1. Injury, Int. J. Care Injured 45S5 (2014) SX–SX
Introduction
Hip fracture is a severe and common injury that occurs
predominantly in the elderly [1-5]. It is the leading cause of
morbidity and mortality in this population [6-10]. The incidence
of intertrochanteric fractures of the femur is race- and sex-
dependent, and varies across countries. In the United States, the
annual incidence rate of such fractures is approximately 63 per
100,000 in elderly females and 34 per 100,000 in elderly males
[11]. As the population ages, the number of hip fractures tends to
increase. In 2040, an estimated 512,000 hip fractures will occur
in the U.S. population alone, at a cost of USD 16 billion [6]. These
fractures have a long-term impact on the quality of life of patients
and their carers. One-year mortality rates are high, ranging
from 14% to 47% across studies [1]. The functional outcomes of
patients with intertrochanteric fractures can be surprisingly
poor, and many become limited to ambulation within the home
and dependent on carers for the activities of daily living [11].
The dynamic hip screw (DHS) fixation device is widely
used for the surgical treatment of intertrochanteric fractures
of the femur [12,13]. This device is considered to be the gold
standard for management of these fractures in the elderly
[14]. In 1996, AO/ASIF developed the proximal femoral nail
(PFN) as an intramedullary fixation device for pertrochanteric,
intertrochanteric, and subtrochanteric fractures of the femur
[15]. The PFN is a minimally-invasive implant and a good
treatment option for fractures of the proximal end of the femur,
particularly when closed reduction is possible [15]. Whether
K E Y W O R D S
Intertrochanteric fractures
Intramedullary nail
Sliding compression hip screw
Functional outcome
A B S T R A C T
Introduction: Intertrochanteric fractures of the femur are prevalent in the elderly, and leave patients
with functional restrictions after surgical treatment. The aim of this study was to compare the
functional recovery at 1-year follow-up of elderly patients with intertrochanteric fractures treated
surgically with the dynamic hip screw (DHS) or proximal femoral nail (PFN) fixation techniques.
Material and methods: This prospective, randomised, blinded trial included patients aged over
65 years with intertrochanteric fractures classified as AO group 31.A1 or 31.A2. The patients were
allocated into one of two treatment groups: one treated with DHS and the other with PFN. Data on
functional recovery were obtained using the Functional Recovery Score developed by Zuckerman for
elderly patients with hip fracture. Variables were described as means and standard deviations, and
the non-parametric Kolmogorov–Smirnov test was used to verify the normality of data distribution.
Non-normally distributed variables were compared using the non-parametric Friedman and Mann–
Whitney U tests. Data processing and analysis were carried out in SPSS 10.0. Results were deemed
significant at the 5% level (p0.05).
Results: There were no significant between-group differences in age (p=0.152), sex (p=0.363), or
American Society of Anaesthesiologists (ASA) score (p=0.579). Functional recovery scores in the DHS
group at 3 and 6 months after surgery were significantly reduced from preoperative baseline scores
(p=0.007) compared with in the PFN group. However, there were no statistically significant differences
between the two groups in functional recovery scores at baseline (p=0.346) or at 3 months (p=0.880),
6 months (p=0.699), and 12 months (p=0.468) after surgery. There was no between-group difference
in mortality (p=0.140).
Conclusion: At 1-year follow-up, functional recovery scores were similar in elderly patients treated
with the DHS and PFN techniques. However, DHS-treated patients exhibited significant loss of function
in the first 6 months after surgery, which did not occur in the PFN-treated group.
© 2014 Elsevier Ltd. All rights reserved.
Functional recovery of elderly patients with surgically-treated intertrochanteric
fractures: preliminary results of a randomised trial comparing the dynamic hip
screw and proximal femoral nail techniques
Marcelo T.E. Guerraa,
*, Sandro Pasqualinb
, Marcos Paulo Souzac
, Renata Lenzb
a
Hospital Universitário de Canoas, Canoas, RS, Brazil; Universidade Luterana do Brasil (ULBRA), Porto Alegre, RS, Brazil
b
Hospital Universitário de Canoas, Canoas, RS, Brazil
c
Hospital Mãe de Deus, Porto Alegre, RS, Brazil
* Corresponding author at: Av. Nilo Peçanha, 450/901, 90470-000 - Porto
Alegre, RS - Brazil. Tel.: +55-51-9982-7988; fax: +55-51-3012-0575.
