European Journal of Cardiovascular Medicine

Subtrochanteric femur fractures are defined as fractures occurring within 5 cm distal to the lesser trochanter of the proximal femur. These injuries pose a considerable challenge to orthopaedic surgeons because this region is characterised by dense cortical bone, complex fracture patterns, and substantial biomechanical stresses generated by surrounding musculature. As a result, achieving stable fixation and reliable fracture union in this area remains difficult. Subtrochanteric fractures account for approximately 25% of all hip fractures and 4–7% of all femoral fractures, highlighting their clinical importance and frequency in orthopaedic practice [1-5]. The aetiology of subtrochanteric femur fractures varies with age. In younger individuals, these fractures typically result from high-energy trauma such as road traffic accidents or falls from height, whereas in elderly patients, they are more commonly associated with low-energy falls, often compounded by osteoporosis. Regardless of the mechanism, these fractures are associated with significant morbidity, prolonged rehabilitation, and a substantial impact on functional recovery, making optimal surgical management essential for early mobilisation and restoration of function.

Over the years, the surgical management of subtrochanteric femur fractures has evolved considerably, with the primary goal being stable fixation that allows early weight bearing and minimises complications. Currently, two main fixation strategies are widely employed: intramedullary (IM) and extramedullary (EM) fixation techniques. Intramedullary fixation involves the placement of a load-sharing device within the medullary canal of the femur, offering biomechanical advantages by aligning the implant closer to the mechanical axis of the limb. This method is associated with minimal soft-tissue disruption, shorter operative time, reduced blood loss, and the potential for early weight bearing, making it an attractive option in modern fracture management [2,4].

Extramedullary fixation, in contrast, utilises plate-and-screw constructs applied along the lateral surface of the femur, providing rigid fixation and controlled fracture alignment. These implants have traditionally been preferred in certain fracture patterns, particularly those with comminution or where intramedullary nailing is technically challenging. However, extramedullary devices may be associated with greater soft-tissue stripping, longer operative time, and higher mechanical stresses at the implant–bone interface. Despite widespread use of both techniques, there remains ongoing debate regarding the optimal fixation method for subtrochanteric femur fractures. Differences in biomechanical behaviour, union rates, complication profiles, and functional outcomes have been reported, with no clear consensus favouring one technique universally. This lack of agreement underscores the need for further comparative evaluation to guide evidence-based surgical decision-making.

The present study aims to compare intramedullary and extramedullary fixation methods in the management of subtrochanteric femur fractures by evaluating clinical outcomes, complication rates, and overall effectiveness. Specifically, this study assesses the results of treatment using intramedullary devices, including intramedullary femoral nails and proximal femoral nails (PFN), and extramedullary devices, such as the 95° condylar plate and locked anatomical proximal femoral plate. By systematically comparing these fixation techniques, the study seeks to provide clinically relevant evidence to assist orthopaedic surgeons in selecting the most appropriate treatment modality for optimal patient outcomes.

This retrospective observational study was conducted in the Department of Orthopaedics at Patna Medical College and Hospital, Patna, Bihar, India. Patients who underwent surgical management for subtrochanteric femur fractures and subsequently presented for routine postoperative follow-up were evaluated. Clinical records and radiological data were retrieved from the hospital’s medical record system and digital imaging database. All procedures were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. In view of the retrospective study design and use of de-identified clinical data, informed consent was waived in accordance with institutional ethical guidelines.

Study Population

Patients operated for subtrochanteric femur fractures were screened for eligibility based on predefined inclusion and exclusion criteria. Only those with adequate clinical documentation and radiographic follow-up of at least 12 months were considered.

Sample Size Calculation

The sample size was estimated using G*Power software (Version 3.1.9.7). Based on effect sizes reported in previously published comparative studies evaluating intramedullary and extramedullary fixation techniques for subtrochanteric femur fractures, a moderate effect size (d = 0.5) was assumed [5]. A power (1−β) of 80% and a two-tailed α error probability of 0.05 were considered for the calculation. The minimum required sample size was calculated to be 72 patients. To account for possible exclusions due to incomplete follow-up, missing radiological data, or postoperative mortality, and to improve the robustness of statistical analysis, the sample size was increased. Accordingly, 85 patients were included in the final study population.

