Intertrochanteric fractures of the femur represent one of the most common orthopedic injuries encountered in the elderly population and constitute a significant public health burden worldwide. These fractures typically occur as a result of low-energy trauma such as a simple fall in osteoporotic individuals, while high-energy trauma is more commonly responsible in younger patients. With increasing life expectancy and rising prevalence of osteoporosis, the incidence of intertrochanteric fractures is steadily increasing, especially in developing countries. These injuries are associated with high morbidity, prolonged immobilization, loss of independence, and increased mortality, making early surgical intervention and optimal fixation strategies essential for achieving favorable clinical outcomes ^[1,2].

The primary goals of treatment in intertrochanteric fractures include restoration of anatomical alignment, stable fixation, early mobilization, fracture union, and rapid functional recovery. Over the past few decades, surgical management has largely replaced conservative treatment due to the high complication rates associated with prolonged bed rest, such as deep vein thrombosis, pressure sores, pulmonary complications, muscle wasting, and joint stiffness. Among various fixation devices, proximal femoral nailing (PFN) has gained widespread acceptance owing to its biomechanical advantages, including shorter lever arm, better load sharing, reduced bending moment, and superior rotational stability, particularly in unstable fracture patterns ^[3].

Achieving an adequate fracture reduction is a critical determinant of surgical success in proximal femoral nailing. Reduction can be performed either by closed methods using traction and manipulation under fluoroscopic guidance or by open reduction when satisfactory alignment cannot be achieved by closed techniques. Closed reduction preserves fracture hematoma, minimizes soft tissue disruption, reduces operative time, and lowers blood loss and infection risk. However, in cases with severe comminution, displaced fragments, medial calcar disruption, or irreducible fracture patterns, open reduction may be necessary to restore anatomical alignment and achieve stable fixation ^[4].

The choice between open and closed reduction techniques continues to be a subject of debate. While closed reduction is generally preferred due to its minimally invasive nature, some studies suggest that open reduction may provide better fracture alignment and implant positioning in complex fracture patterns, potentially improving union rates and long-term functional outcomes. Conversely, open reduction is associated with increased soft tissue dissection, longer operative time, and higher blood loss, which may negatively impact early postoperative recovery^[5].

Aim

To compare open and closed reduction techniques in proximal femoral nailing for intertrochanteric fractures with respect to functional recovery and fracture union rates.

Objectives

1. To evaluate and compare functional outcomes following open and closed reduction techniques using standardized functional scoring systems.
2. To compare fracture union rates and time to union between open and closed reduction groups.
3. To assess perioperative parameters such as operative time, blood loss, and postoperative complications in both techniques.

Source of Data

Data was collected from patients diagnosed with intertrochanteric fractures who underwent surgical fixation using proximal femoral nailing at the study center. Clinical records, operative notes, radiological images, and follow-up assessment sheets were used as primary sources of data.

Study Design

This study was conducted as a prospective observational comparative study.

Study Location

The study was carried out in the Department of Orthopaedics at a tertiary care teaching hospital.

Study Duration

The study was conducted over a period of 18 months, including patient recruitment, surgical intervention, and follow-up assessment.

Sample Size

A total of 50 patients with intertrochanteric fractures treated with proximal femoral nailing were included in the study. Patients were divided into two groups based on the reduction technique used:

• Group A: Closed Reduction (CRIF)
• Group B: Open Reduction (ORIF)

Inclusion Criteria

• Patients aged ≥ 18 years with radiologically confirmed intertrochanteric fractures.
• Patients treated with proximal femoral nailing.
• Patients willing to participate and provide informed consent.
• Patients available for regular follow-up.

Exclusion Criteria

• Pathological fractures due to tumors or metabolic bone disease.
• Polytrauma patients with associated major injuries.
• Subtrochanteric fractures extending beyond the defined intertrochanteric region.
• Patients with previous ipsilateral hip surgery.
• Patients medically unfit for surgery.

Procedure and Methodology

After admission, all patients were clinically evaluated and stabilized. Preoperative investigations including complete blood count, renal function tests, coagulation profile, electrocardiogram, and radiographs of the pelvis with both hips were performed. Fractures were classified using standard classification systems. Surgical fitness was obtained from anesthesiology and medical teams.

All surgeries were performed under spinal or general anesthesia on a fracture table with fluoroscopic guidance. Closed reduction was attempted initially in all patients using traction and manipulation. If acceptable alignment could not be achieved, open reduction was performed through a minimal lateral incision to directly visualize and reduce fracture fragments. Proximal femoral nail fixation was then carried out following standard surgical protocols.

Postoperatively, patients received intravenous antibiotics and thromboprophylaxis as per hospital protocol. Early mobilization with partial or full weight bearing was initiated depending on fracture stability and surgeon’s assessment. Patients were followed up at regular intervals to assess radiological union and functional recovery.