E-mail address: mguerraz@terra.com.br (M.T.E. Guerra).
0020-1383/$ – see front matter © 2014 Elsevier Ltd. All rights reserved.
Contents lists available at SciVerse ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury

2. S2 M.T.E. Guerra et al. / Injury, Int. J. Care Injured 45 S5 (2014) SX–SX
intramedullary nailing with the PFN has any advantage over
the DHS in intertrochanteric fractures remains controversial
[16]. However, in many patients, and particularly in the elderly,
functional recovery is more important than implant selection.
The purpose of this study was to compare the functional
recovery achieved with the DHS and PFN devices in elderly
patients with surgically-treated intertrochanteric fractures.
Materials and methods
Patients
The study population comprised patients aged over 65 years
with intertrochanteric fracture of the femur, classified as 31.A1
or 31.A2 under the AO system, who were treated at Hospital
Independência (Porto Alegre, Brazil) from October 2007. Patients
were excluded from the study if they met any of the following
criteria: compound femoral fracture, aged under 65 years, history
of previous femoral fracture, contraindications to surgery, non-
ambulatory before the presenting injury, or presence of any
other traumatic fractures. Two patients were excluded from the
study for refusing to provide informed consent.
Data collection
Data collection took place at the study hospital starting
November 2007. The Functional Recovery Score questionnaire
proposed by Zuckerman et al. [17] was administered to measure
functional recovery on inclusion and 3, 6, and 12 months post-
operatively. Patients were also assessed for pre-operative
physical condition (American Society of Anaesthesiologists [ASA]
status). The Zuckerman questionnaire comprises 11 items and
yields a score of 0 to 44; higher scores denote better functional
capacity. The type of fixation device (DHS or PFN) was chosen at
random. Briefly, the departmental secretary, who had access to a
box containing 20 envelopes - 10 containing the words “dynamic
hip screw” and 10 containing the words “proximal femoral nail” -
was contacted by telephone. After random selection, the chosen
envelope was returned to the box. The selection procedure was
carried out in the operating suite.
Functional Recovery Scores were obtained by a staff physical
therapist blinded to treatment allocation, who calculated
the initial score on patient admission and administered the
instrument again, by telephone, at 3, 6, and 12 months after
surgery.
Statistical analysis
Statistical analyses consisted of tables, charts, descriptive
statistics (means and standard deviations), and a series of
statistical tests.
The non-parametric Kolmogorov–Smirnov test was used
to evaluate variables for normality. This goodness-of-fit test
assesses the degree of agreement between the distribution of a
set of sample values and a certain theoretical distribution - in
this case, the normal distribution [18].
The assumption of normality was violated for some of the
measurements of interest. For this reason, and due to great
variability in some variables, non-parametric tests were selected
for further analyses: the Friedman test for pairwise comparison
of Functional Recovery Scores (at baseline, 3, 6, and 12 months)
and the Mann–Whitney U test (independent samples) for
comparison between device types.
Data processing and analysis were carried out in the SPSS 10.0
software environment. Results were deemed significant at the
5% level (p0.05).
Results
The study population profile is shown in Table 1. The DHS and
PFN groups were similar, as shown in Tables 2 and 3 (p=0.363
for sex, p=0.579 for ASA status, and p=0.152 for age). The study
population was predominantly female (25 of 31 patients).
Most of the fractures were due to low-energy trauma; 29 of 31
fractures were due to falls from a standing height. Approximately
95% of patients in the DHS group and 83% in the PFN group were
classified as ASA status II or III. No patient was classified as ASA I.
Table 4 presents a within-group comparison of Functional
Recovery Scores at baseline (pre-operatively) and 3, 6, and
12 months after surgery. In the DHS group, there was great data
variability, which meant that the mean was a poor measure of
central tendency for the behaviour of this variable. The median
was used instead as this is not affected by outliers.