Inclusion Criteria

Adult patients aged between 18 and 65 years with radiologically confirmed subtrochanteric femur fractures, defined as fractures occurring within 5 cm distal to the lesser trochanter, were included. Patients must have undergone operative treatment using either intramedullary (IM) or extramedullary (EM) fixation techniques. Complete availability of preoperative, intraoperative, and postoperative clinical details, along with serial radiographs, was mandatory.

Exclusion Criteria

Patients younger than 18 years or older than 65 years were excluded. Other exclusion criteria included pathological, periprosthetic, or open subtrochanteric fractures; a history of previous surgery on the affected femur; incomplete clinical or radiological records; inadequate follow-up; non-operative management; and severe comorbid conditions known to adversely affect fracture healing, such as advanced diabetes mellitus, active malignancy, or severe osteoporosis.

Grouping of Patients

Patients were divided into two groups based on the fixation method used. Group A comprised 62 patients who underwent intramedullary fixation using either an intramedullary femoral nail or a proximal femoral nail (PFN). Group B included 23 patients treated with extramedullary fixation using either a 95° condylar plate or a locked anatomical proximal femoral plate.

Preoperative Evaluation and Surgical Management

Patient demographics, clinical history, and imaging data were obtained from hospital records. Standard preoperative imaging included anteroposterior radiographs of the pelvis and affected femur, along with knee radiographs. In cases where fracture extension into the piriform fossa was suspected, computed tomography of the hip and femur was performed.

All patients received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis according to institutional protocol. Preoperative skeletal traction was applied in 36 patients (42.3%), depending on the degree of fracture displacement. All surgeries were performed using a traction table. Early postoperative mobilisation was encouraged as soon as the patient’s clinical condition allowed.

Data Collection and Outcome Assessment

Recorded variables included age, sex, side of injury, mechanism of trauma, type of anaesthesia, preoperative waiting time, fracture pattern, duration of follow-up, and intraoperative or postoperative mechanical complications.

Functional outcome was assessed using the Harris Hip Score (HHS). Due to the inability to perform physical examination in some patients during follow-up, the examination component of the original HHS was excluded. A modified HHS based on patient self-reporting was used, which has demonstrated a 99% correlation with the conventional HHS [6,7]. The obtained score was multiplied by a factor of 1.1 and recalculated on a 100-point scale [8]. Outcomes were graded as excellent, good, fair, or poor.

Radiological Evaluation

Postoperative radiographs were evaluated using the hospital’s digital imaging system. Coronal plane alignment (varus–valgus) and sagittal plane alignment (procurvatum or flexion deformity) were measured. Angulations less than 10° were considered acceptable. Limb shortening in displaced or multipart fractures was assessed by comparison with radiographs of the contralateral femur. Fracture union was assessed radiologically and defined as the presence of bridging callus in at least three of the four cortices on both anteroposterior and lateral radiographs.

Statistical Analysis

Data were entered into Microsoft Excel and analysed using the Statistical Package for the Social Sciences (SPSS, version 25.0; IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Comparisons between the intramedullary (Group A) and extramedullary (Group B) fixation groups were performed using the independent samples t-test for continuous variables and the Chi-square test or Fisher’s exact test for categorical variables, as appropriate. The association between malalignment and postoperative complications was analysed using Fisher’s exact test due to small subgroup sizes. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant.

The baseline demographic and clinical characteristics of the study population are summarised in Table 1. The mean age of patients in Group A (intramedullary fixation) was 47.24 ± 5.14 years, while in Group B (extramedullary fixation) it was 45.87 ± 6.12 years, with no statistically significant difference between the groups (p = 0.29). Females constituted the majority of patients in both groups, with no significant difference in sex distribution (p = 0.41). The distribution of fracture side was comparable between the two groups, with right-sided fractures being slightly more common than left-sided fractures in both groups; this difference was not statistically significant (p = 0.88). The mean preoperative waiting time was 5.12 ± 1.20 days in Group A and 4.35 ± 1.50 days in Group B, and this difference also did not reach statistical significance (p = 0.07). Overall, the two groups were well matched with respect to baseline demographic and clinical parameters, allowing for a reliable comparison of treatment outcomes between intramedullary and extramedullary fixation methods. The most frequent cause of subtrochanteric fractures was falling from a height. Regional (spinal) anaesthesia was used for 64 patients, and general anaesthesia was administered to 21 patients.

