10.1007/s11999-008-0285-5