Intertrochanteric fractures are a specific type of extracapsular hip fracture that occurs commonly in elderly people. [1] These fractures occur due to age-related bone loss, osteoporosis, and falls from height [2]. The increasing age expectancy of the global population has caused an increased incidence of intertrochanteric fractures and is now causing significant challenges to healthcare systems worldwide. [3] This kind of fracture causes acute pain, loss of mobility as well a high risk of long-term complications such as functional dependence, decreased quality of life, and increased risk of mortality [4]. Therefore, the major goal of the treatment of intertrochanteric fractures is to restore mobility, minimize complications, and improve overall outcomes [5]. Surgical management is the gold standard for the treatment of such fractures because it facilitates early mobilization, which is important in preventing complications such as deep vein thrombosis (DVT), pneumonia, bedsores, and muscle atrophy [4]. Among the surgical techniques available, internal fixation is the most widely preferred approach. Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) are two commonly employed devices. Each has its advantages and mechanisms of action, making them suitable for different fractures; thus, the choice of implant remains an important consideration in clinical practice [1]. The Dynamic Hip Screw (DHS) is a widely preferred method of fixation of intertrochanteric fractures particularly those which are classified as stable fractures. Its mechanism of working involves sliding a screw anchored in the femoral head which allows fixation at the fracture site [6].  This ensures fracture stability, encourages bone healing, and enables early weight bearing. Other factors favoring the use of DHS include its simplicity, cost-effectiveness, and predictable outcomes in suitable fracture patterns [4].  However, it has limitations in its use, especially in unstable fractures where it can cause complications such as excessive shortening, implant failure, and compromised functional outcomes [2, 7] Therefore, proximal femoral nails (PFN) are contemporary intramedullary fixation devices designed to overcome the limitations of the DHS for unstable fractures [1].

The important advantages of PFN are that it provides biomechanical stability due to its intramedullary location, shorter lever arm, and resistance to torsional and axial forces. In addition, it is minimally invasive for soft tissue, potentially leading to faster recovery and decreased rates of wound complications [1].  PFN is advantageous for fractures with comminution, reverse obliquity and subtrochanteric extension. The disadvantages are higher implant cost and potential technical challenges such as difficulty in achieving precise nail placement [8]. Although both are used widely there is a lack of consensus on the optimal fixation. Several studies have explored the functional and radiological outcomes of these devices, although the results were inconclusive because of different fracture patterns, patient profiles, surgical techniques, and follow-up durations. Few studies have highlighted the superiority of PFN in unstable fractures, whereas others have emphasized the reliability and affordability of DHS in stable fractures. Since there is a lack of consensus, further research is needed to determine the most appropriate method for patients based on fracture characteristics. Based on this background, we in the current study aimed to comprehensively evaluate and compare the functional and radiological outcomes of intertrochanteric fractures treated with DHS and PFN.

This prospective study was done in the Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences (RIMS), Adilabad, Telangana from July 2023 to Dec 2024. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study and possible outcomes in vernacular language.

Inclusion Criteria

1. Patients with fractures of the intertrochanteric region.
2. Patients aged > 18 years.
3. Males and Females
4. All closed fractures.
5. Grade 1 compound fracture.

Exclusion criteria

1. Patients aged less than 18 years.
2. Fractures presenting with early or delayed features of compartment syndrome.
3. Open fractures other than grade 1.
4. Pathological fractures.
5. Patients with severe comorbidities are them high risk for surgery.

Based on the inclusion and exclusion during the duration of this study we treated n= 30 patients with intertrochanteric fractures. The demographic profile of the cases included age distribution; the gender of study participants was recorded for each patient the details of the fractures including laterality were recorded. Laboratory investigations included Complete Blood Count (CBC), Coagulation Profile (PT, INR, aPTT), Blood Grouping & Cross-matching.  Renal Function Tests (BUN, Creatinine, Electrolytes), Liver Function Tests (LFTs), Blood Glucose (RBS/FBS, HbA1c if diabetic). HIV, HBsAg, HCV. Urine Routine and Microscopic Examination.

Intraoperative details: Average length of incision (cm), Average intraoperative blood loss (mL), Radiation exposure (no. of exposures) and mean operative time (minutes) were recorded. Post-operative details: Average hospital stay (days) were noted down Complications were noted down.

