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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 24-31

Comparative analysis of functional and radiological outcome of proximal femoral nail versus dynamic hip screw in treatment of intertrochanteric fractures


Department of Orthopaedics, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India

Date of Submission17-Jul-2021
Date of Acceptance01-Dec-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Arpit Choyal
Department of Orthopaedics, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_73_21

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  Abstract 


Background: Intertrochanteric fracture is one of the most common fractures of the hip, especially in the elderly with osteoporotic bones, usually due to low-energy trauma like simple falls. This study was done to compare the functional and radiological outcome of PFN with dynamic hip screw (DHS) in treatment of type 31-A2, intertrochanteric fractures. Materials and Methods: From June 2019 to June 2021, prospective randomized and comparative study was conducted on the 162 patients of type 31-A2 intertrochanteric fractures of hip who were operated using PFN or DHS. Intraoperative complications were noted. Functional outcome was assessed using Harris hip score (HHS) and radiological findings were compared at 6, 12, and 24 months postoperatively. Results: In our study, out of 162 patients, 77 patients are managed with DHS, while 85 patients are managed with PFN. The average age group of the patients was 61–70 years. In our series, we found that patients with DHS had longer duration of surgery (111 min) and required longer time for mobilization, while patients who underwent PFN had shorter duration of surgery (97 min) and allowed early mobilization. In addition, complications such as DVT, lag screw cutout, shortening, and superficial infection are more in DHS group as compared to PFN group. The patients treated with PFN started early ambulation as they had better HHS in the early postoperative period as well as late postoperative period. Conclusion: PFN is better than DHS in type 31-A2 intertrochanteric fractures in terms of decreased blood loss, reduced duration of surgery, early weight-bearing and mobilization, reduced hospital stay, decreased risk of infection, and decreased complications.

Keywords: Dynamic hip screw, fracture, Harris hip score, intertrochanteric, PFN


How to cite this article:
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. J Orthop Traumatol Rehabil 2022;14:24-31

How to cite this URL:
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. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 26];14:24-31. Available from: https://www.jotr.in/text.asp?2022/14/1/24/347373




  Introduction Top


Intertrochanteric fractures are those fractures which involve upper femoral end through and in between greater and lesser trochanters which may extend into upper femoral shaft.[1] Intertrochanteric fractures are commonly encountered in osteoporotic elderly patients.[2] By 2040, the incidence is evaluated to be doubled due to higher longevity and rising incidence of road traffic accidents.[3] The intertrochanteric fractures can be treated operatively and nonoperatively. The nonoperative method used to be the treatment of choice in the early 19th century when enough surgical technique was not evolved to stabilize the fracture.[4] The conservative approach has a high complication rate. Operative methods include dynamic hip screw (DHS) or PFN. DHS is commonly used in extramedullary fixation, whereas PFNs are commonly used devices in the intramedullary fixation.[5]

The risk of implant failure is lessened in DHS with fixed-angle locking side plate and is valuable in unstable fractures with osteoporosis.[6]

PFN provides a more biomechanically stable construct by reducing the distance between hip joint and implant.[1],[7],[8] PFN prevents lateral translation of the proximal fragment and its intramedullary location at the junction between the nail and lag screw resists the bending force and thus allows early weight-bearing in unstable intertrochanteric femur.[9],[10],[11] However PFN remains comparatively more costly than DHS. The results of review of literatures show no significant advantage of PFN over DHS in terms of complications and functional outcomes.[12],[13] In spite of several benefits of PFN, it is associated with technical failures.[14],[15] With DHS, patient mobilization is comparatively delayed than PFN.

Hence, we conducted a study to compare the result of treatment of these fractures by either of those two methods that is proximal femoral nailing and DHSs.


