European Journal of Cardiovascular Medicine

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Origin: United Kingdom
Website: https://www.healthcare-bulletin.co.uk/ Volume 13 Issue: 2 - 2023
Open Access

Functional Outcome of Proximal Femoral Nailing Versus Dynamic Hip

Screw in Intertrochanteric Fractures: A Retrospective Cohort Study
Dr. Praveen Garg1, Dr. Suraj Dandotiya2, Dr. Anant Agarwal3

Abstract: Background: It is essential to determine the optimal treatment for intertrochanteric (IT) AFFILIATIONS
1
fractures due to their high incidence and related public health burden. Debate remains as to Associate Professor, Department
whether dynamic hip screws (DHS) or proximal femoral nails (PFNs) are best practices, and our of Orthopaedics, RMCH, Bareilly,
study seeks to gather information relevant to this query. Methods: We undertook a retrospective U.P, India
2
audit of 90 patients in Rohilkhand Medical College between 2017 to 2021, who received a Junior Resident, Department of
dynamic hip screw (Group A) or a proximal femoral nail (Group B) in order to compare age, sex, Orthopaedics, RMCH, Bareilly,
U.P, India
duration of surgery, blood loss, fluoroscopy time, functional outcome based on Harris hip score 3
Assistant Professor, Department
and radiological outcome was compared. Intraoperative and pre-operative data were collected
of Orthopaedics, RMCH, Bareilly,
from the record and patients were followed up for functional outcomes. Results: Out of 90 patients U.P, India
45 (50%) patients were placed in each group. The average age of the patients was 64.43±17.17 CORRESPONDING AUTHOR
years. Intraoperative blood loss in the PFN group(157.11ml) was significantly less compared to
the DHS group (388.44ml), the mean duration of surgery in PFN group was 73.44min and Dr. Suraj Dandotiya
92.56min in DHS group(P<0.001), a shorter incision in PFN group compared to DHS group. The
average limb shortening in both groups was not significant. The patients treated with PFN had
better results than DHS when compared to Harris hip score. Conclusion: This study demonstrated
PFN was found to be a better implant as compared to DHS, among patients undergoing
intertrochanteric fracture fixation via PFN or DHS.

Keywords: Intertrochanteric fractures, DHS, PFN.

INTRODUCTION
Intertrochanteric fractures are responsible for 38-50% of all fractures1 of the femur and 5-20% of total fractures2,
affecting mainly the elderly population. Poor bone quality with complex fracture pattern makes these fractures
challenging to treat. These fractures are commonly because of trivial fall (Low energy trauma) or because of fall from
height, or road traffic accidents.3,4 Intertrochanteric fracture treatment focuses on reviewing the anatomy and functional
capability of individuals close to preoperative status, that too, in the shortest possible time, and minimizing the chance of
medical complications. Various methods of fixation of these fractures namely nail- plate fixation, plate-screw, condylar
blade plate, dynamic hip screw, dynamic condylar screw, Gamma nail, recon nail, trochanteric fixation nail and long
proximal femur nail, partial or total hip arthroplasty and others are described with their own merits and demerits. Method
of fixation changes outcome and complication of fixation.

DHS with side plate assembly is most used device for fixation of intertrochanteric fractures. 5-7 Early weight bearing is
good with noncomminuted and stable fractures, an inclination to penetrate or retract through the pinnacle is concern in
compound and comminuted fractures. Proximal femoral nail (PFN), overcomes the shortly coming related to dynamic
hip screw like open reduction, interference with fracture hematoma, soft tissue handling and extensive periosteal
stripping which further jeopardizes vascularity of bone. Its biomechanical properties are more favorable like short lever
arm, greater implant length, smaller and versatile distal ends and an additional anti-rotational screw in femoral neck.
Moreover, DHS is an eccentric and load bearing device whereas PFN is an axial and load shearing device. There was still
debate is there whether to use DHS or PFN as a treatment for intertrochanteric fracture. So, we conducted this

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Article Title: Functional Outcome of Proximal Femoral Nailing Versus Dynamic Hip Screw in Intertrochanteric
Fractures: A Retrospective Cohort Study
comparison to investigate whether there is a significant difference between PFN and DHS fixation in the treatment of
intertrochanteric fractures in terms of various functional and radiological outcomes.