Surgical procedure

In preoperative Planning for patients undergoing DHS fixation, the length of Richard's screw was calculated preoperatively using an anteroposterior (AP) view radiograph, accounting for magnification error. The neck-shaft angle was determined on the unaffected side using a goniometer on the AP X-ray to guide the selection of an appropriate barrel plate angle. A side plate with at least four holes was used in all DHS procedures. In PFN procedures, the diameter of the nail was determined intraoperatively through sequential reaming of the femoral canal. A standard-length PFN nail (either 180 mm or 240 mm) with a fixed 135° angle was utilized in all cases.

Operative Technique: All surgeries were performed under spinal anesthesia on a fracture table by a single experienced orthopedic surgeon. Initially, all fractures were managed with an attempt at closed reduction. If closed reduction failed, open reduction was performed.

Perioperative Protocol: Prophylactic intravenous antibiotics were administered 30 minutes before the skin incision and continued for 48 hours postoperatively. Postoperative radiographs of the hip were obtained immediately to evaluate fracture alignment and implant positioning.

Postoperative Care and Mobilization: Physiotherapy began on the first postoperative day. Patients were instructed in static quadriceps exercises, as well as ankle and knee mobilization. Weight-bearing was allowed as tolerated by the patient. Wound inspection and drain removal were routinely performed on the second postoperative day. The majority of patients were discharged between the 5th and 6th postoperative day. Sutures were removed on the 14th day post-surgery.

Follow-Up and Outcome Assessment: Patients were followed up at regular intervals—1 month, 3 months, 6 months, and 12 months after surgery. During each visit, clinical evaluation included an assessment of pain levels, walking ability, and functional outcomes using the Harris Hip Score (HHS). Radiographs were also taken to monitor the progress of fracture healing.

Harris Hip Score (HHS) Evaluation:  The HHS was used to assess overall hip function and includes parameters such as pain, daily function, presence of deformity, and range of motion. The scoring system has a maximum of 100 points, with higher scores indicating better functional outcomes.

Statistical analysis: The available data was entered into MS Excel and checked for completeness. The collected data was analyzed using Statistical Package for Social Sciences version 28.0 (SPSS V 28). Descriptive statistics were obtained as means and standard deviation for continuous variables and frequency and percentage for categorical variables. Chi-square was done for categorical variables, independent t-test, and ANOVA for continuous variables and the value of p value ≤0.05 was considered statistically significant.

A total of n=30 cases were allotted into two groups DHS and PFN group. Table 1 shows the baseline characteristics of the cohort in the DHS and PFN groups. A critical analysis of the table shows that the mean age of the DHS group was (60.93 ± 8.51 years) slightly higher as compared to the PFN group (57.67 ± 10.19 years), although the differences were not significant. The distribution of cases based on the gender distribution (male/female) between the two groups showed p-values of 0.500 similarly, the laterality of distribution (right/left side) was similar between groups with a p-value of 0.650 which indicates that these differences were comparable in both groups for outcome analysis.

Table 2 shows the comparison of surgical parameters between DHS and PFN treatments for intertrochanteric femur fractures. A critical analysis of the table shows that PFN is associated with significantly shorter incision length as compared with DHS (4.27 ± 0.51 cm vs. 15.35 ± 0.98 cm), the mean operative time between PFN and DHS was (34.40 ± 7.96 min vs. 60.93 ± 2.25 min), and the mean blood loss for PNF versus DHS was (84.14 ± 17.49 ml vs. 217.02 ± 36.64 ml), all the values were p < 0.001. However, PFN required more intraoperative radiation exposure (40.27 vs. 20.53 images). Hospital stay was slightly shorter in the PFN group (7.47 vs. 8.47 days, p = 0.010), suggesting overall procedural efficiency.

          *Significant

Table 3 describes the mean Harris Hip Scores at various follow-up intervals for patients treated with DHS and PFN. At 6 weeks, the difference in scores between the DHS (33.00 ± 21.82) and PFN (39.13 ± 22.39) groups was not statistically significant (p = 0.454). However, at 3 months, PFN showed significantly better functional outcomes (57.60 ± 16.48 vs. 41.47 ± 20.04; p = 0.023). This trend continued at 6 months, where PFN patients had significantly higher scores (82.73 ± 12.83) compared to DHS (65.33 ± 18.96; p = 0.006), indicating superior recovery with PFN.