  Materials and Methods Top


A prospective randomized and comparative study was conducted on the patients admitted in the department of orthopedics of tertiary care center of metropolitan city of India. Our study population mainly consisted 162 patients. The study period was about 24 months, from June 2019 to June 2021. All patients who were in the age group of more than 50 years of either sex with intertrochanteric fracture type 31-A2 (OTA classification) without any systemic or psychiatric illness and patients fit for anesthesia were included in our study. The present study was undertaken in patients more than 50 years of age with the following objectives: to compare the DHS and the proximal femoral nail method of fixation in intertrochanteric fracture of femur in the adults with respect to intraoperative parameters (total duration of surgery, intraoperative blood loss, and intraoperative complication); to compare the functional outcome with respect to union of the fracture, functional return, and complications in the two groups; to determine which ideal implant for the fracture type so as to provide the best results with the least complications; and to study the long-term follow-up of the two groups with respect to any residual impairment of function, chronic infection, and overall tolerability of implant. The important tools of study are.

Clinical

  1. Wound condition
  2. Shortening
  3. Harris hip score (HSS).


Radiological

  1. Union
  2. Amount of collapse
  3. Complication like screw cutout.


After obtaining ethical clearance from the institutional ethics committee, the study was conducted among the study populations after obtaining written informed consent in accordance with the Ethical Standards of the 1964.

Declaration of Helsinki was revised in 2000. The relevant information was collected from all patients including history and general and systemic examination findings. Initial radiograph of the hip joint was conducted besides routine preanesthetic investigations. One hundred sixty-two patients were divided into two groups, 77 in DHS group and 85 in PFN Group. The patients under Group A were treated by proximal femoral nailing and patients under Group B were treated by DHS. Postoperative X-ray is taken in anteroposterior (AP) and lateral view. All drains were removed by 48 h. The wounds were inspected on the 2nd and 5th postoperative day. Stitches were removed on the 13th day. Patients were followed up 6 months, 12 months, and 24 months in which X-ray is taken in AP and lateral view in which union, amount of collapse, and any complication like screw cutout are observed [Figure 1], [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10].
Figure 1: Proximal femoral nail: Preoperative

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Figure 2: Proximal femoral nail: Postoperative

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Figure 3: Proximal femoral nail: 6 months follow up

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Figure 4: Proximal femoral nail: 12 months follow up

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Figure 5: Proximal femoral nail: 24 months follow up

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Figure 6: Dynamic hip screw: Preoperative

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Figure 7: Dynamic hip screw: Postoperative

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Figure 8: Dynamic hip screw: 6 months follow up

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Figure 9: Dynamic hip screw: 12 months follow up

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Figure 10: Dynamic hip screw: 24 months follow up

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  Observations and Results Top


There were 77 (47.5%) patients in the DHS group and 85 (52.5%) patients in the PFN group [Table 1].
Table 1: Distribution of patients according to Implant used

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In the DHS group, 11 (14.3%) patients were in the age group of 50–60 years, 54 (70.1%) were in 61–70 years, 10 (13.0%) were in 71–80 years, and 2 (2.6%) were in >80 years age group. In the PFN group, 29 (34.1%) patients were in the age group 50–60 years, 42 (49.4%) were in 61–70 years, and 14 (16.5%) were in 71–80 years age group. Majority of the patients in our study were in the age group of 61–70 years [Table 2].
Table 2: Distribution of patients according to age in relation to groups

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In the DHS group, 39 (50.6%) patients were females and 38 (49.4%) patients were males. In the PFN group, 45 (52.9%) patients were females and 40 (47.1%) patients were males. In both the groups, there was a female preponderance [Table 3].
Table 3: Distribution of patients according to sex in relation to groups

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In the DHS group, 43 (55.8%) patients sustained injury due to fall and 34 (44.2%) patients sustained due to road traffic accidents. In the PFN group, 45 (52.9%) patients sustained injury due to fall and 40 (47.1%) patients sustained due to road traffic accidents. Majority of the patients in both the groups sustained injury due to fall [Table 4].
Table 4: Distribution of patients according to mode of injury in relation to groups

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In the DHS group, 38 (49.4%) patients had left-sided involvement and 39 (50.6%) patients had right-sided involvement. In the PFN group, 44 (51.8%) patients had left-sided involvement and 41 (48.2%) patients had right-sided involvement [Table 5]. Majority of the patients in both the groups sustained left-sided involvement.
Table 5: Distribution of patients according to side of injury in relation to groups

