Intertrochanteric fractures are among the most common proximal femur injuries encountered in adults, particularly older individuals with age-related bone loss. Their incidence continues to rise in many countries as populations age and mobility patterns change.[1] Although most injuries occur after low-energy domestic falls, younger adults may sustain similar fractures through higher-velocity trauma such as road-traffic collisions.[2] These fractures span a wide morphological spectrum, ranging from simple two-part configurations to reverse-oblique and comminuted variants classified under the AO/OTA 31A1–31A3 system.[3] The mechanical environment becomes progressively unstable as posteromedial comminution increases, and the lateral wall weakens, making implant selection critical. Surgical fixation remains the standard of care because it allows early mobilisation and reduces complications associated with prolonged recumbency. Historically, extramedullary devices such as sliding hip screws dominated treatment, yet their performance declines in fractures with lateral wall breach or varus-prone patterns.[4] Intramedullary implants such as the proximal femoral nail (PFN) were introduced to address these limitations. Their central position reduces the bending moment on the implant, improves load sharing, and supports controlled collapse, features that improve stability in more complex fracture patterns.[5]Despite these advantages, intramedullary nails are not free from complications. Technical challenges with the entry point and screw positioning may lead to problems such as the “Z-effect” or implant migration, particularly in osteoporotic bone.[6] As an alternative, locking compression plates designed for the proximal femur (PFLCP) offer a fixed-angle construct with good purchase in the femoral head and neck. These plates can provide stability across a range of fracture morphologies, although they typically require wider exposure and may be associated with greater blood loss.[7]The available literature offers mixed conclusions when comparing PFN and PFLCP, partly because many studies restrict inclusion to unstable patterns, whereas real-world hospital cohorts often present with a blend of AO/OTA 31A1, 31A2, and 31A3 fractures. Data from such heterogeneous populations remains limited, especially from resource-constrained public hospitals where both implants are used according to fracture morphology, surgeon preference, and implant availability. The present prospective study was conducted to evaluate perioperative characteristics and six-month functional outcomes of PFN and PFLCP fixation in adults with intertrochanteric fractures of mixed AO/OTA subtypes. By analysing a consecutive cohort without artificially narrowing the fracture spectrum, the study aims to reflect everyday clinical practice more accurately while providing a transparent account of implant performance across varied morphological patterns.

Study Design and Setting A prospective comparative study was conducted in the Department of Orthopaedics, Government medical college & hospital, Dharmapuri. Tamil Nadu, India, in the years 2019-2022. The aim was to evaluate the perioperative and functional outcomes of proximal femoral nailing (PFN) and proximal femur locking compression plate (PFLCP) fixation in adults with intertrochanteric femur fractures. Recruitment occurred over a defined period, and all eligible patients presenting consecutively were included. Eligibility Criteria All adults aged 18 years and above with radiologically confirmed intertrochanteric femur fractures were considered. Fractures classified under AO/OTA 31A1, 31A2, and 31A3 were included, reflecting the heterogeneity commonly encountered in routine hospital practice. Patients with open injuries, pathological fractures, polytrauma affecting another ipsilateral limb segment, or those medically unfit for anaesthesia were excluded. No restrictions were applied based on fracture stability pattern, degree of comminution, or side of involvement. Sample Size and Group Allocation Twenty patients meeting the eligibility criteria were enrolled. Ten underwent PFN fixation, and ten underwent PFLCP fixation. Allocation followed a consecutive case sequence, determined by implant availability, fracture morphology, and the operating surgeon’s preference. No randomisation was attempted. Pre-operative Assessment Each patient underwent a standardised evaluation that included clinical examination, assessment of comorbidities, documentation