European Journal of Cardiovascular Medicine

Intertrochanteric (I/T) femur fractures, predominantly encountered in the geriatric population, represent the most ubiquitous subset of hip fractures, imposing a considerable burden on global healthcare systems due to their associated morbidity and mortality rates [1]. The etiology of these fractures is multifactorial, with low-energy mechanisms such as trivial falls being the predominant cause in older individuals, particularly in the presence of comorbidities like osteoporosis, which compromises bone integrity [2]. In contrast, the younger demographic experiences I/T fractures predominantly due to high-energy trauma scenarios such as road traffic accidents or falls from significant heights, reflecting differences in bone density, biomechanical resilience, and trauma patterns across age groups [3]. Risk factors that accentuate the likelihood of sustaining an intertrochanteric femur fracture include advanced age, female gender—owing partly to postmenopausal osteoporosis—abnormal gait patterns, and a history of previous slips and falls, further complicating the clinical picture [4].The management strategies for I/T fractures encompass both non-operative and operative modalities, each bearing distinct prognostic implications. Conservative management approaches, such as skeletal traction and immobilization, though viable in certain clinical scenarios, often culminate in complications including malunion, varus deformity, and external rotation deformities. Such complications can precipitate a shortened limb gait and further diminish patients' quality of life [5]. The primary objective of treating I/T fractures is to achieve early stabilization through rigid and stable fixation, thereby mitigating the complications associated with prolonged immobilization, such as bedsores, deep vein thrombosis, and pulmonary complications, which are particularly deleterious in an elderly population [6, 7].

Operative management of I/T fractures is favored due to its potential to restore anatomical alignment, allow early weight-bearing, and reduce the sequelae of immobility. The overarching aim of surgical intervention is to accomplish a biomechanically stable construct that permits early mobilization, thus fostering prompt rehabilitation and functional recovery. Despite the advances in surgical techniques and implant design, the treatment of choice for I/T fractures remains a subject of ongoing debate in orthopaedic circles, particularly in the context of unstable fracture patterns [8]. Various fixation devices are employed in the surgical management of these fractures, broadly classified into extramedullary devices like the dynamic hip screw (DHS) and intramedullary devices such as the proximal femoral nail (PFN). The selection of an appropriate implant is intricately linked to the fracture pattern—whether stable or unstable—with unstable fractures presenting a greater challenge due to comminution, posteromedial involvement, lateral wall blowout, reverse obliquity, transverse obliquity, or subtrochanteric extension [9].

The inherent complexity of unstable intertrochanteric fractures necessitates a surgical approach that addresses the biomechanical demands imposed by these patterns. Unstable I/T fractures, typified by three-fragment fractures with postero-medial comminution, multiple intermediate fragments indicating lateral wall compromise, reverse oblique, and transverse oblique orientations, as well as fractures extending into the subtrochanteric region, pose significant treatment challenges due to their propensity for varus collapse, cut-out, and fixation failure [10]. The ideal fixation device should provide a robust solution to counteract these forces, ensuring restoration of the mechanical axis, minimizing the lever arm, and reducing bending moments on the implant to thwart varus collapse and hardware failure [11].Introduced in 1996 by the ArbeitsgemeinschaftfürOsteosynthesefragen (AO), the proximal femoral nail (PFN) emerged as a promising solution in the fixation of both intertrochanteric and subtrochanteric femur fractures [12]. The PFN, with its intramedullary placement, offers biomechanical advantages such as a shorter lever arm and enhanced load-sharing characteristics compared to extramedullary devices, theoretically decreasing the risk of varus collapse and mechanical failure [13]. The design of the PFN, which often incorporates derotation screws, allows for optimal positioning near the mechanical axis of the femur, reducing the bending moment on the implant and facilitating early weight-bearing, which is particularly beneficial in osteoporotic bone where purchase may be compromised [14]. Moreover, the minimally invasive nature of PFN insertion reduces surgical trauma, soft tissue disruption, and operative time, subsequently diminishing intraoperative blood loss and lowering the risk of postoperative infections [15]. These features collectively render the PFN an attractive option for managing unstable I/T fractures.

