Trochanteric fractures are among the most common injuries encountered in orthopaedic practice, predominantly affecting patients over sixty years of age1. These fractures occur three to four times more frequently in women, largely due to osteoporosis, with a trivial fall being the most common mechanism of injury. In elderly individuals, proximal femoral fractures usually result from minimal to moderate trauma acting on osteoporotic bone, whereas in younger patients they are typically caused by high-energy trauma. Pathological fractures also contribute significantly and are often characterized by unusual fracture patterns2.Historically, trochanteric fractures received limited attention because they occur through cancellous bone with excellent blood supply and were thought to heal satisfactorily without operative intervention. However, conservative treatment often resulted in malunion with varus and external rotation deformities, leading to limb shortening, abnormal gait, and a high mortality rate due to complications of prolonged immobilization.3 These complications—such as pressure sores, urinary tract infections, pneumonia, joint stiffness, deep vein thrombosis, pulmonary embolism, and general debility—collectively constitute “fracture disease” and significantly increase morbidity and mortality.Although conservative methods like traction and plaster immobilization are still practiced in resource-limited settings due to cost constraints and lack of fixation instruments, surgical treatment has become the standard of care. With improved availability of implants and indigenous production in India, operative management is now widely adopted.4 The primary challenge in managing trochanteric fractures is achieving and maintaining stability, defined as the ability of the fixation construct to resist muscle forces and gravitational stresses that tend to produce varus collapse. Both intrinsic factors (osteoporosis, comminution) and extrinsic factors (quality of reduction, implant choice, and surgical technique) influence fixation success.Surgery allows early mobilization with controlled weight bearing, which is essential in elderly patients. Various implants have been used, including the dynamic hip screw (DHS), proximal femoral nail (PFN), PFNA, DCS, blade plates, and proximal femoral locking plates. Sliding devices like DHS are effective in stable fractures but may fail in unstable or comminuted patterns due to excessive collapse, screw cut-out, or implant breakage. Intramedullary devices such as PFN offer biomechanical advantages by positioning the implant closer to the mechanical axis, reducing the bending moment and allowing load sharing rather than load bearing3,4.PFN provides better rotational stability, shorter lever arm, less blood loss, and faster surgery, but complications such as screw cut-out and the “Z-effect” have been reported. To overcome these limitations, PFNA-2 (helical blade proximal femoral nail) was introduced5,6. The helical blade compacts cancellous bone, increases bone-implant contact, provides superior rotational and angular stability, and demonstrates better purchase in osteoporotic bone. By eliminating the need for a separate derotation screw and minimizing bone reaming, PFNA-2 improves fixation stability and functional outcomes, particularly in unstable intertrochanteric fractures7,8. AIM The aim of this study is to compare and evaluate the long-term radiological and functional outcomes of dynamic hip screw (DHS) versus proximal femoral nail antirotation-2 (PFNA-2) fixation in the management of two-part (AO/OTA 31-A1) intertrochanteric femoral fractures in adult patients.

This was a prospective randomized comparative study conducted to evaluate and compare dynamic hip screw (DHS) fixation with proximal femoral nail antirotation-2 (PFNA-2) in the treatment of intertrochanteric femoral fractures in adult and elderly patients . The study was carried out in the orthopaedic wards of SMS Medical College, Jaipur, Rajasthan, over a period extending from April 2018 to June 2019. A total of 80 patients fulfilling the eligibility criteria were enrolled and randomly allocated into two equal groups. Group I consisted of 40 patients treated with PFNA-2, while Group II included 40 patients treated with DHS. Patients were included in the study if they had a closed unilateral intertrochanteric fracture of the femur, classified as AO/OTA 31-A1, belonged to the adult age group between 50 and 80 years or above, and were willing to provide informed consent for surgical intervention. Only patients without associated injuries and those who were able to ambulate independently without walking aids prior to the fracture were selected to ensure uniform functional baseline status. Patients were excluded from the study if they had open or pathological intertrochanteric fractures, fractures associated with vascular injury or metastatic disease, or if they were medically or anaesthetically unfit for surgery. Additionally, patients who refused consent for operative treatment were also excluded.

