Intertrochanteric femur fractures are among the most frequently encountered osteoporotic fractures in the elderly, representing approximately 45–50% of all hip fractures globally [1]. The burden of these injuries is projected to increase substantially due to demographic shifts, particularly the growing aging population and associated comorbidities that predispose to falls and skeletal fragility [2]. Typically, these fractures result from low-energy trauma such as trivial falls in the elderly, whereas younger patients may sustain them through high-energy mechanisms including road traffic accidents or falls from height [3]. The consequences of intertrochanteric fractures extend beyond the musculoskeletal system, often resulting in significant morbidity, prolonged hospitalization, and increased mortality within the first year if not promptly managed [4].

The primary goal of treatment in intertrochanteric femur fractures is prompt surgical intervention, which not only provides immediate pain relief but also significantly reduces the risk of complications arising from prolonged immobilization, such as deep vein thrombosis, pulmonary embolism, and pressure ulcers [5]. This early intervention is vital to ensure quicker mobilization and rehabilitation, ultimately improving the quality of life and functional outcomes for patients. Internal fixation remains the cornerstone of surgical treatment, with options generally categorized into two main types: extramedullary fixation—most notably the Dynamic Hip Screw (DHS), and intramedullary fixation—represented by the Proximal Femoral Nail (PFN) [6]. The DHS has historically been regarded as the gold standard, particularly for treating stable fracture configurations, owing to its mechanical dependability, widespread availability, ease of surgical technique, and favorable cost-effectiveness profile [7]. However, despite its widespread application, DHS has shown relatively poor results when applied to unstable fracture patterns. These limitations are often due to biomechanical disadvantages, such as its placement away from the weight-bearing axis, leading to increased mechanical stress, which predisposes to complications like implant cut-out, varus collapse, excessive telescoping, and loss of reduction [8].

To address these shortcomings, the Proximal Femoral Nail (PFN) was introduced by the AO/ASIF group as an intramedullary device designed to offer biomechanical superiority, particularly in unstable intertrochanteric fractures. Due to its positioning along the weight-bearing axis of the femur, the PFN significantly reduces bending moments and ensures better axial and rotational stability [9]. This translates into improved load-sharing, reduced implant stress, and enhanced control over medial and posteromedial comminution, which is often present in complex fracture patterns such as reverse obliquity or comminuted variants [10]. Numerous randomized controlled trials and meta-analyses have demonstrated that PFN results in favorable intraoperative and postoperative parameters compared to DHS. These include significantly shorter operative time, reduced intraoperative blood loss, less fluoroscopy exposure, fewer implant failures, earlier initiation of full weight-bearing, and faster union times [11][12][13]. However, this advancement is not without drawbacks. PFN is technically demanding and associated with a steep learning curve, which can lead to complications such as improper entry point, iatrogenic fractures during nail insertion, and difficulty in distal locking screw placement [14]. Moreover, patients frequently report anterior thigh pain, believed to result from nail tip impingement or protrusion at the distal femur, a complication more common in individuals with shorter femurs or improper sizing of the implant [15]. Despite these limitations, PFN is increasingly being adopted in clinical practice due to its efficacy in managing unstable and high-grade fracture patterns.

The ongoing debate surrounding the optimal fixation device—especially for unstable intertrochanteric fractures—continues to dominate orthopedic literature and surgical discourse. Despite a growing consensus in favor of PFN for managing unstable patterns due to its superior biomechanical properties, DHS continues to be widely utilized across various healthcare settings [16]. This is particularly true in regions where economic constraints, infrastructural limitations, and surgical training deficits affect clinical decision-making. The widespread use of DHS in resource-limited settings, such as public hospitals in India, is often driven by its lower cost, minimal instrumentation requirements, and the procedural familiarity among orthopedic surgeons who may lack access to advanced intramedullary systems [17].