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In the DHS group, 12 (15.6%) patients had excellent outcomes, 46 (59.7%) had good outcomes, and 19 (24.7%) had fair outcomes. In the PFN group, 24 (28.2%) patients had excellent outcomes, 52 (61.2%) had good outcomes, and 9 (10.6%) had fair outcomes [Table 6]. In majority of the patients in both the groups, the patient's final outcome was good to excellent. The prevalence of fair outcome was more in DHS group.
Table 6: Distribution according to final outcome

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In the DHS group, 65 (84.4%) patients had no complications. Four (5.2%) patients had DVT, 5 (6.5%) patients had shortening, and 3 (3.9%) patients had superficial infection. In the PFN group, 75 (88.2%) patients had no complications. 4 (4.7%) patients had lag screw cutout, 2 (2.4%) patients had shortening, and 4 (4.7%) patients had superficial infection [Table 7]. Slightly higher prevalence of complications was seen in DHS group in comparison to PFN group [Figure 11], [Figure 12].
Table 7: Distribution according to complications

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Figure 11: Screw cut out

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Figure 12: Superficial infection

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In DHS group, shortening and DVT are more common complications, while in PFN group, lag screw cutout and superficial infections are more common complications [Table 8].
Table 8: Comparison of operative time between the two groups

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The mean operative time in DHS group was 111.53 ± 15.39 min and in PFN group, it was 97.15 ± 8.06 min. The difference was found to be statistically significant (P = 0.001), showing a significantly higher operative time in DHS group in comparison to PFN group [Table 9].
Table 9: Comparison of number of radiation shoots between the two groups

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The mean number of radiation shoots in DHS group was 88.59 ± 14.79, and in PFN group, it was 91.94 ± 7.96. The difference was found to be statistically not significant (P = 0.072), showing a comparable mean number of radiation shoots between the two groups [Table 10].
Table 10: Comparison of mean hospital stay between the two groups

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The mean hospital stay in DHS group was 6.77 ± 1.62 days and in PFN group, it was 5.66 ± 0.99 days. The difference was found to be statistically significant (P = 0.001), showing a significantly longer hospital stay in DHS group in comparison to PFN group [Table 11].
Table 11: Comparison of mean duration to full weight-bearing between the two groups

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The mean duration to full weight-bearing in DHS group was 7.89 ± 0.74 weeks and in PFN group, it was 6.80 ± 0.88 weeks. A statistically significant difference is found (P = 0.001), showing a significantly longer duration to full weight-bearing in DHS group in comparison to PFN group [Table 12].
Table 12: Comparison of mean union time between the two groups

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The mean union time in DHS group was 13.62 ± 1.06 weeks and in PFN group, it was 12.71 ± 0.97 weeks. The difference was found to be statistically significant (P = 0.001), showing a significantly longer time taken for union in DHS group in comparison to PFN group.

At 6 months, the mean HHS in DHS group was 64.27 ± 2.81 and in PFN group, it was 66.61 ± 3.38. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 6 months. At 12 months, the mean HHS in DHS group was 76.36 ± 3.97 and in PFN group, it was 79.87 ± 4.88. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 12 months. At 24 months, the mean HHS in DHS group was 83.22 ± 4.85 and in PFN group, it was 87.33 ± 3.83 [Table 13]. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 24 months. At all the three follow-ups, the mean HHS was significantly higher in the PFN group in comparison to the DHS group.
Table 13: Comparison of mean Harris hip score between the two groups

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  Discussion Top


There have been many numbers of studies comparing the outcome of intertrochanteric fracture managed by DHS versus proximal femur nail (P. F. N.). By doing this study, the aim was not only to evaluate outcomes with DHS or proximal femur nail but also to comparethe procedures so that it can be evaluated which procedure is better in terms of patient compliance and long-term recovery. Development of the DHS in the 1960s saw a revolution in the management of unstable fractures. The extensive surgical dissection, blood loss, and surgical time required for this procedure often made it a contraindication in the elderly with comorbidities. The implant also failed to give good results in extremely unstable and reverse oblique fracture.

