SYSTEMATIC
REVIEW
Comparative
Efficacy of PFNA Versus DHS for Intertrochanteric Hip Fractures:
An Umbrella Review
Nelson Vidal Chang,*
Humbert C. Kelsey Gary,
** Miguel A. Vidal Campo,# Natalia A. Gómez Palencia**
*Orthopedics and Traumatology Department, Universidad de Buenos Aires,
Buenos Aires, Argentina.
**Universidad Simón Bolívar,
Facultad de Medicina, Barranquilla, Atlántico, Colombia.
#Universidad del Norte,
Facultad de Medicina, Barranquilla, Atlántico, Colombia.
ABSTRACT
Introduction: Intertrochanteric hip fractures are common in older patients
and pose a major therapeutic challenge. The
dynamic hip screw (DHS) and proximal femoral nail antirotation
(PFNA) are the most widely used implants, but the evidence regarding their comparative efficacy remains controversial. Objective: To summarize evidence from systematic reviews
and meta-analyses comparing
PFNA with DHS for the treatment of intertrochanteric hip fractures. Materials and
Methods: An umbrella review of systematic reviews and meta-analyses
published between 2013 and 2025 was conducted.
Reviews directly comparing PFNA or other proximal femoral nail variants with DHS and reporting at least one relevant clinical
or perioperative outcome
were included. Because of overlapping primary studies and
methodological heterogeneity, a qualitative narrative synthesis was conducted
without a new meta-analysis. Results: Ten
systematic reviews (nine with meta-analyses) were included, encompassing data
from more than 12,000 patients. PFNA showed consistent perioperative
advantages, with shorter operative times and less intraoperative blood loss.
There were no clinically relevant
differences in long-term function or major
complications. In unstable
fractures, PFNA provided greater biomechanical stability and
showed a trend toward less mechanical failure, varus collapse, or shortening. Conclusions: PFNA offers
perioperative advantages over DHS, particularly in unstable fractures
and in older or high-risk
patients. In the long
term, both implants
yield similar functional outcomes and rates of major complications. Implant
selection should therefore
be individualized according to fracture pattern, patient condition,
surgeon experience, and available resources.
Keywords: Intertrochanteric fracture; proximal femoral nail; PFNA; dynamic hip screw; umbrella review; meta-analysis.
Level
of Evidence: I
Eficacia comparativa del clavo PFNA y el
tornillo DHS en fracturas intertrocantéricas de
cadera: umbrella review
RESUMEN
Introducción: Las fracturas intertrocantéricas
de cadera son frecuentes en pacientes añosos y representan un importante
desafío terapéutico. El tornillo
dinámico de cadera (DHS) y el clavo femoral proximal antirrotatorio
(PFNA) son los implantes más utilizados, pero la evidencia comparativa es aún
controvertida. Objetivo:
Sintetizar la evidencia de revisiones sistemáticas y metanálisis que
comparan PFNA con DHS para tratar las fracturas intertrocantéricas
de cadera. Materiales
y Métodos: Se realizó una umbrella review de revisiones sistemáticas y metanálisis publicados entre 2013 y 2025. Se incluyeron revisiones que compararan directamente PFNA o variantes de clavos femorales
proximales con DHS y con, al menos, un desenlace clínico o perioperatorio relevante. Por solapamiento de estudios primarios
y heterogeneidad metodológica, se efectuó una síntesis narrativa cualitativa sin nuevo
metanálisis. Resultados: Se incluyeron 10
revisiones sistemáticas (9 con metanálisis) que agruparon datos de más de 12.000 pacientes. El PFNA mostró ventajas perioperatorias consistentes, con menor tiempo quirúrgico y menos pérdida
sanguínea intraoperatoria. No hubo
diferencias clínicamente relevantes en la función a largo plazo ni en las
complicaciones mayores. En fracturas inestables, el PFNA tuvo mejor estabilidad biomecánica y menor tendencia a fallos mecánicos, colapso en varo o acortamiento. Conclusiones: El PFNA ofrece ventajas
perioperatorias frente al DHS, especialmente en fracturas
inestables y pacientes añosos o de alto riesgo. A largo plazo,
ambos implantes logran
resultados funcionales y tasas de
complicaciones mayores similares; por lo tanto,
la elección debe individualizarse según
el patrón de fractura, la condición del paciente,
la experiencia del cirujano y los recursos disponibles.
Palabras clave: Fractura intertrocantérica; clavo femoral proximal; PFNA; tornillo dinámico de cadera; umbrella review; metanálisis.
Nivel de Evidencia: I
INTRODUCTION
Intertrochanteric
hip fractures are among the most common injuries in older adults and are
associated with functional decline, increased morbidity and mortality, and
substantial healthcare resource use. Surgical treatment aims to provide stable
fixation that allows early mobilization, reduces complications associated with
bed rest, and supports functional recovery.
The
two most widely used devices are the dynamic hip screw (DHS), an extramedullary
system long considered the standard treatment, and the proximal femoral nail antirotation (PFNA), an intramedullary system that offers
greater biomechanical stability, particularly in unstable fractures.