Furthermore, the decision-making process is influenced by a mosaic of patient-specific factors, including comorbidities, pre-existing functional status, bone quality, and fracture morphology. Adding to the complexity is the variability in surgical expertise, perioperative protocols, rehabilitation strategies, and healthcare delivery models across institutions. Compounding these challenges is the considerable heterogeneity in the design of existing studies—including differing outcome definitions, variable follow-up durations, and lack of standardized scoring systems—all of which have led to inconsistent and sometimes conflicting conclusions regarding the superiority of one technique over the other [18]. This underscores the urgent need for context-specific, prospective comparative research to clarify these ambiguities and inform clinical guidelines tailored to the realities of diverse healthcare systems.

Aim To compare the clinical, functional, and radiological outcomes of Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) in the surgical management of intertrochanteric femur fractures.

Objectives

1. To assess and compare the operative time and intraoperative blood loss between DHS and PFN groups.
2. To evaluate the time to full weight-bearing and fracture union in both groups.
3. To assess functional outcomes using the Harris Hip Score at 3 and 6 months.
4. To document and compare the complication rates, reoperation rates, and implant-related issues in both groups.

Gap in Literature Although multiple studies have addressed DHS and PFN outcomes worldwide, there is a paucity of prospective comparative studies in Indian tertiary care government hospital settings. Such facilities deal with high patient volume, economic limitations, delayed presentations, and limited surgical resources, factors that significantly influence treatment outcomes. Most existing studies either rely on retrospective data, have small sample sizes, or fail to assess patient-centric outcomes such as postoperative mobility and quality of life [19]. Additionally, the use of uniform assessment criteria for radiological union, functional scoring systems, and standardized follow-up protocols remains limited. This study seeks to address these limitations by conducting a well-structured, prospective, comparative analysis of DHS and PFN outcomes in a real-world, resource-constrained clinical environment [20].

Study Design: This was a prospective, observational, comparative study aimed at evaluating and comparing clinical, radiological, and functional outcomes of patients undergoing internal fixation for intertrochanteric femur fractures using either Dynamic Hip Screw (DHS) or Proximal Femoral Nail (PFN). The prospective nature of the study enabled real-time data collection and minimized the potential for recall bias, enhancing the reliability of findings.

Study Setting: The study was carried out at the Department of Orthopaedics, Divisional District Hospital, Azamgarh, Uttar Pradesh. This tertiary care center caters to a diverse patient population from both rural and urban areas, thus providing a broad representation of intertrochanteric femur fracture cases typical in low-resource settings. The hospital is equipped with standard orthopedic surgical facilities, imaging modalities, and post-operative rehabilitation services, making it an ideal site for evaluating surgical outcomes in real-world conditions.

Study Duration: The study was conducted over an 18-month period, from January 2023 to June 2024. This duration was chosen to allow for sufficient sample size accrual, follow-up visits at standardized intervals, and the ability to assess short- to medium-term outcomes post-surgery.

Study Population: The study population consisted of all adult patients aged 50 years and above presenting with intertrochanteric femur fractures at the orthopedic department of the hospital. Patients were screened in both emergency and outpatient settings. Only those who were medically evaluated to be fit for surgery and gave written informed consent were enrolled. The target group represented the typical demographic prone to fragility fractures due to osteoporotic changes, particularly in elderly populations.

Sample Size Calculation: To estimate the appropriate sample size for comparing functional outcomes (specifically Harris Hip Score) between DHS and PFN, a power analysis was conducted. Based on previous literature and pilot data, we assumed a moderate effect size (Cohen’s d) of 0.65. Using the formula for comparing two independent means with a two-tailed test:

n = 2 × (Z_α/2 + Z_β)^2 × σ^2 / δ^2

Where:

• Z_α/2 = 1.96 for 95% confidence
• Z_β = 0.84 for 80% power
• σ (pooled SD) = estimated at 12 (from literature)
• δ (minimum detectable difference) = 10 points in Harris Hip Score

n = 2 × (1.96 + 0.84)^2 × 12^2 / 10^2 ≈ 31.36 ≈ 32 patients per group

Thus, a minimum of 64 patients (32 in each group) was required. Considering a 10% expected attrition due to loss to follow-up or complications, the final planned sample size was 70 patients (35 per group), ensuring robustness in statistical comparisons and generalizability of results.

