Subtrochanteric femur fractures, defined as fractures occurring within 5 cm distal to the lesser trochanter, represent a complex orthopaedic challenge due to the predominance of cortical bone and high biomechanical stress concentration in this region [1]. These fractures account for approximately 10% to 30% of all peritrochanteric fractures [2]. Their occurrence follows a bimodal distribution, with high-energy trauma being the predominant cause in younger individuals and low-energy falls in elderly osteoporotic patients [3]. Early surgical stabilization is crucial to minimize the risk of complications associated with prolonged immobilization, such as deep vein thrombosis, pulmonary infections, urinary tract infections, and pressure ulcers [4]. However, achieving stable fixation in the subtrochanteric region is technically demanding, owing to the complex anatomy and strong deforming muscle forces. This often results in higher rates of non-union and malunion [5]. Various implants and fixation strategies have been used in the surgical management of subtrochanteric fractures, with the two most commonly used being the Proximal Femoral Nail (PFN) and the Dynamic Condylar Screw (DCS). PFN is an intramedullary device aligned with the mechanical axis of the femur, offering biomechanical advantages such as reduced bending moments, improved load-sharing, and early mobilization [6]. DCS, on the other hand, is an extramedullary implant that provides angular stability and has historically been used for complex subtrochanteric and distal femoral fractures [7]. Both implants have distinct mechanical properties and clinical profiles, with varying outcomes reported in literature. Several studies have shown that intramedullary fixation using PFN results in shorter operative time, lower blood loss, faster mobilization, and fewer complications compared to extramedullary devices [8,9]. However, other investigations have demonstrated comparable functional and radiographic outcomes between PFN and DCS, especially when anatomical reduction is achieved [10–12]. Furthermore, limitations in earlier studies—such as heterogeneous fracture patterns and retrospective designs—warrant further prospective comparative studies focused specifically on subtrochanteric fractures [13–15]. The aim of this study was to evaluate and compare the clinical and radiological outcomes of Proximal Femoral Nail (PFN) and Dynamic Condylar Screw (DCS) fixation in subtrochanteric femur fractures.

This was a prospective observational study conducted in the Department of Orthopaedics at Government Medical College (GMC), Jammu, over a period of 18 months The study included a 6-month enrollment phase and a minimum follow-up period of 12 months. A total of 90 patients with subtrochanteric femur fractures who underwent surgical fixation using either Proximal Femoral Nail (PFN), Dynamic Condylar Screw (DCS), or Dynamic Hip Screw (DHS) were included. Inclusion Criteria • Patients aged ≥18 years of both sexes. • Radiologically confirmed cases of subtrochanteric femur fractures. Exclusion Criteria • Skeletally immature individuals. • Patients with pathological fractures. Methodology Fractures were classified according to Russell-Taylor’s classification, taking into account the integrity of the lesser trochanter and the extension of fracture lines into the greater trochanter or posteriorly into the piriformis fossa. This allowed identification of specific fracture patterns associated with higher complication rates. All patients presenting with subtrochanteric fractures were resuscitated according to Advanced Trauma Life Support (ATLS) guidelines in the emergency department. Radiographs included anteroposterior views of the pelvis with both hips, as well as AP and lateral views of the affected hip, femur, and knee. Skin traction was applied using a Bohler-Braun frame until surgery. Routine preoperative investigations and anaesthesia fitness assessments were obtained. All surgeries were performed on a fracture table in the supine position under image intensifier guidance. Fixation was carried out using standard surgical protocols based on the type of implant (PFN or DCS). In the PFN group, long titanium or stainless steel nails (320–440 mm) with a proximal diameter of 17 mm and distal diameters ranging from 9 to 12 mm were used. In the DCS group, after lag screw placement, an appropriate-length side plate was affixed to the proximal femoral shaft. In a few cases, DHS was used based on surgeon discretion. Postoperatively, all patients began quadriceps strengthening and hip range of motion exercises from the first day. Toe-touch weight-bearing with the aid of crutches or walker was permitted depending on the fracture configuration and stability of fixation. Antiseptic dressings were done on the third postoperative day, and sutures were removed after 14 days. Follow-up radiographs were taken to assess implant position and initial fracture alignment. Patients were followed up clinically and radiologically on postoperative day 2, at 4 weeks, 12 weeks, 6 months, and subsequently up to 1 year. Healing was assessed clinically by evaluating pain and mobility at the fracture site, and radiologically by evidence of bridging callus in at least three cortices or trabeculations across the fracture line. Functional outcomes were evaluated using the Salwati and Wilson Hip Function Scoring System, which includes four domains: pain, walking ability, muscle power and range of motion, and functional status. Each domain was scored out of 10, with a maximum cumulative score of 40 indicating full function. Complications such as infection, implant failure, delayed union, non-union, thigh or knee pain, joint stiffness, and limb length discrepancy were also documented at each follow-up. Implants Used • Proximal Femoral Nail (PFN): Long PFNs made of titanium or steel, with proximal diameter of 17 mm and distal diameter options of 9–12 mm. • Dynamic Condylar Screw (DCS): Angular side plates with lag screws. • Dynamic Hip Screw (DHS): Used in a limited number of cases based on intraoperative judgment. Statistical Analysis Data were analyzed using SPSS version 25.0. Continuous variables such as age, hospital stay, and time to union were expressed as mean ± standard deviation and compared using Independent t-test or ANOVA. Categorical variables like implant type, intraoperative findings, and complications were compared using Chi-square or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.