Table 1 – Age distribution of study groups Age group (years) PFNA2 DHS Total N % N % N % 50 - 59 6 15 8 20 14 17.5 60 - 69 17 42.5 14 35 31 38.75 70 - 79 10 25 15 37.5 25 31.25 ≥80 7 17.5 3 7.5 10 12.5 Total 40 100 40 100 80 100 Mean± SD 69.22 ± 9.61 66.65 ± 8.07 67.94 ± 8.82 In table no. 1 shows the maximum number of patients in the range of 60 to79 years of age in both groups, and in group I seven patients' ages are above 80 years and in group II three patients' ages are above 80 years. Table 2: Comparison of mean size of incision (cm) among study groups Group N Mean Std. Deviation PFNA2 40 6.93 1.56 DHS 40 15.4 1.72 t-test - t = -23.078 with 78 degrees of freedom; P < 0.001 (S) As shown in table no 2,there is significant difference between two groups in terms of size of incision.In PFNA2 fixation size of incision is significantly less than DHS fixation. Table 3: Comparison of mean duration of surgery (min) among study groups Group N Mean Std. Deviation PFNA2 40 62.6 11.74 DHS 40 102.1 8.18 t-test - t = -17.473 with 78 degrees of freedom; P < 0.001 (S) The above table no. 3 shows Mean +Sd of duration of surgery in 2 groups of subject. The mean duration of surgery in group I and group II was 62.60 + 11.74 min and 102.1+ 8.18 min respectively. The mean duration of surgery of group II was found to be higher as compare to group I subjects These two mean duration of surgery differ highly significantly i.e. P < 0.0001. Table 4: Comparison of mean blood loss (ml) among study groups Group N Mean Std. Deviation PFNA2 40 137.4 26.44 DHS 40 224.8 50.82 t-test - t = -9.649 with 78 degrees of freedom; P < 0.001 (S) Table no.4 shows blood loss during surgery that was mean 137.4 ml in 40 patients of group I.Mean 224.8 ml blood loss was present in 40 patients of group II. Mean±sd was 137.4±26.44 & 224.8±50.82 in group I & group II respectively which is highly significant (p<.001). Table 5: Comparison of mean time to ambulation (months) among study groups Group N Mean Std. Deviation PFNA2 40 1.32 0.26 DHS 40 2.57 0.48 t-test - t = -14.504 with 78 degrees of freedom; P < 0.001 (S) Table no 10 shows mean time of ambulance in group I and group II is 1.32 and 2.57 respectively which is highly significant. In PFNA2 fixation, as it is an intramedullary device patients can be ambulated early as compared to DHS fixation which is an extramedullary implant Table 6 – Distribution of study subjects according to Singh’s index Singh’s index PFNA2 DHS Total N % N % N % 2 6 15 6 15 12 15 3 20 50 19 47.5 39 48.75 4 14 35 12 30 26 32.5 5 0 0 3 7.5 3 3.75 Total 40 100 40 100 80 100 Table no 6 shows that the majority of patients included in study having singh`s index 3 and 4 were fixed with PFNA2 and DHS. We found that group I with lower singh`s index gave good results as compared to group II. In osteoporotic patients PFNA2 gives good results. Table 7 – Incidence of complications among study groups Complications PFNA2 DHS P value N % N % Screw cut out 1 2.5 3 7.5 0.615 Lateral cortex fracture 1 2.5 3 7.5 0.615 Non union 1 2.5 2 5 1.000 Varus collapse 0 0 2 5 0.494 Implant failure 1 2.5 4 10 0.359 Wound infection 1 2.5 5 12.5 0.201 Table no 14 shows difference in complications between two groups which concludes that due to intramedullary fixation, shorter incision size and fixation with help of outer zig the PFNA2 fixation has less complication rate than DHS fixation. Table 8– Distribution of study subjects according to LLD LLD PFNA2 DHS Total N % N % N % 0 32 80 31 77.5 63 78.75 1 6 15 2 5 8 10 2 2 5 3 7.5 5 6.25 3 0 0 3 7.5 3 3.75 4 0 0 1 2.5 1 1.25 Total 40 100 40 100 80 100 The table is showing that 80% patients of group I and 77.5% of group II had no LLD (limb length discrepancy). Maximum shortening of (4 cm) was not found in any patient of group I, whereas, in group II, 1 patients showed max. Shortening of 4 cm. Table 9– Distribution of study subjects according to need for re-surgery Re-surgery PFNA2 DHS Total N % N % N % Not required 37 92.5 34 85 71 88.75 Required 3 7.5 6 15 9 11.25 Total 40 100 40 100 80 100 Table shows that 9 patients in group I and 6 patients in group II required re-operation in terms of minor or major which was not significant in relation to final outcome. Table 10: Comparison of mean Harris Hip Score among study groups Group N Mean Std. Deviation PFNA2 40 83.55 4.25 DHS 40 80.44 4.49 t-test - t = 3.185 with 78 degrees of freedom; P = 0.002 (S) The table shows Harris' hip score at final follow up was 83.55 in group I and 80.44 in group II which is significant.

