ORIGINAL ARTICLE

Comparison of Dynamic Hip Screw and Proximal Femoral Nail

in Intertrochanteric Femur Fractures.
Raja Adnan Ashraf1, Ahmed Javed2, Kamran Asghar3, Ayesha Amin4, Sohail Iqbal Sheikh5

1,2,5
Department of Orthopaedics,
ABSTRACT
Pakistan Railway General Hospital, Objective: To compare the radiological and functional outcome of stable
Islamic International Medical intertrochanteric femur fractures treated with Dynamic Hip Screw(DHS)
College, Rawalpindi
3
Department of Orthopaedics Fauji and Proximal Femoral Nail(PFN).
Foundation Hospital Rawalpindi Methods: This randomized controlled trial was conducted in Department
4
Department of Radiology Benazir of Orthopaedics Pakistan Railway General Hospital Rawalpindi from 20th
Bhutto Hospital Rawalpindi March 2018 and 19th March 2020. All patients with stable intertrochanteric
fractures fulfilling the inclusion criteria were randomly allocated to group A
(DHS) and B (PFN). Patients were reviewed radiologically for healing and
Authorship and contribution functional assessment was done with Harris Hip Score (HHS) and graded
Declaration: as poor (score <70), fair( 70 to 80),good( 80 to 90) and excellent(90 to
Each author of this article fulfilled
ALL 4 Criteria of Authorship:
100). Comparison of outcomes in both groups were done at 3rd, 6th and
1. Conception and design or 12th month and P value was calculated with independent sample t test and
acquisition of data, or analysis & Chi-square test. P<0.05 was considered significant.
interpretation of data. Results: The total number of patients were 60.They were equally and
2. Drafting the manuscript or
revising it critically for important randomly divided into group A and B with 30 patients in each. The mean
intellectual content. age of group A was 59.20±5.94 years and group B was 58.80±6.67 years.
3. Final approval of the version for Male patients were 19(63.33%) in group A and 17(56.66%) in group B.
publication. Female patients were 11(36.66%) in group A and 13(43.33%) in group B.
4. All authors agree to be
responsible for all aspects of The mean radiological union time in group A was 13.4±3 weeks while in
their research work. group B 13.5±5 weeks (P>0.05). The Harris Hip Score(HHS) at 3 months
follow up was 53.50±3.91(poor) and 34.93±3.98(poor) in group A and B
respectively.(P< 0.05) At 6 months group A had HHS 89.37±4.03(good)
and B 81.87±4.10.( P< 0.05)At one year HHS was 93.73±1.99(excellent)
and 92.57±2.30(excellent) in group A and B.( P>0.05).
Conclusion: For stable intertrochanteric fractures both DHS and PFN
yielded similar outcome in terms of radiological union. The short term
functional outcome of both DHS and PFN at 3rd and 6th was poor and good
but DHS had statistically better score than PFN.At one year follow up both
DHS and PFN had similar excellent functional outcome but without any
statistically significant difference in the score.
Keywords: Dynamic hip screw, Harris hip Score, Intertrochanteric
fracture, Proximal femoral nail.

Ashraf RA, Javed A, Asghar K, Amin A, Sheikh SI.

Corresponding author: This article may Comparison of Dynamic Hip Screw and Proximal Femoral
Raja Adnan Ashraf be cited as:  Nail in Intertrochanteric Femur Fractures. J Pak Orthop
E-mail: [email protected] Assoc 2021;33(3):

INTRODUCTION fractures.4 Fracture union with minimum complications

and early mobilization is the main aim of treating
Hip fractures are a source of great concern and a
intertrochanteric fractures.5 Although Dynamic Hip
significant health problem worldwide.1,2 It has been
Screw (DHS) is the most commonly used implant to
estimated that by the year 2050 Asian population
treat stable intertrochanteric fractures,6 the proximal
would account for more than half of hip fractures
femoral nail (PFN) has been increasingly favored in
owing to rise in life expectancy.3 Intertrochanteric
recent times7 because of biomechanically more stable
fractures account for almost half of the elderly hip
design.8 Reports of PFN failures however, have been

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Comparison of Dynamic Hip Screw and Proximal Femoral Nail in Intertrochanteric Femur Fractures ?????