The functional outcomes following PFN fixation in unstable I/T fractures can be systematically evaluated using the modified Harris Hip Score (mHHS), an adaptation of the original Harris Hip Score specifically tailored to enhance its relevance in diverse patient populations, including Indian patients in rural settings where certain functional activities such as squatting and sitting cross-legged are culturally significant [16]. The mHHS, by incorporating culturally pertinent activities, provides a more comprehensive assessment of post-operative function and quality of life in these populations. The score evaluates four domains: pain, function, absence of deformity, and range of motion, culminating in a composite index where higher scores correlate with better functional outcomes. The interpretation of mHHS is stratified into categories where scores of 90-100 are deemed excellent, 80-89 good, 70-79 fair, and less than 70 poor, thus providing a quantifiable measure of surgical success and patient recovery [16].This research seeks to critically analyze the functional outcomes of PFN fixation in unstable I/T fractures by employing the mHHS as the primary assessment tool. The impetus for this study stems from a need to refine and adapt existing evaluation metrics to better reflect the functional realities and cultural contexts of specific patient populations, addressing potential limitations of the original Harris Hip Score in capturing activities of daily living that are integral to patients in rural Indian settings [16]. Furthermore, by focusing on unstable fracture patterns, this research endeavors to delineate the efficacy of PFN in scenarios that traditionally pose higher risks of fixation failure and suboptimal outcomes due to the complexities inherent in the fracture morphology.

In the context of surgical innovation and outcome assessment, the integration of the modified Harris Hip Score into the evaluation protocol underscores a commitment to patient-centered care, where functional recovery is assessed not solely by radiographic union but by the restoration of pre-injury activities and lifestyle. As the field of orthopaedic surgery continues to evolve with advancements in implant design and surgical techniques, it becomes imperative to correlate these technological strides with tangible improvements in patient outcomes, particularly in populations that may have been underrepresented in prior research paradigms [11, 16].

The current investigation builds on a robust body of literature that highlights the biomechanical superiority and clinical advantages of intramedullary fixation in unstable I/T fractures while recognizing the persistent debates surrounding optimal implant selection and surgical technique. By systematically applying the mHHS in a cohort of patients undergoing PFN fixation for unstable I/T fractures, this study aims to contribute valuable insights into the long-term functional implications of this treatment modality. It aspires not only to validate the clinical utility of the PFN in such complex fracture patterns but also to refine outcome measurement tools to better serve diverse patient demographics, thus fostering a more nuanced understanding of surgical success that transcends mere radiographic parameters [1, 2, 5].This research is timely and significant, given the aging global population and the concomitant rise in fragility fractures, which necessitate efficacious and reliable treatment protocols that maximize functional recovery while minimizing complications. The findings of this study are expected to have broad implications for clinical practice, potentially guiding surgical decision-making, influencing implant selection, and informing post-operative rehabilitation strategies to enhance patient quality of life [4, 5].

Aims and Objectives

The study aims to evaluate functional outcomes in patients with unstable intertrochanteric fractures treated using Proximal Femoral Nail (PFN). Specifically, it seeks to grade outcomes via the Modified Harris Hip Score and to systematically document complications during follow-up, enhancing treatment strategies and patient care.

Study Design

This prospective, observational study was conducted at ESI-PGIMSR, New Delhi, from October 2019 to April 2021. It focused on evaluating functional outcomes in patients with unstable intertrochanteric fractures treated with the Proximal Femoral Nail (PFN). Standardized surgical techniques, postoperative protocols, and regular follow-ups at 1, 3, and 6 months were employed. Data on demographic characteristics, operative details, complications, and functional assessments using the Modified Harris Hip Score (mHHS) were systematically recorded. The study design emphasized rigorous patient selection, consistency in surgical intervention, and meticulous outcome tracking to ensure reliable and valid results.

Inclusion Criteria

The study included adult patients aged between 18 and 70 years presenting with unstable intertrochanteric fractures as per the Evans-Jensen classification. Only those fractures deemed suitable for fixation using the Proximal Femoral Nail (PFN) were considered. Patients needed to be medically fit for surgery and capable of adhering to postoperative rehabilitation protocols. The study sought individuals without prior surgical intervention on the proximal femur and with fractures that were acute, avoiding complications associated with non-union, malunion, or pathological etiologies. This careful selection ensured a homogeneous study population appropriate for evaluating PFN outcomes.

