Intertrochanteric fractures of the femur are a common and increasingly important cause of morbidity and loss of independence in older adults. These extracapsular hip fractures frequently follow low-energy falls and are associated with substantial reductions in function and health-related quality of life; many patients require prolonged rehabilitation and a significant proportion do not regain pre-fracture independence. Early stable fixation that permits prompt mobilization is therefore a clinical priority in this population. [1]

Two broad fixation strategies are commonly employed for extracapsular (intertrochanteric/trochanteric) fractures: extramedullary sliding-hip-screw constructs (dynamic hip screw, DHS or sliding hip screw, SHS) and intramedullary cephalomedullary devices (proximal femoral nails or other intramedullary nails, IMN/PFN). Historically the DHS was regarded as the standard implant for many intertrochanteric patterns, but intramedullary nails have gained wide acceptance because of their favorable biomechanical profile, smaller incision and perceived advantages for unstable fracture patterns. Nevertheless, the literature reports conflicting results: some randomized and observational studies have suggested faster recovery and fewer mechanical failures with intramedullary devices for certain unstable patterns, while other high-quality trials found no clinically important advantage of IMN over SHS for the majority of patients. [2–4]

Several recent systematic reviews and meta-analyses have attempted to synthesize available evidence. Meta-analytic data indicate that intramedullary constructs (including PFN/PFNA) may be associated with shorter operative time, reduced visible blood loss, earlier return to weight-bearing and higher postoperative hip scores in some series, and a lower incidence of varus collapse or malunion; however, intramedullary nails have also been linked to greater intraoperative fluoroscopy time and concerns about hidden blood loss and device-specific complications in other reports. Network and pairwise meta-analyses therefore reach nuanced conclusions and underline that differences may depend on fracture stability, implant design and patient selection. [3–6] Classic randomized comparisons and prospective series (including earlier trials) also show heterogeneity in outcomes, suggesting that implant choice should be informed by fracture morphology, surgeon experience and resource considerations. [5,7]

Given this ongoing equipoise, additional prospective cohort data that directly compare perioperative metrics, complication profiles and functional recovery in elderly patients are clinically valuable. The present prospective cohort analysis was designed to compare proximal femoral nail (PFN) fixation and dynamic hip screw (DHS) fixation in elderly patients with intertrochanteric femur fractures, focusing on intraoperative parameters, complication rates and functional outcome measured by the Harris Hip Score.

This prospective cohort study was carried out at Subbaiah institute of medical sciences Hospital, Shivamogga karnataka in 2024. The study included elderly patients aged 60 years and above who presented with intertrochanteric fractures of the femur following low-energy trauma, primarily domestic falls. Diagnosis was confirmed by clinical examination and radiographic evaluation with anteroposterior and lateral views of the hip.

Inclusion and Exclusion Criteria

Patients with closed intertrochanteric femur fractures classified according to the AO/OTA system (types 31-A1 and 31-A2) were included. Exclusion criteria comprised open or pathological fractures, polytrauma cases, associated fractures in the ipsilateral limb, previous hip surgeries, fractures extending into the subtrochanteric region, and patients unfit for anesthesia or who declined participation.

Study Population and Grouping

A total of 80 patients fulfilling the eligibility criteria were enrolled after obtaining informed written consent. They were divided into two groups based on the surgical implant used:

• Group A (PFN group): 40 patients underwent internal fixation using a proximal femoral nail.
• Group B (DHS group): 40 patients underwent fixation with a dynamic hip screw.

Surgical Technique

All procedures were performed under spinal anesthesia with patients in the supine position on a fracture table. Standard surgical techniques were employed for both PFN and DHS fixation, performed by senior orthopedic surgeons experienced in both procedures. Intraoperative parameters, including surgical duration, blood loss, and fluoroscopy time, were documented.

Postoperative Care and Follow-up

Patients in both groups received perioperative intravenous antibiotics and thromboprophylaxis as per institutional protocol. Quadriceps strengthening and ankle pump exercises were initiated from the first postoperative day. Partial weight-bearing was allowed after radiographic evidence of callus formation, with progression to full weight-bearing based on clinical and radiological assessment.

Follow-up evaluations were conducted at 6 weeks, 3 months, and 6 months postoperatively. Clinical outcomes were assessed using the Harris Hip Score (HHS), and radiological outcomes were monitored for evidence of union, implant-related complications, and malalignment.

Statistical Analysis

All collected data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Comparisons between the two groups were performed using the Student’s t-test for continuous variables and the chi-square test for categorical data. A p-value <0.05 was considered statistically significant.