                                           *Significant

Table 4 compares the functional outcomes based on Harris Hip Scores at 6 weeks, 3 months, and 6 months postoperatively in the cohort. The results showed that at 6-week intervals, both DHS and PFN groups had similarly poor outcomes, with 93.3% of patients in each group scoring poorly and only one patient per group achieving fair/good status (p = 0.759). By 3 months, the results showed differences between the two with 26.7% of PFN patients improved to fair/good scores compared to just 6.7% in the DHS group, showing a statistically significant difference (p = 0.018). At 6 months, functional recovery was better in the PFN group, where 33.3% achieved excellent outcomes and 80% had fair/good/excellent scores overall, significantly outperforming the DHS group, where only 6.7% reached excellently and 46.7% had fair/good/excellent results (p = 0.044).

                                           *Significant

Table 5 depicts the postoperative complications observed in both DHS and PFN groups. The analysis of the results showed that Implant failure occurred in 13.5% of DHS cases and 6.7% of PFN cases (p = 0.500). Non-union rates were equal in both groups (6.7%, p = 0.759). Infections were reported only in the DHS group (13.5%) but not in PFN, though not statistically significant (p = 0.241). On the contrary, greater trochanter splintering occurred only in PFN patients (13.5%), with none in the DHS group (p = 0.241), indicating no significant difference in complication rates between groups.

Intertrochanteric fractures which occur in the proximal femur are becoming a significant global health concern due to the aging population due to osteoporosis. Low-energy falls are the primary mechanism of injuries in the elderly population and high-energy trauma causes them in the younger age group. Although hip fractures in general are common intertrochanteric fractures account for a substantial proportion and it is estimated to be around 50% of all hip fractures. These fractures are common in elderly females with a female-to-male ratio ranging from 2:1 to 8:1 due to menopausal loss of bone density [9].  Surgical fixation remains the mainstay of treatment for Intertrochanteric fractures as it allows early mobilization and minimizes complications. Traditionally DHS was the implant of choice for stable fractures and it had satisfactory outcomes. However, in cases of unstable intertrochanteric fractures, DHS was associated with higher rates of mechanical failures, including varus collapse, malalignment, and screw cut-out. This was because of extramedullary design and suboptimal load-sharing capacity [1, 3] Because of these limitations the proximal femoral nail (PFN) which is an intramedullary device was introduced. PFN offered biomechanical advantages because of the shorter lever arm and improved load transmission along the mechanical axis. These properties make PFN suitable for unstable fractures with additional benefits including smaller incisions, reduced blood loss, and early weight bearing [10]. However, complications along with technical difficulties are the factors of concern. Screw misplacement and specific mechanical issues like Z-effect" is known to occur in a few cases of PFN implants [11]. Therefore, an ideal screw placement within a safe zone and surgical expertise are important for optimal outcomes.

The results of our study showed that intertrochanteric fractures have similar age and gender distributions. The mean age in DHS was 60.93 ± 8.514 years compared to the PFN group was 57.67 ± 10.189 years, respectively (P = 0.349). Similar findings have been reported by Kassem et al. [12] and Chandy et al. [5]. A male predominance was noted in our groups of our study because most of the cases were RTA accidents which predominantly involved male patients. Similar male predominance was noted by Parikh et al. [13] and Tambe et al. [1], though Kassem et al. [12] reported gender parity for intertrochanteric fractures. The laterality of fractures did not show any consistent pattern in the literature. Our current study showed equal right-side involvement (66.7%) in both groups. Kassem et al. [12] and Shukla et al. [14] have shown variable distribution of fractures. We found that functional outcomes based on Harris Hip Score (HHS) were not significant at 6 weeks. However, at 3 months and 6 months, we found PFN performed better as compared to DHS and the mean HSS scores were statistically significant (Table 4). Similar findings have been reported by Kumar et al. [2] Shukla et al. [14], and Chandy et al. [5], while Chaitanya et al. [15] did not report any significant difference between the groups. The length of the incision and intraoperative blood loss were found to be significantly lower in the PFN group. The mean incision length of our cases was 27 cm (PFN) versus 15.35 cm (DHS). The blood loss in our study was 84.14 mL (PFN) versus 217.02 mL (DHS). A similar observation has been reported by corroborated by Ansari et al. [16], Kumar et al. [2], and Hemant et al. [4]. The mean radiation exposure in the PFN group was higher due to fluoroscopic guidance in this study (40.27 vs. 20.53 units) other similar studies have reported a similar finding [14, 16] The mean operative time was shorter in the PFN group as compared to DHS group (34.40 min vs. 60.93 min) our findings are in concurrence with observation of Ansari et al. [16], Hemant et al. [4], and Shukla et al. [14]. We found that hospital stay was slightly shorter for PFN group cases as compared to DHS group cases (7.47 days vs. 8.47 days). Kumar et al. [2], Ansari et al. [16], and Shukla et al. [14] have shown similar observations in their respective studies. Overall, we found that both implants are viable however, PFN showed superior outcomes in unstable fractures across multiple perioperative functional parameters.