Sample Processing

Radiological images were analyzed for fracture reduction quality, implant position, and evidence of callus formation. Functional outcome scores were recorded during follow-up visits. All collected data were entered into a structured database for analysis.

Data Collection

Data collection included demographic details, mechanism of injury, fracture type, reduction technique used, operative time, blood loss, postoperative complications, time to fracture union, and functional outcome scores. Follow-up assessments were conducted at 6 weeks, 3 months, 6 months, and 1 year postoperatively.

Statistical Methods

Data were analyzed using statistical software. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Comparison between groups was performed using independent t-test or Mann-Whitney U test for continuous variables and Chi-square test for categorical variables. A p-value of less than 0.05 was considered statistically significant.

Table 1: Baseline Characteristics and Overall Outcome Comparison Between Closed and Open Reduction Groups (N = 50)

Table 1 shows the baseline characteristics and overall outcome comparison between the closed and open reduction groups. The mean age of patients was comparable between the closed reduction group (63.4 ± 8.6 years) and the open reduction group (65.1 ± 7.9 years), with no statistically significant difference (p = 0.442). Male predominance was observed in both groups, accounting for 57.7% in the closed reduction group and 58.3% in the open reduction group, without significant intergroup variation (p = 0.936). The distribution of right-sided fractures was also similar in both groups (53.8% vs 54.2%; p = 0.972). Likewise, the proportion of unstable AO type A2/A3 fractures was comparable between closed (65.4%) and open reduction groups (66.7%) (p = 0.908), indicating well-matched baseline characteristics. Functional outcome assessment at six months demonstrated a significantly higher mean Harris Hip Score in the closed reduction group (84.2 ± 6.9) compared to the open reduction group (79.6 ± 7.4), with a statistically significant difference (p = 0.013). Furthermore, radiological union was achieved in a higher proportion of patients in the closed reduction group (96.2%) than in the open reduction group (87.5%), which was statistically significant (p = 0.041), suggesting superior union outcomes with closed reduction techniques.

Table 2: Comparison of Functional Outcome Scores Between Closed and Open Reduction Groups (N = 50)

Table 2 compares functional outcome parameters between the two groups. At three months postoperatively, patients treated with closed reduction demonstrated a significantly higher mean Harris Hip Score (72.6 ± 7.2) compared to those treated with open reduction (68.1 ± 6.8) (p = 0.022). This difference persisted at six months, with the closed reduction group maintaining better functional scores (84.2 ± 6.9 vs 79.6 ± 7.4; p = 0.013). The proportion of patients achieving excellent to good functional outcomes was also significantly higher in the closed reduction group (76.9%) compared to the open reduction group (58.3%) (p = 0.048). Additionally, the mean time to independent ambulation was significantly shorter in the closed reduction group (5.6 ± 1.4 weeks) than in the open reduction group (6.9 ± 1.7 weeks), indicating faster functional recovery with closed reduction (p = 0.006).

Table 3: Comparison of Fracture Union Rate and Time to Union Between Groups (N = 50)

Table 3 presents the comparison of fracture union outcomes. The mean time to radiological union was significantly shorter in the closed reduction group (13.8 ± 2.1 weeks) compared to the open reduction group (15.6 ± 2.7 weeks) (p = 0.011). A higher proportion of patients in the closed reduction group achieved fracture union within 16 weeks (88.5%) compared to the open reduction group (70.8%), and this difference was statistically significant (p = 0.037). Delayed union was observed less frequently in the closed reduction group (7.7%) than in the open reduction group (20.8%), with this difference reaching statistical significance (p = 0.044). Although non-union rates were lower in the closed reduction group (3.8%) compared to the open reduction group (8.3%), this difference was not statistically significant (p = 0.312).

Table 4: Comparison of Perioperative Parameters and Complications Between Groups (N = 50)

Table 4 highlights the comparison of perioperative parameters and postoperative complications. The mean operative time was significantly shorter in the closed reduction group (58.6 ± 9.3 minutes) compared to the open reduction group (76.4 ± 11.8 minutes) (p < 0.001). Intraoperative blood loss was also significantly lower in the closed reduction group (118.2 ± 28.6 ml) than in the open reduction group (192.5 ± 41.4 ml) (p < 0.001). Similarly, the duration of hospital stay was significantly shorter in patients undergoing closed reduction (6.1 ± 1.3 days) compared to those undergoing open reduction (7.8 ± 1.6 days) (p < 0.001). Postoperative infection rates were lower in the closed reduction group (3.8%) than in the open reduction group (12.5%), with a statistically significant difference (p = 0.041). Implant-related complications were also less frequent in the closed reduction group (7.7%) compared to the open reduction group (16.7%), and this difference was statistically significant (p = 0.048), indicating a more favorable perioperative profile for closed reduction techniques.