MATERIALS AND METHODS:

The present retrospective cohort study was conducted in the Department of Orthopaedics and Medical record
department, Rohilkhand Medical College and Hospital, Bareilly, on records of patients admitted during the period
between November 2017 to October 2021, where 90 patients with intertrochanteric fractures were selected. 45 patients
had undergone proximal femoral nailing, and 45 patients had undergone dynamic hip screw fixation. These patients were
divided into 2 groups. Group A patients were treated with DHS(45 Patients) and Group B patients were treated with
PFN(45 patients). Preoperative and intraoperative data were taken from the records available and functional outcome was
based on Harris hip score.8

Inclusion Criteria:
1. Intertrochanteric fractures operated either by Dynamic Hip screw or Proximal femoral nailing.

Exclusion Criteria:
1. Compound fractures
2. Subtrochanteric fractures
3. Fractures in children
4. Pathological fractures
5. Polytrauma
6. Any type of malignancy

RESULTS:
1. AGE:
The mean age of the patients was 64.43±17.35 years (range 22 to 90 years).
2. SEX:
In PFN group, there were 24 females and 21 males, while in the DHS group there were 20 females and 25
males. Males were slightly higher than female patients.

3. MODE OF INJURY:
28 (31.11%) patients had fractures due to trivial falls; 30 (33.33%) were due to road traffic accidents.

4. TYPE OF FRACTURE:
Types of fracture according to Boyd and Griffin9. In Group A, 62.22% had Type -II,37.78% had Type – I
fracture (Figure-2). In Group PFN, 53.33% had Type -III, 33.33% had Type - II, 8.89% had Type- I and 4.44% had
Type– IV fracture (Figure-2).

Overall, most common fractures in our study were Type II and type III i.e., 47.78% and 26.67% followed by
type I fracture (23.33%). Only 2 (2.22%) patients are type IV fracture.

5. LENGTH OF INCISION:
Patients treated with PFN required an average 7.82 cm shorter incision than DHS (p < 0.0001).

6. FLUOROSCOPY TIME:
Fluoroscopy time for DHS group (was significantly less as compared to PFN group (p < 0.0001).
Method No. of cases Mean (sec) Std. dev (Z)
DHS 45 57.11 4.71 34.48
PFN 45 71.33 6.16 P<0.0001 (HS)
Table 1: Fluoroscopy time

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Article Title: Functional Outcome of Proximal Femoral Nailing Versus Dynamic Hip Screw in Intertrochanteric
Fractures: A Retrospective Cohort Study
7. DURATION OF SURGERY-
The mean duration of surgery was significantly shorter for the PFN as compared to DHS (p value <0.0001).
Method No. of cases Mean (min) Std. dev (t)
DHS 45 92.56 7.43 11.85
PFN 45 73.44 7.96 P<0.0001 (HS)
Table 2: Duration of surgery

8. BLOOD LOSS:
The average blood loss in group B was 157.11ml, which was significantly less in group I (388.44ml)
(P<0.0001).

9. LIMB SHORTENING:
The average limb shortening was comparable in both groups. Shortening was not significant enough to cause any gait
or functional impairment.

10. FUNCTIONAL OUTCOME:

In this study, patients with excellent results were 22(48.89%) in group A and 29(64.44%) in group B, patients
with good results were 11(24.44%) and 12(26.67%), patients with fair results were 8(17.78%) and 3(6.67%) and patients
poor with results were 4(8.89%) and 1(2.22%) in group A and B respectively (Graph-1).
Dynamic Hip Screw Proximal Femoral-Nail Total
Outcome
No. % No. % No. %
Excellent 22 48.89 29 64.44 51 56.67
Good 11 24.44 12 26.67 23 25.56
Fair 8 17.78 3 6.67 11 12.12
Poor 4 8.89 1 2.22 5 5.56
Total 45 100 45 100 90 100
8
Table 3: Functional outcome compared on Harries Hip Score.

OUTCOME
(ACCORDING TO HARRIS HIP SCORE)
PFN
group
2.22
Poor 8.89

6.67
Fair 17.78
Grading

26.67
Good 24.44

64.44
Excellent 48.89

0 20 40 60 80 100

Percentage of cases →

Graph-1: Functional outcome based on Harris Hip score8.

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Article Title: Functional Outcome of Proximal Femoral Nailing Versus Dynamic Hip Screw in Intertrochanteric
Fractures: A Retrospective Cohort Study

11. POSTOPERATIVE COMPLICATION-

Post-operative complication like Malunion was more in case of DHS group as compared to PFN group, 3(6.67%)
patients have wound infection in DHS group and 1(2.22%) in case of PFN group.

A B C

Fig.1: Patient treated with DHS

A B

C
Figure 2: X-ray shows (a) Pre-Operative (b) Immediate Post-Operative (c) At 9 Months Post-Operative

DISCUSSION:
Intertrochanteric fractures are considered by the orthopaedic community to be a significant challenge not only to
achieve fracture healing, but also to restore optimal function in the shortest possible time with minimal complications.

