European Journal of Cardiovascular Medicine

Intertrochanteric femur fractures are among the most common injuries affecting the elderly population, primarily due to osteoporosis and low-energy trauma such as falls from standing height (1). With increasing life expectancy and a growing geriatric demographic, the incidence of these fractures is expected to rise substantially in the coming decades (2). Prompt surgical management is essential to reduce complications associated with prolonged immobilization, such as pressure sores, pneumonia, and deep vein thrombosis, and to improve functional outcomes (3).

Two of the most widely employed surgical fixation techniques for intertrochanteric fractures are the Dynamic Hip Screw (DHS) and the Proximal Femoral Nail (PFN). The DHS has long been considered a standard treatment, offering reliable results in stable fracture patterns. However, its efficacy in unstable and comminuted fractures has been questioned due to risks such as implant failure, excessive sliding, and varus collapse (4). Conversely, PFN, an intramedullary device introduced in the 1990s, offers biomechanical advantages including shorter lever arm, load sharing closer to the femoral axis, and reduced risk of rotational instability, particularly in unstable fracture configurations (5).

Recent comparative studies have reported varied outcomes regarding functional recovery, complication rates, and rehabilitation duration between PFN and DHS. Some evidence suggests that PFN may lead to earlier mobilization and reduced blood loss, whereas others argue that DHS remains superior in terms of surgical familiarity and lower hardware-related complications in select cases (6,7). Despite multiple investigations, there remains no clear consensus on the superiority of one method over the other, especially in the elderly with compromised bone quality.

This study aims to provide a prospective cohort analysis comparing the clinical and functional outcomes of PFN and DHS fixation in elderly patients with intertrochanteric femur fractures, with the goal of identifying the more effective and safer treatment modality in this vulnerable population.

A total of 80 elderly patients, aged 60 years and above, diagnosed with intertrochanteric femur fractures were enrolled following informed consent.

Inclusion Criteria:

• Patients aged ≥60 years.
• Radiologically confirmed intertrochanteric femur fractures (AO/OTA classification 31-A1 to 31-A3).
• Patients medically fit for surgery.

Exclusion Criteria:

• Pathological fractures other than osteoporosis.
• Polytrauma or associated fractures of the ipsilateral limb.
• Patients with prior surgery on the affected hip.
• Non-ambulatory patients before injury.

Participants were randomly allocated into two groups of 40 each using a computer-generated randomization table:

• Group A: Treated with Proximal Femoral Nail (PFN).
• Group B: Treated with Dynamic Hip Screw (DHS).

All surgeries were performed under spinal or general anesthesia by experienced orthopedic surgeons. In the PFN group, a standard closed reduction was followed by internal fixation using a short proximal femoral nail under fluoroscopic guidance. In the DHS group, fracture fixation was performed using a 135-degree sliding hip screw with a side plate after fracture reduction.

Postoperative protocols, including antibiotic prophylaxis, thromboprophylaxis, and physiotherapy, were standardized for both groups. Partial weight-bearing was initiated based on radiographic and clinical assessments.

Outcome Measures:

• Operative time (in minutes).
• Intraoperative blood loss (measured by suction volume and gauze weight).
• Time to full weight-bearing (weeks).
• Fracture union time (radiologically assessed).
• Functional outcome (measured by Harris Hip Score at 6 months).
• Postoperative complications (implant failure, infection, limb shortening, etc.).

Follow-up was done at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Statistical analysis was performed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation, and comparisons between groups were made using the Student’s t-test and Chi-square test. A p-value <0.05 was considered statistically significant.

A total of 80 patients were enrolled in the study, with 40 patients in each group. The demographic profile of both groups was comparable with no statistically significant differences in age or gender distribution (p > 0.05). The mean age of patients in the PFN group was 72.1 ± 6.4 years, and in the DHS group, it was 71.5 ± 7.1 years.

Operative and Intraoperative Parameters:
The mean operative time was significantly lower in the PFN group (58.2 ± 8.4 minutes) compared to the DHS group (72.5 ± 10.1 minutes) (p = 0.001). Similarly, the PFN group had significantly less intraoperative blood loss (145.6 ± 30.5 mL) than the DHS group (210.4 ± 42.3 mL) (p < 0.001). These findings are detailed in Table 1.