Exclusion Criteria

Patients were excluded if they had pathological fractures, prior surgeries on the proximal femur, or fractures treated with alternative fixation methods. Cases with old non-unions, malunions, or open hip fractures were not considered. These criteria eliminated confounding factors that might affect healing or functional outcomes. Additionally, patients outside the specified age range or those unable to comply with the follow-up schedule were omitted. This exclusion aimed to ensure the study focused on a consistent and relevant patient cohort, improving the reliability of the results related to PFN treatment efficacy.

Data Collection

Data were prospectively collected on demographic variables, injury characteristics, surgical details such as operative time, nail dimensions, and intraoperative findings. Postoperative follow-ups at 1, 3, and 6 months included clinical assessments using the Modified Harris Hip Score (mHHS) and radiological evaluations. Complications, blood transfusions, and time to union were meticulously documented. Standardized forms and electronic databases ensured accurate data capture, with regular audits to maintain quality and reliability in the collection process.

Data Analysis

Collected data were analyzed using SPSS version 26.0. Descriptive statistics such as means, medians, standard deviations, and percentages were calculated for continuous and categorical variables. Comparative analyses evaluated changes in mHHS scores over time, employing paired t-tests or non-parametric equivalents where appropriate. The significance of differences in outcomes was determined using p-values, with a threshold of <0.05 considered statistically significant. Regression analysis explored factors influencing functional recovery, and complications were summarized as incidence rates. Data visualization included charts and tables for clear interpretation. This rigorous statistical approach ensured robust conclusions regarding the efficacy and safety of PFN in unstable intertrochanteric fractures.

Ethical Considerations

The study was approved by the Institutional Ethics Committee of ESI-PGIMSR. All participants provided informed consent, and confidentiality was maintained throughout the research. The study adhered to the Declaration of Helsinki principles, ensuring patient safety, privacy, and ethical treatment. Participation was voluntary, and patients could withdraw at any time without affecting their care. These ethical practices safeguarded participant rights and integrity, fostering trust and compliance, and reinforcing the study's commitment to responsible research conduct.

The present study was conducted in the Department of Orthopaedics, ESI-PGIMSR, New Delhi with the objective to evaluate the functional outcomes in unstable I/T fracture treated with PFN using mHHS and any complication encountered during follow up at 1, 3, and 6 months.

Age Distribution

A total 25 cases were studied. Mean age of the patients was 57 years with the youngest patient being 22 years and oldest being 80 years, with the range lying between 22-80 years. In the study 11(44%) cases were in the age group of 61-70 years, 3(12%) belonged to age of 51-60 years, 3(12%) belongs to age of 41-50 years, 3(12%) belongs to age of 31-40 years and rest 2(8%) belongs to 20-30 years of age.

Table1: Studyofsocio-demographiccharacteristicsofstudysubjects

Table2:Rangewiseagedistributionofstudysubjects

Figure 4:Distributionofageofstudysubject

Gender Distribution

The majority of study patients i.e. 18(72%) were male while remaining 7(28%) cases were females with ratio of male to female being 2.5:1.

Table3:Distributionaccordingtogenderofstudysubjects

Figure 5:Distributionofgenderofstudysubjects

Side of Surgery

In the study of 25 patients, 52% (13 patients) of the patients had right side intertrochanteric fractures while the rest 48% (12 patients) had left side intertrochanteric fractures.

Table4: DistributionAccordingtotheSideofInjury

Figure 6:Distributionaccordingtothesideofinjury

Mode of Injury

The majority of patients under the age of 50 had high energy trauma, while those over 50 years had low energy trauma.

Table5: DistributionAccordingtoMechanismofInjury

Figure 7: DistributionAccordingtoMechanismofInjury

Operative Time

The minimum operative time was recorded as 70 minutes, whereas the maximum operative time was 130 minutes. The mean operative time was found to be 80.2 minutes, which ranged from 70-130 minutes.

Table6:OperativeTimeDistribution

Nail Dimension

Various nail diameters were used such as 9mm, 10mm, and 11mm. 9mm nail diameter was used in 14 patients, 10mm in 10 patients and 11mm in 1 patient. The nail lengths used were 340mm, 360mm, 380mm and 400mm. 340mm nail length was used in 8 patients, 360mm in 6 patients, 380mm in 7 patients and 400mm in the remaining 4 patients.

Table7: Distributionof NailDimensions

Figure 9:DistributionofPFNDiameter

Figure 10: DistributionAccordingtotheLengthofPFN

Complications

Only one case of deep infection was noted. This was treated by debridement and antibiotics. One case showed screw migration at 1 month of follow up, which was later recommended non-weight bearing for 8 weeks. The average time for fracture union was 12-18 weeks.