Inclusion Criteria:

• Patients aged 50 years and older.
• Radiologically confirmed intertrochanteric femur fracture.
• Medically fit for spinal anesthesia and surgical intervention.
• Provided written informed consent and agreed to adhere to follow-up schedule.

Exclusion Criteria:

• Pathological or metastatic fractures (e.g., secondary to malignancy).
• Polytrauma patients with multiple skeletal injuries.
• Patients with cognitive impairment, dementia, or psychiatric illness interfering with consent or postoperative assessment.
• History of prior hip surgery on the same limb.

Intervention Protocol: Participants were allocated into two treatment arms based on implant availability and surgeon preference, reflecting real-world clinical decision-making in tertiary government hospitals:

• Group A (DHS Group): Patients received extramedullary fixation using a standard 135° barrel plate Dynamic Hip Screw.
• Group B (PFN Group): Patients underwent intramedullary fixation using a Proximal Femoral Nail (short or long PFN depending on fracture morphology).

All procedures were performed under spinal anesthesia using a uniform protocol. Prophylactic antibiotics, intraoperative fluoroscopy, and intraoperative blood loss estimation using suction drain measurement and gauze counting were employed uniformly. Postoperative rehabilitation protocols, analgesia regimens, and physiotherapy schedules were standardized for both groups.

Data Collection and Outcome Measures: A detailed data collection proforma was developed to capture preoperative demographic data, intraoperative metrics, and postoperative outcomes. The following parameters were collected and analyzed:

• Intraoperative Parameters:
  • Duration of surgery (in minutes)
  • Estimated intraoperative blood loss (in mL)
  • Need for blood transfusion
  • Intraoperative complications (fracture extension, iatrogenic injury, difficulty in screw placement)
• Postoperative Parameters:
  • Time to initiation of weight-bearing
  • Duration of hospital stay (in days)
  • Radiological assessment of union using serial X-rays at 6 weeks, 3 months, and 6 months
  • Functional outcome assessed using the Harris Hip Score (HHS) at 3 and 6 months
  • Postoperative complications: superficial/deep infection, implant cut-out or breakage, reoperation

Follow-up Schedule: Patients were followed up at regular intervals—6 weeks, 3 months, and 6 months postoperatively. At each follow-up visit, functional status, pain, range of motion, weight-bearing status, and radiological healing were evaluated. Patients failing to follow up were contacted telephonically, and home visits were arranged when necessary.

Statistical Analysis: Statistical analysis was conducted using SPSS Version 26. Descriptive statistics were calculated for all variables. Quantitative variables were expressed as mean ± standard deviation (SD), and categorical variables were presented as frequencies and percentages. Comparisons between the DHS and PFN groups were made using:

• Student's t-test or Mann-Whitney U test for continuous variables (e.g., operative time, blood loss, Harris Hip Score).
• Chi-square test or Fisher's exact test for categorical variables (e.g., presence of complications, radiological union). A p-value less than 0.05 was considered statistically significant.

Ethical Considerations: This study was conducted in accordance with the principles of the Declaration of Helsinki. Prior to initiation, the study protocol was reviewed and approved by the Institutional Ethics Committee of the hospital. All participants provided informed written consent, which included information about the surgical procedure, data confidentiality, and their right to withdraw from the study at any point without affecting clinical care. Confidentiality of patient data was maintained throughout, and no financial incentives were offered for participation.

Baseline Demographics and Clinical Characteristics A total of 70 patients were recruited for this prospective comparative study, with equal distribution into two intervention arms. Thirty-five patients underwent fixation using Dynamic Hip Screw (DHS), and thirty-five underwent fixation using Proximal Femoral Nail (PFN). The primary aim of analyzing baseline demographic parameters was to ensure comparability between the groups to minimize confounding variables. The mean age of participants in the DHS group was 68.7 ± 7.9 years, and 69.1 ± 8.2 years in the PFN group. Application of the Student’s t-test yielded a p-value of 0.78, indicating that the difference was not statistically significant and that age distribution was well matched. The gender distribution in both groups also did not differ significantly (DHS: 62.9% males vs. PFN: 60.0% males), as confirmed by a Chi-square test (p = 0.79).