Table 1: Comparison of Operative Parameters Between PFN and DHS Groups

Postoperative Recovery and Mobilization:
Patients in the PFN group were able to start full weight-bearing earlier (9.2 ± 2.3 weeks) than those in the DHS group (11.5 ± 2.9 weeks), with a statistically significant difference (p = 0.004). The average time to radiographic union was 14.1 ± 2.5 weeks in the PFN group and 15.7 ± 3.1 weeks in the DHS group. These findings are shown in Table 2.

Table 2: Postoperative Mobilization and Union Time

Functional Outcome:
At the 6-month follow-up, the mean Harris Hip Score was significantly higher in the PFN group (82.4 ± 6.5) than in the DHS group (76.1 ± 7.3) (p = 0.002), indicating better functional outcomes among PFN-treated patients (Table 3).

Table 3: Functional Outcome at 6 Months Using Harris Hip Score

Complication Rates:
Postoperative complications were fewer in the PFN group (12.5%) compared to the DHS group (25%). The most common complication observed in the DHS group was varus collapse (10%), while in the PFN group, it was screw back-out (5%). Infection and limb length discrepancies were slightly higher in the DHS group (Table 4).

Table 4: Complications Observed During Follow-Up

These findings suggest that PFN fixation provides better intraoperative and functional outcomes with a lower rate of complications compared to DHS fixation in elderly patients with intertrochanteric femur fractures.

Intertrochanteric femur fractures in elderly individuals represent a significant burden on healthcare systems due to associated morbidity, mortality, and functional decline. Surgical fixation remains the treatment of choice for these fractures, with the primary objective of restoring mobility, minimizing complications, and ensuring rapid rehabilitation (1,2). In this study, the Proximal Femoral Nail (PFN) demonstrated superior outcomes compared to the Dynamic Hip Screw (DHS) in several key domains, including operative efficiency, blood loss, time to mobilization, functional recovery, and complication rates.

The reduced operative time observed in the PFN group aligns with previous findings, where intramedullary devices were shown to facilitate quicker surgical procedures due to their minimally invasive nature and ease of insertion in trained hands (3,4). The DHS, although widely used, often requires more extensive soft tissue dissection and lateral exposure, which prolongs the procedure and increases the risk of infection and blood loss (5). Our findings regarding significantly less intraoperative blood loss in the PFN group are consistent with the literature, where studies have consistently reported a 30–40% reduction in blood loss compared to DHS (6,7).

Early mobilization is critical in elderly patients to prevent complications like venous thromboembolism, pneumonia, and muscle atrophy (8). The current study observed earlier full weight-bearing and radiographic union in the PFN group, corroborating prior research suggesting that intramedullary fixation offers a biomechanical advantage by sharing axial loads more effectively, particularly in unstable fractures (9,10). This characteristic is crucial in elderly individuals with compromised bone quality, where fixation failure and delayed union are common concerns.

The functional outcome, measured by the Harris Hip Score, was significantly better in the PFN group at 6 months postoperatively. These findings echo those of previous prospective and randomized trials indicating improved hip function, reduced pain, and higher patient satisfaction scores with PFN compared to DHS (11,12). The central placement of the PFN along the medullary canal provides better stabilization, especially in comminuted or reverse oblique fracture patterns, where DHS has shown inferior biomechanical performance (13).

Complication rates were notably lower in the PFN group in this study. DHS-related complications such as varus collapse, excessive lag screw sliding, and limb shortening have been frequently reported in the literature and are attributed to the longer lever arm and lateral entry point of the implant (14). Conversely, PFN-related issues such as screw cut-out and implant migration can be minimized with proper surgical technique and implant positioning (15). Although PFN requires fluoroscopic guidance and a steeper learning curve, its benefits in terms of outcomes justify its preference, particularly for unstable fracture configurations.

Overall, this study supports the growing consensus that PFN is a more suitable fixation method in elderly patients with intertrochanteric fractures, offering advantages in surgical time, blood conservation, early rehabilitation, and long-term function. However, surgeon expertise, implant availability, and fracture morphology should continue to guide the choice of fixation on a case-by-case basis.

Proximal Femoral Nailing demonstrated better clinical and functional outcomes compared to Dynamic Hip Screw fixation in elderly patients with intertrochanteric femur fractures. It offers shorter operative time, reduced blood loss, earlier mobilization, and fewer complications, making it a more effective treatment option in this population.

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