In the early 1990s, PFN was developed with biomechanical advantages over DHS and has become more prevalent in use. Majority of the patients in our study were in the age group of 61–70 years. A similar finding was observed in a study conducted by Pajarinen et al.[16] The average age of the patient in his study was (PFN/DHS) 80.9 ± 9.1/80.3 ± 10.8.

In our study in the DHS group, 39(50.6%) patients were female and 38(49.4%) patients were males in PFN group 45(52.9%) patients were female and 40(47.1%) were male. In both the groups, there was a female preponderance. In addition to these findings, males are more affected with IT fractures in the study done by Jonnes et al. in which it was noted that out of the 30 patients, 16 patients (53%) were males and 14 patients (47%) females.[3] In contrast, Mundla MKR et al.[17] reported that out of 60 cases, 27 patients (45%) were males and 33 patients (55%) were females. Females are more affected than males. A preponderance of female sex has been reported by Harrington and Johnston, Kuderna et al., Poigenfürst and Schnabl, and Laskin et al.[18],[19],[20],[21],[22] In the DHS group, 43 (55.8%) patients sustained injury due to fall and 34 (44.2%) patients sustained due to road traffic accidents. In the PFN group, 45 (52.9%) patients sustained injury due to fall and 40 (47.1%) patients sustained due to road traffic accidents. Majority of the patients in both the groups sustained injury due to fall. In addition, Mundla MKR et al.[18] found that the most common mode of injury for IT was slip and fall (70%), followed by road traffic accidents (23.3%). Patients with slip and fall mode of injury were older, whereas patients with renal tubular acidosis were younger. In the present study, in the DHS group, 38 (49.4%) patients had left-sided involvement and 39 (50.6%) patients had right-sided involvement. In the PFN group, 44 (51.8%) patients had left-sided involvement and 41 (48.2%) patients had right-sided involvement. Majority of the patients in both the groups sustained left-sided involvement. In the present study, in the DHS group, 65 (84.4%) patients had no complications, 4 (5.2%) patients had DVT, 5 (6.5%) patients had shortening and 3 (3.9%) patients had superficial infection. In the PFN group, 75 (88.2%) patients had no complications, 4 (4.7%) patients had lag screw cutout, 2 (2.4%) patients had shortening, and 4 (4.7%) patients had superficial infection. Slightly higher prevalence of complications was seen in DHS group in comparison to PFN group. The mean operative time in DHS group was 111.53 ± 15.39 min and in PFN group, it was 97.15 ± 8.06 min. The difference was found to be statistically significant (P = 0.001), showing a significantly higher operative time in DHS group in comparison to PFN group. A similar study was conducted by Pan et al.[6] where the average duration of surgery for PFN was 59.16 min which is shorter than the average time required for DHS which is 87.35 min. DHS group requires a significantly longer time for wound closer, probably due to larger incision and extensive dissection as compared to the percutaneous technique of PFN. The mean number of radiation shoots in DHS group was 88.59 ± 14.79 and in PFN group, it was 91.94 ± 7.96. The difference was found to be statistically not significant (P = 0. PFN group, it was 6.80 ± 0072), showing a comparable mean number of radiation shoots between the two groups. The mean hospital stay in DHS group was 6.77 ± 1.62 days and in PFN group, it was 5.66 ± 0.99 days. The difference was found to be statistically significant (P = 0.001), showing a significantly longer hospital stay in DHS group in comparison to PFN group. The mean duration to full weight-bearing in DHS group was 7.89 ± 0.74 weeks and in 88 weeks. The difference was found to be statistically significant (P = 0.001), showing a significantly longer duration to full weight-bearing in DHS group in comparison to PFN group. The mean union time in DHS group was 13.62 ± 1.06 weeks and in PFN group, it was 12.71 ± 0.97 weeks. The difference was found to be statistically significant (P = 0.001), showing a significantly longer time taken for union in DHS group in comparison to PFN group. At 6 months, the mean HHS in DHS group was 64.27 ± 2.81 and in PFN group, it was 66.61 ± 3.38. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 6 months. At 12 months, the mean HHS in DHS group was 76.36 ± 3.97 and in PFN group, it was 79.87 ± 4.88. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 12 months. At 24 months, the mean HHS in DHS group was 83.22 ± 4.85 and in PFN group, it was 87.33 ± 3.83. The difference was found to be statistically significant (P = 0.001), showing a better improvement in HHS in the PFN group in comparison to DHS group at 24 months. Similar finding was observed in a study conducted by Cyril Jonnes et al.[23] compared the outcome of 30 cases with intertrochanteric fractures treated with DHS and PFN. Results showed that the patients treated with PFN started early ambulation as their HHS at 3 month 6 month and 12 month is comparatively better. A similar finding was observed in a study conducted by Chaitanya et al.[24] who compared the results of Intertrochanteric fractures by DHS over proximal femoral nailing. Out 60 patients with intertrochanteric fractures, 30 were treated with sliding hip screw with plate and 30 were treated by an intramedullary hip screw. HHS did not show any significant change in both the group from 1 month to 1 year period. HHSs of DHS and PFN for 6 months and 1 year follow-up were the same (94.2 for DHS, 94.6 for PFN). PFN group had better HHS than DHS group but not statistical significant at 4 weeks to 1 years. similar finding was observed in a study done by bhakat and bandyopadhayay in his study in the dhs group, the 1-month hip score (mean = 24.5) was less than that of the PFN group (mean = 35.23), P < 0.0001, 6-month hip score in DHS (mean = 78.8) was also less than that of PFN (mean = 82.8), P = 0.021. However, this difference disappeared with the two groups after 1 year follow-up being same (DHS – 92.1 and P FN – 92.57). Similar finding was observed in a study done by Dr. Bakshi et al \ in his study the mean HHS in pfn group was 84.25 and in the DHS group, it was 83.45, The results obtained in the current study were comparable to available literature. It was found to be not statistically significant and shows that long-term results of both intramedullary and plate fixation are almost similar. But at 6 months, most of cases belong to excellent and good groups are of PFN, but in DHS, most of cases belong to good and fair group of HHS.