A total of 81 patients with subtrochanteric femur fractures were included in the study. Two cases of pathological fractures due to metastatic disease were excluded. Of the 81 patients, 44 (54.3%) were treated with Proximal Femoral Nail (PFN), 32 (39.5%) with Dynamic Condylar Screw (DCS), and 5 (6.2%) with Dynamic Hip Screw (DHS). Primary bone grafting was performed in 4 patients, while secondary bone grafting was required in 2 cases due to delayed union. The most common age group was 30–39 years (29.6%), followed by 60–69 years (18.5%), with a mean age of 48.1 ± 19.4 years (range: 18–95 years). Males predominated with 59 cases (72.8%), while females comprised 22 cases (27.2%), yielding a male-to-female ratio of 2.7:1.Road traffic accidents (RTA) were the leading cause of injury (66.7%), followed by fall from height (33.3%). The right side was involved in 44 patients (54.3%) and the left in 37 patients (45.7%). Pelvic injuries (35.8%) were the most frequent associated injuries, followed by injuries to other long bones (13.6%). According to the Russell-Taylor classification, the most common subtype was Type IIA (32.1%), followed by Type IB (30.9%). Among the 81 patients, PFN was used in 44 (54.3%), DCS in 32 (39.5%), and DHS in 5 (6.2%). PFN was most commonly used for Type IB fractures (31.8%), DCS for Type IIA (40.6%), and DHS for Type IB and IIA.Excessive blood loss (250–350 ml) was more commonly observed with DCS (25.0%) and DHS (20.0%) compared to PFN (13.6%). Difficult fracture reduction (≥3 attempts) occurred in 15.9% of PFN, 21.9% of DCS, and 20% of DHS cases. PFN cases had longer operative times (70.5%) compared to DCS (43.8%) and DHS (40%). However, the differences in blood loss, reduction difficulty, and operative time among the groups were not statistically significant (p > 0.05)(Table 1). Postoperative complications were generally fewer in the PFN group. Infection rates were highest with DCS (12.5%) compared to PFN (4.5%) and none with DHS. Shortening >2 cm was observed in 9.4% of DCS cases and 40% of DHS cases, but not in any PFN case (p = 0.009, PFN vs DHS). Implant failure occurred in 4.5% (PFN), 9.4% (DCS), and 20% (DHS) cases (Table 2). Delayed union (>6 months) was noted in 4.5% of PFN, 9.4% of DCS, and 20% of DHS patients. Nonunion was observed in 1 PFN and 2 DCS patients. The mean duration of hospital stay was significantly shorter for PFN patients (11.3 ± 2.35 days) compared to DCS (15.6 ± 2.18 days, p < 0.001) and DHS (15.4 ± 1.95 days, p = 0.002 for DHS vs PFN). There was no significant difference between DCS and DHS groups (p = 0.849).Radiological and clinical union was achieved earlier in the PFN group (mean: 13.4 ± 2.79 weeks) compared to DCS (15.7 ± 1.79 weeks, p < 0.001) and DHS (15.3 ± 1.41 weeks, p = 0.043 for DHS vs PFN). No significant difference was observed between DCS and DHS (p = 0.481).According to the Salwati and Wilson Hip Function Scoring System, 77.3% of PFN patients had excellent scores, compared to 62.5% in the DCS group and 60% in the DHS group. Poor and fair outcomes were more common in DCS (9.4% poor, 15.6% fair) and DHS (20% poor, none fair) than in PFN (4.5% poor, 6.8% fair). Table 1: Intraoperative Findings Among PFN, DCS, and DHS Groups Intraoperative Parameter PFN (n = 44) DCS (n = 32) DHS (n = 5) p-value (PFN vs DCS / PFN vs DHS / DCS vs DHS) Excessive blood loss (250–350 ml) 6 (13.6%) 8 (25.0%) 1 (20.0%) 0.207 / 0.554 / 1.000 Difficult reduction (≥3 attempts) 7 (15.9%) 7 (21.9%) 1 (20.0%) 0.508 / 0.815 / 0.924 Short operative time (<1 hour) 13 (29.5%) 18 (56.3%) 3 (60.0%) 0.201 / 0.631 / 0.875 Long operative time (1–2 hours) 31 (70.5%) 14 (43.8%) 2 (40.0%) 0.203 / 0.629 / 0.877 Table 2: Postoperative Complications in PFN, DCS, and DHS Groups Complication PFN (n = 44) DCS (n = 32) DHS (n = 5) p-value (PFN vs DCS / PFN vs DHS / DCS vs DHS) Infection (superficial/deep) 2 (4.5%) 4 (12.5%) 0 (0.0%) 0.232 / 1.000 / 0.949 Shortening ≥ 2 cm 0 (0.0%) 3 (9.4%) 2 (40.0%) 0.071 / 0.009* / 0.126 Implant failure 2 (4.5%) 3 (9.4%) 1 (20.0%) 0.644 / 0.281 / 0.456 Varus deformity 1 (2.3%) 2 (6.3%) 0 (0.0%) 0.569 / 1.000 / 1.000 Delayed union (>6 months) 2 (4.5%) 3 (9.4%) 1 (20.0%) 0.644 / 0.281 / 0.456 Nonunion (>9 months) 1 (2.3%) 2 (6.3%) 0 (0.0%) 0.569 / 1.000 / 1.000 *Statistically significant (p < 0.05)