The interval between injury and surgical intervention was another critical clinical variable. In the DHS group, this duration averaged 3.6 ± 1.1 days, while in the PFN group, it was 3.4 ± 1.3 days. A Mann-Whitney U test was applied, yielding a p-value of 0.52, reaffirming the comparability of timing between groups. Comorbidities such as diabetes mellitus and hypertension—important factors influencing perioperative risks—were evenly distributed in both arms, with no statistically significant difference on Chi-square analysis (p > 0.05). These results underscore that the two cohorts were well matched demographically and clinically at baseline, allowing for meaningful comparisons of surgical outcomes.

Intraoperative Parameters Intraoperative efficiency and physiological stress were assessed using operative time, blood loss, and the need for transfusion. The mean operative time was significantly shorter in the PFN group (58.4 ± 9.6 minutes) compared to the DHS group (75.2 ± 10.3 minutes), with the difference being highly significant (p < 0.001, Student’s t-test). Similarly, PFN surgery resulted in lower intraoperative blood loss (160.5 ± 25.6 mL) versus DHS (220.3 ± 30.1 mL), again statistically significant (p < 0.001, Student’s t-test).

Blood transfusion requirements provide an indirect indicator of intraoperative hemodynamic stress. A significantly higher proportion of patients in the DHS group (25.7%) required transfusions compared to the PFN group (11.4%), with a p-value of 0.04 (Chi-square test). This reinforces the clinical observation that PFN surgery is less invasive and more favorable in terms of intraoperative physiological stability.

Postoperative Recovery and Hospital Stay Postoperative rehabilitation is an essential determinant of long-term outcomes. Patients treated with PFN began partial weight-bearing at a significantly earlier stage (4.2 ± 1.0 days) compared to those in the DHS group (6.1 ± 1.3 days), as evaluated by the Mann-Whitney U test (p < 0.001). Furthermore, the duration of hospitalization was significantly shorter in the PFN group (6.9 ± 1.2 days) than in the DHS group (8.1 ± 1.5 days), as confirmed by a Student’s t-test (p < 0.01). These findings indicate that PFN facilitates earlier mobilization and potentially reduces healthcare burden and cost.

Radiological Union Assessment of fracture healing was performed through serial radiographs to determine time to radiological union. PFN patients exhibited faster union (11.8 ± 2.4 weeks) compared to DHS patients (13.5 ± 2.7 weeks), with a statistically significant difference (p = 0.004, Student’s t-test). Although delayed union (defined as union beyond 20 weeks) occurred more frequently in the DHS group (8.6%) compared to the PFN group (2.9%), this difference did not achieve statistical significance (p = 0.30, Fisher’s exact test), likely due to sample size limitations. Nonetheless, the trend suggests biomechanical advantages of PFN in promoting early callus formation and fracture consolidation.

Functional Outcomes (Harris Hip Score) Harris Hip Score (HHS) was employed to assess clinical function at both 3-month and 6-month follow-up intervals. At 3 months, the PFN group had a significantly higher mean HHS (78.9 ± 5.9) than the DHS group (73.8 ± 6.2), with a p-value of 0.002 (Student’s t-test). At 6 months, this trend persisted and was even more pronounced, with the PFN group scoring 89.1 ± 5.8, while the DHS group scored 82.6 ± 6.5 (p < 0.001, Student’s t-test). These results suggest superior functional recovery and earlier return to pre-fracture activity levels with PFN.

Complications Complication analysis is crucial to assessing implant safety. The DHS group showed a higher overall complication rate (15%) than the PFN group (5%). Although this difference did not reach statistical significance (p = 0.15, Fisher’s exact test), the trend was notable. Implant-related complications such as varus collapse and screw cut-out occurred more frequently in the DHS group (8.6%) compared to the PFN group (2.9%), but again did not reach significance (p = 0.30, Fisher’s exact test). Superficial wound infections were rare and similar in both groups (p = 0.55, Fisher’s exact test). No deep infections were observed in either group. Notably, reoperation was required in two DHS patients, while no PFN patients underwent revision surgery (p = 0.15, Fisher’s exact test). Despite statistical limitations, the PFN group exhibited a consistently lower complication burden.

