Hip fractures are one of the most debilitating injuries in the elderly, associated with increased morbidity, mortality, and healthcare burden [1]. Among these, intertrochanteric fractures constitute nearly 45–50% of all hip fractures and their incidence is expected to rise globally in parallel with increasing life expectancy [2]. These fractures are defined as extracapsular injuries of the proximal femur occurring between the greater and lesser trochanters—a region rich in trabecular bone and blood supply, favoring union compared to femoral neck fractures [3].

The anatomy of the proximal femur plays a key role in understanding fracture patterns and stability. The greater trochanter provides insertion for the gluteus medius, gluteus minimus, piriformis, and obturator internus, while also serving as the origin for the vastus lateralis [4]. The lesser trochanter, conversely, is the insertion site for the iliopsoas muscle [5]. The calcar femorale, a dense vertical plate of bone extending from the posteromedial femoral shaft to the femoral neck, is a crucial determinant of stability [6]. Fractures with intact posteromedial cortex are generally stable, while unstable types—such as those with comminution, reverse obliquity, or subtrochanteric extension—pose significant management challenges [7].

The mechanism of injury differs by age and bone quality. In elderly patients with osteoporosis, low-energy trauma such as a fall from standing height is the predominant cause. In contrast, younger patients usually sustain intertrochanteric fractures from high-energy trauma such as road traffic accidents [8]. Additional risk factors include neurological conditions (e.g., Parkinson’s disease, stroke), pathological bone conditions (e.g., metastasis, osteomalacia), prolonged corticosteroid use, and lifestyle factors like smoking and alcohol consumption [9].

Surgical management is the cornerstone of treatment, aiming to restore mobility, reduce complications, and improve survival. Proximal Femoral Nailing (PFN) has emerged as the gold standard for unstable intertrochanteric fractures, offering superior biomechanical stability, reduced soft-tissue disruption, and early mobilization [10]. On the other hand, External Fixation remains an option in polytrauma patients or those medically unfit for prolonged surgery, due to its minimally invasive nature and shorter operative time. However, it is associated with complications such as pin tract infections, malalignment, and limited long-term stability [11].

Given these considerations, the present study was undertaken to compare the outcomes of PFN and External Fixation in trochanteric fractures. Special emphasis was placed on reduction and retention rates, probability of union, functional outcomes, complication rates, and cost-effectiveness, thereby providing insights for evidence-based decision-making in orthopedic practice.

Study Design

The present study was designed as a Randomized Controlled Trial (RCT) and was conducted in the Department of Orthopedics, Era’s Lucknow Medical College & Hospital (ELMCH), Lucknow. ELMCH is a tertiary care teaching hospital equipped with modern facilities and caters primarily to socio-economically underprivileged suburban and rural populations. The total duration of the study was twenty-four months.

Sample Size

A total of 80 patients with intertrochanteric fractures of the femur were enrolled. Patients presenting to the outpatient department and triage during the study period were screened for eligibility. Inclusion criteria consisted of patients above 18 years of age of both sexes with intertrochanteric fractures who provided informed consent. Patients with pathological fractures were excluded from the study.

METHODOLOGY

Prior to initiation, the study obtained ethical clearance from the Institutional Ethical Committee of ELMCH. Informed consent was obtained from all participants. After enrollment, a standardized data record form was used to document patient demographics, fracture characteristics, clinical presentation, and radiographic findings. Patients were then randomly allocated into two treatment groups: one group treated with Proximal Femoral Nailing (PFN) and the other with External Fixation. Standard perioperative care, anesthesia protocols, and postoperative rehabilitation were followed according to institutional guidelines. Clinical and radiological assessments were conducted at regular intervals until fracture union was achieved.

Outcome Measures

The primary outcomes measured included union rate, cost of treatment, and need for anesthetic support. Secondary outcomes included functional assessment using the Harris Hip Score (HHS), evaluation of limb shortening, and assessment of hip joint range of motion. These measures were chosen to compare not only the clinical and radiological outcomes but also the functional and economic aspects of the two treatment modalities.

Statistical Analysis

Data were compiled and analyzed using SPSS Version 25.0 (Statistical Package for Social Sciences). Continuous variables were expressed as mean ± standard deviation, while categorical data were presented as frequencies and percentages. Standard statistical methods were applied: the Chi-square test was used for comparison of categorical variables, and the Student’s t-test was applied for comparing means between the two groups. Measures of central tendency, such as mean and median, and measures of dispersion, such as standard deviation, were also calculated. A p-value of less than 0.05 was considered statistically significant, while p < 0.01 and p < 0.001 were considered highly significant and very highly significant, respectively.

Table 1: Intergroup comparison of age and gender

Fracture laterality was also evenly distributed, with left-sided fractures in 52.5% of Group A and 47.5% of Group B, and right-sided fractures in 47.5% and 52.5% respectively. This difference was not statistically significant (p = 0.655) (Table 3).

Table 2: Intergroup comparison of laterality

However, significant differences were observed in intraoperative findings between the two groups. The requirement for anesthetic support was 100% in the PFN group compared to only 15% in the External Fixator group (p < 0.001). Mean intraoperative blood loss was also markedly higher in Group B (259.38 ± 78.80 mL) compared to Group A (43.88 ± 19.20 mL), with the difference being highly significant (p < 0.001). Similarly, the mean duration of surgery was almost double in the PFN group (80.68 ± 17.21 minutes) versus the External Fixator group (40.58 ± 12.82 minutes) (p < 0.001). The average cost of treatment was significantly greater in the PFN group (₹27,275.0 ± 2483.87) compared to the External Fixator group (₹13,397.50 ± 1799.08) (p < 0.001). In contrast, duration of hospital stay was similar between the groups, showing no significant difference (p = 0.920) (Table 4).