Most of the patients in the present study were from an age group of more than 60 years. Mean age in years for group I (operated by PFNA2) 69.22 and Mean age in years for group II (operated by DHS) was 66.65.White et al9 did a study for elderly patients after fracture of hip in the 1980`s and concluded that the average age for trochanteric fractures is 75.4 years. Type of fractures In present study, the cases of stable intertrochanteric femur fracture were taken. 37 (46.25%) cases were of 31A1.2 type, 30(37.5%) cases were of 31A1.1 type and 13(16.25%) cases were of 31A1.3 typeAccording to M. Evans 10 the Inter trochantric fractures are considered as stable or unstable depending upon the integrity of the posteromedial cortex. Fractures with intact posteromedial cortex are considered as stable fractures while fractures with loss of posteromedial cortex are considered as unstable fractures. The posteromedial cortex constitutes mainly the lesser trochanter. The length of the incision in the DHS group ranged from 14 cms to 22 cm with a mean of 15.4 cm as compared to mean of only 6.93cm in the PFNA2 group. The smaller incision in the PFNA2 group meant that there was less intra operative blood loss. This was comparable to the study conducted by Baumgaertner et al. 11 The duration of surgery in the DHS group ranged from 90 minutes to 130 minutes with a mean of 102.1 minutes. The duration of surgery in the PFNA2 group ranged from 45 minutes to 90 minutes with a mean of 62.6 minutes. The difference in the operative times in both groups was found to be highly significant and we attributed this difference to the smaller incisions in the PFNA2 group. Baumgaertner et al. 11 also found that the surgical times were 10 per cent higher in the DHS group in their series. The DHS patients had significantly more blood loss intra-operative compared to PFNA2 group. In another study Jacobs RR et al12 found a difference in the amount of blood loss between intramedullary and extramedullary fixation. 38 patients ambulated within 1-2 months in the PFNA2 group while in DHS 32 patients ambulated in 2-3 months. This concludes that with intramedullary fixation patients can be ambulated earlier than extramedullary implants thus minimizing the complication of prolonged recumbency.This is also found by Mert kumbaraii et al 13 in their study that those patients with intramedullary fixation can be ambulated early than extramedullary fixation because intramedullary device acts as internal splints. INFECTION: Superficial wound infection at suture line was seen in 5 cases who were operated by DHS, at the suture site. This may be attributed to more soft tissue exposure, which is more in cases operated by DHS & low immunity status of patient as the patient was of asthenic build and belonging to low socioeconomic status.In all these patients treatment of IV Antibiotics was prolonged, for 10 days. In our protocol we instituted IV antibiotics for 5 days. The only complications we encountered in this series were screw back out, lateral cortex fracture and wound infection. There was no significant difference between the two groups with regards to time of fracture union as all fractures united at 14-18 weeks in case of DHS and 14-16 weeks in case of PFN. In our study 80% patients of group I and 77.5% of group II had no LLD (limb length discrepancy). Maximum shortening of (4 cm) was not found in any patient of group I, whereas, in group II, 1 patient showed max. shortening of 4 cm. In our study one patient of PFNA2 fixation had a hip screw back out due to poor technical performance causing implant failure which was re-operated while in DHS group there were 3 cases of screw back out due to poor purchase in bone causing implant failure. Harris hip score is used in our study to evaluate the functional outcome and comparison between two groups. At last follow-up mean Harris hip scores in the PFNA2 group are significantly superior to that of the DHS group. The mean HHS at 6 months follow up was 83.55 in PFNA2 and 80.44 in DHS. The results were excellent in 7 patients (5 in PFNA2 and 2 in DHS), good in 56 patients (30 in PFNA2 and 26 in DHS), fair in 13 patients (4 in PFNA2 and 9 in DHS), and poor in 4 patients (1 in PFNA2 and 3 in DHS).

In conclusion, our study revealed more duration of surgery, more blood loss, greater size of incision and comparatively greater number of radiographic complications in association with DHS than PFNA2 fixation in type 31A1 IFF`s in adults. In addition, DHS fixation had poorer performance in terms of the postoperative HHS than did PFNA2 fixation during follow up. Based on these findings we conclude that the PFNA2 device is a better implant than the DHS for type 31A1 intertrochanteric femoral fractures.

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