Intertrochanteric femur fractures are common fractures of the proximal femur, especially in elderly people, and are important causes of morbidity, functional disability and loss of independence.[1] The increasing prevalence of osteoporosis, population ageing and fall-related injuries has contributed to the growing global burden of hip fractures.[2] The Global Burden of Disease Study 2021 found that the age-standardised rate of hip fracture among older people rose from 781.56 in 1990 to 948.81 in 2021, showing the large and growing burden of hip fractures on health.[3] The intertrochanteric fracture is difficult to manage as it is often very displaced, comminuted, and occurs in osteoporotic bone.[4] If left untreated, these fractures can cause a long period of immobilisation, complications of staying in bed, and a significant loss of quality of life for patients.[5]

Surgical fixation is the treatment of choice for most intertrochanteric femur fractures and the goals of surgical fixation are to allow for stable fracture fixation, early mobilisation, and for normal fracture healing to take place while restoring pre-injury functional capacity.[6] The two most frequently used fixation methods are the proximal femoral nail (PFN) and the dynamic hip screw (DHS).[7] PFN is an intramedullary fixation device that has a shorter “mechanical lever arm” and load-sharing characteristics, which may yield increased biomechanical stability, especially in unstable fracture configurations.[7] DHS is an extramedullary fixation system that allows for controlled sliding and compression across the fracture site to promote bone healing by axial loading.[8] Both techniques have proven to be clinically successful, but their results might differ depending on fracture stability, bone quality, implant location, and individual patient characteristics.

In recent years, comparative evidence has emerged and identified significant differences between these two fixation methods. In a systematic review and meta-analysis of 12 RCTs on 1,889 patients, Xu et al. (2022) found that PFN showed a statistically significant decrease in the operative time and intraoperative blood loss compared to DHS. However, their study found no significant differences in perioperative non-union, implant failure, or revision surgery.[9] Likewise, Zhang et al. (2023) performed a meta-analysis on 2603 patients with unstable intertrochanteric fracture, and found that PFNA had favourable outcomes when compared to other fixation methods in the outcomes of Harris hip score, fracture healing time, time to full weight bearing, and certain postoperative complications.[10] These results nonetheless suggest that the benefits of intramedullary fixation should be viewed as per fracture type and as per everyone's functional result and not against the background of one implant's superiority.

The functional recovery after intertrochanteric fracture fixation is also an important point to consider, as good radiological union does not necessarily mean good functional recovery of the fractured hip in terms of mobility, independence, or quality of life. In 2024, Wang et al. conducted a network meta-analysis of 15 RCTs and 1,282 patients with unstable intertrochanteric fractures that revealed DHS was associated with reduced Harris Hip Score compared to PFN and hemiarthroplasty.[11] Newer data, however, suggests that functional outcomes disparities may diminish during extended follow-up. In 2025, a systematic review and meta-analysis of intramedullary nails versus DHS showed no significant difference in HHS at 12 months, but there were improved mobility outcomes with intramedullary nails.[12] These results indicate that any long-term recovery differences as a result of early functional advantages do not necessarily translate. When comparing these fixation techniques, therefore, standardised measures of functional outcome, especially the Harris Hip Score (HHS), are essential.

Although implant design and surgery have improved, the most effective method of fixation for intertrochanteric femur fractures remains a significant clinical issue, especially when rehabilitation is the primary goal of treatment. Variability in fracture patterns, patient characteristics, surgical skills, and rehabilitation protocols may affect results, which is why data from individual clinical settings are especially useful. The present study is thus intended to offer a direct comparison between the proximal femoral nail and dynamic hip screw fixation, in addition to fracture union, and to evaluate the effectiveness of each technique in restoring the functional ability of the patient. This study is designed to compare the functional results of both the PFN and DHS groups, and to assess the recovery between these two groups, in order to provide clinically relevant evidence to choose the optimal implant for patients with intertrochanteric femur fractures and increase the orthopaedists' knowledge to provide patient-centred care.

This is a prospective comparative study to compare the functional outcomes of proximal femoral nail (PFN) fixation and dynamic hip screw (DHS) fixation in patients with intertrochanteric femur fractures. The functional recovery after surgery was compared between the two treatment groups using the Harris Hip Score (HHS). This study was done at the Department of Orthopaedic Surgery at the Sheikh Zayed Hospital, Rahim Yar Khan, Pakistan. The study took place for six months, from 1st November 2025 to 30th April 2026.