Since
2013, several systematic reviews with meta-analyses have directly compared PFNA
with DHS.1-10 These reviews
consistently report perioperative benefits with PFNA, including shorter
operative time and lower blood loss, attributed to its minimally invasive
approach. However, long-term functional outcomes, usually assessed using the Harris Hip Score (HHS), and major
complications are generally similar between the two implants. Some reviews
favor PFNA for unstable fractures, particularly because of a lower tendency
toward cut-out, varus collapse, or mechanical failure. In stable fractures,
outcomes appear equivalent.
The
available evidence is spread across systematic reviews that differ to some
extent in their populations, eligibility criteria, outcomes, and methods. This
umbrella review aims to bring these findings together and provide a clinical interpretation that can guide
implant selection for intertrochanteric hip fractures.
MATERIALS AND METHODS
This
umbrella review of systematic reviews followed the recommendations of the
PRISMA 2020 statement adapted for reviews
of reviews and Chapter V of the Cochrane Handbook for Systematic Reviews
of Interventions, which
addresses overviews of reviews.11,12 The protocol was registered in PROSPERO
[CRD420251182097].
The research
question was structured using the PICO framework:
Population: Adults
with stable or unstable intertrochanteric femoral fractures classified as AO/OTA 31-A1 to 31-A3.
Intervention: Intramedullary fixation
with PFNA or variants of proximal femoral
nails.
Comparison: Extramedullary fixation
with DHS.
Primary Outcomes: Operative
time, intraoperative blood loss, long-term function, preferably assessed using the HHS, and major complications such as
cut-out, reoperation, periimplant fracture, deep
infection, or non-union.
Secondary Outcomes: Length of hospital stay, time to full weight-bearing, minor complications, and mortality.
Systematic
reviews with conventional or network meta-analyses were included if they
directly compared PFNA or variants of
proximal femoral nails with DHS and reported at least one primary outcome.
Eligible reviews had to document systematic methods, searches of at least two
databases, and an assessment of the risk of bias or quality of the included
studies.
We
excluded reviews without a direct comparison between PFNA and DHS, narrative
reviews without a meta-analysis or structured synthesis, studies focused
exclusively on other implants or populations outside the scope of the review, and publications with
insufficient information for analysis.
Reviews
were identified from the documents available for analysis. Duplicates, methods,
included populations, comparisons, and reported
outcomes were checked manually. Ten systematic reviews published between 2013
and 2025 were ultimately included, nine of which contained a meta-analysis.
The methodological quality of the included reviews
was assessed qualitatively, considering the comprehensiveness of the search,
duplicate study selection
or data extraction, risk-of-bias assessment, handling of heterogeneity, and transparency of the
synthesis.13
Two reviewers independently extracted the following data: authors, publication year, review type, number of primary studies,
approximate number of patients, fracture
types included, reported
outcomes, and main conclusions.
Because of methodological heterogeneity and partial overlap
among primary studies,
we used a qualitative narrative synthesis with summary tables.
No new quantitative meta-analysis was performed, to avoid double-counting
patients or studies included in more than one review.
RESULTS
Characteristics of the
Included Reviews
The 10
included reviews brought together data from 186 studies and more than 12,000
patients in total, with partial overlap across publications. Most included both
stable and unstable mixed intertrochanteric fractures, although some analyzed these fracture types separately. Table 1 summarizes the main characteristics of the included reviews.
Assessment of Methodological Quality
The
methodological quality of the reviews was generally moderate to
high. Their main strengths were searches across multiple databases, the
inclusion of randomized controlled trials or comparative studies, and the
assessment of clinically relevant outcomes. The most common limitations were
heterogeneity among primary studies, differences in fracture classification,
overlap among studies included in different reviews, and the limited
representativeness of some populations.
Summary of Findings
The reviews
consistently reported perioperative advantages with PFNA or proximal
femoral nails. Eight of
the 10 reviews found shorter operative times with these devices, with
approximate mean differences of 18-21 minutes. Nine of the 10 reported lower
intraoperative blood loss, with approximate reductions of 89-250 mL. Some reviews also reported lower transfusion
requirements, smaller incisions, and shorter hospital stays.
For
functional outcomes, most reviews found no significant long-term differences
between PFNA and DHS. HHS values were similar in most analyses, suggesting
functional equivalence beyond the early postoperative period.
No
consistent differences were observed between the two implants in major
complications, including cut-out, reoperation, deep infection, nonunion, or
mortality. However, PFNA showed a lower tendency toward varus collapse,
shortening, limb length discrepancy, and fixation failure, particularly in
unstable fractures.
Subgroup
analysis suggests that fracture stability is a key factor in implant selection.
In unstable fractures, PFNA showed biomechanical advantages and a lower risk of
mechanical failure. In stable fractures, both devices achieved similar
outcomes, although PFNA retained some perioperative advantages.
Overall,
the evidence favors PFNA for perioperative outcomes and unstable fractures,
while long-term safety and function appear comparable to those of DHS (Table 2).
DISCUSSION
The
main findings of this umbrella review show that PFNA offers perioperative
advantages over DHS. PFNA is associated with shorter operative time and lower
intraoperative blood loss, without appearing to compromise long-term functional
outcomes or increase major complications.