In our study, 81 cases of subtrochanteric fractures were initially managed, out of which 72 patients met the final inclusion criteria. Among these, 44 patients were treated with Proximal Femoral Nail (PFN), 32 with Dynamic Condylar Screw (DCS), and 5 with Dynamic Hip Screw (DHS). Our findings were consistent with existing literature indicating the superiority of PFN over DCS and DHS in managing subtrochanteric fractures, particularly in terms of early union, fewer complications, and better functional outcomes. In our series, the mean age of patients was 48 years, with fall or road traffic accident being the mode of injury in all cases. The mean time to radiological union was 4.1 months, and complications were more commonly associated with DCS and DHS groups, including higher rates of infection, delayed union, implant failure, and varus deformity. Our findings closely align with those reported by Pakut AJ et al. [16], who compared Gamma Nail and DCS and observed earlier recovery in the intramedullary group. Although their mean patient age was higher (70 years), our PFN group demonstrated similar trends of improved outcomes. Implant failure in PFN was 4.5% in our study compared to higher complication rates in the DCS group (implant failure: 9.4%, infection: 12.5%, non-union: 6.3%).The study by Vaidya et al.[17] using DCS with indirect reduction techniques highlighted successful outcomes in comminuted fractures. Although their younger cohort (mean age 32 years) contrasts with our sample, their union rate at 4.9 months compares well with our PFN results (mean 4.1 months), supporting the role of biological fixation methods. Importantly, we noted a single PFN failure (reverse Z-effect) necessitating revision, which ultimately united, emphasizing the importance of proper technique. A comparison with the article by Prakash Wali and Santosh Mared (IJBT 2021)[18] supports our conclusion that PFN results in better outcomes. Their reported delayed union rate of 10% is higher than the 4.5% observed in our PFN group. Similarly, they reported fewer implant-related complications with PFN than with extramedullary devices.In the comparative study by Reddy et al. (2023)[19], it was found that PFN had shorter operative time, reduced blood loss, earlier weight bearing, and lower complication rates than DCS. These findings are corroborated by our study, where PFN not only had fewer complications but also showed superior functional recovery based on Salwati & Wilson hip scores. Their mean union time for PFN was 3.6 months and for DCS was 4.2 months, closely paralleling our observations (PFN: 4.1 months, DCS: 4.8 months).Another comparative study by Satish Kumar et al. (2022)[20] emphasized PFN’s biomechanical advantages in maintaining alignment and early mobilization. In their study, PFN was associated with higher union rates and lower reoperation rates. Our findings are in agreement, with union achieved in the majority of PFN cases without the need for secondary procedures, contrasting with 2 cases of non-union in the DCS group. Finally, similar to the conclusions drawn by Mishra et al.[21] and Akhtar et al.[22], we found that PFN offers significant advantages including less surgical trauma, lower blood loss, shorter hospital stays, and faster mobilization. These benefits are especially valuable in elderly patients and those with comorbidities.