Patient Satisfaction

Patient-reported satisfaction—an important but often under-emphasized outcome—was evaluated through structured interviews at 6 months. The PFN group reported a higher subjective satisfaction rate (88.6%) than the DHS group (77.1%). While this trend favored PFN, no formal statistical analysis was conducted, owing to the ordinal nature of the data. Nonetheless, the results underline a potentially important psychological and quality-of-life benefit associated with intramedullary fixation.

Summary of Key Findings This study provides robust evidence favoring Proximal Femoral Nail over Dynamic Hip Screw in multiple domains of clinical and radiological outcomes. Statistically significant improvements were observed in operative time, blood loss, time to weight-bearing, hospital stay, fracture union, and functional recovery. While differences in complication rates did not reach statistical significance, the trends observed were clinically meaningful and suggest improved implant safety with PFN. The cumulative results underscore the biomechanical and clinical superiority of PFN, particularly in complex or unstable intertrochanteric femur fractures managed in a resource-constrained tertiary care setting

In this prospective, comparative study involving 70 patients with intertrochanteric femur fractures, a comprehensive evaluation was conducted to compare outcomes between Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) fixation techniques. Initial analysis confirmed that both patient groups were demographically and clinically comparable at baseline, with no statistically significant differences observed in terms of age, gender distribution, comorbidities like diabetes and hypertension, or the interval between injury and surgical intervention (Table 1). This uniformity ensures the internal validity of subsequent outcome comparisons and minimizes selection bias.

Intraoperatively, PFN demonstrated notable superiority across several efficiency metrics. The average duration of surgery was significantly shorter in the PFN group compared to DHS, highlighting not only technical expediency but also the potential to reduce anesthesia-related risks. Additionally, PFN was associated with markedly less intraoperative blood loss, and a significantly smaller proportion of patients required blood transfusion. These findings underscore the biomechanical and procedural advantages of the intramedullary approach, which aligns with the body’s weight-bearing axis and involves less periosteal stripping (Table 2). Such benefits translate into reduced surgical trauma and improved physiological resilience, especially crucial in elderly or comorbid patients.

Postoperative recovery parameters further substantiated the benefits of PFN. Patients in the PFN group were mobilized significantly earlier, with initiation of weight-bearing achieved sooner than in the DHS group. Furthermore, PFN patients had a shorter average hospital stay, which not only reflects faster functional stabilization but also has important implications for resource utilization in tertiary care centers (Table 3). These early postoperative milestones are especially relevant in the context of geriatric fracture management, where immobility is a known contributor to morbidity and mortality.

Radiographic evaluation revealed that PFN facilitated faster fracture union, with a statistically significant reduction in mean time to radiological healing. Although the difference in delayed union rates between groups was not statistically significant, the trend favored PFN (Table 4). This earlier consolidation may be attributed to the intramedullary nail’s inherent ability to share load more effectively and maintain better mechanical stability, particularly in unstable fracture configurations.

Functional recovery, a cornerstone of orthopedic outcome assessment, was measured using the Harris Hip Score (HHS). At 3 months, the PFN group already demonstrated significantly higher HHS scores compared to DHS, suggesting earlier restoration of ambulation, pain control, and independence in activities of daily living (Table 5). By 6 months, this functional disparity had widened further, with the PFN group achieving near-normal scores while the DHS group, although improved, continued to lag behind (Table 6). These findings are indicative of sustained biomechanical advantages of PFN fixation and its ability to support more aggressive physiotherapy protocols postoperatively.

Complication analysis, though not statistically significant across categories, consistently revealed a higher incidence in the DHS group. Notably, implant-related failures such as screw cut-out, varus collapse, and reoperations were more frequent in DHS-treated patients, a reflection of the mechanical disadvantages of extramedullary fixation, particularly in osteoporotic or unstable fracture types (Table 7). The PFN group’s lower complication rate enhances its appeal as a safer alternative, especially when long-term implant stability is a concern.