Table8:DistributionofComplication

Functional Outcomes

The modified Harris hip score was used to assess the clinical outcome of these patients. Grades of mHHS were as follows, A score of 90-100 was excellent, 80- 89 was good, 70-79 was fair and less than 70 was poor. The mean mHHS score in our study at 6 months of follow up was 88.84±6.43 (range 70-95), median was 91, whereas mode was calculated to be 92. The score was excellent in 16(64%) cases, good in 6(24%) cases, fair in 3(12%) cases and no patient of poor score was found.

Table9:DistributionofModifiedHarrisHipScoreAfter6Months

Figure 11:DistributionofModifiedHarrisHipScoreAfter3Months

The mean mHHS score at 1 month of follow up was 24.4±2.64, with median of 24 and mode calculated was 26.All patients had poor outcome at the period of 1month.

Table10: DistributionofModifiedHipHarrisScoreAfter1Month

Figure 12:DistributionofModifiedHarrisHipScoreAfter3Months

Cumulative distribution at 1, 3, and 6 months, that all the patients came under poor outcome at 1 month, while the majority of patients at 3 months came under poor outcome as well, but at 6 month most of the patients came under excellent to good outcome.

Table11:CumulativeDistributionofModifiedHarrisHipScore

Figure 13:CumulativeDistributionofModifiedHarrisHipScore

Unstable intertrochanteric (I/T) fractures remain a formidable challenge for orthopedic surgeons due to their complex anatomy, high rates of complications, and significant impact on patient mobility and quality of life [1]. The treatment landscape encompasses various options, including osteosynthesis with dynamic hip screws (DHS), cephalomedullary nailing, and in some cases, arthroplasty. Despite technological advances, consensus on the optimal implant for managing unstable I/T fractures is lacking, largely due to variations in fracture patterns, patient demographics, and surgeon preference [2]. In our study, we employed the Proximal Femoral Nail (PFN) in treating 25 patients with unstable I/T fractures, using the Modified Harris Hip Score (mHHS) to assess functional outcomes. The modification of the Harris Hip Score to include culturally relevant activities—such as squatting and cross-legged sitting—was particularly beneficial in the Indian rural context, where these activities are integral to daily life and social functioning [3].

Comparison with Previous Studies

Demographics and Mechanism of Injury

Our study cohort consisted predominantly of males (72%), with a mean age of 56.56 years, reflecting a similar demographic distribution to that reported by James B. et al., who found a male predominance of 63.64% in their 22-case series of intertrochanteric fractures [4]. This male predominance may be attributed to higher exposure to physical activities and trauma among men in certain populations, although many epidemiological studies report higher incidence in females, particularly due to osteoporosis post-menopause [5]. The disparity in gender distribution among different studies could be due to variations in lifestyle, geographical, and socioeconomic factors that affect both the incidence and reporting of such fractures.The mechanism of injury in our study varied with age, with younger patients experiencing high-energy trauma and older patients predominantly suffering from low-energy falls. The most common cause was self-fall, accounting for 52% of cases, which is lower than the 87.5% reported by Rathore PL et al. in their study on both stable and unstable I/T fractures treated with PFN [6]. This difference might be due to demographic variations or differing definitions of "slip and fall" events across populations. Notably, self-fall being common aligns with findings from multiple studies that emphasize falls as a primary cause of hip fractures in the elderly due to osteoporosis and decreased balance [7].

Complications and Their Management

Our study reported a complication rate of 8%, with only two cases during the 6-month follow-up: one deep infection and one instance of screw migration. The deep infection case was managed effectively through debridement and a three-week course of intravenous antibiotics guided by culture sensitivity results. The overall complication rate in our study was lower compared to the 13% reported by R. K.J. Simmermacheret al.[8], suggesting that PFN can yield favorable outcomes with minimal complications when performed under standardized protocols and by experienced surgeons.The low complication rate in our study might be attributable to several factors: a relatively small sample size, meticulous surgical technique, and careful patient selection adhering to strict inclusion and exclusion criteria. Other studies have reported variable complication rates ranging from 10% to 20% depending on factors such as surgeon expertise, patient comorbidities, and fracture complexity [9,10]. For instance, Simmermacheret al. highlighted that even slight deviations in nail positioning or reduction quality could increase complications such as cut-out, non-union, and malalignment [8]. Our absence of complications like non-union, acetabular penetration, nail breakage, rotational failure, and screw loosening is reassuring, reflecting the biomechanical stability and efficacy of the PFN in appropriately selected unstable I/T fractures.