Table 4 shows the progression of Zuckerman Functional
Recovery Scores over 1 year. As shown in this table, the non-
parametric Friedman test revealed a significant difference in
these values in the DHS group alone. In patients who received
DHS devices, Functional Recovery Scores at 3 and 6 months post-
operatively were significantly lower than pre-operative values.
There were no significant differences in Functional Recovery
Scores at 12 months.
Figures 1 and 2 show the progression of median Functional
Recovery Scores in the DHS and PFN groups, respectively.
Table 5 compares Functional Recovery Scores in the two study
groups. In the DHS group, median scores were lower at 3 and
6 months post-operatively compared with pre-operative values,
and were still lower, but starting to improve at 12 months.
In contrast, median scores in the PFN group were lower at
3 months post-operatively compared with pre-operative values,
but started to improve as early as 6 months after surgery.
Nevertheless, the non-parametric Mann–Whitney U test showed
no significant differences between the DHS and PFN groups in
these comparisons.
Between-group comparison of mortality rates showed that
more deaths occurred in the DHS group than in the PFN group,
see Table 6. However, the chi-square test revealed no significant
association between type of fixation device and occurrence of
death during the study period (2
=2.178; p=0.140) (Figure 3).
Table 1
Sample profile
Fixation device
DHS PFN Total
Variable n % n % n %
Age
75 years or younger 8 42.1 2 16.7 10 32.3
76 to 80 years 6 31.6 5 41.7 11 35.5
81 years or older 5 26.3 5 41.7 10 32.3
Total 19 100.0 12 100.0 31 100.0
Sex
Male 5 26.3 1 8.3 6 19.4
Female 14 73.7 11 91.7 25 80.6
Total 19 100.0 12 100.0 31 100.0
Mechanism of injury
Struck by car 1 5.3 0 0.0 1 3.2
Struck by motorcycle 0 0.0 1 8.3 1 3.2
Fall from standing height 18 94.7 11 91.7 29 93.5
Total 19 100.0 12 100.0 31 100.0
ASA
II 9 47.4 5 41.7 14 45.2
III 9 47.4 5 41.7 14 45.2
IV 1 5.3 2 16.7 3 9.7
Total 19 100.0 12 100.0 31 100.0
DHS = dynamic hip screw, PFN= proximal femoral nail.

3. M.T.E. Guerra et al. / Injury, Int. J. Care Injured 45 S5 (2014) SX–SX S3
Discussion
The primary objective of this study was to ascertain whether
there are differences in functional recovery of elderly patients
after treatment of intertrochanteric fractures with two distinct,
well-established fixation techniques. The intramedullary PFN
tolerates greater static loads and much greater cyclic loading than
the DHS device. Consequently, the fracture consolidates with PFN
treatment even in the absence of primary restoration of medial
support, as the implant temporarily compensates the function
of the medial column [19]. Other studies have shown that the
DHS is a reliable method for stabilisation of intertrochanteric
fractures [16]: it is technically simple, allows weight-bearing
as early as the first post-operative day, is associated with low
complication rates, and provides good outcomes across a broad
spectrum of indications [20].
The present study was a prospective, randomised, blinded
clinical trial. The small sample size may have introduced bias, but
it was still possible to detect statistically significant differences.
The patient population in this study had a particularly high
female-to-male ratio (8:2), as reported elsewhere [1,15-17,19-31].
Overall, 93% of intertrochanteric fractures were due to low-
energy trauma (fall from standing height). This is consistent with
previous studies that have demonstrated the high prevalence of
these mechanisms of injury, predominantly falls at home [21,22].
As noted above, the two study groups were similar in terms of
age, sex, and ASA status.
The reasons why one method may produce outcomes
superior to another can depend on several factors. Small changes
in implant shape can make a difference [32]. The DHS device is
considered the gold standard, as studies have demonstrated its
superiority in relation to other extramedullary fixation devices
[33]. On the other hand, the use of intramedullary implants is
growing in popularity in the U.S., but morbidity and mortality
rates have remained unchanged [34,35].