reported in literature mainly due to technical A uniform post operative rehabilitation protocol
errors.9,10 Many studies had compared the outcome of under the supervision of a qualified physiotherapist
DHS and PFN in unstable intertrochanteric fractures was started on the first post operative day. All patients
but comparisons in stable intertrochanteric fractures were encouraged to perform frequent Isometric
are lacking.11 Quadriceps and Abductor exercises. Patients in both
The objective of our study was to compare the groups were allowed non weight bearing with walker
radiological and functional outcome of stable or crutches on second post operative day. The post
intertrochanteric femur fractures treated with operative follow up visits were scheduled at 2 weeks,3
Dynamic Hip Screw (DHS) and Proximal Femoral Nail months, six months and one year. Radiological
(PFN). We hypothesized that better radiological and assessment of fracture healing was done by noticing
functional outcome would be achieved with DHS callus on AP and lateral radiograph. Functional
rather than with PFN for stable intertrochanteric outcome was assessed with Harris Hip Score(HHS).14
fractures. The HHS was graded as poor(score <70),fair( 70 to
80),good( 80 to 90) and excellent(90 to 100).
METHODS We analysed our data with SPSS version 24.
Frequencies and percentages were calculated for
We conducted this randomized controlled trial in
qualitative variables while mean and standard
Department of Orthopaedics Pakistan Railway General
Hospital Rawalpindi from 20th March 2018 and 19th
deviation for quantitative variables. Comparison of
March 2020.All adults patients of either gender and important demographic features and outcomes in both
age with stable intertrochanteric fracture femur( groups were done at 3rd,6th and 12th month and P
(AO/OTA type 31-A1)12 presented to the Accidents value was calculated with independent sample t test
and Emergency or OPD of our hospital within one and Chi-square test. P<0.05 was considered
week of sustaining the fractures were included in this significant. CONSORT(Consolidated Standards of
study. All patients with pathological fractures, open Reporting Trials) guidelines by Moher et al 15 have
fractures, segmental fractures, previous hip surgery, been followed while conducting and reporting this
bilateral fractures and polytrauma patients were trial. The data was presented in tables where
excluded. Complete history, physical examinations and appropriate.
relevant investigations were ordered in all patients.
The study protocols were approved by the hospital RESULTS
Ethical Committee. Informed written consent was A total of 79 patients were assessed for eligibility of
obtained from all participants of the study. Patients this study and 64 were enrolled in the study based
were randomly divided into group A(DHS) and group upon inclusion and exclusion criteria as shown in
B(PFN) through lottery method. CONSORT flow chart (Fig I). Final analysis included 30
Surgical Techniques patients in group A (DHS) and 30 in group B (PFN).
All the surgeries were performed under spinal or The base line demographic variables like age, gender
general anaesthesia on radiolucent table and image and side of surgery were identical in both groups
intensifier control. The same surgical team performed (Table I). PFN group had smaller incision, less
all the surgeries following the same standard surgical operative time and less amount of intraoperative blood
techniques for DHS and PFN. Fractures were reduced loss than DHS group (P <0.05). The mean radiological
closely. A 5cm linear lateral incision was used distal to union time in group A was 13.4±3 weeks while in
the greater trochanter at appropriate place for group B 13.5±5 weeks (P 0.06).No non union was
exposure of DHS(®Esmeco) entry point. We used a 4 reported. The Harris Hip Score(HHS) at 3 months
hole side plate of 135° angle and appropriate size lag follow up was 53.50±3.91(poor) and
screw and 4.5 mm cortical screws for application of 34.93±3.98(poor) in group A and B respectively(P
DHS. The lag screw position was maintained 0.002). At 6 months group A had HHS
posterioinferior in the neck of femur and the tip apex 89.37±4.03(good) and B 81.87±4.10.( P 0.001)At one
distance(TAD) was maintained <25 mm. For PFN a 5 year HHS was 93.73±1.99(excellent) and
cm incision just proximal to the tip of greater 92.57±2.30(excellent) in group A and B.( P
trochanter was used for entry point. PFN(®Rech) of 0.30).Superficial skin infection was noted in 2(6.66%)
135° neck shaft angle and 240mm length with distal patients in DHS group and 1(3.33%) patient in PFN
locking was used in all cases. At the end of surgery all group but all resolved with wound dressing and
swabs were weighted and blood loss was determined antibiotics. DHS cut out was documented in 1(3.33%)
as per Lee method.13 patient and PFN breakage in 1(3.33%) patient. Both

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Comparison of Dynamic Hip Screw and Proximal Femoral Nail in Intertrochanteric Femur Fractures ?????

were treated with revision surgery. No mortality was

noted in our series.

Fig. I: Enrollment of our study participants as per CONSORT guidelines.

Table 1: Comparison of baseline demographics and outcome variables of both groups.