  Conclusion Top


Both proximal femoral nail and DHS are excellent method for surgical fixation of intratrochanteric femur fractures. Both of these methods yield in comparable results in terms of functional outcomes (union of the fracture, return to functional activity, morbidity, and implant failure) and intraoperative parameters (total surgery duration, detailed intraoperative research regarding intraoperative blood loss and other intraoperative complication); however, proximal femoral nail holds edge over DHS in terms of lesser blood loss, operative time, early ambulation, and less incidence of complication. However, furthermore studies are recommended for more outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar R, Singh RN, Singh BN. Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture femur. J Clin Orthop Trauma 2012;3:28-36.  Back to cited text no. 1
    
2.
Hong JY, Suh SW, Park JH, Shin YS, Yoon JR, Yang JH. Comparison of soft-tissue serum markers in stable intertrochanteric fracture: Dynamic hip screw versus proximal femoral nail – A preliminary study. Injury 2011;42:204-8.  Back to cited text no. 2
    
3.
Jonnes C, Sm S, Najimudeen S.Type II Intertrochanteric Fractures: Proximal Femoral Nailing (PFN) Versus Dynamic Hip Screw (DHS). Arch Bone Jt Surg. 2016;4:23-8.  Back to cited text no. 3
    
4.
Bhakat U, Bandyopadhayay R. Comparitive study between proximal femoral nailing and Dynamic hip screw in intertrochanteric fracture of femur. Open J Orthop 2013;3:291-5.  Back to cited text no. 4
    
5.
Bakshi AS, Kumar P, Brar BS. Comparative study between DHS and PFN in intertrochanteric fractures of femur. Int J Orthop Sci 2018;4:259-62.  Back to cited text no. 5
    
6.
Pan XH, Xiao DM, Lin BW. Dynamic hip screws (DHS) and proximal femoral nails (PFN) in treatment of intertrochanteric fractures of femur in elderly patients. Chin J Orthop Trauma 2004;7:785-9.  Back to cited text no. 6
    