Table 1: Comparison of Baseline Demographic and Clinical Characteristics of the Study Population

Subtrochanteric fractures were classified according to the Seinsheimer classification system: three fractures were type 2A, 36 were type 2B, six were type 2C, 15 were type 3A, eight were type 3B, four were type 4, and 13 were type 5. Intramedullary fixation was performed in 62 patients, including intramedullary femoral nails in 36 patients (42.35%) and proximal femoral nails in 26 patients (30.59%). Extramedullary fixation was used in 23 patients, with 95° condylar plates in 11 patients (12.94%) and locked anatomical proximal femoral plates in 12 patients (14.12%).

The mean time to radiological union was 20.8 ± 4.2 weeks in Group A (intramedullary fixation) and 21.6 ± 4.8 weeks in Group B (extramedullary fixation), with no statistically significant difference between the two groups (p = 0.42).

The comparison of complication rates between Group A (intramedullary fixation) and Group B (extramedullary fixation) is presented in Table 2 and Figure 1. Delayed union was observed more frequently in Group A, occurring in 16 patients (25.80%), compared to three patients (13.04%) in Group B; however, this difference was not statistically significant (p = 0.29). Non-union was noted in three patients (4.83%) in Group A and one patient (4.35%) in Group B, with no significant difference between the groups (p = 0.91).

Malalignment was observed in nine patients (14.51%) in Group A and two patients (8.69%) in Group B, and this difference was also not statistically significant (p = 0.48). Implant failure occurred in five patients (8.06%) in Group A and two patients (8.69%) in Group B, showing comparable rates between the two fixation methods (p = 0.92). Limb shortening was noted in four patients (6.45%) in Group A and two patients (8.69%) in Group B, with no statistically significant difference (p = 0.73).

Postoperative infection was uncommon and was observed in one patient (1.61%) in Group A and one patient (4.35%) in Group B, without a statistically significant intergroup difference (p = 0.45). Overall, although certain complications such as delayed union and malalignment were numerically higher in the intramedullary fixation group, no statistically significant differences were observed between the two groups with respect to complication rates.

Table 2: Comparison of Complication Rates Between Group A and Group B

Figure 1: Bar diagram showing comparison of postoperative complication rates between Group A (intramedullary fixation) and Group B (extramedullary fixation).

Patients with malalignment showed a significantly higher incidence of delayed union compared to those without malalignment (p = 0.009). Although non-union and implant failure were more frequent in patients with malalignment, these differences did not reach statistical significance (p = 0.08 and p = 0.06, respectively) (Table 3). The mean Harris Hip Score (HHS) for the overall study population was 86.5, and there was no statistically significant difference in HHS between Group A and Group B.

Table 3: Showing the comparison of the complication rate in patients with and without malalignment.

The optimal fixation method for subtrochanteric femur fractures remains a subject of ongoing debate, and no clear consensus exists regarding the superiority of intramedullary (IM) or extramedullary (EM) fixation techniques. The present study was undertaken to compare the clinical, radiological, and functional outcomes of these two commonly employed treatment modalities. Our findings demonstrated no statistically significant difference between IM and EM fixation with respect to complication rates or functional outcomes, suggesting that both methods can be used effectively when appropriately applied.

Subtrochanteric fractures are relatively less common than femoral neck or intertrochanteric fractures but are associated with greater technical difficulty due to the unique biomechanical environment of this region. The proximal fragment is subjected to deforming forces resulting in flexion, abduction, and external rotation, while the area itself bears substantial axial load. These factors contribute to difficulties in achieving and maintaining stable reduction, which explains the relatively higher complication rates historically reported for fractures in this region. Due to these challenges, the choice of fixation method often depends on fracture morphology, bone quality, and surgeon expertise rather than a universally accepted standard.

In the present study, both IM and EM fixation groups demonstrated satisfactory clinical outcomes, consistent with findings reported in the existing literature. Mirbolook et al. retrospectively evaluated 114 patients treated with IM nails and proximal femoral locking compression plates and found no significant difference in outcomes between the two groups [9]. Similarly, Cook et al. analysed 244 subtrochanteric fractures and reported comparable outcomes between patients treated with IM and EM implants, with the exception of a higher requirement for blood transfusion in the EM group [10]. Pakuts compared dynamic condylar screws and gamma nails and observed no significant difference in clinical outcomes or complications, although patients treated with nails demonstrated earlier functional recovery [11]. These observations align closely with the results of the present study. Biomechanical studies have also supported the use of both fixation strategies. Sowmianarayanan et al., using finite element analysis, demonstrated comparable mechanical behaviour among dynamic hip screws, dynamic condylar screws, and proximal femoral nails [12]. Although intramedullary implants theoretically offer biomechanical advantages due to load-sharing and medial cortex support, clinical superiority over extramedullary implants has not been conclusively demonstrated, reinforcing the findings of the current investigation.