The sample size was calculated using the sample size calculator for comparing two independent means from OpenEpi. This calculation was based on a prior study done by Prakash et al. (2022) that showed mean Harris Hip Score at 24-week follow-up was 89.26 ± 6.53 in the PFN group and 84.30 ± 7.68 in the DHS group.[13] The sample size was determined with a 95% confidence level, 80% statistical power, and a 1:1 allocation ratio. These parameters estimated that the sample size would be about 33 patients per group. A sample size of 37 patients per group (74 patients total) was used after adjusting for a potential 10% loss to follow-up.

Non-probability consecutive sampling was used to recruit eligible patients. Patients were consecutively recruited until the required sample size was reached, if they met the predetermined inclusion criteria. They were categorised into two groups according to the surgical fixation technique received. Group A included patients who were treated with proximal femoral nail fixation, while Group B included patients who were treated with a cementless total hip arthroplasty (THA).

Patients in the study had fresh closed intertrochanteric fractures and were aged 40 years or older. Patients were both men and women. Patients with unilateral fractures who were medically suitable for surgery and ambulatory prior to the fracture were accepted. Patients with stable or unstable intertrochanteric fracture patterns (as defined by the AO /OTA classification system) were included. Patients with open intertrochanteric fractures, pathological fractures, bilateral hip fractures, or fractures related to major neurovascular injuries were excluded. Those patients with a prior hip surgery and/or previous deformities of the hip joint, significant hip disease, and previous mobility impairment that would affect the functional assessment were also excluded. Those who had multiple major injuries, severe medical conditions that precluded surgical treatment, or who could not complete the follow-up assessment were excluded.

After obtaining approval from the Institutional Ethical Review Committee, eligible patients were enrolled in the study after obtaining written informed consent. A predesigned structured proforma was used for the collection of detailed demographic and clinical data: age, gender, occupation, mechanism of injury, affected side, comorbidities, and duration between injury and surgery. A detailed clinical assessment and appropriate radiographic studies, including anteroposterior and lateral radiographs of the affected hip, were obtained to establish diagnosis and categorize the fracture as per the AO/OTA classification system.[14]

A proximal femoral nail or dynamic hip screw was used to fix the fracture, depending on the clinical assessment and fracture characteristics of the treating surgeon. All surgeries were carried out under a suitable anaesthetic and in a conventional manner. The operative time, the estimated blood loss, and any intraoperative complications were recorded. Analgesia, antibiotics, and mobilisation/ stage weight-bearing were administered according to the treating team's protocol.

Functional outcome was evaluated by a validated 100-point scoring system (Harris Hip Score) that includes assessment of pain, functional activities, deformity, and range of motion.[15] At 6 weeks and 12 weeks after surgery, patients were evaluated, and their functional recovery was compared between these two groups. The final HHS was used as the primary outcome measure. Scores were categorised as excellent (90–100), good (80–89), fair (70–79), and poor (below 70). Follow-up information was also collected on postoperative complications such as infection, implant failure, delayed union, non-union, and limb shortening.

The collected data were entered and analyzed with the use of Statistical Package for the Social Sciences (SPSS) version 26. The quantitative variables such as age, operative duration, estimated blood loss, and Harris Hip Score were presented as mean ± standard deviation. The qualitative variables (gender, fracture classification, affected side, type of fixation, and postoperative complications) were displayed as frequencies and percentages. Shapiro–Wilk test was used to determine the normality of quantitative data. Normally or non-normally distributed continuous variables were compared between the two groups using an independent-samples t-test. The chi-square test and Fisher's exact test were used to compare categorical variables between the groups. The p-value of < 0.05 was taken as statistically significant.

In total, 74 participants were involved, 37 in each treatment arm. The demographics of the two groups were similar. Mean age was 68.4 years ± 10.2 years in the proximal femoral nail group (PFN) and 69.7 years ± 9.8 years in the dynamic hip screw group (DHS). However, there was no statistically significant difference in gender distribution, occupations, or the prevalence of comorbidities such as diabetes mellitus and hypertension between the groups (Table 1).