A total of 80 patients with intertrochanteric femur fractures were enrolled, with 40 patients in each treatment group. The mean age was 71.4 ± 6.2 years in the PFN group and 70.9 ± 6.5 years in the DHS group, with no significant difference between them (p = 0.72). Gender distribution and fracture laterality were also comparable across groups. According to the AO/OTA classification, type A1 fractures accounted for 45% of cases in the PFN group and 47.5% in the DHS group, while type A2 fractures constituted 55% and 52.5%, respectively (Table 1).

Intraoperative findings demonstrated that the PFN group had a significantly shorter operative time (78.6 ± 10.4 minutes) compared with the DHS group (92.3 ± 11.7 minutes, p < 0.001). Similarly, mean intraoperative blood loss was significantly lower in the PFN group (148.5 ± 32.1 ml) than in the DHS group (212.7 ± 38.5 ml, p < 0.001). However, the fluoroscopy exposure was greater in the PFN group (69.8 ± 9.2 seconds) compared with the DHS group (55.6 ± 8.7 seconds, p < 0.001) (Table 2).

Postoperative complications were less frequent in the PFN group (12.5%) compared to the DHS group (30.0%), and this difference was statistically significant (p = 0.048). Implant cut-out and varus malunion were more commonly observed in the DHS group, while rates of superficial infection and delayed union were comparable between groups (Table 3).

Functional outcomes, assessed by the Harris Hip Score, showed progressive improvement in both groups over time. At 6 weeks, the mean score was 52.3 ± 7.6 in the PFN group and 49.5 ± 8.1 in the DHS group, with no significant difference (p = 0.12). At 3 months, patients treated with PFN demonstrated superior functional recovery (71.8 ± 8.4) compared to those treated with DHS (65.6 ± 9.3, p = 0.004). At 6 months, the PFN group continued to have significantly better outcomes (86.2 ± 6.5 vs. 78.9 ± 7.1, p < 0.001) (Table 4).

Table 1. Baseline demographic and clinical characteristics of study participants

Table 2. Intraoperative parameters

Table 3. Postoperative complications

Table 4. Functional outcome (Harris Hip Score)

In this prospective cohort study, proximal femoral nail (PFN) fixation demonstrated several perioperative and functional advantages over dynamic hip screw (DHS) fixation: shorter operative time, reduced visible intraoperative blood loss, greater intraoperative fluoroscopy exposure, fewer overall complications, and superior Harris Hip Scores at 3 and 6 months.

Shorter operative time and reduced visible blood loss with PFN have been reported repeatedly and are commonly attributed to the smaller incision and less soft-tissue dissection required for intramedullary techniques. Our observation of significantly lower mean operative time and blood loss in the PFN group mirrors pooled findings from comparative-effectiveness reviews that reported reduced operative duration and lower estimated blood loss for intramedullary devices versus sliding-hip-screw constructs [8,9].

Consistent with the literature, PFN in our series required more fluoroscopic imaging than DHS. Intramedullary nailing demands accurate guide-wire placement, reaming and implant positioning within the canal, which generally increases intraoperative fluoroscopy time — a finding that has been quantified in several observational studies and meta-analyses. Surgeons should therefore balance the perioperative benefits of PFN against the trade-off of greater radiation exposure and take measures to minimize fluoroscopy time when possible [10,11].

We observed a lower overall complication rate in the PFN group (12.5% vs. 30.0%), driven principally by fewer instances of varus malunion and implant cut-out. The broader literature reports heterogeneous results for implant-related complications: some large syntheses and registry-based analyses report similar rates of major postoperative complications between intramedullary nails and DHS, whereas other meta-analyses indicate lower mechanical failure and reoperation rates with intramedullary devices for unstable fracture patterns. Differences across studies likely reflect variation in fracture morphology (stable versus unstable), implant subtypes (PFN, PFNA, InterTAN, Gamma nail), surgeon experience, and outcome definitions. Our findings support the view that PFN can reduce mechanical complications in typical elderly intertrochanteric fractures when performed by experienced teams [12].

Functional outcomes in our cohort, measured by Harris Hip Score, diverged in favour of PFN at 3 and 6 months. Several recent clinical series and meta-analyses report a trend toward faster early functional recovery with intramedullary fixation, especially for AO/OTA 31-A2 (unstable) patterns, although long-term scores (≥12 months) are often comparable between implants. Our results suggest clinically meaningful earlier recovery with PFN — an important consideration in elderly patients where earlier mobilization reduces medical complications and accelerates return to baseline activity [13,14].

Strengths of this study include its prospective design, pre-specified follow-up schedule, and use of a validated functional outcome measure. Limitations warrant careful interpretation: this was a single-center cohort rather than a randomized trial, so residual confounding related to surgeon selection or subtle case-mix differences cannot be excluded. Sample size (n=80) was adequate to detect moderate differences in common perioperative measures, but the study may be underpowered for less frequent outcomes such as peri-prosthetic fracture or rare device failures. Finally, our fluoroscopy measurements reflect local practice and may vary with surgeon experience and equipment; cumulative radiation risk was not quantified beyond exposure time.