In this comparative study of subtrochanteric femur fractures treated with Proximal Femoral Nail (PFN), Dynamic Condylar Screw (DCS), and Dynamic Hip Screw (DHS), PFN emerged as the superior fixation method. It demonstrated better functional outcomes, earlier fracture union, fewer complications, and shorter hospital stays compared to DCS and DHS. Although DCS remains a reliable option in specific fracture patterns, PFN, due to its biomechanical advantages and minimally invasive nature, is better suited for managing most subtrochanteric fractures. Careful preoperative planning, proper implant selection, and surgical expertise remain key factors in optimizing patient outcomes.

1. Court-Brown CM, Heckman JD, McQueen M, Ricci W, Tornetta P III, McKee M. Rockwood and Green’s fractures in adults. 8th ed. Wolters Kluwer; 2015. pp. 2075–2083. 2. Burnei C, Popescu G, Barbu D, Capraru F. Intramedullary osteosynthesis versus plate osteosynthesis in subtrochanteric fractures. J Med Life. 2011;4(4):324–329. 3. Kumar GN, Sharma G, Khatri K, Farooque K, Lakhotia D, Sharma V, Meena S. Treatment of unstable intertrochanteric fractures with proximal femoral nail antirotation II: our experience in Indian patients. Open Orthop J. 2015;9:456–459. doi:10.2174/1874325001509010456. 4. Celebi L, Can M, Muratli HH, Yagmurlu MF, Yuksel HY, Bicimoğlu A. Indirect reduction and biological internal fixation of comminuted subtrochanteric fractures of the femur. Injury. 2006;37(8):740–750. doi:10.1016/j.injury.2005.12.022. 5. Hu SJ, Zhang SM, Yu GR. Treatment of femoral subtrochanteric fractures with proximal lateral femur locking plates. Acta Ortop Bras. 2012;20(6):329–333. 6. Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J. 2017;99-B:128–133. doi:10.1302/0301-620X.99B1.BJJ-2016-0134.R1. 7. Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury. 2004;35:142–151. doi:10.1016/s0020-1383(03)00287-0. 8. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am. 2008;90:700–707. doi:10.2106/JBJS.G.00517. 9. Bohl DD, Basques BA, Golinvaux NS, et al. Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database. J Bone Joint Surg Am. 2014;96:1871–1877. doi:10.2106/JBJS.N.00041. 10. Shen J, Hu C, Yu SP, Huang K, Xie Z. A meta-analysis of percutaneous compression plate versus intramedullary nail for treatment of intertrochanteric hip fractures. Int J Surg. 2016;29:151–158. doi:10.1016/j.ijsu.2016.03.065. 11. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006;30:69–78. doi:10.1007/s00264-005-0028-0. 12. Asif N, Ahmad S, Qureshi OA, et al. Unstable intertrochanteric fracture fixation – is proximal femoral locked compression plate better than dynamic hip screw. J Clin Diagn Res. 2016;10:RC09–13. doi:10.7860/JCDR/2016/11179.7084. 13. Knobe M, Drescher W, Heussen N, et al. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res. 2012;470:2302–2312. doi:10.1007/s11999-012-2268-9. 14. Chua IT, Rajamoney GN, Kwek EB. Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients. J Orthop Surg (Hong Kong). 2013;21:308–312. doi:10.1177/230949901302100309. 15. Li YJ, Li ZB, Yu WH, Bo CF. Case-control study on dynamic hip screw and proximal femoral nail anti-rotation for the treatment of unstable intertrochanteric fractures in elderly patients. Zhongguo Gu Shang. 2013;26:977–980. 16. Pakut AJ, El Santo. Unstable subtrochanteric fractures--gamma nail versus dynamic condylar screw. Int Orthop. 2004 Feb;28(1):21-4. 17. Vaidya SV, Dholakia DB, Chatterjee A. The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture. Injury. 2003 Feb;34(2):123-8. 18. Wali P, Mared S. Pro’s and Con’s of proximal femoral nail in peri trochanteric fractures. Int J Orthop Sci. 2018;4(3):209–13. 19. Reddy DV, Kumar S, Rabari Y, Bhatt N, Suri N, Jadhav A. Comparative study between DHS and PFN in the management of treatment of trochanteric and subtrochanteric femoral fractures. Orthop Paper. 2017. 20. Satish Kumar SM, Deepak CE, Gaur K, Shurendra S. Study of internal fixation of subtrochanteric fracture of femur with DHS, DCS and PFN – a retrospective study. Int J Res Med Sci. 2018;6(3):1011–6. 21. Mishra A, Gillani HUR, Khan KR. Comparison between PFNA and DCS in the management of unstable proximal femoral fractures in terms of mean union time. Pak J Med Health Sci. 2016;10(2):555–8. 22. Akhtar MS, Gillani HUR, Khan KR. Comparison between proximal femoral nail antirotation and dynamic condylar screw in the management of unstable proximal femoral fractures in terms of mean union time. PJMHS. 2016;10(2):555–8.