Functional Outcomes and Rehabilitation

Functional outcome assessment using the Modified Harris Hip Score (mHHS) in our study showed encouraging results. At the 6-month follow-up, 64% of patients achieved an excellent outcome, 24% good, and 12% fair, with a mean mHHS of 88.84 ± 6.43. This functional recovery trajectory compares favorably with previous studies. For example, Rathore PL et al. reported 73% of patients had excellent to good results using PFN, though their cohort included both stable and unstable fractures and reported some poor outcomes [11]. Our findings align with the notion that PFN provides robust fixation in unstable fractures, facilitating early mobilization and improved functional outcomes [12].Early weight bearing in our cohort was initiated based on patient tolerance and radiological assessment. Approximately 58% of patients began partial weight bearing by the seventh week, and 50% transitioned to full weight bearing within 2-3 months. These rates are comparable to findings reported in other studies, where timely mobilization contributed to fewer complications such as deep vein thrombosis, pulmonary embolism, and muscle atrophy [13, 14]. The improved functional outcomes at six months can also be attributed to the rigorous rehabilitation protocol which emphasized early mobilization, quadriceps strengthening, and gradual progression to full weight-bearing activities.

Biomechanical Considerations and PFN Efficacy

The biomechanical rationale for using PFN in unstable I/T fractures lies in its intramedullary position, which allows for a shorter lever arm and better load sharing compared to extramedullary devices like the DHS [15]. This design reduces the bending moment on the implant and minimizes the risk of varus collapse, particularly in osteoporotic bone where traditional fixation methods may fail [16]. Our study supports these biomechanical advantages, as evidenced by the low incidence of mechanical complications and high rates of successful fracture union within the 12–18-week timeframe.Several biomechanical studies have demonstrated that the PFN provides superior rotational stability and resistance to varus collapse in unstable fracture models compared to other fixation systems [17, 18]. The inclusion of derotation screws in the PFN construct further enhances stability by preventing rotational displacement at the fracture site [19]. Our outcomes, with no reported cases of rotational failure or screw loosening, underscore the effectiveness of PFN design features in providing stable fixation and facilitating early weight bearing.

Cultural Relevance of Modified Harris Hip Score

The Modified Harris Hip Score (mHHS) was employed in our study to accommodate culturally specific activities such as squatting and sitting cross-legged, which are essential for Indian patients, especially those in rural settings. The original Harris Hip Score did not account for these activities, potentially underestimating functional recovery in populations where such movements are routine [20]. By modifying the score, our study could more accurately reflect the functional capabilities and limitations of our patient cohort. This culturally tailored approach likely contributed to the more nuanced understanding of patient recovery and satisfaction post-surgery.Comparative studies that have utilized the standard Harris Hip Score may not capture the full scope of functional recovery in similar populations. For instance, a study by Singh et al.  emphasized the need for culturally adapted assessment tools in evaluating outcomes for rural populations, aligning with our rationale for using the mHHS[21]. This adaptation ensures that improvements in hip function translate into meaningful gains in daily activities, thereby enhancing the overall quality of life.

Comparison of Our Results with Other Studies

Our study's functional outcomes compare favorably with other research in the domain. For example, James B. et al. reported good to excellent outcomes in a similar patient population, albeit with a slightly lower percentage of excellent results than our 64% excellent rating [4]. Similarly, Rathore PL et al. found that 73% of patients achieved excellent to good outcomes with PFN fixation, which is consistent with our findings of 88% excellent and good outcomes combined [11]. These comparisons suggest that our results are within the expected range for PFN treatment, reaffirming the implant's reliability.The low complication rate of 8% in our study is noteworthy when compared to other reports. Simmermacher et al. documented a complication rate of 13%, which included a range of mechanical and infection-related issues [8]. The lower incidence of complications in our cohort could be due to rigorous surgical protocols, effective perioperative care, and careful patient selection. Additionally, the reduced sample size in our study may have contributed to a lower observed complication rate; larger studies might reveal a slightly different profile.Another significant aspect is the progressive improvement in mHHS over time. At 1 month, all patients scored poorly, reflecting the immediate postoperative phase where pain, limited mobility, and dependence are prevalent. By 3 months, although the majority still fell into the poor outcome category, a few patients transitioned to fair outcomes. The most remarkable improvement was observed at 6 months, where none of the patients remained in the poor outcome category, and 88% achieved good to excellent results. This trajectory underscores the importance of long-term follow-up and rehabilitation in the recovery process following PFN surgery. Studies by Parker et al. and others support the concept that functional improvements continue for many months after hip fracture surgery, influenced by factors such as physiotherapy, patient motivation, and absence of complications [22].