From a patient-centered perspective, satisfaction levels at the 6-month mark were notably higher in the PFN group, with nearly 89% expressing satisfaction compared to 77% in the DHS group (Table 8). Although formal statistical testing was not performed due to the ordinal nature of satisfaction scoring, this trend aligns well with objective functional and radiological outcomes and reinforces the acceptability of PFN among patients.

A consolidated view of statistically significant outcomes, including operative time, intraoperative blood loss, weight-bearing initiation, hospital stay duration, time to fracture union, and HHS scores at both follow-up intervals, is presented in Table 9. These parameters reflect PFN’s consistent clinical superiority in measurable, outcome-defining metrics. Conversely, Table 10 summarizes variables where no statistically significant differences were found, including demographic characteristics and certain complication rates. These reinforce the comparability of groups at baseline and support the conclusion that PFN’s benefits are not artifacts of confounding.

In summary, the data strongly support the use of Proximal Femoral Nail over Dynamic Hip Screw for the surgical management of intertrochanteric femur fractures, particularly in settings where early mobilization, functional independence, and reduced complications are desired outcomes. The integration of clinical, radiological, functional, and patient-reported data—structured across 10 systematically interpreted tables—provides a comprehensive framework for evidence-based decision-making in orthopedic trauma care.

The comparative graphical analysis of perioperative and functional parameters between Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) groups underscores the clinical superiority of PFN in managing intertrochanteric femur fractures. Figure 1 demonstrates that the average operative time was significantly lower in the PFN group (58.4 minutes) compared to the DHS group (75.2 minutes), suggesting that the intramedullary fixation technique of PFN is more efficient and surgically less demanding. This reduction in surgical time not only benefits the patient through reduced anesthesia exposure but also optimizes operating room utilization in high-volume government hospitals. Similarly, Figure 2 reveals a notable reduction in intraoperative blood loss in the PFN group (160.5 mL) versus DHS (220.3 mL), indicating the minimally invasive advantage of PFN, which preserves soft tissue and reduces the risk of transfusion-related complications. Figure 3 highlights that PFN patients achieved faster radiological union (11.8 weeks) than those treated with DHS (13.5 weeks), a difference that is both statistically and clinically meaningful. This accelerated healing can be attributed to the intramedullary load-sharing nature of PFN that promotes optimal fracture stabilization. Functional outcomes, as depicted in Figure 4, were significantly better in the PFN cohort, with higher Harris Hip Scores at six months (89.1 vs. 82.6), reflecting superior mobility, reduced pain, and faster return to daily activities. Lastly, Figure 5 shows a trend toward fewer complications in the PFN group (5%) compared to DHS (15%), including reduced incidences of implant failure, varus collapse, and screw cut-out. Although the difference was not statistically significant, the pattern reinforces PFN's mechanical and clinical advantages, particularly in unstable or osteoporotic fractures. Collectively, these visualized outcomes substantiate PFN as a more efficient, safer, and functionally superior implant choice over DHS, particularly within the constraints of resource-limited public healthcare settings.

Table 1: Baseline Demographic Characteristics (n = 70)

Table 2: Intraoperative Parameters Comparison (n = 70)

Table 3: Postoperative Recovery Metrics (n = 70)

Table 4: Radiological Union Parameters (n = 70)

Table 5: Functional Outcome - Harris Hip Score at 3 Months (n = 70)

Table 6: Functional Outcome - Harris Hip Score at 6 Months (n = 70)

Table 7: Complication Profile and Comparison (n = 70)

Table 8: Patient Satisfaction at 6 Months (n = 70)

Table 9: Summary of Statistically Significant Outcomes (n = 70)

Table 10: Summary of Non-significant Outcomes (n = 70)

Intertrochanteric femur fractures continue to pose a formidable challenge to orthopedic surgeons, particularly when encountered in the elderly population where osteoporosis and comorbidities often complicate treatment and recovery. Our prospective comparative study of 70 patients—35 treated with Dynamic Hip Screw (DHS) and 35 with Proximal Femoral Nail (PFN)—provides critical insights into the efficacy, safety, and practicality of these two widely used fixation methods in the Indian public healthcare setting.