of the mode of injury, and radiographic characterisation of the fracture pattern. Routine blood tests, anaesthesia clearance, and pre-operative optimisation were completed before surgery. Surgical Procedure PFN Technique: Surgery was performed on a fracture table under spinal anaesthesia. Closed reduction was attempted using traction, adduction, and internal rotation. A trochanteric entry point was established through a short proximal incision. After guidewire placement and canal preparation, the nail was inserted and fixed using a lag screw and derotation screw under fluoroscopic guidance. Distal locking was carried out in either static or dynamic mode. Any intra-operative challenges, including implant-related difficulties, were recorded. PFLCP Technique: A lateral approach was used with splitting of the fascia lata and elevation of the vastus lateralis. The contoured locking plate was positioned along the lateral aspect of the proximal femur. Proximal locking screws were inserted into the femoral head and neck, with the kickstand screw added where appropriate. Distal fixation was achieved using bicortical screws. Exposure, reduction quality, and implant placement were confirmed under image guidance. Post-operative Management All patients received intravenous antibiotics for the first 48 hours, followed by oral medication as required. Dressings were changed on postoperative days 2, 5, and 8, and sutures were removed around day 12. Early hip and knee mobilisation exercises were encouraged. Weight-bearing status was individualised based on construct stability: PFN patients typically progressed earlier, while PFLCP patients waited until early callus formation. Follow-up reviews were scheduled monthly for the first three months and again at six months. Outcome Assessment Functional outcomes were assessed using the Harris Hip Score at six months and categorised as Excellent, Good, Fair, or Poor. Additional outcomes recorded included operative time, intra-operative blood loss, time to full weight bearing, radiological union, and any complications such as infection, implant failure, peri-implant fracture, or technical issues like guidewire breakage. Statistical Analysis Continuous variables such as operative duration, blood loss, and time to full weight bearing were analysed using non-parametric tests due to the small sample size. The Mann–Whitney U test was used for group comparisons. Categorical variables were evaluated using Fisher’s exact test. A p-value <0.05 was considered statistically significant. No imputation was used, and all analyses were based on available data.

Twenty adults with intertrochanteric femur fractures were included, with 10 patients treated using a proximal femoral nail (PFN) and 10 using a proximal femur locking compression plate (PFLCP). Baseline characteristics The two groups were broadly comparable at baseline. The mean age was slightly higher in the PFN cohort (around the early 60s) compared with the PFLCP cohort (late 50s). Women were more frequent in the PFN group, whereas men predominated in the PFLCP group. Right-sided fractures were more common overall. Most injuries followed a low-energy self-fall, with road-traffic trauma accounting for a minority of cases, particularly in the PFLCP arm. AO/OTA classification showed that the cohort comprised a true mix of fracture types. The PFN group included stable 31A1, unstable 31A2, and reverse-oblique 31A3 patterns, and a similar distribution was seen in the PFLCP group with a slightly higher proportion of 31A2 fractures. A small proportion of patients in each group had documented medical comorbidities such as diabetes mellitus or hypertension. Figure 2. Age-group distribution across PFN and PFLCP (bar chart) Table 1. Baseline demographic and fracture characteristics Variable PFN (n = 10) PFLCP (n = 10) Total (N = 20) Mean age (years) 61.2 56.9 – Sex, n (male/female) 4 / 6 6 / 4 10 / 10 Side of fracture, n (right / left) 8 / 2 8 / 2 16 / 4 Mode of injury, n (self-fall / RTA) 9 / 1 6 / 4 15 / 5 Any comorbidity, n (%) 2 (20%) 3 (30%) 5 (25%) AO/OTA 31A1, n 4 2 6 AO/OTA 31A2, n 3 6 9 AO/OTA 31A3, n 3 2 5 Figure 1. Gender distribution in the study population (pie chart) Most patients were evenly distributed by sex, with a slight female predominance in the PFN group and a slight male predominance in the PFLCP group. The majority of fractures clustered in the 60–70-year age band, reflecting the typical geriatric burden of intertrochanteric injuries. Operative details and union Timing