Medical

International Journal of Medical and Pharmaceutical Research

Functional Outcome of Intertrochanteric Femur Fractures Treated with Proximal Femoral Nail versus Dynamic Hip Screw

Abstract Background: Intertrochanteric femur fractures are common injuries, especially in the elderly, and are associated with significant morbidity. Surgical fixation using Proximal Femoral Nail (PFN) or Dynamic Hip Screw (DHS) is the standard treatment, but the optimal method remains debated. Objective: To compare the functional and radiological outcomes of intertrochanteric femur fractures treated with PFN versus DHS. Methods: This hospital-based comparative observational study was conducted over a period of one year and included 60 adult patients with intertrochanteric femur fractures. Patients were divided into two groups: PFN (n=30) and DHS (n=30). Functional outcome was assessed using the Harris Hip Score (HHS), along with operative parameters, radiological union, and complications. Results: The PFN group demonstrated significantly better functional outcomes, with 83.3% of patients achieving excellent to good Harris Hip Scores compared to 66.7% in the DHS group. The mean operative time and intraoperative blood loss were significantly lower in the PFN group (p < 0.05). Fracture union occurred earlier in patients treated with PFN (mean 12 ± 2 weeks) compared to DHS (14 ± 3 weeks). PFN also allowed earlier mobilization and weight-bearing. Complications such as implant failure and limb shortening were more frequently observed in the DHS group, whereas PFN-related complications were minimal and manageable. Conclusion: PFN provides superior functional outcomes with earlier mobilization and fewer complications, particularly in unstable fractures, whereas DHS remains effective in stable fracture patterns. Keywords Intertrochanteric fracture Proximal femoral nail Dynamic hip screw Harris Hip Score Functional outcome Hip fracture fixation. INTRODUCTION Intertrochanteric fractures of the femur are among the most common fractures encountered in orthopedic practice, particularly in the elderly population. These fractures occur in the region between the greater and lesser trochanters of the femur and are typically associated with osteoporosis and low-energy trauma such as trivial falls. In contrast, younger individuals usually sustain these fractures following high-energy trauma such as road traffic accidents (1,2). The incidence of intertrochanteric fractures has been steadily increasing due to rising life expectancy and the growing geriatric population. These fractures are associated with significant morbidity, loss of independence, and increased mortality if not managed appropriately. Early surgical intervention is considered the standard of care, as it facilitates early mobilization, reduces complications such as deep vein thrombosis, pulmonary infections, and pressure sores, and improves overall functional outcomes (3). Historically, the Dynamic Hip Screw (DHS) has been regarded as the gold standard for the management of intertrochanteric fractures, particularly stable fracture patterns. DHS is an extramedullary device that allows controlled collapse and impaction at the fracture site, promoting union. However, in unstable fracture patterns, DHS is associated with complications such as excessive collapse, limb shortening, medialization of the shaft, and implant failure (4,5). In recent years, intramedullary devices such as the Proximal Femoral Nail (PFN) have gained popularity due to their biomechanical advantages. PFN acts as a load-sharing device with a shorter lever arm, providing better stability, especially in unstable and comminuted fractures. It also requires a smaller incision, results in less soft tissue dissection, and is associated with reduced intraoperative blood loss and earlier mobilization (6,7). Biomechanically, intramedullary implants are closer to the mechanical axis of the limb, thereby reducing bending stress and improving fixation stability. This is particularly beneficial in osteoporotic bone, where achieving stable fixation is challenging. Additionally, PFN allows for controlled impaction and rotational stability, reducing the risk of implant cut-out and fixation failure (8). Despite these advantages, PFN is technically more demanding and may be associated with complications such as screw cut-out, Z-effect, and intraoperative fractures if not performed correctly. On the other hand, DHS remains a simpler and cost-effective option, particularly in resource-limited settings and in stable fracture configurations (9). Given the advantages and limitations of both techniques, the choice between PFN and DHS remains a topic of ongoing debate. The decision is influenced by multiple factors including fracture pattern, bone quality, patient age, surgeon expertise, and available resources. Therefore, a comparative evaluation of functional and radiological outcomes between these two modalities is essential to guide clinical decision-making. The present study aims to compare the functional outcomes of intertrochanteric femur fractures treated with Proximal Femoral Nail and Dynamic Hip Screw, and to determine the most effective treatment modality based on clinical and radiological parameters. MATERIALS AND METHODS: Study Design This study was conducted as a hospital-based comparative observational study to evaluate and compare the functional outcomes of intertrochanteric femur fractures treated with Proximal Femoral Nail (PFN) and Dynamic Hip Screw (DHS). Study Setting The study was carried out in the Department of Orthopaedics at a tertiary care teaching hospital, where a high volume of trauma cases are routinely managed. Study Duration The study was conducted over a period of one year. Patient recruitment was performed during the first six months, and all patients were followed up for a minimum duration of six months. Sample Size A total of 60 patients with intertrochanteric femur fractures were included and divided into two groups: PFN Group: 30 patients DHS Group: 30 patients Sampling Method Patients were selected using consecutive sampling, including all eligible patients presenting during the study period who met the inclusion criteria. Inclusion Criteria Patients aged ≥18 years Intertrochanteric femur fractures (confirmed radiologically) Closed fractures Patients medically fit for surgery Patients willing to participate and available for follow-up Exclusion Criteria Pathological fractures Polytrauma patients Previous surgery on the affected hip Open fractures Patients with severe comorbid conditions precluding surgery Patients lost to follow-up Preoperative Evaluation All patients underwent: Detailed history taking (mode of injury, comorbidities, pre-injury mobility status) Thorough clinical examination Radiological assessment: X-ray pelvis with both hips (AP view) X-ray affected hip (lateral view) Fractures were classified using the Boyd and Griffin / AO classification system into stable and unstable types. Routine preoperative investigations were performed, and patients were optimized medically prior to surgery. Treatment Protocol Patients were allocated into two groups based on surgeon preference and fracture pattern. Group A: Proximal Femoral Nail (PFN) Surgery performed under spinal/epidural anesthesia Closed reduction under fluoroscopic guidance on fracture table Entry point at tip of greater trochanter Insertion of intramedullary nail Placement of lag screw and anti-rotation screw into femoral head Distal locking performed Postoperative care: Early mobilization from first or second postoperative day Partial weight-bearing as tolerated Full weight-bearing based on radiological union Group B: Dynamic Hip Screw (DHS) Open reduction performed Fixation using dynamic hip screw with side plate Proper positioning of lag screw within femoral head Postoperative care: Delayed weight-bearing compared to PFN Gradual mobilization Physiotherapy initiated early Follow-Up Protocol Patients were followed up at: 6 weeks 3 months 6 months At each follow-up: Clinical evaluation Radiological assessment for fracture union Functional assessment Outcome Measures Primary Outcome Harris Hip Score (HHS) Secondary Outcomes Operative time Intraoperative blood loss Time to radiological union Time to weight-bearing Complications Assessment Criteria Harris Hip Score Interpretation 90–100 → Excellent 80–89 → Good 70–79 → Fair <70 → Poor Complications Assessed Implant failure Screw cut-out Limb shortening Infection Non-union or delayed union Z-effect (in PFN) Statistical Analysis All data were entered into Microsoft Excel and analyzed using SPSS 19.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies and percentages. Comparison between the PFN and DHS groups was performed using the independent sample t-test for continuous variables and the Chi-square test for categorical variables. A p-value of less than 0.05 was considered statistically significant. Ethical Considerations The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all patients prior to their inclusion in the study.