As shown in Table 6, despite the higher mortality rate
observed in the DHS group - in contrast to the studies of Dujardin
et al. [22], in which between-group mortality rates were similar,
and Saarenpää et al. [23], in which mortality at 4 and 12 months
was lower in the DHS group - the percentage of patients who
Table 3
Between-group comparison of variable age
Fixation
Variable device n Median Mean SD Mean rank p
Age DHS 19 73.0 77.89 6.92 14.13 0.152
PFN 12 80.0 80.17 4.73 18.96
DHS = dynamic hip screw, PFN= proximal femoral nail, SD = standard
deviation.
Table 2
Between-group comparison of variables sex and ASA status
Fixation device
DHS PFN Total
Variable n % n % n % p
Sex
Male 5 26.3 1 8.3 6 19.4 0.363
Female 14 73.7 11 91.7 25 80.6
Total 19 100.0 12 100.0 31 100.0
ASA
II 9 47.4 5 41.7 14 45.2 0.579
III 9 47.4 5 41.7 14 45.2
IV 1 5.3 2 16.7 3 9.7
Total 19 100.0 12 100.0 31 100.0
DHS = dynamic hip screw, PFN= proximal femoral nail.
Table 4
Within-group comparison of Zuckerman Functional Recovery Scores at
baseline (pre-operative) and 3, 6, and 12 months after surgery
Mean
Comparison n Min Max Median Mean SD rank p
DHS group
FRS, pre-operative 19 3 44 43.0 28.84 14.93 3.45A
0.007
FRS, 3 months 12 10 42 37.0 28.83 12.09 1.86B
FRS, 6 months 11 10 39 35.0 32.00 8.96 1.91B
FRS, 12 months 11 9 43 37.0 35.09 9.61 2.77AB
PFN group
FRS, pre-operative 12 1 44 41.0 34.58 13.58 3.25 0.097
FRS, 3 months 11 7 41 31.5 28.45 10.84 1.85
FRS, 6 months 11 2 40 35.5 31.82 11.09 2.35
FRS, 12 months 10 17 42 36.5 33.80 7.11 2.55
DHS = dynamic hip screw, FRS = Functional Recovery Score, PFN= proximal
femoral nail, SD = standard deviation.
* Mean rank values followed by the same superscript letter are statistically
similar.
Table 5
Between-group comparison of Functional Recovery Scores over time
Fixation
Comparison device n Median Mean SD Mean rank p
FRS, pre-operative DHS 19 43.0 28.84 14.93 14.76 0.346
PFN 12 41.0 34.58 13.58 17.96
FRS, 3 months DHS 12 37.0 28.83 12.09 12.25 0.880
PFN 11 31.5 28.45 10.84 11.73
FRS, 6 months DHS 11 35.0 32.00 8.96 10.95 0.699
PFN 11 35.5 31.82 11.09 12.05
FRS, 12 months DHS 11 37.0 35.09 9.61 12.00 0.468
PFN 10 36.5 33.80 7.11 9.90
DHS = dynamic hip screw, FRS = Functional Recovery Score, PFN= proximal
femoral nail, SD = standard deviation.
Fig. 1. Comparison of median Functional Recovery Scores at baseline (pre-operative), 3, 6, and 12 months in the DHS group.

4. S4 M.T.E. Guerra et al. / Injury, Int. J. Care Injured 45 S5 (2014) SX–SX
did not die was essentially the same in both groups, which made
this finding non-significant (2
=2.178; p=0.140). The 12-month
mortality rate was 32.3%. This exceeds the rates observed in
some studies, which have reported 20%9
and 14.5%[21] mortality,
but is within the range reported by Holt et al. [1] (14–47%).
The potential advantages of intramedullary nailing over
extramedullary devices for treatment of intertrochanteric
fractures remain a matter of debate [36]. When a difference is
found, it does not appear to be explained by the type of soft tissue
injury, because a study has demonstrated that no significant
difference exists between the injuries caused by extra- and
intramedullary techniques [37]. Nevertheless, several studies
have attempted to demonstrate differences in treatment, first
comparing the DHS versus the Gamma Nail device [23-27] and,
as in the present investigation, comparing DHS and PFN [21,28].