These advantages may be explained
by the less invasive technique
and intramedullary design of PFNA, which require less soft-tissue
dissection than the more extensive approach used for DHS. The benefit was
particularly evident in the included network meta-analyses, where PFNA ranked
more favorably for operative time and blood loss.4-6 Reducing operative time by 15-30 minutes and
blood loss by 89-250 mL may be clinically important in older or frail patients
and those with cardiovascular comorbidities, preoperative anemia, or high
anesthetic risk.
For functional outcomes, the available
evidence shows similar
long-term HHS results.
This is consistent with the biomechanical principles of each device: DHS
provides good compression in stable fractures, whereas PFNA offers greater
rotational and axial stability in unstable fractures.9,10 Several
studies also favor PFNA for early mobilization and weight-bearing in patients
with unstable fractures, which may allow faster rehabilitation and shorter
hospital stays.
No
consistent significant differences were found between the two groups in
cut-out, reoperation, deep infection, nonunion, or mortality. PFNA showed a
lower tendency toward varus collapse and shortening, particularly in unstable
fractures, where its intramedullary design provides better control of axial loading.3,8
Subgroup
analyses by fracture type help inform clinical practice. In unstable fractures,
classified as AO/OTA 31-A2 and
31-A3, PFNA showed advantages in stability and a lower risk of mechanical
failure. In stable fractures, classified as AO/OTA
31-A1, both devices achieved similar results. The choice may therefore depend
on surgeon experience, implant availability, cost, and preference for a less
invasive approach.9,10
The
strengths of this review include the synthesis of recent systematic reviews and
meta-analyses, the direct comparison of two widely used implants, and the
practical interpretation of findings according to fracture stability. The decision not to perform a new
quantitative meta-analysis also avoids double-counting
caused by overlap among primary studies.
The
main limitations are moderate overlap among primary studies, heterogeneity in
outcome definitions, differences in fracture
classification, and methodological variability across reviews.
Other considerations include
the limited representation of some populations and the scarcity
of studies with long-term follow-up, cost-effectiveness analyses, and patient-reported outcomes.
Clinical Implications and Future Research
In
clinical practice, PFNA appears preferable for unstable fractures and for older
patients or those at greater perioperative risk, whereas
DHS remains a valid option for stable fractures. In all cases, adequate reduction, early surgery, and early rehabilitation are key determinants of
outcome.
Future
research should include multicenter trials with longer follow-up, economic
analyses, subgroups defined by fracture stability, evaluation of newer implant
versions, and patient-reported outcomes.
CONCLUSIONS
PFNA
offers perioperative advantages over DHS in the treatment of intertrochanteric
hip fractures, chiefly shorter operative time, lower blood loss, and reduced
transfusion requirements.
In
unstable fractures, PFNA provides greater stability and a lower risk of
mechanical failure. In stable fractures, both implants yield similar outcomes,
although PFNA retains benefits in the immediate postoperative period.
PFNA
may therefore be considered the preferred option for older patients, unstable
fractures, and situations involving greater perioperative risk. DHS remains
an acceptable alternative for stable fractures, depending on the clinical, technical, and economic
context.
Recommendations
For unstable intertrochanteric fractures and
older patients at high surgical risk, PFNA should be considered the first
option when it is available and the surgical team has
experience with its use.
For
stable fractures, both PFNA and DHS are acceptable options. The choice should be individualized
according to the fracture pattern, surgeon experience, implant availability,
and institutional resources.
In all
cases, surgery should be performed early, adequate reduction achieved, and
rehabilitation started as soon as possible.
Use of Artificial Intelligence
During the preparation of this work, the authors
used GROK to organize tables
and synthesize information. They then reviewed and
edited the content as needed and take full
responsibility for the content of the manuscript.
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N. Vidal Chang ORCID ID: https://orcid.org/0009-0006-0132-0358
M. A. Vidal Campo ORCID ID: https://orcid.org/0009-0004-7477-3169
N. A. Gómez Palencia ORCID ID: https://orcid.org/0009-0001-8300-5055
Received on May 9th, 2026. Accepted after
evaluation on June 7th, 2026 • Dr. HUMBERT
C. KELSEY GARY • humbert.kelsey@unisimon.edu.co • https://orcid.org/0009-0008-4746-3922
How to cite this article: Vidal Chang N, Kelsey Gary HC, Vidal Campo MA, Gómez Palencia NA. Comparative Efficacy
of PFNA Versus DHS for Intertrochanteric Hip Fractures: An Umbrella Review. Rev Asoc Argent Ortop
Traumatol 2026;91(5):448-454. https://doi.org/10.15417/issn.1852-7434.2026.91.5.2365
Article
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Identification:
https://doi.org/10.15417/issn.1852-7434.2026.91.5.2365
Published: October, 2026
Conflict
of interests: The authors
declare no conflicts
of interest.
Copyright: © 2026, Revista de la Asociación Argentina de Ortopedia y
Traumatología.
License: This article is under Attribution-NonCommertial-ShareAlike 4.0 International Creative Commons License
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