In In conclusion, we found that Both DHS and PFN are effective in the treatment of intertrochanteric fractures; however, PFN demonstrated superior outcomes in terms of functional recovery, reduced operative time, shorter incision length, less blood loss, and shorter hospital stay. While radiation exposure was higher with PFN, the benefits in clinical and functional outcomes suggest that PFN may be a preferable option, particularly in suitable patients.

1. Tambe D, Kumar P, Raut S, Kandarkar S, Sihora Y, Shendge S, Patel N, Patel S. Functional and radiological outcome of unstable intertrochanteric femur fractures in elderly patients treated with proximal femoral nail – A prospective study from Mumbai, Maharashtra. Int J Health Clin Res. 2021;4(13):194–98.
2. Kumar M, Kumar V. Functional outcome of the intertrochanteric fracture of femur managed by Dynamic hip screw and proximal femoral nail: A prospective comparative study. Indian J Orthop Surg 2021;7(4):326-31.
3. Raagul TS, Prem Kumar KV, Seetharaman K, Bharath V, Ranganathan T, Murugesan V. Fixation in intertrochanteric fractures using short proximal femoral nail anti-rotation-2: A functional and radiological prospective study. J Orthop Case Rep. 2025;15(5):261–68.
4. Hemant HK, Yadav PK, Sushobhit, Azam M. Functional outcomes of intertrochanteric femur fractures treated with dynamic hip screw vs. proximal femoral nail: A prospective comparative study. Int J Pharm Clin Res. 2024;16(12):1856–61.
5. Chandy G, Saju S. A comparative study on the functional outcome of intertrochanteric fractures treated by proximal femoral nailing or dynamic hip screw fixation. Int J Res Orthop.2021;7:51-5.
6. Jain RK, Verma A, Jain A, Patel Y. Factors determining failure of intertrochanteric fracture fixation with a dynamic hip screw: a retrospective analysis. Int J Res Orthop. 2018; 4:720-25.
7. Palakurthi V, Bachu S. Study of management of intertrochanteric fractures of femur in adults by various surgical modalities. J Orthop Educ. 2018;4(2):85–89.
8. Kanthimathi B, Narayanan V. Early Complications in Proximal Femoral Nailing Done for Treatment of Subtrochanteric Fractures. Malays Orthop J. 2012;6(1):25-29.
9. Alpantaki K, Papadaki C, Raptis K, Dretakis K, Samonis G, Koutserimpas C. Gender and Age Differences in Hip Fracture Types among Elderly: A Retrospective Cohort Study. Maedica (Bucur). 2020 Jun;15(2):185-190.
10. Das PB, Singh A, Lenka BS, Pani S. Osteosynthesis of intertrochanteric fractures by PFN and DHS. A prospective randomized comparative study. Journal of Orthopaedics, Traum, and Rehabilitation. 2020:2210491720971832.
11. Herman A, Landau Y, Gutman G, et al. Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail. Injury 2012; 43(6): 856–63.
12. Kassem E, Younan R, Abaskhron M, Abo-Elsoud M. Functional and radiological outcomes of dynamic hip screw with trochanteric stabilizing plate versus short proximal femoral nail in management of unstable trochanteric fractures: A randomized controlled trial. Joint diseases and related surgery. 2022;33(3):531.
13. Parikh KN, Parmar C, Patel M, Shah SB. Functional and radiological outcome of proximal femoral nailing versus dynamic hip screw in unstable intertrochanteric femur fractures. Int J Res Orthop. 2018;4(6):861.
14. 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. Journal of Orthopaedics, Traumatology and Rehabilitation. 2022;14(1):24-31.
15. Chaitanya M, Mittal A, Rallapalli R, Biju R, Prasad YS. Comparison of dynamic hip screw and plate with proximal femoral nail in trochanteric fractures of femur. IOSR J Dent Med Sci. 2015;14(4):73-82.
16. Ansari AH, Ansari AH. A comparative study of proximal femoral nail and dynamic hip screw for intertrochanteric fractures of the femur. Karnataka Medical Journal. 2024;47(1):3-8.