Intramedullary nails provide adequate resistance to deforming forces in the subtrochanteric region and have become increasingly popular with advancements in implant design. Umer et al. reported a 94% success rate using proximal femoral nails, recommending their use in most subtrochanteric fractures except Seinsheimer type IV fractures [13]. Imerci et al. compared proximal femoral nails with distal femoral LISS plates and found slower fracture consolidation in the plate group, although Harris Hip Scores were higher in that group, with no significant difference in complication or reoperation rates [14]. These mixed findings highlight that functional recovery and radiological union may not always correlate directly with implant choice.

Correct fracture alignment is a critical determinant of successful outcomes in subtrochanteric fractures. White et al. reported significantly higher rates of non-union and implant failure when IM nails were applied without adequate reduction [15]. In the present study, malalignment was significantly associated with delayed union, although its association with non-union and implant failure did not reach statistical significance. Zhou et al. emphasised the importance of adequate reduction, reporting successful union in nearly all patients treated with IM fixation, most of whom required limited open reduction [16]. Riehl et al. similarly demonstrated that malreduction was strongly associated with delayed union and non-union in patients treated with IM nails [17]. Lee et al. further recommended minimal open reduction when closed reduction fails to achieve acceptable alignment, as malalignment and non-union were more frequent with closed techniques alone [18]. Malalignment in subtrochanteric fractures typically manifests as varus, flexion, and external rotation deformities, leading to abductor insufficiency, limb shortening, and altered hip biomechanics [19]. Extramedullary implants such as the dynamic condylar screw have traditionally been used for certain fracture patterns, particularly those with short proximal fragments. Neogi et al. reported favourable outcomes using dynamic condylar screws in multipart subtrochanteric fractures [20]. In our series, one patient treated with a 95° condylar plate developed delayed union due to implant failure. Rohilla et al. reported excellent outcomes with dynamic condylar screws, with no cases of non-union or implant failure [21].

Proximal femoral locking compression plates represent a modern alternative to traditional extramedullary devices, particularly for unstable fractures with small proximal fragments. Previous studies have demonstrated satisfactory results with these implants [22-24]. In our study, the use of proximal femoral locking plates was associated with complications including infection, delayed union, non-union, and implant failure, underscoring the importance of careful patient selection and meticulous surgical technique.

Overall, extramedullary fixation techniques are associated with disadvantages such as extensive soft-tissue dissection, increased blood loss, longer operative time, and higher infection risk, although they may facilitate more accurate anatomical reduction. Intramedullary fixation offers the advantages of minimal invasiveness, better load-sharing, and medial cortex support, but carries a higher risk of malalignment, particularly when closed reduction is inadequate. The literature does not clearly favour one approach over the other, and our findings support this lack of definitive superiority.

Limitations of the Study: This study has certain limitations that should be acknowledged. The retrospective design may be associated with inherent selection bias and dependence on the accuracy and completeness of medical records. The unequal distribution of patients between the intramedullary and extramedullary fixation groups may have reduced the statistical power to detect small but clinically relevant differences. Functional outcomes were assessed using a modified Harris Hip Score due to the inability to perform physical examination in some patients, which may not fully reflect all components of hip function. In addition, the study was conducted at a single tertiary care centre, which may limit the generalizability of the findings. The heterogeneity of implants used within each fixation group also represents a limitation. Despite these constraints, the study provides meaningful comparative data on fixation methods for subtrochanteric femur fractures. Future prospective, randomised studies with larger sample sizes and longer follow-up periods are warranted to validate these findings and establish clearer treatment guidelines.

Both intramedullary and extramedullary fixation techniques were found to be effective in the surgical management of subtrochanteric femur fractures, with comparable clinical, radiological, and functional outcomes. No statistically significant differences were observed between the two fixation methods with respect to complication rates or functional recovery. However, malalignment was significantly associated with delayed fracture union, highlighting the critical importance of achieving accurate reduction and stable fixation irrespective of the implant used. These findings suggest that the choice of fixation method should be guided by fracture characteristics, surgeon expertise, and intraoperative achievement of optimal alignment to ensure favourable outcomes.

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