Limitations of Our Study

While our findings contribute valuable insights into the management of unstable I/T fractures with PFN, several limitations must be acknowledged. First, the small sample size of 25 patients, reduced from an initial 45 due to the COVID-19 pandemic, limits the generalizability of our results. A larger patient cohort would enhance the statistical power and potentially reveal less common complications or variations in functional outcomes [23]. Secondly, the follow-up duration of 6 months, although sufficient to assess early functional recovery, does not provide insights into long-term outcomes such as implant longevity, late complications, or the sustainability of functional improvements. Longer follow-up periods are necessary to evaluate these aspects fully.Additionally, our study did not include a control group or comparison with other fixation methods such as DHS or arthroplasty, which limits the ability to draw definitive conclusions about the relative efficacy of PFN. Comparative studies or randomized controlled trials would be beneficial to establish the superiority or equivalence of PFN relative to other surgical options. Finally, while the use of the Modified Harris Hip Score was advantageous in our cultural context, it may limit direct comparisons with studies that employed the original Harris Hip Score, potentially introducing variability in outcome interpretation.

Future Directions and Recommendations

Given the encouraging results from our study, future research should aim to include larger sample sizes and longer follow-up periods to validate the findings. Comparative studies involving PFN and other fixation techniques could better delineate the advantages and disadvantages of each method in treating unstable I/T fractures. Additionally, incorporating patient-reported outcome measures (PROMs) alongside objective functional scores would provide a more comprehensive evaluation of patient satisfaction and quality of life post-surgery.Exploration into minimally invasive surgical techniques, newer implant designs, and enhancements in perioperative care could further improve outcomes and reduce complication rates. The integration of advanced imaging and computer-assisted surgical planning may also enhance the precision of PFN implantation, potentially reducing operative time and improving biomechanical alignment. Given the cultural adaptations made in this study, similar modifications could be explored in other contexts to ensure that functional outcome measures remain relevant and meaningful for diverse patient populations.In summary, the current study supports the use of PFN in managing unstable intertrochanteric fractures, demonstrating low complication rates, reliable fracture union, and excellent to good functional outcomes at 6 months postoperatively. Our results are consistent with other studies that highlight the advantages of PFN, particularly in terms of biomechanical stability and patient recovery. The data suggest that PFN, when applied with precise surgical technique, comprehensive preoperative planning, and adherence to postoperative rehabilitation protocols, is a highly effective implant in the treatment of unstable I/T fractures.

The study demonstrates that the Proximal Femoral Nail (PFN) is an effective and reliable implant for treating unstable intertrochanteric fractures. The use of PFN yielded excellent to good functional outcomes in the majority of patients by six months postoperatively, as measured by the Modified Harris Hip Score. Complication rates were low, and the implant provided stable fixation, allowing for early mobilization and weight-bearing. These findings, consistent with other literature, underscore the importance of precise surgical technique, thorough preoperative planning, and appropriate postoperative care. Further studies with larger cohorts and longer follow-ups are recommended to validate these results and optimize treatment protocols.

Acknowledgment
We extend our sincere gratitude to the Department of Orthopaedics at ESI-PGIMSR, New Delhi, for their support throughout this study. We acknowledge the contributions of our colleagues, staff, and participating patients, whose cooperation and trust made this research possible. Special thanks to our mentors and the Institutional Ethics Committee for guidance and approval. Their invaluable assistance and encouragement were instrumental in completing this study.

Abbreviations

I/T          Intertrochanter

PFN        Proximal Femoral Nail

PFNA     Proximal femoral Nail Antirotation

HHS       Harris Hip Score

mHHS    Modified Harris Hip Score

AO         ArbeitsgemeinschaftfürOsteosynthesefragen

DHS       Dynamic hip screw

ML         millilitre

Funding: No funding sources

Conflict of interest: None declared.

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