In terms of severity of injury, low-energy falls constituted the largest category in both groups, with 83.8% in the PFN group and 81.1% in the DHS group. Unstable fracture patterns were seen in 59.5% of the PFN group and 54.1% of the DHS group. There were no significant differences in the distribution of fracture types classified by the AO/OTA, side of fracture, or mean interval between fracture and surgery between the two groups (Table 2).

Comparison of intraoperative and perioperative outcomes demonstrated significantly better results in the PFN group. Patients having PFN fixation had a significantly shorter mean operative time than patients having DHS fixation (64.8 ± 12.1 minutes vs. 78.6 ± 14.3 minutes; p < 0.001). Similarly, mean intraoperative blood loss was significantly lower in the PFN group (112.5 ± 35.6 vs. 168.3 ± 48.2 mL; p < 0.001). The mean postoperative hospital stay was also significantly shorter in the PFN group (5.2 ± 1.6 days vs. 6.1 ± 1.9 days; p = 0.031) (Table 3).

The functional outcomes using the Harris Hip Score (HHS) improved in both groups after surgery. At six weeks, the mean HHS was higher in the PFN group than in the DHS group (64.7 ± 8.9 vs. 60.8 ± 9.4); however, the difference was not statistically significant (p = 0.073). At 12 weeks, the PFN group demonstrated a significantly higher mean HHS compared with the DHS group (78.6 ± 8.1 vs. 73.2 ± 8.7; p = 0.007). Also shown is the distribution of excellent, good, fair, and poor functional outcomes at 12 weeks (Table 4).

At least one postoperative complication was observed in 5 (13.5%) patients in the PFN group compared with 8 (21.6%) patients in the DHS group. The DHS group had a higher incidence of surgical site infection, implant failure, delayed union, non-union, and limb shortening. The overall complication rate between the two groups, however, failed to show significant statistical difference (p = 0.354) (Table 5).

Table 1. Baseline demographic and clinical characteristics

 Table 2. Injury characteristics and fracture profile

Table 3. Intraoperative and perioperative outcomes

 Table 4. Comparison of postoperative Harris Hip Scores

Table 5. Postoperative complications during follow-up

The present study aimed to compare functional outcomes between two proximal femur fixation methods, the proximal femoral nail (PFN) and dynamic hip screw (DHS) in 74 patients with intertrochanteric femur fractures. The results showed that the PFN fixation was significantly linked to a shorter operative time, less blood loss during surgery, shorter hospital stay, and higher Harris Hip Score at 12 weeks. There was no significant difference in the overall rate of complications after surgery, however. The results were compared with the latest comparable studies to test the consistency of the results obtained.

The mean age of patients was similar for the PFN group (68.4 ± 10.2 years) and the DHS group (69.7 ± 9.8 years), and there were no significant differences in the baseline demographic characteristics. The same comparison was reported by Sarfraz et al. (2022) in a randomized controlled trial of 80 patients with intertrochanteric fracture, who were divided into two groups of 40 patients each.[16] Similarly, the 2025 study by Yeo et al. was a randomized controlled trial with 33 patients, and no differences were found in the demographics of patients across treatment groups. The establishment of similar baseline characteristics is important when comparing postoperative outcomes, but it is still possible that there is confounding in a non-randomized study.[17]

In this study, PFN fixation significantly decreased operative time (64.8 ± 12.1 minutes versus 78.6 ± 14.3 minutes) and intraoperative blood loss (112.5 ± 35.6 mL versus 168.3 ± 48.2 mL). The results were similar to those of a meta-analysis of 12 trials and 1,889 patients from the randomized trial group by Xu et al. (2022), who found that the time of operation was shorter and the blood loss was less with PFN than with DHS.[18] Likewise, Khan et al. (2023), in their study on unstable intertrochanteric fracture, found significantly less blood loss and less operative time with PFN.[19] Thusoo et al. (2024), in their comparative study of 200 patients, also reported advantages of PFN, particularly in unstable fracture patterns.[20]

There was also a significant difference in postoperative hospital stay between the PFN and the control groups (5.2±1.6 days versus 6.1±1.9 days, respectively). This was similar to the conclusion of the study by Musa et al. (2025), which conducted a systematic review of the available literature on stable intertrochanteric fractures and concluded that mobilization and hospital discharge were earlier in patients who underwent PFN fixation.[7] In a similar 2025 study by Ali et al. of unstable AO/OTA 31-A2 fractures, blood loss and operating time were also found to be lower with PFN, without any significant differences in hospital stay.[21] These results show a heterogeneity of the benefits of PFN depending on fracture configuration, surgical technique, and institutional practice.