Demographic/outcome variable Group A (DHS) (n=30) Group B (PFN) (n=30) P value
Age(years)±SD 59.20±5.94 58.80±6.67
Gender
Male 19( 63.33% 17( 56.66%) 0.40
Female 11(36.66%) 13(43.33% ) 0.52
Surgery side
Right 20(66.6%) 17(56.66) 0.32
Left 10(33.33%) 13(43.33) 0.75
Incision length(cm) 7.62±0.91 4.71±0.74 0.001
Duration of surgery(min) 70.50±6.86 52.83±5.67 0.02
Intraoperative blood loss(ml) 224.33±43.44 122.33±33.18 0.01
Radiological union(weeks) 13.4±3 13.5±5 0.06

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Comparison of Dynamic Hip Screw and Proximal Femoral Nail in Intertrochanteric Femur Fractures ?????

DISCUSSION increased frequency of re operations in PFN group

than in DHS group. Similarly Harish17 treated 30
We treated 30 patients with DHS and 30 with PFN. Our
patients with DHS and PFN and concluded that PFN
results revealed that the mean radiological union time
was better than DHS but technically demanding.
in DHS group was 13.4±3 weeks while in PFN group
Karanam and colleagues 18compared the outcome of
13.5±5 weeks. (P>0.05) ). The Harris Hip Score (HHS)
20 patients treated with DHS and 20 with PFN. Stable
at 3 months follow up was 53.50±3.91(poor) and
intertrochanteric fractures were 23 (57.5%) and
34.93±3.98 (poor) in group A and B respectively(P
unstable 17 (42.5%).They concluded that patients
0.002). At 6 months group A had HHS
with unstable intertrochanteric fractures had
89.37±4.03(good) and B 81.87±4.10.( P 0.001)At one
significantly better functional outcome when treated
year HHS was 93.73±1.99(excellent) and
with PFN while for stable intertrochanteric fractures no
92.57±2.30(excellent) in group A and B.( P
significant difference in outcome was found when
0.30).Kamboj 11 treated 42 patients with DHS and PFN
these fractures were fixed with DHS or PFN. Bhakat19
and noted radiological union at 15.84±1.4 weeks in
treated 31% stable intertrochanteric fractures, 58%
DHS group while in PFN group the average radiological
unstable and 11% reverse oblique type fractures with
union time was 14.30±1.38 weeks( P > 0.05).The
DHS and PFN. The mean HHS at one month in DHS
functional outcome as per HHS at 6 months was 77.2
group was 24.5 while in PFN it was 35.2. (P 0.0001).
in DHS group and 86.9 in PFN group(P 0.03).These
At 6th month HHS 78.8 in DHS group and 82.8 in PFN
authors concluded that PFN was associated with less
group(P 0.02).At one year DHS had HSS of 92.1 and
per operative blood loss and post operative
PFN 92.5 (P 0.4). These authors concluded that PFN
complications. Patients with PFN were earlier
performed well in old osteoporotic and unstable
mobilized and had better HHS than DHS. This study
intertrochanteric fractures while DHS had good
however had small sample size and short follow up
outcome in younger patients. Similar to Bhakat results,
period of only six months. Sharma16 treated 60
Kumar and Singh20 treated 50 patients with mean age
patients of stable intertrochanteric fractures with DHS
62.3 years with DHS and PFN. At 1 month and 3 month
and PFN. The HHS was 53.4 in DHS and 47.6 in PFN
PFN had better functional outcome in terms of better
at 3 months(P <0.01).At 6 months HHS was 88.7 in
HHS than DHS but long term outcome of both implants
DHS and 82.2 in PFN(P< 0.01).At 2 years HHS was
were the same. These authors concluded that elderly
94.2 in DHS and 94.0 in PFN group(P 0.79).Sharma
osteoporotic patients with unstable fractures did well
had concluded that although PFN had less
with PFN while young patients with stable
complications related to the surgical wound, chances
intertrochanteric fractures were suitable for DHS.
of technical errors were more which could lead to