of surgery from injury was similar in both groups, with most patients operated within the first few days of admission. Operative duration was consistently shorter with PFN, while the PFLCP procedures took longer, partly due to the greater exposure and plate application needed. Intra-operative blood loss followed the same pattern, with lower average blood loss in the PFN arm and higher volumes recorded in the PFLCP arm. All fractures proceeded to radiological union within the follow-up period. None of the patients showed persistent non-union at the final six-month review, although one PFLCP case developed a delayed union with varus collapse that required later corrective surgery. Table 2. Operative parameters and radiological outcome Variable PFN (n = 10) PFLCP (n = 10) p-value* Interval from injury to surgery (days), mean 3.3 2.7 – Operative time (minutes), mean 87.1 128.0 < 0.001 Intra-operative blood loss (ml), mean 66 139 < 0.001 Radiological union within 20 weeks, n (%) 10 (100%) 10 (100%) – *p-values derived from non-parametric comparison (Mann–Whitney U); no rank-sum values are shown to avoid duplication or confusion. Weight-bearing and functional recovery Patients in the PFN group progressed to full weight bearing earlier than those treated with PFLCP. On average, PFN patients were allowed full weight bearing at around 11 weeks, whereas PFLCP patients reached this milestone closer to 14 weeks. This difference reflects both the intramedullary load-sharing nature of the nail and the more cautious rehabilitation often adopted for plate constructs in osteoporotic bone. At six months, Harris Hip Scores indicated that most patients in both groups had regained acceptable hip function. The distribution of categories was skewed towards good and excellent outcomes, with a small number of fair and poor outcomes in each group. When analysed as continuous scores, there was no statistically significant difference between PFN and PFLCP, despite the earlier mobilisation seen with PFN. Figure 3. Mode of injury by implant group (stacked bar chart) Self-fall from standing height remained the dominant mechanism in both groups, with road-traffic accidents contributing to a minority but clinically relevant subset. Comorbidities and complications Comorbidities were present in one quarter of the cohort and were similarly distributed between the PFN and PFLCP arms. Most patients had either diabetes mellitus or hypertension; none had complex multi-organ disease that prevented early surgery. Complications were infrequent but informative. Superficial wound infections occurred in both groups and were managed with antibiotics and local care. In the PFN cohort, one patient sustained a peri-implant fracture following a subsequent fall; this was managed with revision to a longer nail. Another PFN patient experienced an intraoperative guide wire breakage, with the fragment retained in the femoral head; this was observed and did not lead to additional morbidity within the follow-up period. In the PFLCP group, one patient developed varus collapse with delayed union, requiring valgus osteotomy and revision fixation. No deep infections or implant breakages were recorded. Table 3. Comorbidity profile and complications Variable PFN (n = 10) PFLCP (n = 10) Total (N = 20) Patients with ≥ 1 comorbidity, n (%) 2 (20%) 3 (30%) 5 (25%) Superficial wound infection, n 1 1 2 Peri-implant fracture after new trauma, n 1 0 1 Retained broken guide wire, n 1 0 1 Varus collapse / delayed union requiring revision, n 0 1 1 Any revision surgery, n 1 1 2 Figure 4. Distribution of comorbidities in the study cohort (donut chart) Three-quarters of patients had no major comorbidities, which likely facilitated early surgical intervention and postoperative rehabilitation. Table 3. Comorbidities and complication profile Variable PFN (n = 10) PFLCP (n = 10) Total (N = 20) p-value (Fisher’s) Any comorbidity, n (%) 2 (20%) 3 (30%) 5 (25%) 1.000 Superficial infection, n 1 1 2 1.000 Peri-implant fracture, n 1 0 1 1.000 Non-union with varus collapse, n 0 1 1 1.000 Revision surgery performed, n 1 1 2 1.000 Functional outcome At the six-month follow-up, all fractures had united, and all patients were ambulant. Harris Hip Scores showed a predominance of excellent and good outcomes in both groups. When analysed as continuous scores, there was no statistically significant difference in functional outcome between PFN and PFLCP (z = –1.138, p = 0.255), despite the clear peri-operative advantages observed with PFN.