Table 3: Intergroup comparison of intraoperative findings

The comparison of clinical outcomes between the two groups is summarized in Table 5. Union was achieved in 95% of patients in Group A (External Fixator) and in 100% of patients in Group B (PFN); however, the difference was not statistically significant (p = 0.152). Gait abnormality was observed in 10% of cases in Group A, whereas none of the patients in Group B developed such abnormality (p = 0.122). With respect to limb shortening, the mean value was slightly higher in Group A (3.8 ± 8.7 mm) compared to Group B (1.0 ± 3.0 mm), but this difference did not reach statistical significance (p = 0.062). Similarly, the range of motion score was marginally lower in Group A (4.63 ± 0.77) compared to Group B (4.85 ± 0.36), though again the difference was not statistically significant (p = 0.100).

Table 4: Intergroup comparison of outcomes

Table 5: Intergroup comparison of Harris Hip Score at different intervals

Functional recovery was assessed using the Harris Hip Score (HHS) at three follow-up intervals (3 weeks, 3 months, and 6 months). As shown in Table 6, Group B consistently demonstrated significantly higher HHS compared to Group A across all time points. At 3 weeks, the mean HHS was 34.80 ± 6.09 in Group A versus 52.93 ± 3.11 in Group B (p < 0.001). At 3 months, the scores improved to 59.45 ± 6.59 and 72.05 ± 2.99, respectively (p < 0.001). By 6 months, patients in Group B continued to show superior functional recovery with a mean score of 82.95 ± 3.65 compared to 75.58 ± 5.35 in Group A (p < 0.001). These results indicate that PFN provided earlier and sustained functional benefits compared to External Fixation.

Table 6: Intergroup comparison of complications

The comparison of postoperative complications is summarized in Table 7. Pin loosening occurred in 3 patients (7.5%) and pin tract infection was noted in 13 patients (32.5%) in Group A, whereas no such complications were observed in Group B. The difference between groups was statistically significant (p < 0.001).

Figure 1: Postoperative radiographs of the left femur showing fixation of an intertrochanteric fracture with an external fixator. The anteroposterior (left) and lateral (right) views demonstrate multiple Schanz pins inserted into the proximal femur and shaft, stabilized by connecting rods and clamps, providing fracture alignment and external stabilization.

Figure 2: Postoperative radiographs of the left femur showing fixation of an intertrochanteric fracture with a Proximal Femoral Nail (PFN). The anteroposterior (left) and lateral (right) views demonstrate intramedullary nail fixation with proximal reconstruction screws and distal locking bolts providing stable internal fixation.

Trochanteric fractures remain a significant clinical challenge due to their frequency in the elderly population and their association with osteoporosis and falls [12,15,16,]. The present study compared Proximal Femoral Nailing (PFN) and External Fixation (EF) in terms of cost, operative variables, union rates, functional outcomes, and complications.

Our findings indicate that while PFN was associated with significantly greater operative time, higher intraoperative blood loss, and increased costs compared to EF, it consistently provided superior functional outcomes as reflected in Harris Hip Scores at 3 weeks, 3 months, and 6 months. These results align with studies by Liang et al. [17] and Bedrettin et al. [18], who similarly reported better functional recovery with PFN. However, contrary to our observation of frequent pin-related complications with EF (pin tract infection 32.5%, pin loosening 7.5%), Yousry et al. [19] documented minimal complications, likely attributable to differences in technique, patient selection, and postoperative pin care.

Union rates in our study were high and comparable between groups (95% EF vs. 100% PFN), consistent with earlier reports [12,20,21]. Nevertheless, PFN demonstrated earlier mobilization and better gait restoration, corroborating Khairnar & Patil [12] and Habeeb et al. [20]. Interestingly, Liang et al. [17] found that EF patients eventually caught up functionally by 6 months, suggesting rehabilitation protocols and patient profiles may influence recovery trajectories.

The complication profile also strongly favored PFN in our cohort. While minor implant-related issues such as varus malreduction and Z-effect have been described in literature [13,14,17], none were observed here, possibly reflecting strict adherence to reduction principles. Conversely, EF showed a higher incidence of pin tract infections, similar to reports by Bedrettin et al. [18], emphasizing the importance of meticulous pin care and appropriate patient selection.

Advances in implant design, such as the TFN-A and PFNA-2, have further improved PFN outcomes, as highlighted by Mallya et al. [15] and Siddartha et al. [16]. Despite using a standard PFN in this study, excellent union and functional outcomes were achieved, underscoring the role of surgical expertise and perioperative protocols.

Overall, our findings reinforce PFN as the preferred modality for trochanteric fractures in resource-equipped settings, owing to its superior functional recovery and lower complication profile. EF, however, remains a pragmatic option in select scenarios—particularly in elderly, high-risk patients or in resource-limited environments—provided that strict pin care protocols and careful patient selection are applied. Future studies should focus on standardized rehabilitation strategies, fracture classification, and implant design to enable more robust comparisons.

In conclusion, both Proximal Femoral Nailing (PFN) and External Fixation (EF) proved effective in achieving high union rates in the management of trochanteric fractures, but PFN consistently demonstrated superior functional recovery, earlier mobilization, and fewer complications, despite being associated with longer operative time, greater blood loss, and higher treatment costs; EF, while minimally invasive and more economical, was limited by higher rates of pin-related complications and comparatively poorer functional outcomes, making it better suited for elderly, comorbid, or high-risk patients and resource-limited settings, whereas PFN should remain the preferred option for most patients, particularly those with unstable fracture patterns and higher functional demands.

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