Table II: Results of Zhang et al 23

meta analysis comparing DHS and PFN.
S Year of Operation Time(min) Blood Loss(ml) Wound Complications Re Mortality
No publicati operation
Author on of DHS PFN PFN
Name study DHS PFN DHS PFN Even Total Events Total DHS PF DHS
ts N
1 Parker M24 2012 46±12.3 49±12.7 NA NA 09 300 06 300 13 05 85 85
2 Huang ZY25 2010 52.4±18. 50.5±20.2 225 202 03 48 04 48 00 00 00 00
3
3 Liu XW26 2009 53.4±8.3 46.5±20.5 152 136 02 65 06 69 00 00 00 00
4 Pajarinen JJ27 2005 45 (20– 55 (35– 357±495 320±3109 05 40 04 40 11 08 11 10
105) 200)
5 Giraud B28 2005 42 35 325 410 NA NA NA NA 00 03 01 02
6 Papasimos 2005 59.2 71.2 (60– 282.4 265 0o 54 00 54 03 05 01 01
S29 (40–100) 240)
7 Pan X30 2004 87.35± 59.16± 489.88± 273.33±12 04 34 02 30 00 00 00 00
21.29 16.92 177.90 0.8
8 Saudan M31 2002 65± 26 64 ±33 NA NA 10 106 11 100 06 11 17 21
9 Our study 2021 59.20± 58.80±6. 224.33 122.33± 02 30 01 30 01 01 00 00
5.94 67 ±43.44 33.18

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 ORIGINAL ARTICLE
Chandy and Saju21 treated 35 stable and 13 3. Cheung CL, Ang SB, Chadha M, Chow ES, Chung
unstable intertrochanteric fractures with DHS while YS, Hew FL, et al. An updated hip fracture
PFN was used for fixation of 34 stable and 14 unstable projection in Asia: The Asian Federation of
intertrochanteric fractures. DHS produced good Osteoporosis Societies study. Osteoporos
functional outcome in stable fractures only. Overall Sarcopenia 2018;4(1):16-21.
PFN had better radiological outcome and better HHS 4. Tay E. Hip fractures in the elderly: operative
than DHS in all follow up visits. Zaho et al22 treated 32 versus nonoperative management. Singapore
A1 fractures with DHS and 12 A1 with PFN and noted Med J 2016;57(4):178-81.
the therapeutic effect of both the implants was the 5. Li J, Zhang L, Tang P. Evolving concept in
same. Zhang et al23 conducted a meta-analysis of 8 treatment of intertrochanteric fractures and
studies comparing DHS and PFN in stable and unstable development of internal fixation devices.
intertrochanteric fractures with mean follow up period Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.
of 9.6 months.(table II)This meta analysis indicated a 2019;33(1):1-7.
significantly shorter operative time, smaller incision 6. Zhang WQ, Sun J, Liu CY, Zhao HY, Sun YF.
and less intra operative blood loss in PFN than in DHS. Comparing the Intramedullary Nail and Extra
This was exactly our findings.According to Zhang et al medullary Fixation in Treatment of Unstable
a higher(but not significant) infection rate was noted Intertrochanteric Fractures. Sci Rep
in DHS group. A higher(but not significant) re surgery 2018;8(1):23-29.
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regarding mortality rates. We had not documented Nailing (PFN) Versus Dynamic Hip Screw (DHS).
any mortality in our series. Arch Bone Jt Surg 2016;4(1):23-8.
Our study had few limitations. Our sample size 8. Gadegone WM, Shivashankar B, Lokhande V,
was small and our follow up period was only one year. Salphale Y. Augmentation of proximal femoral
We recommend further studies to address these nail in unstable trochanteric fractures. SICOT J
limitations and to further verify our results. 2017;3:12-18.
9. Pires RES, Santana EO, Santos LEN, Giordano V,
CONCLUSION Balbachevsky D, dos Reis FB. Failure of fixation
of trochanteric femur fractures: clinical
For stable intertrochanteric fractures both DHS and
recommendations for avoiding Z-effect and
PFN yielded similar outcome in terms of radiological
reverse Z-effect type complications. Patient
union. The short term functional outcome of both DHS
Safety in Surgery 2011; 5(1):1-6.
and PFN at 3rd and 6th was poor and good but DHS had
10. Pavelka T, Matejka H, Cervenkova H.
statistically better score than PFN. At one year follow
Complications of internal fixation by a short
up both DHS and PFN had similar excellent functional
proximal nail. Acta Chirurgiae Orthopaedicae et
outcome but without any statistically significant
Traumatologiae Cechoslovaca 2005;72(6):344-
difference in the score. The operating surgeon
354.
therefore can use any of the two implants for stable
11. Kamboj P, Sharma PK, Jesadia B, Arora S, Siwach
intertrochanteric fractures.
RC. A comparative prospective study of
osteosynthesis in intertrochanteric fractures,
Conflict of Interest: None
using dynamic hip screw (DHS) and proximal
Grants/Funding: None
femoral nailing (PFN). Int J Orthop Sci
2019;5(2):954-960.
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