7.
Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br 1991;73:330-4.  Back to cited text no. 7
    
8.
Khan IA. O1013 to nail or to screw? J Bone Joint Surg Br 2004;86:225-6.  Back to cited text no. 8
    
9.
Valverde JA, Alonso MG, Porro JG, Rueda D, Larrauri PM, Soler JJ. Use of the Gamma nail in the treatment of fractures of the proximal femur. Clin Orthop Relat Res. 1998:56-61.  Back to cited text no. 9
    
10.
Pavelka T, Matejka J, Cervenková H. Complications of internal fixation by a short proximal femoral nail. Acta Chir Orthop Traumatol Cech 2005;72:344-54.  Back to cited text no. 10
    
11.
Suckel AA, Dietz K, Wuelker N, Helwig P. Evaluation of complications of three different types of proximal extra-articular femur fractures: Differences in complications, age, sex and surviving rates. Int Orthop 2007;31:689-95.  Back to cited text no. 11
    
12.
Reindl R, Harvey EJ, Berry GK, Rahme E, Canadian Orthopaedic Trauma Society (COTS). Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: A prospective randomized controlled trial. J Bone Joint Surg Am 2015;97:1905-12.  Back to cited text no. 12
    
13.
Siddiqui YS, Khan AQ, Asif N, Khan MJ, A Sherwani MK et al. Modes of failure of proximal femoral nail (PFN) in unstable trochanteric fractures. MOJ Orthop Rheumatol. 2019;11:7-16.  Back to cited text no. 13
    
14.
Bienkowski P, Reindl R, Berry GK, Iakoub E, Harvey EJ. A new intramedullary nail device for the treatment of intertrochanteric hip fractures: Perioperative experience. J Trauma 2006;61:1458-62.  Back to cited text no. 14
    
15.
Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN) – A minimal invasive treatment of unstable proximal femoral fractures: A prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand 2003;74:53-8.  Back to cited text no. 15
    
16.
Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005;87:76-81.  Back to cited text no. 16
    
17.
Mundla MKR, Shaik MR, Buchupalli SR, Chandranna B. A prospective comparative study between proximal femoral nail and dynamic hip screw treatment in trochanteric fractures of femur Int J Res Orthop. 2018;4:58-64.  Back to cited text no. 17
    
18.
Harrington KD, Johnston JO. The management of comminuted unstable intertrochanteric fractures. J Bone Joint Surg Am 1973;55:1367-76.  Back to cited text no. 18
    
19.
Shen HM, Liang CW, Fan YQ. The clinical study of the treatment of intertrochanteric fractures in the elderly with DHS, Gamma nail and PFN. Chin J Clin Med 2007;2:226-8.  Back to cited text no. 19
    
20.
Poigenfürst J, Schnabl P. Multiple intramedullary nailing of pertrochanteric fractures with elastic nails: Operative procedure and results. Injury 1977;9:102-13.  Back to cited text no. 20
    
21.
Laskin RS, Gruber MA, Zimmerman AJ. Intertrochanteric fractures of the Hip in the elderly. Clin Orthop 1979;101:110-9.  Back to cited text no. 21
    
22.
Jonnes C, Sm S, Najimudeen S. Type II intertrochanteric fractures: Proximal femoral nailing (PFN) versus dynamic hip screw (DHS). Arch Bone Jt Surg 2016;4:23-8.  Back to cited text no. 22
    
23.
Chaitanya M, Mittal A, Rallapalli R, Biju R, Siva Prasad Y. Comparision of dynamic hip screw and plate with proximal femoral nail in trochanteric fractures of femur. J Dent Med Sci 2015;14:73-82.  Back to cited text no. 23
    
24.
Qidwai SA, Singh R, Mishra AN, Trivedi V, Khan AA, Kushwaha SS, et al. Comparative study of functional outcome of the intertrochanteric fracture of femur managed by Dynamic hip screw and proximal femoral nail. Natl J Clin Orthop 2019;3:26-30.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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