Taken together with contemporary meta-analyses and large cohort studies, our data support the preferential use of PFN for many elderly patients with intertrochanteric fractures — particularly where earlier recovery and lower intraoperative blood loss are priorities and when surgical expertise in intramedullary fixation is available. Nonetheless, implant selection should remain individualized, considering fracture stability, patient comorbidity, resource considerations (including fluoroscopy capability), and surgeon familiarity with the device. Future research should prioritise adequately powered randomized trials or large registry analyses that stratify outcomes by fracture subtype and include cost-effectiveness, radiation dose quantification, and long-term functional and reoperation endpoints.

In this prospective cohort analysis, proximal femoral nail fixation demonstrated clear advantages over dynamic hip screw fixation in the management of intertrochanteric femur fractures in elderly patients. PFN was associated with shorter operative time, reduced intraoperative blood loss, fewer postoperative complications, and superior functional recovery as measured by the Harris Hip Score. These findings suggest that PFN offers a more effective and reliable fixation method for improving outcomes in this patient population, although careful patient selection and surgical expertise remain essential for optimal results.

1. Mianehsaz E, Aghaei F, Tabatabaee SM, Haghpanah B, Azadchehr MJ, Kalanfarmanfarma K. Functional Outcomes and Quality of Life in Elderly Patients Following Intertrochanteric Femur Fracture: A One-Year Follow-Up Study. Bull Emerg Trauma. 2025;13(1):25-31. doi: 10.30476/beat.2025.104314.1546.
2. Schemitsch EH, Nowak LL, Schulz AP, Brink O, Poolman RW, Mehta S, et al; INSITE Investigators. Intramedullary Nailing vs. Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open. 2023 Jun 1;6(6):e2317164. doi: 10.1001/jamanetworkopen.2023.17164.
3. 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 Feb 10;102(6):e32920. doi: 10.1097/MD.0000000000032920.
4. Kim JH, Kim HS, Yoo JJ. What is the Reason for the Trend Shift from Dynamic Hip Screw to Cephalomedullary Nailing for the Treatment of Intertrochanteric Fractures? A Comprehensive Retrospective Study in a Single Tertiary Referral Hospital. Clin Orthop Surg. 2025 Jun;17(3):381-388. https://doi.org/10.4055/cios24425
5. Yu W, Zhang X, Wu R, Zhu X, Hu J, Xu Y, et al. The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high- risk patients: a retrospective comparative study with a minimum 3 years of follow-up. BMC Musculoskelet Disord. 2016 Jul 11;17:269. doi: 10.1186/s12891-016-1143-3.
6. Zhou Y, Zhang X, Wei Y, Xu Y, Feng M, Wang C. Different surgical interventions for unstable intertrochanteric fracture of the femur: Network meta-analysis. Medicine (Baltimore). 2024 Sep 13;103(37):e39676. doi: 10.1097/MD.0000000000039676.
7. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005 Jan;87(1):76-81.
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 Jun 3;17(1):292. doi: 10.1186/s13018-022-03189-z.
9. Yu F, Tang YW, Wang J, Lin ZC, Liu YB. Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis. BMC Musculoskelet Disord. 2023 Jul 18;24(1):588. doi: 10.1186/s12891-023-06715-0.
10. Vishwanathan K, Akbari K, Patel A. Comparison of fluoroscopy time in short and long cephalomedullary nailing for 31A2 intertrochanteric hip fractures. Acta Orthop Belg. 2021 Jun;87(2):305-311.
11. Ma KL, Wang X, Luan FJ, Xu HT, Fang Y, Min J, et al. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res. 2014 Dec;100(8):859-66. doi: 10.1016/j.otsr.2014.07.023.
12. Wessels JO, Bjarnesen MP, Erichsen JL, Palm H, Gundtoft PH, Viberg B. Sliding hip screw vs. intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis. Injury. 2022 Mar;53(3):1149-1159. doi: 10.1016/j.injury.2021. 12.034.
13. Shukla R, Pathak P, Choyal A. Comparative analysis of functional and radiological outcome of proximal femoral nail versus dynamic hip screw in treatment of intertrochanteric fractures. J Orthop Traumatol Rehabil. 2022;14(1):24-31.
14. Wessels JO, Bjarnesen MP, Erichsen JL, Palm H, Gundtoft PH, Viberg B. Sliding hip screw vs. intramedullary nail for AO/OTA 31A1–A3: a systematic review and meta-analysis. Injury. 2022;53(3):1149–59. doi:10.1016/j.injury.2021.12.034.