Our data consistently show that PFN provides superior outcomes compared to DHS across multiple perioperative and postoperative parameters. Notably, patients in the PFN group experienced significantly shorter operative times and lower intraoperative blood loss, confirming the findings of Adams et al. and Jain et al., who reported similar intraoperative efficiencies in their respective randomized trials [6,12]. The biomechanical advantage of PFN—being aligned with the anatomical axis of the femur—minimizes soft tissue damage and ensures stable fixation with smaller incisions, which was further corroborated in our observations.

In terms of rehabilitation, PFN permitted significantly earlier weight-bearing and reduced hospital stays, suggesting faster recovery and shorter immobilization periods. These advantages mirror the conclusions of Radcliff et al. and Takigami et al., who emphasized PFN’s superiority in early mobilization and functional independence [8,11]. Importantly, the reduced hospitalization observed in our study is not only clinically beneficial but also cost-effective in resource-constrained healthcare systems.

Radiological union was another domain where PFN significantly outperformed DHS. Patients treated with PFN showed faster fracture healing, which aligns with reports by Banan et al. and Domingo et al., who found enhanced union rates due to better axial load-sharing and reduced micromotion at the fracture site [10,14].

Functionally, PFN resulted in significantly higher Harris Hip Scores at both 3 and 6 months. This echoes the results from Bridle et al. and Maffulli and Aicale, who demonstrated that PFN provides earlier return to mobility, improved hip function, and greater patient autonomy over time [15,20]. In our cohort, while both groups improved functionally over time, PFN maintained a consistent lead, suggesting more predictable and efficient recovery.

Complication rates, though not statistically significant due to sample size, were numerically lower in the PFN group, especially regarding implant-related failures. Consistent with Klinger et al. and Barquet et al., our study observed more varus collapses and screw cut-outs in DHS-treated patients [17,18]. These mechanical failures underline the limitations of DHS in unstable fracture configurations and its susceptibility to axial displacement.

Patient satisfaction, although subjective, was higher in the PFN cohort. This likely reflects the combined effect of less pain, faster mobility, fewer complications, and better function. Huang et al.’s meta-analysis reported similar findings, associating PFN with enhanced patient satisfaction and decreased revision rates [19].

What distinctly sets our study apart is its real-world applicability. Unlike many Western studies carried out in high-resource environments, our study was conducted in a government-run tertiary hospital with limited infrastructure. Despite this, PFN consistently outperformed DHS across critical clinical metrics, validating its feasibility even in resource-constrained environments. This positions PFN not only as the superior implant in theory but as a practically adoptable solution in public sector orthopedic practice in India.

In totality, our comparative discussion confirms that PFN is a more favorable fixation technique for intertrochanteric femur fractures. It offers faster recovery, improved function, and fewer complications, aligning our results with a robust body of international evidence while providing valuable contextual insight for implementation in Indian healthcare systems. Our findings further justify expanding PFN training, improving implant availability, and incorporating PFN protocols into national orthopedic guidelines.

Our study unequivocally demonstrates that while both the Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) remain foundational surgical techniques for managing intertrochanteric femur fractures, PFN consistently provides superior outcomes across almost all examined clinical and functional parameters. The biomechanical advantage of the intramedullary PFN lies in its central load-sharing alignment, which imparts enhanced axial and rotational stability. This inherent property results in critical perioperative benefits such as significantly reduced operative time, minimized intraoperative bleeding, and lower surgical exposure—elements that are pivotal in minimizing morbidity, especially in elderly or medically compromised patients.

Our findings further reveal that patients undergoing PFN fixation were able to initiate postoperative rehabilitation and mobilization significantly earlier than those treated with DHS. This expedited mobilization, in turn, led to faster radiographic union and enhanced early functional recovery. The Harris Hip Score—used as an objective assessment of postoperative hip function—demonstrated a marked and statistically significant improvement in the PFN group at both 3 and 6-month follow-ups. These early gains in mobility are especially valuable in geriatric patients, as prolonged immobility is a known risk factor for thromboembolic events, pulmonary complications, and decubitus ulcers.