Operative treatment in the form of internal fixation enables early rehabilitation and offers the most effective chance
for functional recovery, which is why it has become the treatment of choice for majority of fractures in the trochanteric

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Article Title: Functional Outcome of Proximal Femoral Nailing Versus Dynamic Hip Screw in Intertrochanteric
Fractures: A Retrospective Cohort Study
region. Out of many implants available, i.e., fixed nail plate, sliding nail/screw plate, and intramedullary device, the
compression hip screw is most used, but recently the closed intramedullary nailing technique has gained popularity.

In this study, we sought to chart, evaluate, document, and quantify our success in managing such individuals with
PFN and DHS implants and compare outcomes in the two groups. The study was conducted on ninety patients with
intertrochanteric fractures in the Department of Orthopaedics, Rohilkhand Medical College, Bareilly. The study group
was divided into two groups, group A and group B consisting of 45 patients each. Group A patients were treated with
DHS, and group B were treated with PFN. Patients were evaluated postoperatively a minimum 6 months after being
treated with these implants. Epidemiological, clinical, functional outcomes, rehabilitation results and complications were
evaluated in patients. In our study, intertrochanteric fracture was common due to trivial fall & road traffic accident, age
ranged between 22-90 years, mean age of 64.43±17.17 years. In a study conducted by Amandeep et al. (2018)10 they
found out the mean age in the DHS group was 60.3, which in the PFN group was 56.85 in a study group of 40 patients. In
another study of 52 patients by Parik et al. (2018)11, the mean age in the DHS group was 65 years, which was 70.2 in the
PFN group. Males were common, contributing to 51.11%. Our study has similar results as in other studies such as
Shakeel et al (2019)12 with male predominance. Right-sided fractures were common accounting for 51.11%. Type II
Boyd and Griffin9 fractures were common, consisting of 47.78%. Type I was 23.33% and Type III was 26.67% each.
Boyd & Griffin (1949)9 in his study observed that, patients with type III and IV fractures are not easy to treat. These
fractures were managed better with PFN as seen in our study. Mean frequency of radiation exposure was 71.33 and 57.11
seconds in PFN and DHS respectively(Table-1). comparable results were observed by Baumgaertner and associates
(1998)13 in which fluoroscopic time, with 10 percent higher times for the PFN group, but no difference between the
fluoroscopy time found by Saudan et al. (2002)14 in their study. Mean duration of operation was 92.56 and 73.44 in
minutes(Table-2), mean blood loss was 157.11 ml and 388.44 ml for PFN and DHS respectively. Our results correlated
with Santosha JB (2019)15 study in which higher mean blood loss in DHS group with mean of 260.80ml in comparision
to PFN group with mean loss of 69.68ml. According to Harris hip score8, excellent results were more in the PFN group
(64.44%) than the DHS group (48.89%). Parikh KN et al. (2018).11 In a study of 52 patients, six (23%) of the DHS group
had excellent results, five (19%) had good results, 13 (50%) had fair results, and two had poor results. (8%). In the PFN
group, excellent results were seen in four (15%), good results in 14 (54%), fair results in seven (27%) and poor results in
one (4%) (Table-3). Post-operative complication like Malunion and infection was more in the case of the DHS group
than the PFN group.

CONCLUSION:
In intertrochanteric fractures, both techniques are accurate, time-tested, and require a fair amount of surgical skill.
The problem with both methods is that the difference is very narrow. PFN helps in achieving biological reduction and
adds stability. PFN prevents excessive collapse and shortening of the limb. It thus helps to achieve an overall good
functional result. The PFN can be a weight shearing device and offers stability to the fracture area proximally and the
diaphysis distally, therefore the PFN is a biomechanically sounder implant choice for fixation of femoral
intertrochanteric fractures. PFN is a better implant of choice than DHS in terms of blood loss during surgery and early
rehabilitation.

Therefore, we recommend using PFN over DHS for intertrochanteric femoral fractures unless the trochanteric PFN
entry point is compromised. It’s always the surgeon’s choice to use the implant and depends on the surgeon’s skills.
From our study, regarding functional results obtained from the Harris Hip Score 8, we conclude that PFN provides better
results in intertrochanteric fractures than the DHS fixation.

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fracture in women. The Northeast Hip Fracture Study Group. N Engl J Med. 1991;324:1326– 31.

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Fractures: A Retrospective Cohort Study
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