Saudan et al. [21] assessed social functioning and mobility
scores at 3, 6, and 12 months after surgery with PFN or DHS.
Although findings at intermediate months were not explained
in the study text, at 1-year follow-up, the authors found no
significant differences in terms of return to pre-fracture levels
of ambulation and independence between the PFN-treated and
DHS-treated groups. Thus, they concluded that intramedullary
nails (such as the PFN) offer no advantage over extramedullary
devices (such as the DHS) for the treatment of intertrochanteric
fractures caused by low-energy trauma (AO types 31.A1 and
31.A2). Another study [28] compared functional recovery 1 year
after trochanteric nail or DHS repair. Final assessment was
conducted over the phone, and no between-group differences in
recovery scores were found.
In a randomised, prospective study comparing intramedullary
versus extramedullary fixation, Baumgaertner et al. [29] found
no between-group differences in functional recovery rates.
Saarenpää et al. [23] compared functional outcomes with the
DHS and Gamma Nail fixation systems in terms of parameters
including ability to walk and ability to dress and undress both
pre-operatively and 4 months after surgery. Although there were
no between-group differences in the use of walking aids, in the
DHS group, 4-month outcomes were significantly better than
pre-injury levels compared with the Gamma Nail group.
In the current study, assessment of Zuckerman Functional
Recovery Scores showed that patients in the DHS group
experienced a significant reduction in scores from baseline at
Fig. 2. Comparison of median Functional Recovery Scores at baseline (pre-operative), 3, 6, and 12 months in the PFN group.
Fig. 3. Between-group comparison of mortality rates.
Table 6
Between-group comparison of mortality during the study period
Fixation device
DHS PFN Total
Mortality n % n % n %
Deceased 8 42.1 2 16.7 10 32.3
Not deceased 11 57.9 10 83.3 21 67.7
Total 19 100.0 12 100.0 31 100.0
DHS = dynamic hip screw, PFN= proximal femoral nail.

5. M.T.E. Guerra et al. / Injury, Int. J. Care Injured 45 S5 (2014) SX–SX S5
3 and 6 months after surgery (p=0.007), whereas no such loss
of function occurred in the PFN-treated group (p=0.097), unlike
in the Saarenpää et al. study [23]. Nevertheless, there were no
between-group differences in final scores. Little et al. [38] also
found that intramedullary nailing enabled faster recovery of
mobility.
Regarding functional recovery, Dujardin et al. [22] showed
that hip strength and mobility progressed similarly in the first
3 months after surgery in patients treated with the DHS and
in those treated with static nailing, but significant differences
favouring the intramedullary nail group were apparent
6 months after surgery. This is consistent with the findings in
the present study, where functional recovery was faster in PFN-
treated patients in the first 6 months after surgery. However, the
authors found no differences in walking ability or recovery of
independence. Again, this is consistent with our findings, even
though Dujardin et al. [22] followed patients for a shorter time
(26 weeks) and used different scores.
The finding that functional recovery in the first 6 months after
surgery is significantly poorer after DHS treatment is important,
because it is widely known that elderly patients require faster
recovery. Similar findings have been reported by Goulidakis et
al. [39] and Calderón et al. [40]. Conversely, Eschler et al. [41]
found that patients treated with an extramedullary device fared
subjectively better. Ultimately, however, both groups had similar
functional recovery outcomes and no significant loss of function
at 1-year follow-up. The importance of this finding in elderly
patients is relative. There were more deaths in the DHS group,
although the difference was not significant.
Taken together, these data indicate that despite similar
final scores, the most important result is that patients treated
with the PFN technique exhibited functional improvement as
early as 6 months after surgery, unlike DHS-treated patients. In
practice, this means that PFN treatment is associated with faster
improvement in quality of life than the DHS technique.
Conclusion
At 1-year follow-up, there were no significant differences
in functional recovery scores between PFN-treated and DHS-
treated elderly patients with intertrochanteric fractures of the
femur in this study. However, DHS-treated patients experienced
significant loss of function in the first 6 months after surgery
compared with no such loss of function in the PFN-treated group.
Conflict of Interest Statement
??????
Funding sources
None.
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