An important outcome in the present study was functional recovery. The PFN group had a higher mean Harris Hip Score at six weeks, but this was not significant. At 12 weeks, the difference became statistically significant, favouring PFN (78.6±8.1 versus 73.2±8.7; p=0.007). A similar tendency towards better functional outcomes with PFN was reported by Khan et al. (2026), who observed significantly higher six-month HHS in the PFNA group than in the DHS group (84.6 ± 7.5 versus 78.3±8.2).[22] In a network meta-analysis of 15 RCTs including 1282 patients with unstable fractures, Zhou et al. (2024) also found that DHS is associated with better HHS than PFN.[11] The present results were supportive of the functional benefit found in this study, but the follow-up periods and fracture stability must be taken into account.

But the evidence on which to base a choice of PFN versus non-PFN is not uniformly favorable in terms of functional results. Sarfraz et al. (2022) reported the scores for functional outcome differed between the groups at earlier follow-up time points, but both techniques gave excellent HHS results at one year.[16] Also, Yeo et al. (2025) in the STRIVE RCT (stable intertrochanteric fractures) reported that the DHS was not inferior in Harris Hip Score or Parker Mobility Score to PFNA II.[17] Similarly, satisfactory functional recovery was reported in both types of fixation in a comparative study of 60 patients by Ansari and Ansari (2024).[23] Functional results should be interpreted taking into account these differences, which emphasize the significance of fracture stability and follow-up period.

Regarding postoperative complications, the present study recorded complications in 13.5% of patients in the PFN group and 21.6% in the DHS group; however, this difference was not statistically significant. The same results were obtained by Xu et al. (2022), who also noted no significant difference between the two methods in terms of non-union, implant failure, or revision surgery.[9] However, the 2025 systematic review and meta-analysis by Jabeen et al., which combined results from 33 comparative studies, concluded that there was no significant difference in terms of implant failure or long-term functional outcome.[24] The present study revealed no significant difference in the overall complications, whereas Khan et al. (2026) showed fewer postoperative infections in PFNA than in DHS.[22] Differences in individual complications in the present study may have been less easily detected because of the relatively small sample size.

However, functional outcomes results should be taken with a pinch of salt. In their systematic review of stable intertrochanteric fractures, Musa et al. (2025) noted that PFN demonstrated improvements in early functional recovery and in the time to weight-bearing, but there was a lack of significant difference in the time until fracture union.[7] In another systematic review and meta-analysis of 33 studies, Rasul et al. (2025) noted that PFN was linked to shorter operating room time and less blood loss, yet there was no significant difference between the two methods in terms of long-term Harris Hip Scores or implant failure rates.[25] The present study support the potential for an early recovery advantage with PFN but do not confirm it is always better than DHS.

The results of the present study showed that overall the patients who received PFN had more favorable peri-operative outcomes and improved functional scores at 12 weeks, although there was no statistically significant difference in the number of postoperative complications. These findings were broadly similar to several recent comparative studies and systematic reviews, but in some randomized trials similar functional outcomes were reported, especially in those cases with stable fracture patterns. The findings were limited in their generalizability due to the relatively small sample size, short follow-up period, and possible impact of fracture characteristics. Additional research would be helpful with larger numbers and longer follow-up to determine what early functional benefit of PFN remains over time.

Limitations

There were some limitations to the study. Firstly, the relatively small sample size and single-center study design may restrict generalizability of the results. Second, the follow-up period was short (12 weeks) to evaluate the long-term functional recovery, fracture healing and late implant-related complications. Thirdly, there may be selection bias and potential confounding due to the non-randomized patient allocation and fracture characteristics and patient factors. In addition, the small number of postoperative complications could have decreased the statistical power to find differences between the two treatment groups. The multicenter studies with longer follow-up and more patients are therefore recommended.

Proximal femoral nail fixation resulted in a shorter surgical time, less blood loss during surgery, a shorter hospital stay, and better functional outcomes at 12 weeks than dynamic hip screw fixation. However, there was no significant difference between the overall postoperative complication rates of the two groups. The two methods were effective intertrochanteric femur fracture treatments. Therefore, the choice of fixation method shall be guided by fracture stability, patient factors, and surgical experience.

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