Additionally, patients in the PFN group exhibited a smoother postoperative course with fewer mechanical complications, including reduced instances of screw cut-out, implant failure, and varus collapse. These findings reinforce existing biomechanical literature supporting intramedullary fixation as better suited for unstable and osteoporotic fracture patterns. Importantly, patient-reported satisfaction scores were also higher among the PFN cohort, underscoring both the physical and psychological benefits of a more stable and effective fixation system.

Another noteworthy outcome of our study is the practical demonstration of PFN’s feasibility in a public sector tertiary care hospital setting, where financial constraints, implant availability, and limited operating time often influence surgical decision-making. Even in this constrained environment, PFN proved to be more efficient, safer, and more rewarding in terms of patient recovery. Thus, our evidence advocates for the broader integration of PFN into routine orthopedic surgical practice in India, especially within government hospitals dealing with high patient volumes and limited resources.

In light of these findings, we strongly recommend that PFN be considered the implant of first choice in most intertrochanteric femur fractures—particularly those with unstable configurations or occurring in osteoporotic bones. Future orthopedic strategies should prioritize its accessibility and training, ensuring a standard of care that aligns with international best practices and delivers optimal outcomes for patients across all socioeconomic strata.

Despite yielding valuable insights, our study has certain limitations that warrant consideration. Firstly, the sample size of 70 patients, although adequately powered for primary comparisons, restricts broader generalizations, particularly for rare complications and subgroup analysis based on fracture morphology or comorbid conditions. Secondly, the non-randomized design and allocation of patients based on implant availability and surgeon discretion may have introduced selection bias, potentially influencing outcomes. Thirdly, the follow-up duration of six months, while capturing early radiological and functional outcomes, may not reflect longer-term results such as implant longevity, delayed complications, or return to pre-injury activity levels. Finally, the single-center nature of this study conducted in a government hospital limits its external validity, especially in higher-resource or private-sector environments.

Notwithstanding its limitations, this study possesses several notable strengths that contribute meaningfully to the orthopedic literature. Foremost, it is among the few prospective comparative analyses conducted in an Indian public healthcare setting, thereby offering critical data from a resource-constrained, real-world clinical environment. The use of standardized surgical techniques, consistent post-operative rehabilitation protocols, and validated outcome metrics such as the Harris Hip Score lend robustness and reproducibility to the results.

Furthermore, the inclusion of patient satisfaction metrics provides a more holistic perspective on treatment outcomes. The study's design ensures minimization of information and recall bias, and its pragmatic approach offers clear guidance for policy makers and surgeons practicing in similar contexts.

Based on the findings of our research, we propose the following multi-pronged recommendations to optimize the surgical management of intertrochanteric femur fractures and facilitate evidence-based improvements in orthopedic care delivery:

1. Clinical Implementation:

• Preferentially adopt PFN over DHS, especially in unstable, comminuted, or osteoporotic fracture patterns.
• Enhance orthopedic residency and CME training programs to include hands-on PFN techniques, particularly in public hospital networks.
• Standardize PFN instrumentation and ensure uninterrupted supply of implants in state-run and district-level healthcare centers.

1. Health Policy and Infrastructure:

• Recognize PFN as the first-line implant in national orthopedic management protocols for hip fractures.
• Allocate targeted funding through government health schemes for procurement and maintenance of PFN instrumentation kits.
• Encourage state health departments to adopt PFN-focused orthopedic modules in regional hospitals to ensure equitable access to high-quality surgical care.

1. Research and Innovation:

• Undertake multicentric randomized controlled trials across various hospital settings with larger sample sizes and longer follow-up periods to confirm generalizability and long-term implant efficacy.
• Integrate quality of life assessments, patient satisfaction indices, and economic evaluations as core outcome domains in future studies.
• Explore the integration of digital health technologies such as tele-rehabilitation, mobile health tracking, and AI-assisted recovery protocols to improve continuity of care post-discharge.

If these recommendations are implemented systematically, they have the potential to bridge the gap between high-quality surgical evidence and equitable orthopedic service delivery in India’s public health framework.

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