This study compared proximal femoral nailing and proximal femur locking compression plate fixation in adults with intertrochanteric femur fractures spanning the AO/OTA 31A1–31A3 spectrum. Unlike studies that limit inclusion strictly to unstable patterns, this cohort reflects real-world clinical practice in public hospitals, where fracture morphology is often heterogeneous at presentation. The mixed distribution here, with stable two-part, unstable multi-fragmentary, and reverse-oblique variants represented in both groups, adds practical relevance to the findings. The key peri-operative differences observed between implants align with the broader biomechanical expectations of intramedullary versus extramedullary fixation. PFN demonstrated shorter surgical duration and lower intra-operative blood loss, advantages consistently reported in earlier comparative studies.[8,9] The intramedullary position allows load sharing and minimises soft-tissue disruption, making it favourable for patients with compromised physiology who may not tolerate prolonged surgery. PFLCP fixation, while technically straightforward in many fracture patterns, required broader exposure and consequently resulted in higher blood loss and longer operative time in this study. Radiological union occurred reliably in both groups. Six-month functional outcomes, as measured by the Harris Hip Score, were largely comparable. This mirrors prior reports showing that both constructs can achieve acceptable functional recovery when reduction quality and implant placement are adequate.[10] What distinguished PFN in this series was the earlier transition to full weight bearing, a feature that carries meaningful clinical value, particularly for elderly patients susceptible to deconditioning. Complications were infrequent but noteworthy. The intra-operative guide-wire breakage in one PFN case highlights a recognised technical pitfall with cephalomedullary nails. Previous literature describes similar events, often linked to suboptimal entry angles or excessive torque during screw placement.[11] The varus collapse and delayed union observed in one PFLCP patient align with reports that plate constructs depend heavily on maintaining the integrity of the lateral femoral wall and achieving stable buttress support.[12] These isolated complications do not alter the overall interpretation but emphasise the importance of careful technique with either implant. Taken together, the findings suggest that while both PFN and PFLCP can deliver satisfactory functional outcomes in mixed AO fracture patterns, PFN offers consistent perioperative advantages and facilitates earlier rehabilitation. The ability to withstand earlier loading makes PFN a compelling choice for frail or elderly individuals. Even so, PFLCP remains a useful option in select scenarios, such as unusual proximal femoral anatomy, lateral wall reconstruction, or when intramedullary implants are contraindicated. Ultimately, clinical judgement, fracture morphology, and surgical expertise should guide implant selection. Limitations The study has several limitations that warrant acknowledgment. The sample size was small, limiting statistical power and the ability to detect subtle functional differences. Allocation was consecutive rather than randomised, raising the possibility of selection bias. The inclusion of the full AO/OTA 31A1–31A3 range, while reflective of everyday practice, introduces heterogeneity that complicates direct comparison between implants. Follow-up was restricted to six months, thereby missing longer-term outcomes such as late implant-related issues, persistent gait asymmetry, or post-traumatic osteoarthritis. In addition, minor discrepancies in the original thesis rank-sum calculations could not be resolved, and cautious interpretation of the statistical comparisons is advisable. These limitations do not negate the study’s findings but do temper the generalisability of its conclusions.

Both proximal femoral nailing and proximal femur locking plate fixation provided satisfactory functional outcomes at six months in adults with unstable intertrochanteric fractures. However, PFN consistently offered important perioperative advantages, including shorter operative time, less intraoperative blood loss, and earlier progression to full weight bearing. These benefits carry particular relevance for older patients who are vulnerable to complications of prolonged immobility. While PFLCP remains a viable option in selected anatomical situations, PFN appears to be the more efficient and biologically favourable construct for routine management of unstable intertrochanteric fractures.

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