Table 1 shows that the baseline demographic and fracture-related characteristics were comparable between the two groups, with no statistically significant differences in age distribution, gender proportion, laterality of fracture, or fracture pattern (AO type A2/A3). Similar baseline comparability has been reported by Siddiki AM et al. (2025)^[5], who emphasized that matched demographic and fracture characteristics are essential for unbiased comparison of reduction techniques. In the present study, the significantly higher mean Harris Hip Score at six months in the closed reduction group (84.2 ± 6.9 vs 79.6 ± 7.4; p = 0.013) aligns with findings by Telgheder ZL et al. (2020)^[3], who reported superior functional outcomes with closed reduction owing to reduced soft tissue trauma and preservation of fracture biology. Furthermore, the higher radiological union rate observed in the closed reduction group (96.2%) compared to the open reduction group (87.5%) is consistent with the observations of Salman LA et al. (2023)^[4], who demonstrated that minimal soft tissue disruption and preservation of fracture hematoma contribute to enhanced bone healing.

With regard to functional recovery, Table 2 highlights significantly better early and late functional outcomes in the closed reduction group. The higher Harris Hip Scores at both three and six months and the greater proportion of excellent to good outcomes reflect faster rehabilitation and improved hip function. Similar trends have been reported by Korytkowski PD et al. (2023)^[1], who observed that patients treated with closed reduction achieved earlier mobilization and better functional scores due to reduced postoperative pain and faster recovery. Additionally, the significantly shorter time to independent ambulation in the closed reduction group in the present study is comparable to the findings of Que W et al. (2025)^[6], who emphasized that minimally invasive techniques facilitate early weight-bearing and reduce hospital dependency.

Analysis of fracture union parameters shown in Table 3 further supports the superiority of closed reduction. The significantly shorter mean time to union and higher proportion of patients achieving union within 16 weeks in the closed reduction group are consistent with reports by Li Q et al. (2025)^[7], who noted faster union rates in closed reduction techniques due to preserved periosteal blood supply. The lower incidence of delayed union in the closed reduction group also mirrors findings by Berk T et al. (2022^)[8], who reported that extensive soft tissue dissection during open reduction can compromise local vascularity and delay bone healing. Although non-union rates were slightly lower in the closed reduction group, the difference was not statistically significant, which is comparable to several previous studies reporting overall low non-union rates with intramedullary fixation techniques.

Perioperative outcomes presented in Table 4 demonstrate clear advantages of closed reduction in terms of surgical efficiency and complication profile. The significantly shorter operative time and reduced intraoperative blood loss in the closed reduction group are in agreement with observations by Panteli M et al. (2022)^[9], who attributed these benefits to avoidance of additional surgical exposure and reduced tissue handling. The shorter hospital stay observed in the closed reduction group further supports the enhanced recovery associated with minimally invasive approaches. Moreover, the lower incidence of postoperative infection and implant-related complications in the closed reduction group is consistent with findings by Güzel İ et al. (2025)^[10], who reported reduced infection risk and implant-related issues when soft tissue dissection is minimized.

The present study demonstrates that closed reduction techniques in proximal femoral nailing provide superior clinical outcomes compared to open reduction for the management of intertrochanteric fractures. Patients treated with closed reduction showed significantly better functional recovery, as evidenced by higher Harris Hip Scores at both early and late follow-up periods, faster achievement of independent ambulation, and a greater proportion of excellent to good functional outcomes. Additionally, fracture union parameters favored closed reduction, with shorter mean time to union, higher rates of early radiological union, and a lower incidence of delayed union.

Perioperative outcomes further highlighted the advantages of closed reduction, including shorter operative time, reduced intraoperative blood loss, shorter hospital stay, and lower postoperative complication rates. These findings suggest that preservation of fracture biology and minimization of soft tissue trauma play a crucial role in enhancing healing and functional restoration.

However, open reduction remains a valuable option in irreducible or complex fracture patterns where acceptable alignment cannot be achieved by closed methods. Overall, the results support the preferential use of closed reduction whenever feasible, while emphasizing the importance of individualized surgical decision-making based on fracture characteristics and patient factors.

LIMITATIONS OF THE STUDY

1. The study had a relatively small sample size, which may limit the generalizability of the findings.
2. The study was conducted at a single tertiary care center, and results may vary across different institutions and surgical settings.
3. Allocation to open or closed reduction groups was not randomized, which may have introduced selection bias.
4. The follow-up duration was limited and may not fully reflect long-term functional outcomes and late complications.
5. Functional outcomes were assessed using a single scoring system, which may not capture all aspects of patient-reported quality of life.
6. Surgeon experience and intraoperative decision-making were not standardized, potentially influencing surgical outcomes.

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